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Mboera et al.

MWJ 2013, 4:19

Towards
m
a
l
a
r
i
a

ion for
vector
control
,
disease
manag
ement
and
livelih
oods in
Tanza
nia

e
l
i Leonard E.G.
m Mboera1*,
i Humphrey D.
n Mazigo2, Susan
a F. Rumisha1,
t Randall A.
3
i Kramer
1
o
Natio
n
nal
Instit
ute
for
Medi
cal
Rese
arch,
P.O.
Box
9653,
Dar
es
Salaa
m,
Tanz
ania

a
n
d
i
t
s
i
m
p
l
i
c
a
Duke
t

Catholic
University
of Health
and Allied
SciencesBugando,
P.O. Box
1464,
Mwanza,
Tanzania
Global
H
ealth
Insti
tute,
D
ukeU

niversity,
Durham
NC,
United
States
America
*marked decline
lmboera@n
imr.or.tz
shown a of
from 2000 to 2010.
During the same period,
Abstract
area specific studies in
Muheza,
Korogwe,
Over Muleba and Mvomero
the
have also reported a
years, similar declining trend in
malari malaria prevalence and
a hasincidence. The decline in
remain malaria prevalence has
ed thebeen observed to coincide
numbe with
a
decline
in
r onetransmission
indices
cause including
anopheline
of
mosquito densities. The
morbi decline
in
malaria
dity prevalence
has
been
and attributed
to
a
mortal combination of factors
ity inincluding improved access
Tanzanto
effective
malaria
ia.
treatment with artemisinin
Popula combination therapy and
tion protection from mosquito
based bites
by
increased
studies availability of insecticide
have treated bednets and indoor
indicat residual spraying. The
ed aobjective of this paper
declin was to review the
e
inchanging landscape of
overall malaria and its implication
malari for disease management,
a
vector
control,
and
preval livelihoods in Tanzania. It
ence seeks to examine the links
among within a broad framework
under- that considers the different
fives pathways
given
the
from multiplicity of interactions
18.1% that
can
produce
in
unexpected outcomes and
2008 trade-offs. Despite the
to
remarkable decline in
9.7% malaria burden, Tanzania
in
is faced with a number of
2012. challenges. These include
The the
development
of
declin resistance of malaria
e
ofvectors to pyrethroids,
malari changing
mosquito
a
behaviour and livelihood
infecti activities that increase
on hasmosquito productivity and
occurr exposure to mosquito
ed inbites. In addition, there
all
are challenges related to
geogra health
systems,
phical community perceptions,
zones community involvement
of theand
sustainability
of
countr funding to the national
y.
malaria
control
Malari programme. This review
a
indicates that malaria
mortal remains an important and
ity andchallenging disease that
cumul illustrates the interactions
ative among
ecosystems,
probab livelihoods, and health
ility ofsystems. Livelihoods and
deaths several
sectoral
have development
activities
also including
construction,

water tivity and transmission.


resour Consequently,
these
ce
situations
require
develo innovative and integrative
pment re-thinking
of
the
and strategies to prevent and
agricul control
malaria.
In
tural conclusion, to accelerate
practic and
sustain
malaria
es
control in Tanzania, the
contrib prevention strategies must
ute
go hand in hand with an
signifi intersectoral participation
cantly approach that takes into
to
account ecosystems and
malari livelihoods that have the
a
potential to increase or
mosqu decrease
malaria
ito
transmission.
produc

al and urbaneco
areas. Fourno
plasmodia mic
[7]
1 species,
and
In namely
Plasmodium heal
tr falciparum, th
od P. vivax, P.syst
malariae, ems
uc and P. ovale fact
tio are preva-ors
in the[8,9
n lent
country.
]
Malaria riskmay
Ma in Tanzaniapro
lari is
vide
a isheterogene- an
en ous
withaddi
de malaria
mi prevalence tion
c rates,
al
in parasite
risk
mo densities
as a
st and
resu
par entomologic lt of
ts al
an
of inoculation incr
Ta rates
ease
nzavarying
d
nia from
oneexp
, area
andosur
an season
toe to
d another [1-the
re 4].
Thisdisma distribution ease
ins is
.
a determined
I
ma in part byn
jor climatic,
cauecological Tan
zani
se and
of topographic a,
mal
mo factors
aria
rbi which
dit influence is
mai
y the
an distribution nly
d patterns oftran
mo the vectorssmit
rtal [3,5,6]. Inted
ity addition,
by
bot human
Ano
h activities, phe
in behaviour -les
rur and socio-ga

mbi
ae,
An.
ara
bie
nsis
and
An.
fun
estu
s
[10]
.
Oth
er
imp
orta
nt
vect
ors
incl
ude
An.
mer
us
[5,1
1],
An.
rivu
loru
m
and
An.
mar
shal
lii
[1214].
The
re
are
clea
r
spat
ial
and

shortly after[3,1
the
8te mosquito 20].
mp densities
M
ora peak, nearalar
l breeding
ia
var sites wheretran
iati adult
smi
onsmosquitoes ssio
in emerge, andn
the around the
inte
mo edges
ofnsit
squareas where
ito humans arey in
po aggregated Tan
pul [18]. Thesezani
ati sources ofa is
on, spatial andclos
ely
biti temporal
ng heterogeneit rela
rat y in theted
e distribution to
an of mosquitopre
d populations vale
ma are
nce
lari associated of
a with
themal
tra variability inaria
ns the humanin
mi biting rate,the
ssi the
pop
on proportion ulat
int of
ens mosquitoes ion.
Obs
ity that
are
am infectious, eron and in thevati
g risk
ofons
in
dis human
nort
tric infection
hts, [18].
east
vill Seasonal
ern
ag- malaria
es transmis- and
an sion
iscent
d common inral
agr many placesTan
o- of
sub-zani
ecoSaharan
a
sys Africa, withhav
te most of thee
ms transmission indi
[3, occurring atcat4,1 the end of
5- the
long
17] rainy
. Itseasons
has [3,15]. It has
beebeen
n observed
shothat vector
wn species
tha behaviour,
t density, and
the the
hu entomologic
ma al inoculan tion
rate
biti (EIR)
are
ng dependent
rat on seasonal
e ischanges in
hig envihes ronmental
t variables

M
al
ar
ia
W
or
ld
Jo
ur
n
al,
w
w
w.
m
al
ari
a
w
or
ld.
or
g.
IS
S
N
22
14
43
74

1
D
ec
e
m
be
r
20
13
,
Vo
l.
4,
N
o.
19

Mboera et al. MWJ 2013, 4:19


on [3,22]
s
and
hence
and, more
malaria
important
transmis
ly,
to
ed
sion
that identify
intensity
when malaria
[23].
the hotspots.
Some
agricultu
mean
ral
annua 2
producti
l EIR Malari
on
is
a and
systems
high, liveliho
provide
the
conditio
ods
mean
ns well
annusuited
2.1 I
for
al
mosquito
m
parasi
breeding,
te
p
with
preval
ac
clear,
ence
temporar
t
is
y bodies
of
also
coincidin
li
g with
high
ve
the time
[3,21]
of crop
. The
li
cultivati
under
h
on, and
stando
other
ing of
human
o
indice
activities
ds
s
. High-er
o
malaria
relati
prevalen
n
ng to
ce
has
malar
m
been
ia
al
reported
trans
more
ar
missi
often in
ia
on is
vil-lages
centra
with
In
crop
l to its Tanzania
irrigation
contr , malaria
schemes
ol
is
[3,4,24].
throu predomi
Agricult
nantly a
gh
ural
quanti rural
activities
fying disease
such as
the where
tilling
agricultu
the soil
potent re forms
and
ial
the
weeding
risk backbon
using
of
e of the
hoes
infect economy
generate
ion . Various
larval
and livelihoo
breeding
d
sites.
elucid
activities
However
ating have
,
the
the impact
knowled
patter on
ge
of
ns of mosquito
anthropo
diseas producti
genic
vity,
e
activities
trans mosquito
that
contribut
missi biting

exposure

e to malaria
malar prevalen
ia
ce,
in
trans- economi
missi es that
on depend
amon heavily
g
on
rural agricultu
farmi re,
ng innovati
com ve
muni approach
ties es
are
in
required
Tanz to satisfy
ania food
remai needs,
ns
increase
limit househol
ed d welfare
[25]. and
M alleviate
alaria pov-erty
, in [26,27],
turn, while
impe minimisi
des ng
huma malaria
transmis
n
work sion.
Agric
force
outpu ultural
t and intervent
agric ions are
ultur available
to
al
prod control
uctio the
spread of
n,
espec malaria.
ially Availabl
e
at
times techniqu
when es
activi include
ties filling
are at and
draining
a
peak of small
[26,2 water
7]. bodies,
Since environ
vario mental
modifica
us
agric -tions,
ultur and
alternate
al
prod wetting
uctio and
drying of
n
syste rice
ms fields
supp (intermit
ort tent
mosq irrigation
uito ).
prod Intermitt
uctivi ent
irrigation
ty
and in rice
henc fields in
Africa
e
highe has been
shown to
r

significa
ntly
reduce
the
density
of
malaria
vectors
by
curtailin
g their
larval
development,
while
still
maintain
ing
yields,
saving
water,
and
reducing
methane
emission
s [27].
Addressi
ng
the
adverse
impact
of
agricultu
ral water
projects
on both
malaria
and the
environ
ment is a
challeng
e.
Commun
ities as
well as
the
agricultu
ral and
irrigation
sectors
tend to
focus on
economic
benefits,
paying
little
attention
to
assessing
public
health
and
environ
mental
impact.
Agricult
ural
projects
are
normally
planned
and
managed
in
isolation

from due
to
other the fact
aspec that
ts of much of
devel it is rain
opme -fed, and
nt. hence
More drainage
over, cannot
the be
succe carried
ssful out
imple effectivel
y.
ment
Lives
ation tock
of
keeping
meas is
ures another
to
importan
mini t
mise economi
such c
acimpa tivity for
cts is
con- a number
strain of
ed by commun
pauci ities in
ty of Tanzania
infor and other
matio subSaharan
n,
techn African
ical countries
facto [28].
rs, Large
and groups
limit of liveation
s in
huma
n,
finan
cial
and
instit
ution
al
capac
ity as
well
as
lack
or
weak
inters
ector
al
colla
borat
ion.
In
addition,
malar
ia
contr
ol is
diffic
ult in
agric
ultur
al
areas

stock
keepers
in
the
region
are either
nomadic
or agropastoralis
ts.
Nomadic
populatio
n
moveme
nts have
contributed to
the
spread of
infectiou
s
diseases
[29]. The
constant
migration
of
pastoralis
ts from
hightransmiss
ion areas
in search
of
pasture
and
water can
introduce
malaria
parasites
into lowtransmiss
ion areas.
With a
poor
health
system,
tracking
and
treating
these
populatio
ns can be
challengi
ng
as
they are
often
highly
mobile
and
concentra
te
in
remote
locations.
It
has
been
observed
that
failure to
consider
no-madic
moveme
nts
contribut
ed
to
failure of

malar presence
of cattle
ia
eradi- may
catio increase
malaria
n
camp prevalenc
aigns e (a phein thenomenon
1950s known as
and zoopoten
1960s tiation)
[30]. [32] by
As attracting
the mosquito
count es to the
ry isgeneral
strivi proximit
ng toy of the
elimi human
nate populamalar tion [33].
ia, itHowever,
the role
is
imporof
tant livestock
in
to
diverting
exam mosine quitoes
the from
impa feeding
ct ofon
noma humans,
dic and
pasto transmitti
ralis ng
m onmalaria
the (zooprop
trans- hylaxis)
missi has long
on ofbeen
the known
disea [33,34].
se. The use
T of
he animals
hoof as bait to
prints attract
mosquito
of
is
cattle,es
sheep likely to
a
and be
goats promhave ising
been malaria
incri control
minat strategy
ed to[35].
create Fishi
habit ng
ats constitute
for s
an
mosq important
uito source of
breed livelihoo
ing d for a
[25,3 sizeable
1]. Inproportio
additi n of the
on, Tanzania
some n
studiepopulatio
s
n.
have However,
show malaria
n thathas been
the

reported
as one of
the
occupational
hazards
of fishing
life
(http://w
ww.fao.o
rg/
docrep/0
06/AD15
0E/AD15
0E01.ht
m).
A
high
prevalenc
e
of
malaria
has
recently
been
reported
among
pregnant
women
in
the
fishing
communi
ties
of
Uganda
[36]. In
West
Africa
higher
rates of
malaria
transmiss
ion have
been
reported
in
lagoons
and
coastal
areas
where
An. gambiae and
An.
melas are
the most
common
vectors
[37]. In
Mali,
more
adult
mosquito
es
and
more
productiv
e
mosquito larval
habitats
have
been
found in
fishing
hamlets
dur-ing
the dry
season

and mud-andthese wattle


were dwellings
respo with
a
nsible grass- or
for reedseedi thatched
ng roof.
neigh Such
bouri environm
ng ental
areas condition
with s expose
mosq individua
uitoes ls
to
at themosquito
start bites, and
of thehence
rainy malaria
seaso infecn
tions. A
[38]. study
Fi carried
in
shing out
has Senegal
been establish
docu ed that
ment the
ed toprobabilit
of
facilit y
ate dying at
outdo ages 1-4
or ex-years
posur was 50%
e ofhigher
indivi among
duals children
living in
to
malar traditiona
l homes
ia
vecto common
rs inin fishing
India villages,
[39] than
and among
Brazi those in
modern
l
[40]. homes
Most [41]. The
fishin fact that
many
g
com people
munit sleep in
ies makeshif
live t shelters
in
either or
other
in
tem- quarters
porar that
afford
y,
simpl little
protectio
e
ww
w.m
alari
Ma awo
lar rld.o
ia rg.
Wo ISS
rld N
Jo 2214
urn al, 4374

2
Dec
emb
er
2013
,
Vol.
4,
No.
19

n against
being
bitten by
malaria
mosquito
es,
together
with all
the time
spent on
or near
the water
during
the night
means
that the
possibilit
y
of
exposure
to
malaria
is
maximise
d.
It has
been
shown in
Kenya
that
fishery
-related
activities
aggravate
the
problem
of
malaria
along
Lake
Victoria
basin. In
Kenya,
the
common
use
of
earthwor
ms
as
fish bait
has been
attributed
to
the
increase
in
mosquito
breed-ing
sites. The
earthwor
ms
are
normally
extracted
from wet

Mboera et al. MWJ 2013, 4:19

soil by digging holes using hands. The open excavated pits


that are left behind hold water that supports mosquito
breeding, so exposing local communities to an increased

3 Current malaria strategic interventions

data). Marshes, papyrus swamps, and pools of stagnant


water are also common features around fishing villages
and camps. These are known to offer ideal breeding habitats for mosquitoes.
With the current deforestation in Tanzania, brick making is becoming an important alternative in house construction. Brick making and the need to re-plaster mud
built houses result in the increase of borrow pits that support mosquito breeding [23]. Like in Kenya [42], brick
making in Tanzania is predominantly a dry season activity.
The used stages in the brick making process are excavations, fermentation, moulding, drying and kilning. During
the moulding stage, water is brought into the brick pits and
mixed with soil. Once the pits are abandoned during or
after the kilning stage, the pit accumulates rainwater and/
or groundwater [42] thus, providing potential mosquito
breeding sites. Since brick making is done mostly during
the dry season, it may aid in maintaining mosquito populations year round.

