title: Impact and Lessons Learned from Mass Drug Administrations of Malaria Chemoprevention during the Ebola Outbreak in Monrovia, Liberia, 2014.
abstract: BACKGROUND
  In October 2014, during the Ebola outbreak in Liberia healthcare services were limited while malaria transmission continued. Médecins Sans Frontières (MSF) implemented a mass drug administration (MDA) of malaria chemoprevention (CP) in Monrovia to reduce malaria-associated morbidity. In order to inform future interventions, we described the scale of the MDA, evaluated its acceptance and estimated the effectiveness.
  
  
  METHODS
  MSF carried out two rounds of MDA with artesunate/amodiaquine (ASAQ) targeting four neighbourhoods of Monrovia (October to December 2014). We systematically selected households in the distribution area and administered standardized questionnaires. We calculated incidence ratios (IR) of side effects using poisson regression and compared self-reported fever risk differences (RD) pre- and post-MDA using a z-test.
  
  
  RESULTS
  In total, 1,259,699 courses of ASAQ-CP were distributed. All households surveyed (n = 222; 1233 household members) attended the MDA in round 1 (r1) and 96% in round 2 (r2) (212/222 households; 1,154 household members). 52% (643/1233) initiated ASAQ-CP in r1 and 22% (256/1154) in r2. Of those not initiating ASAQ-CP, 29% (172/590) saved it for later in r1, 47% (423/898) in r2. Experiencing side effects in r1 was not associated with ASAQ-CP initiation in r2 (IR 1.0, 95%CI 0.49-2.1). The incidence of self-reported fever decreased from 4.2% (52/1229) in the month prior to r1 to 1.5% (18/1229) after r1 (p<0.001) and decrease was larger among household members completing ASAQ-CP (RD = 4.9%) compared to those not initiating ASAQ-CP (RD = 0.6%) in r1 (p<0.001).
  
  
  CONCLUSIONS
  The reduction in self-reported fever cases following the intervention suggests that MDAs may be effective in reducing cases of fever during Ebola outbreaks. Despite high coverage, initiation of ASAQ-CP was low. Combining MDAs with longer term interventions to prevent malaria and to improve access to healthcare may reduce both the incidence of malaria and the proportion of respondents saving their treatment for future malaria episodes.
authors: Postgraduate Training for Applied Epidemiology, Robert Koch Institute, Berlin, Germany.|European Programme for Intervention Epidemiology Training (EPIET), ECDC, Stockholm, Sweden.|Epicentre, Paris, France.
authors: Anna
authors: A
authors: Kuehne
authors: Epicentre, Geneva, Switzerland.
authors: Amanda
authors: A
authors: Tiffany
authors: Médecins Sans Frontières, Operational Centre Paris, Tropical Medicine, New York, New York, United States of America.
authors: Estrella
authors: E
authors: Lasry
authors: Médecins Sans Frontières, Operational Centre Paris, Monrovia Project, Monrovia, Liberia.
authors: Michel
authors: M
authors: Janssens
authors: Médecins Sans Frontières, Operational Centre Paris, Monrovia Project, Monrovia, Liberia.
authors: Clement
authors: C
authors: Besse
authors: Médecins Sans Frontières, Operational Centre Paris, Desk Urgence, Paris, France.
authors: Chibuzo
authors: C
authors: Okonta
authors: Liberian National Malaria Control Programme, Ministry of Health, Monrovia, Liberia.
authors: Kwabena
authors: K
authors: Larbi
authors: Liberian National Malaria Control Programme, Ministry of Health, Monrovia, Liberia.
authors: Alfred C
authors: AC
authors: Pah
authors: European Programme for Intervention Epidemiology Training (EPIET), ECDC, Stockholm, Sweden.|Institut Veille Sanitaire, Paris, France.
authors: Kostas
authors: K
authors: Danis
authors: Epicentre, Paris, France.
authors: Klaudia
authors: K
authors: Porten
mesh_terms: D000962:Antimalarials / Q000008:administration & dosage*; D004196:Disease Outbreaks; D005260:Female; D019142:Hemorrhagic Fever, Ebola / Q000453:epidemiology*; D006801:Humans; D007988:Liberia / Q000453:epidemiology; D008288:Malaria / Q000453:epidemiology* / Q000517:prevention & control*; D008297:Male
chemical_list: D000962:Antimalarials