title: Monitoring, characterization and control of chronic, symptomatic malaria infections in rural Zambia through monthly household visits by paid community health workers.
abstract: BACKGROUND
  Active, population-wide mass screening and treatment (MSAT) for chronic Plasmodium falciparum carriage to eliminate infectious reservoirs of malaria transmission have proven difficult to apply on large national scales through trained clinicians from central health authorities.
  
  
  METHODS
  Fourteen population clusters of approximately 1,000 residents centred around health facilities (HF) in two rural Zambian districts were each provided with three modestly remunerated community health workers (CHWs) conducting active monthly household visits to screen and treat all consenting residents for malaria infection with rapid diagnostic tests (RDT). Both CHWs and HFs also conducted passive case detection among residents who self-reported for screening and treatment.
  
  
  RESULTS
  Diagnostic positivity was higher among symptomatic patients self-reporting to CHWs (42.5%) and HFs (24%) than actively screened residents (20.3%), but spatial and temporal variations of diagnostic positivity were highly consistent across all three systems. However, most malaria infections (55.6%) were identified through active home visits by CHWs rather than self-reporting to CHWs or HFs. Most (62%) malaria infections detected actively by CHWs reported one or more symptoms of illness. Most reports of fever and vomiting, plus more than a quarter of history of fever, headache and diarrhoea, were attributable to malaria infection. The minority of residents who participated >12 times had lower rates of malaria infection and associated symptoms in later contacts but most residents were tested <4 times and high malaria diagnostic positivity (32%) in active surveys, as well as incidence (1.7 detected infections per person per year) persisted in the population. Per capita cost for active service delivery by CHWs was US$5.14 but this would rise to US$10.68 with full community compliance with monthly testing at current levels of transmission, and US$6.25 if pre-elimination transmission levels and negligible treatment costs were achieved.
  
  
  CONCLUSIONS
  Monthly active home visits by CHWs equipped with RDTs were insufficient to eliminate the human infection reservoir in this typical African setting, despite reasonably high LLIN/IRS coverage. However, dramatic impact upon infection and morbidity burden might be attainable and cost-effective if community participation in regular testing could be improved and the substantial, but not necessarily prohibitive, costs are affordable to national programmes.
authors.affiliation: Ministry of Health, National Malaria Control Centre, Chainama Hospital College Grounds, off Great East road, P,O, Box 32509, Lusaka, Zambia. bossbusk@gmail.com.
authors.forename: Busiku
authors.initials: B
authors.lastname: Hamainza
authors.forename: Hawela
authors.initials: H
authors.lastname: Moonga
authors.forename: Chadwick H
authors.initials: CH
authors.lastname: Sikaala
authors.forename: Mulakwa
authors.initials: M
authors.lastname: Kamuliwo
authors.forename: Adam
authors.initials: A
authors.lastname: Bennett
authors.forename: Thomas P
authors.initials: TP
authors.lastname: Eisele
authors.forename: John
authors.initials: J
authors.lastname: Miller
authors.forename: Aklilu
authors.initials: A
authors.lastname: Seyoum
authors.forename: Gerry F
authors.initials: GF
authors.lastname: Killeen
mesh_terms: D003150:Community Health Workers / Q000191:economics / Q000706:statistics & numerical data; D003695:Delivery of Health Care / Q000191:economics / Q000379:methods*; D003955:Diagnostic Tests, Routine / Q000191:economics / Q000706:statistics & numerical data; D015994:Incidence; D008288:Malaria / Q000175:diagnosis* / Q000453:epidemiology / Q000469:parasitology / Q000517:prevention & control*; D008403:Mass Screening; D010963:Plasmodium falciparum / Q000302:isolation & purification / Q000502:physiology*; D015995:Prevalence; D012424:Rural Population; D013997:Time Factors; D015024:Zambia / Q000453:epidemiology