Early and accurate diagnosis of malaria is critical for proper case management. However, most malaria diagnoses in
Tanzania are based on history and clinical examination.
Malaria case definition poses a challenge because patients
usually present with signs and symptoms that are characteristics of many other febrile illnesses. Tanzania has an
extensive network of both public and private health facilities. The majority, however, do not provide laboratory
services.
Studies in Tanzania have shown that service provision
for malaria case management has shown some improvement in terms of coverage. In studies carried out in
2008/2009 and 2012, the capacity for both malaria diagnosis and treatment was reported to be available in over 80%
of all facilities in Tanzania [46,47] (Table 1). This shows a
marked increase as compared to 33% in 2006. In Tanzania, much improved services for malaria treatment have
been observed in terms of presence of trained staff and
availability of malaria treatment guidelines.
On-site malaria diagnostic capacity has improved
markedly from 30% in 2009 to 75% in 2012 [46,47]. This
is mainly due to the major improvement in the availability
of malaria rapid diagnostic tests (mRDT) [48], which was
only available in 6% of facilities in 2009. The introduction
of mRDT has reduced unnecessary use of antimalarial
drugs [49,50]. On the other hand, the availability of Artemisinin-based Combination Therapy (ACT) was the same
in both the 2008/2009 and 2012 facility surveys with 7780% of the facilities having the first-line antimalarial drug
in stock.
Intermittent preventive treatment among pregnant
(IPTp) women in Tanzania is still low and declining. According to country-wide population surveys, the propor-

risk of mosquito bites (W.R. Mukabana et al., unpublished

2.2 Impact of malaria on livelihoods


Agriculture and other kinds of livelihoods generate income
and, thus, influence living conditions, which can affect the
transmission and severity of malaria. In Tanzania, improved socio-economic status due to rice growing has been
found to lead to reduced malaria prevalence [25]. Similarly, studies in Kenya have shown that malaria prevalence
was lower in irrigated villages, in this case apparently because the predominant mosquito species preferred to feed
on cattle rather than on humans [27]. This situation can be
explained by a number of reasons including the widespread use of mosquito bednets and antimalarial drugs as a
result of the general improved livelihoods. As residents of
the irrigation scheme become wealthier due to income
generated from agricultural production, some of it is diverted to healthcare. It has recently been observed in central Tanzania that households with greater financial resources are better able to purchase and correctly use malaria prevention methods [43].
It should be noted, however, that malaria not only
causes ill health and death, but also has great impact on the
economic development of the household in several ways.
It is important that households realise the economic impact
of malaria that will motivate them to protect themselves
from the disease and increase productivity. Identification
and better understanding of potential risk factors for malaria are important for targeted and cost-effective health
interventions.
Although many socio-economic determinants of disease have been intensively studied, crop agriculture, pastoralism and fishing as important aspects of society and environment have been inadequately addressed. In such communities, poor health reduces income and productivity,
further decreasing peoples ability to address poor health

and inhibiting economic development.

3.1 Malaria disease management

Table 1. Malaria service readiness of health facilities in Tanzania,


2009 and 2012
Variable

2008/

2012

2009

Offering diagnosis (%)


Offering treatment (%)
Facilities with malaria treatment services (n)
Trained staff (diagnosis and treatment) (%)
Guidelines available (%)
Trained in Intermittent Preventive Treat-

ment (%)

Guidelines on Intermittent Preventive Treat-

81
97
603
66
64
-

86
86
1209
59
60
37

ment (%)
Diagnostic capacity on site* (%)

45

30

75

(%)

80

77

Sulfadoxine-pyrimethamine (%)
Insecticide treated mosquito nets (%)
Total health facilities (n)

80
635

78
61
1297

Artemisinin Combination Therapy in stock

* Rapid diagnostic test or microscopy

MalariaWorld Journal, www.malariaworld.org. ISSN 2214-4374


December 2013, Vol. 4, No. 19

Mboera et al. MWJ 2013, 4:19

Sev-eral
factors
can be
tion attribute
d to the
of
moth declinin
ers g use of
who IPTp or
recei low
ved complia
to
two nce
IPTp
dose
s of among
IPTp pregnant
durin women
the
g the in
country.
last
preg These
nanc include
y has sociorema cultural,
ined individu
and
low al
health
over
the system
years related
bein factors
[23,55].
g
22%
3.2 M
in
os
2005
[51],
q
30%
ui
in
to
2008
co
[52],
27%
nt
in
ro
2010
l
[53]
and
31.4 The use
% in of
2012 insectici
[54], de
treated
an nets
errati (ITNs)
c
has been
trend the
whic mainstay
h is of
unlik malaria
ely control
to
in
meet Tanzania
the for the
set past decnatio ade.
nal There
targe has been
t of an
80% increase
the
cove in
rage househol
by d owner2015 ship of
insectici
.

de
treated
mosquit
o
nets
from 9%
in 2001
to 91.5%
in 2012
[53,54]
(Figure
1).
Initially,
the rural
areas
were
reported
to own
fewer
mosquit
o nets as
compared to
urban
areas
[53].
Howeve
r,
a
recent
survey
indicates
that the
level of
mosquit
o
net
ownersh
ip
in
rural
are-as
has
increase
d
to
92.7%
while in
urban
areas it
rose to
86.8%
[55].
The
increase
in
net
ownersh
ip in the
country
is highly
attribute
d
to
governm
ent
initiative
s
and
donor
program
mes to
distribut
e
nets
subsidis
ed
or
free of

char five
ge to years of
hous age. In
ehol 2010
ds or and
to
2011, a
vuln universal
erabl coverage
e
campaig
grou n
was
ps
impleme
[56,5 nted to
7]. cover all
Sinc sleeping
e
spaces.
2004 By 2011,
,
the total
there number
has of
been distribut
an ed ITNs
incre was
ase close to
in
28
avail million
abilit [57].
y
ITN use
and among
acce children
ssibil under
ity five
of
years of
ITNs age
to
increase
preg d
nant massivel
wom y
en country
and wide
infan since
ts
2005
throu (12.2%),
gh reaching
subsi 72.7% in
dies. 2012
Fro [54]. On
m
the other
2008 hand,
to
recent
2010 surveys
, a indicate
mass that
distri 76.2% of
butio the
n
pregnant
cam women
paig use
n
ITNs.
deliv The
-ered proporti
9
on
of
milli pregnant
on women
long- who live
lasti in
ng househol
nets ds with
free at least
of
one ITN
char is
ge to currently
child 82%
ren [54].
unde These
rusage

levels
confirm
that
Tanzania
is well
on

Figure 1.
Insecticide
-treated
mosquito
net
coverage
in
Tanzania,
20012012.

amme
has been
track expanded
to include
to
other
reach holoenits demic
natio areas for
nal malaria
target transmiss
ion,
of
especiall
80% y around
in
the Lake
2013. Victoria.
In A recent
Tanza survey
nia, has
the reported
inuse an
crease of
of
indoo the
percentag
r
of
resid e
ual househol
spray ds
ing sprayed
(IRS) with IRS
the
has in
been Kagera
adapt region
ed to[54].
The
comp
leme utilisatio
nt then of other
scalin malaria
g upinterventi
ons
of
ITNs including
screening
in
epide of houses
mic- and larval
prone source
distri managem
cts. ent
Until (LSM)
2007, has
IRS received
was little
limite attention.
d toThe
epide majority
mic- of houses
prone in ru-ral
areas Tanzania
of theare built
Kage of
wooden
ra
regio polesn inand-mud
north walls,
and
weste thatched
with
rn
Tanza coconut
nia palms or
[53,5 grass
8]. [45]. A
Rece larger
ntly, prohowe portion of
ver, the
the populatio
IRS n in rural
progr area live

in poorly
constructed
houses
and only
a
few
houses
have
windows
with
mosquito
gauze.
Housing
condition
s
have
been
suggeste
d as one
of
the
potential
risk
factors in
malaria
transmiss
ion [59].
A
number
of studies
have
already
shown
that the
design of
a house
significa
ntly
affects
the
incidence
of
malaria
infection
[60-62].
In
a
recent
study
only
23.9%
(range=3.
6-38.9%)
of
the
househol
ds were
reported
to have
window
screens
[45]. The
low
proportio
n
of
houses
with
screened
windows
is
an
important
issue to
consider
while
sustainin
g
the
gains of
malaria
control

throu 4
gh
other Toward
meas s
ures. malari
It is
impora
tant elimina
that
house tion in
chara Tanzan
cteris
tics ia
are
taken There is
into evidence
consi that
derati malaria
on incidence
when and
desig prevalenc
ning e
rates
futureare
interv declining
en- in
tions Tanzania.
again For
st
instance,
malar in 2008,
ia. the
Simil overall
arly, malaria
mosq prevalenc
uito e among
contr underol
fives in
throu Tanzania
gh was
LSM, 18.1%
inclu [52]. In a
ding recent
larvic national
iding, survey
is
(2011limite 2012) an
d. Sooverall
far, prevalenc
the
of
use e
malaria
of
larvic of 9.7%
iding based on
has malaria
been rapid
restri diagnosti
test
cted c
(RDT)
to
Dar and 4.2%
based on
es
Salaa microsco
m, -py
but among
there underare fives was
plans reported
[54].
to
exten Compari
the
d thisng
interv results of
entio 2008 and
n to2012,
other there was
urban a
areas. significan
t decline

(46.4%)
in
malaria
prevalenc
e among
children
underfives in
the
country.
The
decline
of
malaria
prevalenc
e
in
Tanzania
has been
observed
in
all
geograph
ical
zones
(Figure
2) . In
both
surveys,
the Lake,
Southern
and
Western
zones
had the
highest
prevalenc
e.
The
lowest
prevalenc
e
was
observed
in
the
northern
and
southern
highland
zones.
Lake,
Southern,
Western
and
Eastern
regions
also
observed
marked
de-clines
between
2008 and
2012.
Neverthe
less, the
decline
must be
interprete
d
with
caution
because
different
rapid
diagnosti
c
tests
were
used in
the two
surveys.

