RT Journal Article
SR Electronic
T1 Effectiveness and safety of reactive focal mass drug administration (rfMDA) using dihydroartemisinin–piperaquine to reduce malaria transmission in the very low-endemic setting of Eswatini: a pragmatic cluster randomised controlled trial
JF BMJ Global Health
JO BMJ Global Health
FD BMJ Publishing Group Ltd
SP e005021
DO 10.1136/bmjgh-2021-005021
VO 6
IS 6
A1 Vilakati, Sibonakaliso
A1 Mngadi, Nontokozo
A1 Benjamin-Chung, Jade
A1 Dlamini, Nomcebo
A1 Dufour, Mi-Suk Kang
A1 Whittemore, Brooke
A1 Bhangu, Khayelihle
A1 Prach, Lisa M
A1 Baltzell, Kimberly
A1 Nhlabathi, Nomcebo
A1 Malambe, Calisile
A1 Dlamini, Bongani
A1 Helb, Danica
A1 Greenhouse, Bryan
A1 Maphalala, Gugu
A1 Pindolia, Deepa
A1 Kalungero, Muhindo
A1 Tesfa, Getahun
A1 Gosling, Roly
A1 Ntshalintshali, Nyasatu
A1 Kunene, Simon
A1 Hsiang, Michelle S
YR 2021
UL http://gh.bmj.com/content/6/6/e005021.abstract
AB Introduction To reduce malaria transmission in very low-endemic settings, screening and treatment near index cases (reactive case detection (RACD)), is widely practised, but the rapid diagnostic tests (RDTs) used miss low-density infections. Reactive focal mass drug administration (rfMDA) may be safe and more effective.Methods We conducted a pragmatic cluster randomised controlled trial in Eswatini, a very low-endemic setting. 77 clusters were randomised to rfMDA using dihydroartemisin–piperaquine (DP) or RACD involving RDTs and artemether–lumefantrine. Interventions were delivered by the local programme. An intention-to-treat analysis was used to compare cluster-level cumulative confirmed malaria incidence among clusters with cases. Secondary outcomes included safety and adherence.Results From September 2015 to August 2017, 222 index cases from 47 clusters triggered 46 RACD events and 64 rfMDA events. RACD and rfMDA were delivered to 1455 and 1776 individuals, respectively. Index case coverage was 69.5% and 62.4% for RACD and rfMDA, respectively. Adherence to DP was 98.7%. No serious adverse events occurred. For rfMDA versus RACD, cumulative incidences (per 1000 person-years) of all malaria were 2.11 (95% CI 1.73 to 2.59) and 1.97 (95% CI 1.57 to 2.47), respectively; and of locally acquired malaria, they were 1.29 (95% CI 1.00 to 1.67) and 0.97 (95% CI 0.71 to 1.34), respectively. Adjusting for imbalance in baseline incidence, incidence rate ratio for rfMDA versus RACD was 0.93 (95% CI 0.54 to 1.62) for all malaria and 0.84 (95% CI 0.42 to 1.66) for locally acquired malaria. Similar results were obtained in a per-protocol analysis that excluded clusters with <80% index case coverage.Conclusion In a very low-endemic, real-world setting, rfMDA using DP was safe, but did not lower incidence compared with RACD, potentially due to insufficient coverage and/or power. To assess impact of interventions in very low-endemic settings, improved coverage, complementary interventions and adaptive ring trial designs may be needed.Trial registration number NCT02315690.The data that support the findings of this study are not publicly available. Data are available from the authors on reasonable request and with permission of Eswatini Ministry of Health.