A trend in
rea- malaria
specifprevalenc
ic
e in some
studieparts of
s
the counhave try. In the
also Korogwe
show district of
n anorthsimil eastern
ar
Tanzania,
decli communi
n-ing ty -based
rld
Jour
Ma nal,
lar ww
ia w.m
Wo

studies
have
reported
a
progressi
ve
decline in
the
prevalenc
e
of
malaria
parasitae
mia
in
the low-

alari 2214-4374
4
awo
rld.o December
rg. 2013, Vol. 4,
ISSNNo. 19

Mboera et al. MWJ 2013, 4:19

study in
the
neighbo
uring
district
of
Muheza,
a
remarka
ble
decline
of
P.
falcipar
um was
observed
between
1992 and
2012
[64]. In
Figur Muleba
e 2. district
of northMalari western
Tanzania
a
parasit where
IRS is
aemia the main
in
malaria
Tanza control
strategy,
nian a significhildr cant
en <5 decline
from
years
20.1% in
of
2007 to
age, 6.6% in
2008 has
by
been
geogr recorded
aphica [58]. In
Mvomer
l
o district
region in
.
central
Tanzania
, overall
lands district
from malaria
78.4 prevalen
% in ce has
2003 declined
to
from
13.0 34.5% in
% in 2008 to
2008 5.4% in
and 2011
in
(Mboera
the et
al.,
highl unands publishe
from d).
In
24.7 addition,
% to one
3.1% facility[63]. based
In
study in
anot northher ern
recen Tanzania
t

has also
reported
a
decreasi
ng
incidenc
e
of
malaria
during
the
period of
20062010
[65].
Anal
ysis of
Health
Manage
ment
Informat
ion
System
(HMIS)
data also
indicated
some
slight
decline
in
the
number
of
malaria
cases in
the
outpatie
nt
departm
ent.
While a
clear
decline
in
number
of
malaria
cases
among
underfives
was
observed
from
2009,
that of
individu
als over
5 years
was
clear
from
2010.
There
was
a
decline
of
malaria
cases by
28.0% in
underfives

from ne
in
2009 inpatient
to
cases
2012 and
whil deaths in
e a recent
decli years.
ne by Total
29.7 number
%
of
was malaria
obser inpatient
ved s
has
amo slowly
ng declined
indiv by
idual 13.3%
5
from
years 2010 to
and 2012.
abov Among
e
the
from under2010 fives, the
to
number
2012 of
.
admissio
From ns due to
2004 malaria
to
also
2012 decrease
, an d
by
over 25.3%
all during
35.4 the same
%
period.
redu The total
ction number
in
of deaths
mala due to
ria malaria
incid has
ence declined
per by
1000 29.9%
popu (in
latio <5years
n has =37.1%;
been 5years
repor =19.4%)
ted between
in
2009 and
Tanz 2012.
ania.
In
A recent
n
years,
analy malaria
sis of case
facili fatality
ty
rates
data (CFR)
from have
the declined
HMI for
all
S
age
datab
ase groups.
has For
also instance,
indic CFR in
ated <5 years
old group
a
sligh declined
t
from
decli 2.19 in

2009 to
1.84 in
2012
while in
the 5
years old
individua
ls
it
declined
from
2.24 in
2009 to
1.54 in
2012.
The
decline in
CFR was
quite
marked
among
individua
ls
5
years old.
The
decline
indi-cates
an
improve
ment in
malaria
case
managem
ent at facility
level.
The
decline in
number
of deaths
due
to
malaria
in
Tanzania
during
the last
decade
has been
supporte
d by a

markedl
y
decrease
d
between
2000
and
2010
(Figure
3).
The
decline
in
malaria
transmis
sion has
been
reported
to
coincide
Figur with
a
e 3. decrease
Numb in
er of malaria
vectors,
deathsthe An.
and gambiae
cumul complex
ative and An.
proba funestus
bility groups
[67], as
of
well as a
death change
(CPD in
the
) per composit
of
1000 ion
the
popul
ation members
of
the
in
An.
Tanza gambiae
nia, s.l.
1990- complex.
2010. Availabl
e
statistics
rece indicate
that An.
nt
anal arabiens
is is now
ysis the
[66], predomi
whic nant
h
member
indic of
the
ates An.
that gambiae
mala s.l.
ria complex
mort in
ality coastal
areas of
and northcum eastern
ulati Tanve zania,
prob which
abilit was
y of previous
deat ly
hs in dominat
by
Tanz ed
ania An.

gambiae
s.s. [68].
The
cause of
the
observed
decline
in
malaria
mosquit
oes and
change
in
the
composit
ion
of
the
members
of
the
An.
gambiae
s.l.
complex
remains
someho
w speculative.
However
, some
research
ers have
reported
that improved
access to
ITNs has
contribut
ed to an
18-fold
reduction in
the
number
of
infectiou
s bites
per year
[69].
It has
been
reported
elsewher
e
that
mosquit
o control
intervent
ions
using
ITNs can
lower
abundan
ce and
change
the
species
composit
ion
of
anopheli
ne
mosquit
oes
[70,71].
Recent
studies
in northeastern

Tanz s.l.
ania complex
and have
west importan
ern t impliKen- cations
ya for the
has transmis
furth sion of
er
malaria
sugg and
ested might
that partly be
ITNs the
are driver of
more the
effec observed
tive decline
in
in
killin malaria
g An. transmis
gam sion in
biae Tanzania
s.s. [69-71].
and
The
An. decline
funes of
the
tus malaria
than burden
An. has been
ara- reported
biens recently
is
[69,7 in other
0]. areas of
The subchan Saharan
ges Africa
[72].
in
the Analcom yses of
posit malaria
ion incidence
and in
abun endemic
regions
danc have
e of demonAn. strated
gam marked
biae reduction
44374

5
Ma Dec
lar emb
ia er
Wo 2013
rld ,
Jo Vol.
urn 4,
al, No.
19
ww
w.
ma
lari
aw
orl
d.o
rg.
ISS
N
221

s in cases
of
the
disease
largely
through
the use of
long
lasting
insecticid
al nets.
Funding
for
malaria
preventio
n
in
Africa
over the
past
decade
has had a
substanti
al impact
on
decreasin
g malaria
-attributa
ble child
deaths
and that
ITNs
accounte
d
for
99% of
the lives
saved
[73].
Nonethel
ess, one
longitudi
nal study
in northeastern
Tanzania
has
documen
ted that
there was
a signifi-

Mboera et al. MWJ 2013, 4:19

cant
decr
ease
in
mala
ria
trans
miss
ion
befo
re
thes
e
area
s
were
wide
ly
cove
red
with
ITN
s
[67].
It is
likel
y
that,
in
addit
ion
to
ITN
and
IRS,
envi
ron
ment
al
chan
ges,
econ
omic
deve
lop
ment
,
dem
ogra
phic
stabi
lisati
on,
great
er
polit
i-cal
stabi
lity,
and
impr
oved

coverage
of basic
health
ser-vices
have
impacte
d
malaria
morbidit
y
and
mortalit
y
in
these
areas
and
other
parts of
subSaharan
Africa.

5
Imp
licat
ions
and
chal
leng
es
of
mal
aria
elim
inat
ion
stra
tegi
es
in
Tan
zani
a
Despite
the
remarka
ble
progress
in
combati
ng
malaria
in
Tanzania
,
the

country
is faced
by
multiple
challeng
es.
These
include
challeng
es
related
to
the
human
host,
mosquito
vectors,
parasites
and
health
systems
(Table
2).
Table 2.
Challenge
s in
malaria
control in
Tanzania
Challenges
related to:
Humans

Specific issue
Loss of protective immunity
Patient-provider compliance with interventions
Misuse of interventions
Livelihood factors contributing to malaria

Vectors
Parasites
Health

systems

transmission
Mosquito resistance
Mosquito behavioural changes
Parasite resistance

Health care delivery


Weak surveillance system and monitoring and

evaluation
Inadequate local budget and donor dependency
Management of non-malarial fevers
Governance (lack of community engagement

and intersectoral collaboration)

of
ties children
that who were
have admitted
devel with
oped severe
some malaria
level has been
observed
of
anti- [65]. A
malar decrease
ial in malaria
im- transmiss
munit ion
intensity
y
could is known
be
result to
associate
in
loss d with an
increase
or
failur in age of
e tosevere
acqui malaria
cases
re
prote [76]. It is
ctive possible
immu that the
nity initial
and success
incre of ITNs
ase and IRS
the may
burde disappear
n ofduring
the long
disea -term
se inapplicatio
the n because
long of fading
term. preexisting
In
Sene immunity
gal levels.
and The shift
the
Tanza in
nia populatio
intens ns most
ive at risk of
use malaria
raises
of
ITNs important
has questions
result for
ed malariainto eliminati
an ng
age- countries,
shift since
tradiof
malar tional
control
ia
relate interventi
ons are
d
morbi likely to
less
dity be
[64, effective.
74,75 Approach
to
] andes
an eliminati
incre on need
be
ase into
the aligned
medi with
an these
age changes

through
the
developm
ent and
adoption
of novel
strategies
and
methods.
There is a
need for
further
studies to
elucidate
the
conseque
nces of
sustained
reduction
s
in
malaria
transmiss
ion
on
communi
ty
protectiv
e
immunity
.
There
have
been
reports
from
some
African
countries
that ITNs
are used
for
purposes
other
than
mosquito
con-trol
[77].
Reports
of misuse
of nets in
Tanzania
include
the
improvisi
ng of nets
as
wedding
veils, for
fishing,
as protection of
crops, as
chicken
coops to
protect
against
vul-tures,
or
become
used as
ropes.
Consider
able
misuse of
mosquito
nets for

5.1

fishin are likely


using
g andto
nets
dryin increase
during
g ofand may
the cool
fish hamper
and cold
has the
seasons.
been efforts in
In
re- malaria
western
porte control.
Kenya, it
d
has been
Seaso
from nal use of
found
Keny ITNs has
that onea
third of
also been
[77,7 reported
the
8]. in East
mosquito
Altho Africa.
nets
ugh Some
recipient
the workers
s did not
propo [79]
adhere to
rtion reported
net use
of
and that
some
misus househol
net use
ed ds in a
was
nets number
reported
is
to
of
likely districts
decrease
to beof
during
low, Tanzania
hot
such were not
weather
acts
[80].
mal
and and
con
the you
trol
C aria
is
inci ng
parha acq
den chil
asit
ce dre
ae
lle uire
d
of n
mia
ng with
feve carr
and
rs y a
ther
es an
or ver
efor
rel incr
ease
sev y
e
at in
ere hig
onl
mal h
y
ed exp
osur
aria dise
rare
to e to
outc ase
ly
ome bur
suff
th mal
s den
er
e aria
para
incr but
fro
hu sites
ease prot
m
s ecti
sev
m [74,
75].
wit ve
ere
an In
h im
maage mu
lari
ho area
for nity
a
st swith
the dev
sy
an high
first elo
mpt
mo ps
om
d tran
smi
nths wit
s
be ssio
of h
[74
life incr
].
ha n
and eas
Co
vi the
prev
then e in
mm
ou alen
decr age
unit
ease [74
ies
rs ce
and
s ].
or
gra Ad
indi
Pr den
sity
dual
ults
vid
ote
ly and
uals
cti of
[74] old
livi
ve P.
. In er
ng
im falc
thes chil
in
mu ipar
um
e
dre
are
nit
area n
as
y para
sita
s,
are
wh
ag
infa abl
ere
ain emi
nts e to
mal
st a

ari d 5.2
a inte
tra nsiv
ns e
mi use
ssi of
on ITN
is s
lo and
w IRS
an decr
d ease
sea
so s
nal exp
, osur
on e
the and
oth risk
er of
ha mal
nd, aria
re to
ma user
in s
at [63,
hig 72].
h Thu
ris s,
k the
of inte
de nsiv
vel e
opi use
ng
se of
ver thes
e e
dis inte
eas rven
e tion
be s in
ca com
us mun
e iof
the
slo
w
de
vel
op
me
nt
of
ac
qui
red
im
mu
nit
y
[7
6].
he
hig
h
co
ver
ag
e
an

Ch lam
alle bda
cyh
nge alos thri
rel n
[81,
ate 82].
d toIn a
mal rec
ari ent
stu
a dy,
vec sus
tor cep
s tibil
ity

test
5.2. s
1 hav
Insee
ctici sho
de wn
resi that
An.
stan ara
ce bie
nsis
Rec on
ent Pe
stud mb
ies a
in Isla
Aru nd
mer in
u, Zan
Mos zib
hi, ar
Mu are
hez resi
a stan
and t to
Mul the
eba pyr
distr ethr
icts oid
of s
Tan use
zani d
a on
hav IT
e Ns
repo and
rted for
that IRS
An. [83
ga ].
mbi Sim
ae ilarl
s.l. y,
is in
resi Cha
stan d
t toand
per Sen
met ega
hrin l,
,
stu
delt dies
ame hav
thri e
n rev
and eale

d
hig
h
leve
ls
of
resi
stan
ce
to
per
met
hrin
and
delt
ame
thri
n in
several
An.
ga
mbi
ae
s.l.
pop
ulat
ions
[84]
. In
add
itio
n,
stud
ies
in
Mo
zam
biq
ue
and
Mal
awi
rev
eale
d
that
An.
fun
est
us
is
resi
stan
t to
pyr
ethr
oids
[85,
86].
The
eme
rge
nce
and
spre
ad
of
pyr
ethr
oid
resi
stan

ce lex
am grou
on p
g rais
me es
mb seri
ers ous
of ques
the tion
An s
. abo
ga ut
mb the
i- susae tain
co abili
mp ty

M
al
ar
ia
W
or
ld
J
o
ur
n
al,
w
w
w.
m
al
ar
ia
w
or
ld.
or
g.
IS
S
N
22
14
43
74

6
D
ec
e
m
be
r
20
13
,
V
ol.
4,
N
o.
19

of Mo
mal squ
aria ito
vect beh
or
cont avi
rol our
in al
end cha
emi nge
c s
area
s.
IT
5.2. Ns
2 and

IRS
are
opti
mal
ly
effe
ctiv
e
whe
re
the
maj
orit
y

Mboera et al. MWJ 2013, 4:19


r
the two
transmiss
areas. In
ion has
the area
been
with
of
exclusive
baseli replaced
by
ly
An.
ne
arabiensi
trans greatly
s vectors,
missi lowered
residual
the biting
on
transmiss
peak was
occur
ion,
a
observed
s
at around
indoo greater
proportio
midnight
rs.
of
then
With n
which
falling
an
steadily
intens occurs
outdoors
to
its
ive
[69,70].
minimum
use of
a
level at
ITNs In
previous
06:00 am.
and
In
IRS, study in
northcontrast,
malar
eastern
in
the
ia
Tanzania
area
mosq
where
uitoes [87], in
an
area
An.
have
with
a
gambiae
been
and An.
ob- vector
popuarabiensi
serve
s
exist
d to lation
which
together,
increa
the peak
singly consisted
exclusive
was
bite
ly
of
An.
observed
outdo
arabiensi
after
ors. A
s,
per02:00 am
recent
stretching
study methrintreated
to around
in
04:00 am.
south- nets were
shown
to
The
easter
provide
biting
n
some
continued
Tanza
protecuntil
nia
07:00 am
has tion
against
with over
show
5% of the
n that malaria.
Contrary
biting
high
this
occurring
usage to
observati
between
of
on,
in
the
06:00 and
ITNs
area
with
07:00 am
has
a
mixture
- indicatdrama
An.
ing
an
tically of
gambiae
outdoor
altere
and An.
biting
d
arabiensi
preferenc
vector
no
e
popul s,
protectio
following
ations
n
was
the
so
introducti
that detected,
due
to
the
on
of
intens
differenc
insecticid
e,
e treated
predo e in the
materials
minan biting
pattern
of
[87]. The
tly
the
heterogen
indoo
vectors in
eity
in

mosq res
uito functiona
and
biting l
and effective
restin health
systems
g
behav including
iour capable
requir innovativ
e health
es
specif leadershi
p,
ic
target qualified
healthcar
ed
interv e
providers
ention
,
s.
effective
Early human
and resource
very systems,
late reliable
biting data and
activit adequate
y byphysi-cal
malar infrastru
ia
cture
vector [89]. To
s is date, the
likely access to
to
health
have interventions
a
negati is still a
major
ve
impac challeng
t on e for a
the large
effici proportio
ency n of the
rural
of
mosq populatio
uito n.
nets Despite
the
to
national
contr
and
ol
internati
malar onal
ia
efforts to
[88]. support

5.3

malaria

Chal intervent
leng ions in
es terms of
antimarelat larials
ed to and
healt distributi
on
of
h
ITNs, the
syste health
ms system in
TanDeliv zania
ering continue
publi s to be
weak and
c
healt suffers
from
h
servi inadequa
ces te
requi mechanis

ms for
deliverin
g
primary
health
care
services
to
individua
ls
and
communi
ties
in
need
[23]. For
instance,
many of
the
limitatio
ns
of
current
vector
control
practices
can be
attribute
d
to
deficienc
ies
in
health
infrastru
cture that
prevent
access to
proven
intervent
ions. To
be effective,
intervent
ion tools
need to
be usable
within
the
available
health
system
framewo
rk
and
impleme
nted
appropriately so
that the
end user
is able to
benefit
from
them.
5.3.1
Malaria
case
manage
ment
The
introducti
on
of
mRDT is
facing a

numb osis,
er of leading to
challe unnecess
ng-es. ary use of
It has antimalar
result ial
ed in treatment
over- , and
prescr
iption
of
antibi
otics
that
pose
a
threat
on
drug
resist
ance
[48].
There
are
also a
numb
er of
shortc
omin
gs
relate
d to
the
perfor
manc
e and
accur
acy of
the
tests,
which
depen
d on
test
prepa
ration
and
interp
retati
on
[90].
Incorr
ect
prepa
ration
s and
interp
retation
of test
result
s
could
result
into
incorr
ect
diagn

therefore
failure to
address
the real
cause of
fever in
pa-tients
who do
not have
malaria
[91,92].
Malar
ia rapid
diagnosti
c
tests
assist in
the
diagnosis
of
malaria
by
detecting
evidence
of
malaria
parasites
in
human
blood
[93]. The
fact that
the
currently
available
mRDTs
suffer
from low
sensitivit
y when
used in
individuals with
low
malaria
parasitae
mia
[94,95]
emphasis
es
the
need for
the test
to
be
used in
conjuncti
on with
other
meth-ods
to
confirm
the
results,
character
ize
infection
and
moni-tor
treatment
[96]. The
high
costs of
treating
malaria,
to-gether

with years,
recog Tanzania
nition has
of thechanged
imporits firsttance line
of
antimalar
non- ial drug
malar twice. In
ial 2001,
fever first-line
s, hasantiprom malarial
pted atreatment
recon was
siderachanged
tion from
of
chloroqui
anti- ne
to
malar sulfaia
doxinestrate pyrimeth
gies amine
based (SP) and
on in 2006
evide from SP
nce
to arteof
malar misininbased
ia
parasi combinat
taemi ion
therapy
a.
The (ACT)
Worl [97]. An
imd
Healt proveme
nt
in
h
Orga access to
nizati malaria
on treatment
has using
reco ACTs
mme disnded pensed
the through
need accredite
drug
for d
parasi dispensin
tologi g outlets
cal- has been
confirobserved
med in
antim Tanzania
alaria [98].
l
However
treat ,
their
ment widewher spread
e
use for
possi treating
ble patients
[96] with P.
and falciparu
when m
ever malaria
malar raises the
ia isquestions
suspe of
cted. emerging
D drug
uring resistanc
the e [99].
past Studies
twelv in
e
Cambodi

a
and
Thailand
have
shown
growing
evidence
that
P.
falciparu
m
parasites
are
developi
ng
resistance
against
artemisin
in
monother
apy
[100].
To-date,
there are
no
reports of
resistanc
e
to
ACTs in
Tanzania.
Anti
malarial
drug
stockout
is
common
in
Tanzania
[23,46,99
]. It has
been
reported
that the
percenta
ge average stock
out days
of
all
types of
ACT
ranges
from 1.3
to
46
days
[101].
The main
reasons
for
stockout
of
antimalar
-ials at
public
health
facilities
are poor
forecasti
ng and
quantific
ation
[101].
Similar
findings
have
been
reported
from

Keny e
of
a
malaria
[102] treatment
and [105Mala 107]. In
wi a study
[103].on antiIn
malarial
additi drug
on toquality in
fre- parts of
quent Africa it
stock was
out ofobserved
antim that 35%
alaria of tested
l
samples
drugs were
,
substand
malar ard
ia
[108].
case The
mana availabili
ge- ty
of
ment counterfe
in
it drugs
Tanza in
the
nia ismarket is
facin likely to
g abe due to
numb the fact
er ofthat
challegovernm
nges ents in
in
Africa
terms lack the
of theabil-ity
qualit through
y ofcustoms
antim and
alaria policing
l
to stop
drugs these
.
medicine
Almo s
st aentering
third the
of
private
anti- market,
malar where
ial most
drugs people
sold buy their
in
treatment
Tanza [109,
nia 110].
are
There
subst are
a
andar significa
d
nt
[104].number
Subst of febrile
andar diseases
d
that are
ACTs diagnose
are d
as
amon malaria
g thein
threat Tanzania.
s
Early
drivin studies
g
conclinic ducted at
al
a
failur hospital

in northeastern
Tanzania
showed
that 25%
of
the
cases
admitted
as severe
malaria
cases
could not
be
associate
d
with
the
presence
of
malaria
parasites
[111].
This
confirms
that
malaria
misdiagn
osis
is
still
a
problem
[112]. If
the
manage
ment of
nonmalarial
febrile
illness is
not
addresse
d, it is
likely
that
many
cases of
nonmalarial
fever will
continue
to
be
treated
with antimalarial
drugs,
especiall
y at this
time
when
malariarelated
fevers

Ma
lar
ia
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rld
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ww
w.
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. 4,
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Mboera et al. MWJ 2013, 4:19


is weak.
leaders,
The
qualified
healthcar
effectivee
ness of a
have
providers
surveillan
signif ,
ce system
icantl effective
at
the
y
human
district
decli resource
and
ned systems,
facility
reliable
in
levels
ende health
depends
mic informati
on
the
ability of
areas on,
staff
to
[113]. adequate
physical
utilise
the
This infrastruc
inforcould ture, and
mation
lead many
properly.
to
other
Since
drug critical
2001,
inputs.
It
resist
Tanzania
ance is
has been
importan
and
making
that
waste t
concerted
Tanzania
of
efforts to
addresses
expen human
strengthe
sive resource
n
its
Integrated
drugs issues
Disease
such and
Surensures
as
veillance
that
there
ACTs
and
[114]. are
Response
adequate
system.
5.3.2 numbers
In
this
Hum of welltrained
system,
an
personne
malaria is
resou l
to
one of the
rces diagnose
priority
malaria,
diseases
Deliv manage
that are to
ering cases,
be
publi pre-vent
reported
c
transmiss
monthly.
healt ion and
In
a
h
vigilantly
recent
servictrack
study in
es
malaria.
central
requir
Tanzania
es
5.3.3
it
was
functi Malaria
found
onal surveilla
that most
and nce
of
the
effect
health
ive
facilities
count Despite
the
face
ry
difficultie
-level success
s
in
healt recorded
in malaria
submittin
h
g reports
syste control in
ms: Tanza-nia
due
to
capab the
lack
of
disease
le
resources
healt surveillan
and
ce system
h

feedb ndence
ack
from Eightythe five
distric percent
of the
t
autho activities
rity. in the
Most strategic
of theplan of
the
health national
facilit malaria
ies control
perfor program
m
me in
mini Tanzania
mal is funded
data by
analy external
sis donors
[23]. [116].
It isMuch of
over the
Tanzania
10
n
years successes
since in
the malaria
introd control
uction can
of thetherefore
Integr be
ated attributed
Disea to the
financial
se
Surve support
illanc from the
Global
e andFund to
Respo Fight
nse AIDS,
strate Tubercul
gy inosis and
Tanza Malaria
nia, and the
yet US
data President
mana s
geme Malaria
nt hasInitiative
remai . The
Global
ned Fund
weak contribut
in
es about
most twoof thethirds of
distric the
ts
world's
[115]. funding

for
5.3.4 malaria
Inad program
equatmes, and
since its
e
inception
local has
budg supporte
d
et
and distributi
of 230
dono on
million
rITNs and
depe a similar

number
of doses
of
artemisin
in-based
drugs
[117].
Unfortun
ately, the
donor
funding
has
spawned
dependency
and
expectati
on
among
its
recipient
s. Should
it
disappear
, or
radically
diminish,
Tanzania
and other
donor
-depende
nt
countries
would be
hardpressed
to
finance
malaria
control
efforts
and the
conseque
nces will
be severe
(http://w
ww.natur
e.com/ne
ws/globa
l-healthhitscrisispoint1.9951).
Interv
entions
that are
externall
y funded
are not
sustainable
[118].
Internal
funding
should
always
represent
the
ultimate
goal of
local
malaria
interventi
ons
to

ensur
e thatgains
such made.
interv Reliance
entio on
ns are
sustai outside
nable funding
in theis one of
long the reaterm. sons for
Unforintervent
ion
tunat failure
ely,
this once
has external
not funding
been and
political
a
priori will
ty fordiminish
many es [119].
healt
The
h
current
inter- universal
venti coverage
ons with
and interventi
has ons
result needs to
ed inbe
the maintain
failur ed until
e tothe
sustai beginnin
n theg of the
initial elimination
stage,
requiring
longterm
political
commitm
ent and
high and
predictab
le
funding.
However
,
as
successfu
l con-trol
efforts
reduce
the
burden
of
malaria,
there is a
strong
risk
of
donor
fatigue
and that
interest
in
malaria
elimination
could
drop
amongst
key

stakehold
ers. For
governments, it
is likely
that the
attention
on
malaria
will
naturally shift to
other
health
priorities.
On the
other
hand,
there will
be little
motivatio
n among
individua
ls
to
sleep
under
ITNs,
thus
putting
themselv
es at risk
of
malaria
infection.
Risk of
malaria
fatigue
needs to
be
addresse
d
appropriately as it
could
lead
donors to
lower
funding
for
malaria
control,
the
governm
ent to put
less
emphasis
on
malaria
control
and the
public to
reduce
utilisatio
n
of
preventiv
e
and
treatment
measures
[119].
In as
much as
internatio
nal donor
support
is

imporMoreove
tant, r,
as
Tanza economi
nia c growth
and in high
other malaria
count burden
ries countries
in
will
sub- likely
Sahar rebound
an after
Afric incidence
a
goes
shoul down, it
d beis
encou importan
raged t that this
to
is
incre translate
ase d
into
the increased
level national
of
health
intern spendal
ing for
resou malaria
rces and used
spent to
on advocate
malar for
inia tocountry
a
interpoint sectoral
wher and
e theycommuni
can ty-based
sustai approach
n
es
in
their disease
own con-trol.
progr Already,
amm the
es. publicIncre private
asing partnersh
natio ip
has
nal been dehealt scribed
h
to make
budg major
ets contribut
and ions to
the malaria
share control
allocain
ted toTanzania
malar [23,120].
ia
resear5.3.5
ch Commu
and nity
contr involve
ol
will ment
make
funds In
and Tanzania
the
fundi ,
ng current
gaps malaria
more interventi
predi ons are
ctablevertical.
ly

planned
and
impleme
nted, and
there is
limited
involvement of
the
communi
ty. It is
importan
t that the
communi
ty should
take
responsib
ility for
their own
health
and that
communi
ty leaders
should be
involved
in
malaria
prevention
campaig
ns. This
is
because
it
has
been
shown
that
communi
ty
participat
ion
in
health
program
mes
enhances
their
sustainab
ility and
affordabi
lity
compare
d to nonparticipat
ory
program
mes
[121].
Despite
this
knowled
ge that
communi
ty
participat
ion
is
vital in
strengthe
ning primary
health
interventi
ons
[122,123

] littlemunities
progr and other
ess key
has stakehold
been ers see
made the
to
benefits
invol of
ve malaria
com control,
munit even the
ies inbestmalar designed
ia
preventio
contr n stratol
egies are
plan- unlikely
ning to
be
and effective
imple and
ment sustainab
ation le.
in
Tanza 16 Fut
nia.
Unles ure
s
dire
indivi ctio
duals
ns
in
com
and

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lar
ia
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rld
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ISS
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8
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. 4,
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19

app
roac
hes
to
malari
a
cont
rol
Although
there is
evidence
of a
declining
trend in
malaria
prevalen
ce and
incidence
, this
does not
necessari
ly mean

Mboera et al. MWJ 2013, 4:19


ecosyste
the
ms,
nature
and
livelihood
s
and
that dynamics
health
Tanza of certain
poses an
nia isecosyste
opportuni
headi m
ty
and
ng forvariables
challenge
malar and their
relations
for
the
ia
to
elimi hip
various
natio malaria
sectors to
transn.
work
Malarmission
together
is
a
ia
to address
necessar
repre
malaria.
sents y step in
However,
identifyi
a
in
comp ng and
Tanzania,
addressin
lex,
there is a
multi g
major
interventi
disconnec
ons
that
dime
t between
may
nsion
the health
eliminate
al
care
healt malaria
systems
while
h
and other
probl increasin
sector
g
em
systems
with househol
d
within the
a
policy
suite productiv
ity and
and
of
planning
intera maintaini
a
arena.
cting ng
Establishi
varia healthy
ng interbles environsectoral
rangi ment. It
link-ages
ng has
from already
is
the been
important
para- recognise
to
that
site, d
facilitate
mosq these
joint
uito factors
efforts to
vecto affect
tackle
health,
r,
malaria at
ecosy exposure
the
to
illness,
stems
communit
risk for
,
y
level
illnesshuma
because
producin
n
at
that
host, g
level
healt behaviou
developm
rs, and
hent
deliv the
problems
househol
ery
are often
syste d/commu
perceived
ms tonity
holisticall
liveli response
the
y.
hoods to
Institutio
and respectiv
nal
clima e health
problem
linkage is
te
expected
chang [124].
to
e. A The
stimulate
sound fact that
under there are
system
standi linkages
changes
ng ofbetween
by ena-

bling tion and


cross- innovativ
sector e
al
modificat
health ions
to
leader cope with
ship the
teams changing
to
malaria
devel landscape
op
and the
and scaling
launc up
of
h
interventi
innov ons that
ative are
initiat currently
ives being
that instituted.
integr
A
ate new
pivota approach
l
to malaria
health control
syste should
m
constitute
oppor a bridge
tuniti among
es orpublic
addre health, a
ss thestrategy
bottle for
necks.integrated
This manneeds agement
urgentof
the
re
environm
-addr ent and
essing an
if
aecohealth
succe approach
ssful to
health promotin
delive g human
ry
health.
syste This
m ismeans
to bethat
realis ecohealth
ed
ap[121]. proaches
There to malaria
is amust
pressi promote a
ng
holistic
need view of
to
hu-man
streng health,
then livelihoo
the ds
and
count ecosyste
rys ms
capac sustainabi
ities lity
for (http://w
effectiww.idrc.c
ve
a/ecoheal
pro- th).
gram Despite
me this
imple understan
menta d-ing, for

a number
of years,
conventio
nal
malaria
research
and
control
has
tended to
choose
specific
outcomes
and view
them as
the result
of a linear
chain of
events. It
is
envisaged
that
a
more
complex
and
realistic
view
requires
identificat
ion
of
certain
kinds of
livelihood
factors,
which,
although
these are
possible
determina
nts
of
malaria
transmission,
also
generate
income to
improve
the well
being of
the
populatio
n.
Consideri
ng
this
view,
resolution
of malaria
and
livelihood
s requires
going
beyond
traditiona
l health
sector
concerns
and
paying
attention
to
the
ecologica
l
and

socio- epidemio
econo logical,
mic ecologica
conte l
and
livelixt.
Thus, hood
it isfactors,
not innovativ
surpri e
sing approach
es to the
to
find problem
out are
that necessar
progr y. It is
amme importan
that
s thatt
are researche
entire rs, policy
makers
ly
unrela and
ted tomalaria
the control
con- impleme
ventio nters
nal initiate
health new
sector solutions
, such
as
agricu
lture,
water,
irrigation
and
infras
tructu
re
devel
opme
nt,
have
major,
usuall
y
contra
dictor
y,
effect
s on
huma
n
health
.

B
ecaus
e of
the
uniqu
e
natur
e of
the
malar
ia
situat
ion as
a
result
of
micro
-

appropria
te
for
specific
situations
.
Multiple
strategies
,
appropria
te
to
socioculturally
and
ecologica
lly
unique
settings,
must be
impleme
nted in
an
integrate
d
approach
.
With
the
current
declining
trend in
malaria
in
Tanzania,
we need
focused
malaria
control
strategies
that have
direct
benefits
not just
for the
individua
ls who
are
included
in
the
control
efforts
but also
at
the
communi
ty level.
Current
vector
control
strategies
focus
largely
on indoor
measures
. It is
also
importan
t
that
research
and
strategies
targeting
outdoor
feeding
mosquito
es
are
considere
d.
For

exam help
ple, decision
attrac makers
tive address
toxic the
sugar complex
baits, problem
either of
spray malaria
ed oncontrol
veget by
ation providin
or
g
a
provi systemati
ded c
apin
proach to
outdo weighing
or
the costs
bait and
statio benefits
ns, of
have different
been comshow binations
n toof
sig- interventi
nifica ons. One
ntly framewo
reduc rk
for
e
encourag
mosq -ing this
uito approach
densit is
the
ies Malaria
[125].Decision
El Analysis
imina Support
ting Tool
malar (MDAST
that
ia in)
Tanza allows
nia policyma
will kers to
requirweigh
e
athe
coord health,
environm
inated,ental and
inter- economi
sector c tradeoffs of
al
decisi different
on combinat
maki ions of
ng malaria
appro interventi
ach ons
based [126].
on The tool
the has been
best develope
availad
ble collabora
scient tively
ific with
evide extensive
nce. stakehold
The er
field involvem
ent
in
of
decisi Tanzania
on ,
analy Uganda,
sis and
can Kenya. It

is
designed to
facilitate
malaria
control
decision
making
informed
by
a
number
of
different
contextu
al factors
(e.g.
prevalen
ce of the
disease),
weather
factors
(e.g.
rainfall)
and
social
factors
(e.g.
acceptan
ce
of
different
malaria
control
methods)
[127].
The
MDAST
allows
analysis
of
alternativ
es
for
impleme
nting
preventio
n
and
disease
management
interventi
ons, as
well as
of
different
mechanis
ms
for
deliverin
g
the
interventi
ons
to
the target
populatio
n.
The
decision
analysis
framewo
rk
can
promote
an
integrated
approach
to
malaria
manage
ment by

drawi ia vector
ng control
attent and
ion todisease
a
manage
wide ment in
range Tanzania
of
are being
malar threatene
ia
d
by
contr develop
ol
ment of a
optio semins
immune
and human
allow populatio
ing n, paradecisi site and
on insecticid
make e
rs toresistanc
explo e,
re themosquito
impa behaviou
cts ofral
varyi changes
ng
comb and
livelihoo
inatio d factors.
ns ofAs
contr malaria
continues
ol
strate to
gies decline,
is
on it
both importan
the t to take
disea a more
integrate
se
mana d
ge- approach
ment to vector
and control,
vecto attacking
on
r
contr multiple
fronts, to
ol
sides. drive
transmiss
ion
to
7
zero.
An
Con integrate
clusi d
ons approach
employin
g
Rece multiple
nt
interventi
signif ons that
icant are
advan sustainab
ces inle
and
malar locally
al,
ww
w.m
Ma alari
lar awo
ia rld.
Wo org.
rld ISS
N
Jo 2214
urn

appropriate,
is likely
to deliver
better,
synergist
ic
and
sustainable
outcomes
. Such an
approach
must
include
environmenta
l
manage
ment to
reduce
mosquito
productiv
ity and
an
overall
biting
pressure.
An
effective
malaria
strate-gy
must
include
promotio
n
of
screening
of
houses,
environmenta
l
manage
ment of
mosquito
breeding
and
resting
sites,
direct
attacks
on
the
mosquito
larvae,
clever
design
and
operation
of water
resource
develop
ment
projects,
and

No. 19
4374

9
Dec
emb
er
201
3,
Vol.
4,

Mboera et al. MWJ 2013, 4:19

nments
with
very
little
an involve
interf ment of
aith the
com commun
muni ity. In
ty
resource
actio -poor
setn
comp tings,
onent commun
ity
.
None participa
tion in
of
these disease
control
strate is essengies tial.
is
Adding
mutu a
ally commun
exclu ity
sive compon
is
of the ent
other critical,
thus
s,
and a each
comb existing
commun
inatio ity
n of should
be part
effort and
s
parcel
prom of the
ises ma-laria
to
control
offer program
additi me.
ve or Commu
even nities
syner can
effective
be
gistic ly
rewar involved
ds. to
reduce
O nearby
ver mosquit
the o
last breeding
deca sites by
de, local
malar drainage
ia
efforts
inter in
venti villages,
ons fields
have and
been around
vertic ponds
ally and to
imple improve
ment and
ed by screen
natio homes
nal and to
gover

respond
to the
need for
early
diagnos
is and
treatme
nt.
Mal
aria is a
particul
arly
importa
nt
disease
that
illustrates
the
interacti
ons
among
liveliho
od,
ecosyst
ems and
health
systems
; thus,
malaria
is now
more of
a
develop
-ment
problem
than
ever
conside
red
before.
Several
sectoral
activitie
s that
include
constru
ction,
water
resourc
e
develop
ment,
and
agricult
ure,
contribu
te
highly
to
malaria
mosquit
o
breedin
g sites
and
hence
transmi
ssion. It

is im- ons
porta against
nt
malaria.
there To
fore, sustain
to
the
exam gains in
ine ma-laria
the control
links and to
withi move
n a towards
broad its
fram eliminat
ewor ion, it is
k that imconsi portant
ders that the
the national
differ malaria
ent control
path program
ways, me
in
given Tanzani
the a
multi broaden
plicit s
its
y of base and
intera mobilise
ction s
s that resource
can s more
prod broadly
uce to
unex include
pecte national
d
budgets
outco and
mes other
and local
trade sources.
-offs.
In
It is conclusi
impo on,
rtant malaria
that preventi
inves on must
tment go hand
s that in hand
supp with
ort commun
socio ity and
interecon sectoral
omic participa
devel tion.
opme The
nt in future
malar malaria
ia
control
set- strategy
tings should
are be broad
enco based,
urage and
d to intersupp sectoral
ort in
its
effect planning
ive and
and operatio
sustai n at all
nable levels.
inter There is
venti also a

strong
need to
strength
en the
surveill
ance
and
monitor
ing and
evaluati
on
systems
for
malaria
control
progra
mmes.
These
systems
need to
be
science
-based
and
should
ensure
timely
availabi
lity of
informa
tion on
malaria
prevale
nce
coverin
g
all
corners
of the
country
as
a
means
to
promote
evidenc
e based
decision
making.

8
Ackno
wledg
ement
s
The
authors
would
like to
acknow
ledge
Drs.
Stephen
Magesa,
Alphax
ad
Manjur
ano and
Deus
Ishengo
ma for

their
critic
al
revie
w of
an
early
versi
on of
the
manu
script
.

Refe
renc
es
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2.

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a
s
m
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d
i
u
m
f
a
l
c
i
p
a
r
u
m
a
n
d
h
e
l
m
i
n
t
h
c
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infe
ctio
ns
am
ong
sch
ool
chil
dre
n in
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tion
to
agr
oeco
syst
ems
in
Mv
om
ero
Dist
rict,
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a
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a
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Epi
de
mio
log
y
and
Co
ntr
ol
of
Ma
lari
a
Tra
ns
mis
sio
n
by
Res
idu
al
Ho
use
Spr
ayi
ng
wit
h
DD
T
and
La
mb
dac

6.

yha
lot
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n
in
two
Po
pul
ati
ons
of
the
An
oph
ele
s
ga
mb
iae
co
mp
lex
in
Ta
ng
a
Re
gio
n,
Ta
nza
nia.
Ph
D
Th
esis,
Uni
ver
sity
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el,
Sw
itze
rla
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199
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Cla
rk
TD
,
Gre
enh
ous
e
B,
Nja
ma
Me
ya
D,
Nz
aru
bar
a B
et
al.:
Fac
tors
det
er
mi
nin

g
t
h
e
h
e
t
e
r 7.
o
g
e
n
e
i
t
y
o
f
m
a
l
a
r
i
a
i
n
c
i
d
e
n
c
e
i
n
c
h
i
l
d
r
e
n
i
n

8.

K
a
m
p
a
l
a
,
U
g
a
n
d
a
.
J
.
I
n
f
e

ct.
Dis
.
200
8,
198
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3400
.
Mw
ene
si
H,
Har
pha
m
T,
Sno
w
RW
:
Chi
ld
mal
aria
trea
tme
nt
pra
ctic
es
am
ong
mot
hers
in
Ken
ya.
Soc
.
Sci.
Me
d.
199
5,
40:
127
1127
7.
Mb
oer
a
LE
G,
Ka
mu
gish
a
ML
,
Ru
mis
ha
SF,
Ms
ang
eni
HA
et
al.:
The

9.

rela
tio
nsh
ip
bet
we
en
mal
aria
par
asit
ae
mia
and
ava
ilab
ilit
y
of
hea
lthc
are
faci
lity
in
Mp
wa
pw
a
Dis
tric
t,
cen
tral
Tan
zan
ia.
Ta
nza
n.
He
alt
h
Res
.
Bul
l.
200
6,
8:2
227.
Mb
oer
a
LE
G,
Ka
mu
gis
ha
ML
,
Ru
mis
ha
SF,
Kis
inz
a
W
N
et
al.:
Ma
lari

a
a
n
d
m
o
s
q
u
i
t
o
n
e
t
u
t
i
l
i
s
a
t
i
o
n
a10.
m
o
n
g
s
c
h
o
o
l
c
h
i
l
d
r
e
n
i
n
v
i
l
l
a
g
e
s
w
i
t
h
o
r
w
i
t 11.
h
o
u
t
h

ealt
hca
re
faci
litie
s at
diff
ere
nt
altit
ude
s in
Irin
ga
Dist
rict,
Tan
zani
a.
Afr.
He
alth
Sci.
200
8,
8:1
14119
.
Wh
ite
GB:
The
An
oph
eles
ga
mbi
ae
co
mpl
ex
and
mal
aria
tran
smi
ssio
n in
Afri
ca.
Tra
ns.
R.
Soc
.
Tro
p.
Me
d.
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g.
197
4,
68:
278
301
.
Kig
ady
e E:
Mo
squ

12.

ito
ab
un
da
nce
an
d
ma
lari
a
tra
ns
mis
sio
n
in
the
Ruf
iji
Riv
er
Ba
sin,
Ta
nza
nia.
Ph
D
Th
esis
,
Uni
ver
sity
of
Dar
es
Sal
aa
m,
Tan
zan
ia,
200
6.
Ma
ges
a
SM
,
Wil
kes
TJ,
Mn
zav
a
AE
,
Nju
nw
a
KJ
et
al.:
Tri
al
of
pyr
eth
roi
d

i
m
p
r
e
g
n
a
t
e
d
b
e
d
n
e
t
s
i
n

.
Eff
ects
on
the
mal
aria
vect
or
pop
ulat
ion.
Act
a
Tro
p.
199
1,
49:
97108
.

a13. Wil
n
kes
TJ,
Mat
a
ola
r
YG,
e
Cha
a
rlw
ood
o
JD:
f
An
T
oph
a
eles
n
riv
z
ulo
a
n
ru
i
m, a
a
vect
or
h
of
o
hu
l
ma
o
n
mal
e
aria
n
in
d
Afri
e
ca.
m
Me
i
d.
c
Vet.
Enf
tom
o
ol.
r
199
m
6,
a
10:
l
108
a
r
110
i
.
a14. Mal
.
ima
P
RC:
a
Spo
r
roz
t
oite
2
Rat

15.

es
and
Spe
cie
s
Ide
ntit
y
of
Mo
squ
itoe
s
Col
lect
ed
fro
m
Hig
hla
nd
and
Lo
wla
nd
in
Tan
zan
ia.
MS
c.
Dis
sert
atio
n,
Uni
ver
sity
of
Lo
ndo
n,
UK
,
199
9.
Mb
oer
a
LE
G,
Ped
ers
en
EM
,
Sal
um
FM
,
Ms
uya
FH
et
al.:
Tra
ns
mis
sio
n
of
mal
aria
and
ban

c
r
o
f
t 16.
i
a
n
f
i
l
a
r
i
a
s
i
s
i
n
M
a
g
o
d
a
a
r
e
a
,
n
o
r
t
h
e
a
s
t
T
a
n
z
a
n
i
a
.
M
a
l
a
r
.
I
n17.
f
e
c
t
.
D
i
s
.
A
f
r
.
1

997
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Iju
mb
a
JN:
The
Imp
act
of
rice
and
sug
arc
ane
irri
gati
on
on
mal
ari
a
tra
ns
mis
sio
n in
the
Lo
wer
Mo
shi
are
a of
nor
the
rn
Tan
zan
ia.
Ph
D
The
sis,
Uni
vers
ity
of
Cop
enh
agen,
Den
mar
k,
199
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Smi
th
DL,
Dus
hoff
J,
Sno
w
RW
,
Hay
SI:
The
ent
om

18.

olog
ical
ino
cul
atio
n
rate
and
Pla
sm
odi
um
fal
cip
aru
m
infect
ion
in
Afr
ica
n
chil
dre
n.
Nat
ure
200
5,
438
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2498
.
Ma
bas
o
ML
,
Cra
ig
M,
Ro
ss
A,
Sm
ith
T:
En
vir
on
me
ntal
pre
dict
ors
of
the
sea
son
alit
y
of
mal
aria
tra
ns
mis
sio
n in
Afr
ica:

t
h
e
c
h
a
l
rld
Ma Jou
lar rna
ia l,
Wo ww
w.

len
Hy
ge.
g.
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200
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7,
Tro
76:
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38.
d.
ma ISSN 2214-4374
lari 10
aw
orl December
d.o 2013, Vol. 4,
rg. No. 19

Mboera et al. MWJ 2013, 4:19

19.

I
m
b
a
h
a
l
e
S
S
,
M
u
k
a
b
a
n
a
W
R
,
O
r
i
n
d
i
B
,
G
i
t 20.
h
e
k
o
A
K
e
t
a
l
.
:
V
a
r
i
a
t
i
o
n
i
n
m
a
l

ari
a
tra
ns
mis
sio
n
dy
na
mi
cs
in
thr
ee
diff
ere
nt
site
s in
We
ster
n
Ke
nya
. J.
Tro
p.
Me
d.
20
12,
Art
icle
ID:
91
24
08.
Ru
mis
ha
SF,
Sm
ith
T,
Ab
dul
la
S,
Ma
san
ja
H
et
al.:
Asses
sin
g
sea
son
al
var
iati
ons
and
age
pat
ter
ns
in

21.

mo
rtal
ity
dur
ing
the
firs
t
yea
r of
life
in
Tan
zan
ia.
Act
a
Tro
p.
201
3,
126
:28
36.
Ell
ma
n
R,
Ma
xw
ell
C,
Fin
ch
R,
Sha
yo,
D:
Ma
lari
a
and
ana
emi
a at
diff
ere
nt
alti
tud
es
in
the
Mu
hez
a
dist
rict
of
Tan
zan
ia:
chil
dho
od
mo
rbi
dit
y
in
rela

t
i
o22.
n
t
o
l
e
v
e
l
o
f
e
x
p
o
s
u
r
e
t
o
i
n
f
e
c
t
i
o
n
.
A
n
n
.
T
r
o
p
.
M
e
d
.
P
a
r
a
s
i
t
o
l
.
1
9
9
8
,
9
2
:
7
4
1
-

75
3.
Git
hek
o
AK
,
Ser
vic
e
M
W,
Mb
og
o
C
M,
Ati
el
FK
et
al.:
Pla
sm
odi
um
fal
cip
aru
m
spo
roz
oit
e
and
ent
om
olo
gic
al
ino
cul
ati
on
rat
es
in
the
Ah
ero
irri
gat
ion
sch
em
e
and
the
Mi
wa
ni
sug
arbel
t in
we
ster
n
Ke
nya
.
An
n.
Tro
p.
Me
d.

23.

Pa
ras
itol
.
199
3,
87:
379
391
.
Mb
oer
a
LE
G,
Ml
ozi
M
RS,
Ru
mis
ha
SF,
Bw
ana
V
M
et
al.:
Ma
lar
ia,
Ec
osy
ste
ms
an
d
Liv
eli
ho
ods
in
Kil
osa
Dis
tric
t,
Ce
ntr
al
Ta
nza
nia
.
Nat
ion
al
Inst
itut
e
for
Me
dic
al
Res
ear
ch,
Dar
es
Sal
aa
m,

24.

T
a
n
z
a
n
i
a
,
2
0
1
3
.
I
j
u
m
b
a
,
J
.
N
.
T
h
e
I
m
p
a
c
t
o
f
r
i
c
e
a25.
n
d
s
u
g
a
r
c
a
n
e
i
r
r
i
g
a
t
i
o
n
o
n
m
a
l
a

ria
tra
ns
mis
sio
n
in
the
Lo
we
r
Mo
shi
are
a
of
nor
the
rn
Ta
nza
nia
.
Ph
D
Th
esi
s,
Un
ive
rsit
y
of
Co
pen
hagen
,
De
nm
ark
,
19
97.
Mb
oer
a
LE
G,
Sh
ayo
EH
,
Se
nk
oro
KP,
Ru
mis
ha
SF
et
al.:
Kn
ow
led
ge,
per
cep
tio
ns
and
pra
ctic
es

26.

of
far
mi
ng
co
m
mu
niti
es
on
lin
kag
es
bet
we
en
mal
aria
and
agr
icul
tur
e.
Act
a
Tro
p.
200
9,
113
:13
9144
.
van
den
Ber
g
H,
Kn
ols
BG
J:
Th
e
Far
me
r
Fie
ld
Sch
ool
: a
met
hod
for
enh
anc
ing
the
rol
e
of
rur
al
co
m
mu
niti
es
in
mal
aria

c
o
n
t
r
o
l
?
M
a
l
a
r
.
J
.

27.

2
0
0
6
,
5
,
3
.
M
u
t
e
r
o
C
M
,
M
c
C
a
r
t
n
e
y
M
,
B
o
e
l
e
e
E
:
U28.
n
d
e
r
s
t
a
n
d
i
n
g
t
h
e

lin
ks
bet
we
en
agr
icu
ltu
re
an
d
he
alt
h:
agr
icu
ltu
re,
ma
lar
-ia
an
d
wa
ter
ass
oci
ate
d
dis
eas
es.
Bri
ef
6.
Int
ern
ati
ona
l
Fo
od
Pol
icy
Re
sea
rch
Ins
titu
te,
Wa
shi
ngt
on
DC
,
US
A,
20
06.
Afr
ica
n
Un
ion
:
Afr
ica
n
Un
ion
s
Pol
icy
Fr
am

29.

ew
ork
on
Pa
sto
ral
ism
:
Sec
uri
ng,
Pr
ote
cti
ng
an
d
Im
pro
vin
g
the
Liv
es,
Liv
eli
ho
ods
an
d
Rig
hts
of
Pa
sto
ral
ist
Co
m
mu
nities
.
Afr
ica
n
Uni
on,
Ad
dis
Ab
aba
,
Eth
iop
ia,
201
0.
Pro
the
ro
R
M:
Dis
eas
e
and
mo
bili
ty:
a
neg
lect

e
d
f
a
c
t
o
r
i
n
e
p
i
d
e
m
i
o
l
o
g
y
.
I
n
t
.
J
.
E
p
i
d
e31.
m
i
o
l
.

30.

1
9
7
7
,
6
:
2
5
9
2
6
7
.
B
r
u
c
e
C
h
w
a

tt
LJ:
Mo
ve
me
nts
of
po
pul
ati
ons
in
rel
ati
on
to
co
m
mu
nic
abl
e
dis
eas
e in
Afr
ica.
E.
Afr
.
Me
d.
J.
19
68,
45:
26
627
5.
Mu
tuk
u
FM
,
Ba
yo
h
M
N,
Gi
mn
ig
JE,
Vul
ule
JM
et
al.:
Pu
pal
hab
itat
pro
duc
tivi
ty
of
An
op
hel
es
ga
mb

32.

iae
co
mple
x
mo
squ
itoe
s in
a
rur
al
vill
age
in
we
ster
n
Ke
nya
.
Am
. J.
Tro
p.
Me
d.
Hy
g.
200
6,
74:
5461.
Sot
a T,
Mo
gi
M:
Eff
ecti
ven
ess
of
zoo
pro
phy
laxi
s in
ma
lari
a
con
trol
: a
the
ore
tica
l
inq
uir
y,
wit
h a
mo
del
for
mo
squi
to
pop
ulat
ion

s
w
i
t
h
t
w
o
b
l
o
o
d
m
e
a
l
h
o
s
t
s
.
M
e
d
.
V
e
t
.
E
n
t
o
m
o
l
.

33.

1
9
8
9
,
3
:
3
3
7
3
4
5
.
H
e
w
i
t
t
S
,
K
a
m
a
l 34.
M
,

Mu
ha
m
ma
d
N,
Ro
wla
nd
M:
An
ent
om
olo
gic
al
inv
esti
gat
ion
of
the
lik
ely
im
pac
t of
catt
le
ow
ner
shi
p
on
ma
lari
a in
Af
gha
n
ref
uge
e
ca
mp
in
the
No
rth
We
st
Fro
nti
er
Pro
vin
ce
of
Pa
kist
an.
Me
d.
Vet
.
Ent
om
ol.
19
94,
8:1
6016
4.
Au
lt
SK

:
En
vir
on
me
ntal
ma
nag
em
ent:
a
reem
erg
ing
vec
tor
con
trol
stra
teg
y.
Am
. J.
Tro
p.
Me
d.
Hy
g.
199
4,
50:
3549.

35.

g
h
C
,
C
l
a
r
k
e
S
E
,
P
i
n
d
e
r
M
,
S
a
n
36.
y
a
n
g
F
e
t
a
l
.
:
E
f
f
e
c
t
o
f
p
a
s
s
i
v
e
z
o
o
p
r
o
p
h
y
l

axi
s
on
mal
aria
tra
ns
mis
sio
n
in
Th
e
Ga
mb
ia.
J.
Me
d.
Ent
om
ol.
200
1,
38:
822
828
.
Wo
odb
urn
PW
,
Mu
han
gi
L,
Hil
lier
S,
Ndi
baz
za
J et
al.:
Ris
k
fact
ors
for
hel
mi
nth
,
mal
aria
,
and
HI
V
inf
ecti
on
in
pre
gna
ncy
in
Ent
ebb
e,
Ug

37.

38.

and
a.
PL
oS
Ne
gl.
Tro
p.
Dis
.
200
9,
3:e
473
.
Ak
og
bt
o,
M:
La
go
on
al
an
d
coa
stal
ma
lari
a at
Co
ton
ou:
ent
om
olo
gic
al
fin
din
gs.
Sa
nt
20
00,
10:
26
727
5.
So
go
ba
N,
Do
um
bia
S,
Vo
un
ats
ou
P,
Ba
ber
I et
al.:
Mo
nitor

i
n
g
o
f
l
a
r
v
a
l
h
a
b
i
t
a
t
s
a
n
d
m
o39.
s
q
u
i
t
o
d
e
n
s
i
t
i
e
s
i
n
t
h
e
S
u
d
a
n
s
a
v
a
n
n
a
o
f
M
a
l
i
:

im
pli
cat
ion
s
for
ma
lari
a
vec
tor
co
ntr
ol.
A
m.
J.
Tr
op.
Me
d.
Hy
g.
20
07,
77:
8288.
Ba
rai
D,
Hy
ma
B,
Ra
me
sh
A:
Th
e
sco
pe
an
d
lim
itat
ion
s
of
ins
ect
ici
de
spr
ayi
ng
in
rur
al
vec
tor
co
ntr
ol
pro
gra
m
me
s
in
the
stat
es
of

40.

Ka
rna
tak
a
an
d
Ta
mil
Na
du
in
Ind
ia.
Ec
ol.
Di
s.
19
82,
1:2
4325
5.
S
DR
,
So
uza
Sa
nto
s
R,
Es
co
bar
AL
,
Co
im
bra
Jr
CE
:
Ma
lari
a
epi
de
mi
olo
gy
in
the
Pa
kaa
no
va
(W
ari)
Ind
ian
s,
Br
azi
lia
n
A
ma
zo
n.
Bu
ll.
So
c.

P
a
t
h
o
l
.
E
x
o
t
.
2
0
0
5
,

41.

9
8
:
2
8
3
2
.
G
o
l
42.
d
b
e
r
g
H
I
,
M

B
o
d
j
i
F
G
:
I
n
f
a
n
t
a
n
d
e
a
r
l
y
c
h
i
l
d
h
o

od
mo
rtal
ity
in
the
Sin
eSal
ou
m
reg
ion
of
Sen
ega
l.
J.
Bio
soc
.
Sci
.
198
8,
20:
471
484
.
Cal
son
JC,
By
rd
BD
,
O
mli
n
FX
:
Fie
ld
ass
ess
me
nts
in
we
ste
rn
Ke
ny
a
lin
k
ma
lari
a
vec
tor
s
to
en
vir
on
me
nta
lly
dis
tur
be
d

43.

ha
bit
ats
dur
ing
the
dry
sea
son
.
B
M
C
Pu
bli
c
He
alt
h
20
04,
4:3
3.
Di
cki
nso
n
K,
Kr
am
er
R,
Sh
ay
o
E:
So
cio
eco
no
mi
c
stat
us
an
d
ma
lari
arel
ate
d
out
co
me
s in
Mv
om
ero
Dis
tric
t,
Ta
nzan
ia.
Gl
ob.
Pu
bli
c
He
alt
h

2
0
1
2
,

44.

4
:
3
8
4
3
9
9
.
S
o
m
i
M
F
,
B
u
t
l
e
r
J
R
G
,
V
a
h
i
d
F
,
N
j 45.
a
u
J
D
e
t
a
l
.
:
E
c
o
n
o
m
i
c
b
u

rde
n
of
ma
lari
a
in
rur
al
Ta
nza
nia
:
var
iati
ons
by
socio
eco
no
mi
c
stat
us
an
d
sea
son
.
Tr
op.
Me
d.
Int
.
He
alt
h
20
07,
12:
11
3911
47.
Mb
oer
a
LE
G,
Ml
ozi
M
RS
,
Se
nk
oro
KP
,
Rw
eg
osh
ora
RT
et
al.:
M
ala
ria
an
d
Ag
ric

46.

ult
ure
in
Ta
nz
ani
a:
Im
pa
ct
of
La
nduse
an
d
Ag
ric
ult
ur
al
Pr
act
ice
s
on
Ma
lar
ia
Bu
rde
n
in
Mv
om
ero
Di
stri
ct.
Na
tio
nal
Ins
titu
te
for
Me
dic
al
Re
sea
rch
,
Da
r es
Sal
aa
m,
Ta
nza
nia
.
IS
BN
97
899
8791
431
-9,
20
07.
NI
M

R
:
H
e
a
l
t
h
I
m
p
a
c
t
o
f
t
h
e
S
c
a
l
e
u
p
t
o
F
i
g
h
t
H
I
V
,
T
u
b
e
r
c
u
l
o
s
i
s
a47.
n
d
M
a
l
a
r
i
a
i
n
T
a

nz
ani
a:
Di
str
ict
Co
mp
rehe
nsi
ve
As
ses
sm
ent
of
the
Gl
ob
al
Fu
nd
Fi
ver
Ye
ar
Im
pa
ct
Ev
alu
ati
on.
Na
tio
nal
Ins
titu
te
for
Me
dic
al
Re
sea
rch
,
Da
r
es
Sal
aa
m,
Ta
nza
nia
,
20
11.
Mo
HS
W:
Ta
nz
ani
a
Se
rvi
ce
Av
ail
abi
lity
an
d

48.

Re
adi
nes
s
As
ses
sm
ent
(S
AR
A),
20
12.
Mi
nis
try
of
He
alt
h
an
d
So
cia
l
We
lfar
e,
Un
ite
d
Re
pu
bli
c
of
Ta
nza
nia
.
Ma
rch
20
13.
Ka
ha
ma
Ma
ro
J,
D
Ac
re
mo
nt
V,
Mt
asi
wa
D,
Ge
nto
nB
et
al.:
Lo
w
qu
alit
y
of
rou
tin

e
m
i
c
r
o
s
c
o
p
y

49.

f
o
r

m
a
l
a
r
i
a
a
t
d
i
f
f
e
r
e
n
t
l
e
v
e
l
s
o
f
t
h
e
h
e
a
l
t
h
s
y
s
t
e
m
i
n
D
a
r
e
s

Sal
aa
m.
M
ala
r.
J.
20
11,
10:
33
2.
D'
Ac
re
mo
nt
V,
Ka
ha
ma
Ma
ro
J,
Sw
ai
N,
Mt
asi
wa
D
et
al.:
Re
du
cti
on
of
ant
ima
lari
al
co
nsu
mp
tio
n
aft
er
rap
id
dia
gn
ost
ic
test
s
im
ple
me
nta
tio
n
in
Da
r
es
Sal
aa
m:
a
befor
eaft

50.

er
an
d
clu
ste
r
ran
do
mi
zed
co
ntr
oll
ed
stu
dy.
Ma
lar.
J.
20
11,
10:
10
7.
Ma
san
ja
IM,
Sel
em
ani
M,
Am
uri
B,
Kaj
ung
uD
et
al.:
Inc
rea
sed
use
of
mal
aria
rap
id
dia
gno
stic
test
s
im
pro
ves
targ
etin
g
of
anti
mal
aria
l
trea
tme
nt
in
rur
al
Tan
zan
ia:
im

p
l
i
c
a
t
i
o
n
s
f
o
Wo
rld
Jo
Ma ur
lar nal
ia ,

r
gnati
nos
on
tic
wid
test
e
s.
roll
Ma
out
lar.
of
J.
mal
201
aria
2,
rap
11:
id
221
dia
.
wwd.org. ISSN
w. 2214-4374 11
ma
lari December
aw 2013, Vol. 4,
orl No. 19

Mboera et al. MWJ 2013, 4:19

51.

T
D
H
S
:
T
a
n
z
a
n
i
a
D
e
m
o
g
r
a
p52.
h
i
c
a
n
d
H
e
a
l
t
h
S
u
r
v
e
y
2
0
0
4
2
0
0
5
.
N
a53.
t
i
o
n
a
l

Bu
rea
u
of
Sta
tist
ics
Da
r es
Sal
aa
m,
OR
C
Ma
cro
Cal
ver
ton
,
Ma
ryl
and
US
A,
20
05.
TH
MI
S
(20
08)
Ta
nz
ani
a
HI
V/
AI
DS
an
d
Ma
lar
ia
Ind
ica
tor
Su
rve
y
20
0708,
No
ve
mb
er,
20
08.
TD
HS
:
Ta
nz
ani
a

54.

De
mo
gr
ap
hic
an
d
He
alt
h
Su
rve
y
20
10.
Nat
ion
al
Bu
rea
u
of
Sta
tist
ics,
Da
r es
Sal
aa
m,
Ta
nza
nia
,
IC
F
Ma
cro
Cal
ver
ton
,
Ma
ryl
and
,
US
A,
Re
por
t;
Ap
ril
20
11.
TH
MI
S:
Ta
nz
ani
a
HI
V/
AI
DS
an
d
Ma
lar
ia

I
n
d
i
c55.
a
t
o
r
S
u
r
v
e
y
2
0
1
1
1
2
.
T
A
C
A
I
D
S
,
Z
A
C
,
N
B
S
,
O
C
G
S
a
n
d
I
C
F
I
n
t
e
r
n
a
t
i
o
n
a
l
,
M

arc
h
20
13.
Mu
bya
zi
G,
Blo
ch
P,
Ka
mu
gis
ha
M,
Kit
ua
A
et
al.:
Int
ermit
ten
t
pre
ven
tiv
e
tre
at
me
nt
of
ma
lari
a
dur
ing
pre
gna
ncy:
a
qua
lita
tiv
e
stu
dy
of
kn
ow
led
ge,
atti
tud
es
and
pra
ctice
s
of
dist
rict
hea
lth
ma
nag
ers,
ant
ena
tal
car
e

56.

staf
f
and
pre
gna
nt
wo
me
n
in
Ko
rog
we
Dis
tric
t,
No
rthEas
ter
n
Ta
nza
nia
.
Ma
lar.
J.
20
05,
4:3
1.
Bo
nne
r
K,
M
wit
a
A,
Mc
Elr
oy
PD
,
O
ma
ri S
et
al.:
De
sig
n,
im
ple
me
nta
tio
n
and
eva
lua
tio
n
of
a
nat
ion
al
ca
mpai
gn
to
dist
rib

u
t
e
n
i
n
e57.
m
i
l
l
i
o
n
f
r
e
e
L
L
I
N
s
t
o
c
h
i
l
d
r
e
n
u
n
d
e
r
f
i
v
e
y
e
a
r
s
o
f
a
g
e
i
n
T
a
n
z
a
n
i
a
.
M

ala
r.
J.
20
11,
10:
73.
Re
ng
gli
S,
Ma
ndi
ke
R,
Kr
am
er
K,
Pat
ric
k F
et
al.:
De
sig
n,
im
ple
me
nta
tio
n
and
eva
lua
tio
n
of
a
nat
ion
al
ca
mpai
gn
to
del
ive
r
18
mil
lio
n
fre
e
lon
glast
ing
ins
ecti
cid
al
net
s to
unc
ove
red
sle
epi
ng
spa
ces
in

58.

Ta
nza
nia
.
Ma
lar.
J.
20
13,
12:
85.
Ma
sha
uri
FM
,
Ki
nu
ng
hi
SM
,
Ka
ata
no
G
M,
Ma
ges
a
SM
et
al.:
Im
pac
t of
ind
oor
resi
dua
l
spr
ayi
ng
of
la
mb
dacyh
alo
thri
n
on
ma
lari
a
pre
val
enc
e
and
ane
mi
a
in
an
epi
de
mi
cpro
ne
dist
rict
of
Mu
leb
a,

n
o
r
t
h
w
e
s
t
e
r
n

59.

T
a
n
z
a
n
i
a
.
A
m
.
J
.
T
r
o
p
.
M
e
d
.
H
y
g
.
2
0
1
3
,
860.
8
:
8
4
1
8
4
9
.
Y
e
Y
,
H
o
s
h
e
n
M
,
L
o
u
i

s V,
Ser
aph
in
S
et
al.:
Ho
usi
ng
con
diti
ons
and
Pla
sm
odi
um
fal
cip
aru
m
infe
ctio
n:
pro
tective
effe
ct
of
iro
nshe
et
roo
fed
hou
ses.
Ma
lar.
J.
200
6,
5:8.
Ga
ma
geMe
ndi
s
AC
,
Car
ter
R,
Me
ndi
s
C,
De
Zo
ysa
AP
et
al.:
Clu
ster
ing
of
ma
lari
a
inf
ecti

61.

ons
wit
hin
an
end
em
ic
po
pul
ati
on:
ris
k
of
ma
lari
a
ass
oci
ate
d
wit
h
typ
e
of
ho
use
con
str
uct
ion
.
Am
. J.
Tro
p.
Me
d.
Hy
g.
19
91,
45:
7785.
Gh
ebr
eye
sus
TA
,
Hai
le
M,
Wit
ten
KH
,
Get
ach
ew
A
et
al.:
Ho
use
hol
d
ris
k
fac
tor
s
for
ma

l
a
r
i
a
a
m62.
o
n
g
c
h
i
l
d
r
e
n
i
n
t
h
e
E
t
h
i
o
p
i
a
n
H
i
g
h
l
a
n
d
s
.
T
r
a
n
s
.
R
.
S
o
c
.
T
r
o
p
.
M
e
d
.
H
y
g

.
200
0,
94:
1721.
Kir
by
MJ,
Am
eh
D,
Bot
tom
ley
C,
Gre
en
C
et
al.:
Eff
ect
of
two
diff
ere
nt
hou
se
scr
een
ing
inte
rve
ntio
ns
on
exp
osur
e to
mal
aria
vec
tors
and
on
ana
emi
a in
chil
dre
n in
The
Ga
mbi
a: a
ran
do
mis
ed
con
trol
led
tria
l.
La
nce
t
200
9,
374
:
998

100

63.

64.

9.
M
mb
and
o
BP,
Ves
ter
gaa
rd
LS,
Kit
ua
AY
,
Le
mn
ge
M
M
et
al.:
A
pro
gre
ssi
ng
dec
lini
ng
in
the
bur
den
of
ma
lari
a
in
nor
theas
ter
n
Ta
nza
nia
.
Ma
lar.
J.
20
10,
9:2
16.
Ish
eng
om
a
DS
,
M
mb
and
o
BP,
Se
gej
a
M
D,
Ali
fra

n
g
i
s
M
e
t
a
l
.
:
D
e
c
l
i
n
i
n
g
b
u
r65.
d
e
n
o
f
m
a
l
a
r
i
a
o
v
e
r
t
w
o
d
e
c
a
d
e
s
i
n
a
r
u
r
a
l
c
o
m
m

uni
ty
of
Mu
hez
a
dist
rict
,
nor
theas
ter
n
Ta
nza
nia
.
Ma
lar.
J.
20
13,
12:
33
8
Mt
ove
G,
A
mo
s
B,
Na
dj
m
B,
He
ndr
iks
en
IC
et
al.:
De
cre
asi
ng
inc
ide
nce
of
sev
ere
ma
lari
a
and
co
m
mu
nit
yacq
uir
ed
bac
ter
ae
mi
a
am
on
g

hos
pit
aliz
ed
chi
ldr
en
in
Mu
hez
a,
nor
theas
ter
n
Ta
nza
nia
,
20
0620
10.
Ma
lar.
J.
20
11,
10:
32
0.

66.

M
u
r
r
a
y
C
K
,
R
o
s
e
n
f
e
l
d
L
C
,
L
i 67.
m
S
S
,
A
n
d
r
e
w
s
K
G
e
t
a
l
.
:
G
l
o
b
a
l
m
a
l
a
r
i
a
m
o
r
t
a
l
i

ty
bet
we
en
198
0
and
201
0: a
sys
tem
atic
ana
lysi
s.
La
nce
t
201
2,
379
:41
3431
.
Me
yro
wit
sch
D
W,
Ped
ers
en
EM
,
Ali
fra
ngi
s
M,
Sch
eik
e
TH
et
al.:
Is
the
cur
rent
dec
line
in
mal
aria
bur
den
in
Sub
-Sa
har
an
Afr
ica
due
to a
dec
rea
se
in
vec
tor

68.

pop
ulat
ion
?
Ma
lar.
J.
201
1,
10:
188
.
Der
ua
YA,
Ali
fra
ngi
s
M,
Ho
sea
K
M,
Me
yro
wit
sch
D
W
et
al.:
Ch
ang
e in
co
mp
osit
ion
of
the
An
oph
ele
s
ga
mbi
ae
co
mpl
ex
and
its
pos
sibl
e
imp
lica
tion
s
for
the
tran
smi
ssio
n of
mal
aria
and
lym
pha
tic
fila
rias
is
in

n
o
r
t
h
e
a
s
t
e
r
n

69.

T
a
n
z
a
n
i
a
.
M
a
l
a
r
.
J
.
2
0
1
2
,
1
1
:
1
8
8
.
R
u
s
s
e
l
l
T
L
,
G
o
v
e
l 70.
l
a
N
J
,
A
z
i
z
i
S
,
D
r
a
k
e
l

ey
CJ
et
al.:
Inc
rea
sed
pop
ulat
ion
of
out
doo
r
fee
din
g
am
ong
resi
dua
l
mal
aria
vec
tor
pop
ulat
ion
foll
owi
ng
incr
eas
ed
use
of
ins
ecti
cid
etrea
ted
net
s in
rur
al
Tan
zan
ia.
Ma
lar.
J.
201
1,
10:
80.
Lin
dbl
ade
KA
,
Gi
mni
g
JE,
Ka
ma
u
L,
Ha
wle
y
WA
et
al.:
Im

71.

pac
t of
sust
ain
ed
use
of
ins
ecti
cid
etrea
ted
bed
net
s
on
mal
aria
vec
tor
spe
cies
dist
rib
utio
n
and
culi
cin
e
mo
squ
itoe
s.
J.
Me
d.
Ent
om
ol.
200
6,
43:
428
432
.
Ba
yoh
M
N,
Ma
thia
s
DK
,
Odi
ere
MR
,
Mu
tuk
u
FM
et
al.:
An
oph
ele
s
ga
mbi
ae:
hist

o
r
i
c
a
l
p
o
p
u
l
a
t
i
o
n
d
e
c
l
i
n
e72.
a
s
s
o
c
i
a
t
e
d
w
i
t
h
r
e
g
i
o
n
a
l
d73.
i
s
t
r
i
b
u
t
i
o
n
o
f
i
n
s
e
c
t
i
c
i
d
e
t

reat
ed
bed
net
s in
wes
tern
Ny
anz
a
Pro
vin
ce,
Ke
nya
.
Ma
lar.
J.
201
0,
9:6
2.
W
HO
:
Wo
rld
Ma
lari
a
Re
por
t,
201
2.
Wo
rld
He
alth
Organ
izat
ion,
pp.
195
O
Me
ara
WP
,
Bej
on
P,
M
wa
ngi
TW
,
Oki
ro
EA
et
al.:
Eff
ect
of a
fall
in
mal
aria
tran
smi

74.

75.

ssio
n
on
mo
rbi
dity
and
mo
rtal
ity
in
Kili
fi,
Ke
nya
.
La
nce
t
200
8,
372
:15
55
156
2.
Do
ola
n
DL
,
Do
ba
o
C,
Bai
rd
JK:
Ac
qui
red
im
mu
nit
y
to
ma
lari
a.
Cli
n.
Mi
cro
bio
l.
Re
v.
20
09,
22:
1336.
Tra
pe
J-F,
Ro
gier
C:
Co
mb
atin

g
m
a
l
a
r
i 76.
a
m
o
r
b
i
d
i
t
y
a
n
d
m
o
r
t
a
l
i
t
y
b
y
r
e
d
u
c
i
n
g
t
r
a
n
s
m
i
s
s
i
o
n
.
P
a
r
a
s
i
t
o
l
.
T
o
d
a
y

19
96,
12:
236
240
.
Tra
pe
J-F,
Tall
A,
Dia
gne
N,
Ndi
ath
O
et
al.:
Ma
lari
a
mo
rbi
dity
and
pyr
ethr
oid
resi
sta
nce
afte
r
the
intr
odu
ctio
n of
ins
ecti
cid
etrea
ted
bed
net
s
and
arte
mis
inin
bas
ed
co
mbin
atio
n
ther
api
es:
a
lon
gitu
din
al
stu
dy.
La
nce
t
Inf
ect.
Dis

77.

78.

.
201
1,
11:
925
932
.
Eis
ele
TP,
Lar
sen
DA
,
Wal
ker
N,
Cib
uls
kis
RE
et
al.:
Esti
mat
es
of
chil
d
dea
ths
pre
ven
ted
fro
m
mal
aria
pre
ven
tion
scal
eup
in
Afr
ica
200
1201
0.
Ma
lar.
J.
201
2,
11:
93.
Mi
nak
aw
a
N,
Did
a
GO
,
Son
ye
GO
,

F
u
t
a
m
i
K
e
t
a
l 79.
.
:
U
n
f
o
r
e
s
e
e
n
m
i
s
u
s
e
s
o
f
b
e
d
n
e
t
s
i
n
f
i
s
h
i
n
g
v
i
l
l
a
g
e
s
a
l
o
n
g
L
a
k

e
Vic
tori
a.
Ma
lar.
J.
200
8,
7:1
65
Mb
oer
a
LE
G,
Ma
yal
a
BK
,
Sen
kor
o
KP,
Ma
ges
a
SM
et
al.:
Mo
squ
ito
net
Co
ver
age
and
Uti
lisa
tio
n
for
Ma
lari
a
Co
ntr
ol
in
Tan
zan
ia.
Nat
ion
al
Inst
itut
e
for
Me
dic
al
Resea
rch,
Dar
es
Sal
aa
m,
Tan
zan
ia,

80.

81.

200
8.
Ala
ii
JA,
Ha
wle
y
WA
,
Kol
cza
k
MS
, ter
Kui
le
FO
et
al.:
Fac
tors
affe
ctin
g
use
of
per
met
hri
ntrea
ted
bed
net
s
dur
ing
a
ran
do
miz
ed
con
trol
led
tria
l in
wes
tern
Ke
nya
.
Am
. J.
Tro
p.
Me
d.
Hy
g.
200
3,
68:
137
141
.
Ma
tow
o J,
Kul
kar

n
i
a
M
A
,
M
o
s
h
a
F
W
,
O
x
b
o
r
o
u
g
h
R
M
e
t
a
l
.
:
B
i
o
c82.
h
e
m
i
c
a
l
b
a
s
i
s
rld
Jo
Ma urn
lar al,
ia ww
Wo w.

of
M
per
et
met
al.:
hri
Dis
n
triresi
buti
sta
on
nce
and
in
spr
An
ead
oph
of
pyr
ele
ethr
s
oid
ara
and
bie
DD
nsi
T
s
resi
fro
sta
m
nce
Lo
am
wer
ong
Mo
An
shi,
oph
nor
ele
ths
east
ga
ern
mbi
Tan
ae
zaco
nia.
mpl
Ma
ex
lar.
in
J.
Tan
201
zan
0,
ia.
9:1
Me
93.
d.
Ka
Vet.
bul
Ent
a
om
B,
ol.
Tun
201
gu
3,
P,
doi:
Ma
10.
lim
111
a,
1/m
R,
ve.
Ro
120
wla
36.
nd
ma ISSN 2214-4374
lari 12
aw
orl December
d.o 2013, Vol. 4,
rg. No. 19

Mboera et al. MWJ 2013, 4:19

83.

H
a
j
i
K
A
,
K
h
a
t
i
b
B
O
,
S
m
i
t
h
S
,
A
l
i
A
S
e
t
a
l
.
:
C
h
a84.
l
l
e
n
g
e
s
f
o
r
m
a
l
a
r
i
a
e
l
i
m
i
n

atio
n in
Za
nzi
bar
:
pyr
eth
roi
d
resi
sta
nce
in
mal
aria
vec
tors
and
poo
r
per
for
ma
nce
of
lon
glast
ing
ins
ecti
cid
e.
Pa
ras
it.
Vec
tor
s
201
3,
6:8
2.
Ker
ahHin
zou
mb

C,
Pk
a
M,
Nw
ane
P,
Do
nan
Go
uni
I et
al.:
Ins
ecti
cid
e
resi
sta

85.

nce
in
An
op
hel
es
ga
mb
iae
fro
m
sou
thwes
tern
Ch
ad,
Ce
ntra
l
Afr
ica.
Ma
lar.
J.
200
8,
7:1
92.
Hu
nt
RH
,
Ed
war
des
,
Co
etz
ee
M:
Pyr
ethr
oid
resi
sta
nce
in
sou
ther
n
Afr
ica
n
An
op
hel
es
fun
est
us
ext
end
s to
Lik
om
a
Isla
nd

i
n
L
a
k
e
M
a
l
a
w
i
.
P
a
r
a
s
i
t
.
V
e
c
t
o
r
s

86.

2
0
1
0
,
3
:
1
2
2
.
K
l
o
k
e
R87.
G
,
N
h
a
m
a
h
a
n
g
a
E
,
H
u
n
t
R
H
,
C
o
e

tze
e
M:
Vec
torial
stat
us
and
ins
ecti
cid
e
resi
sta
nce
of
An
op
hel
es
fun
estus
fro
ma
sug
ar
est
ate
in
sou
the
rn
Mo
za
mb
iqu
e.
Pa
ras
it.
Vec
tor
s
201
1,
4:1
6.
Ma
ges
a
SM
,
Rw
ego
sho
ra
RT,
Md
ira
KY
,
Ma
lim
a
RC
et
al.:
Co
m
mu
nit
y
pre
ven

88.

tion
of
mal
aria
.
An
nu
al
Re
por
t of
the
Nat
ion
al
Ins
titu
te
for
Me
dic
al
Res
ear
ch
199
4,
13:
3536.
Yo
han
nes
M,
Bo
ele
e
E:
Ear
ly
biti
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1
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h
e
G
l
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bal
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Th
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ma
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rapi
d
dia
gno
sis:
Cla
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tten
inst

r
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c
t
i
o
n
s
a
n
d
h
e
a
l
t
h
w
o
r
k
e
r
p
e
r
f
o
r
m
a
n
c
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T
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S
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Go
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affe
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ma
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dia
gno
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regi
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sho
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Ug
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a
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f
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i
a
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i
d
d
i 95.
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g
n
o
s
t
i
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t
e
s
t
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n
c
o
m
m
u
n
i
t
y
s
t
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die
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thei
r
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o
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I
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a
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:
M
o
l
e
c

ula
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veil
lan
ce
of
dru
gresi
sta
nce
ass
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ate
d
mu
tati
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Ma
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a
Tre
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Tan

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ia
afte
r
swi
tch
to
arte
mis
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co
mbi
nati
on
ther
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the
intr
odu
ctio
n
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tsk
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cart
hur
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JR
o
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al:
i
Th
n
e
g
thr
eat
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r
arte
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t
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tim
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ati
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De
Vei
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jM
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e
Ch
d
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i
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izat
e
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t
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nte
t
rfei
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i
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a
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l
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r
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a
n
l
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ho
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thei
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e

b
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L,
Se
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i
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r
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EK
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Mal
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Wor
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ISSN
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14
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2013
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Vol.
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19