Project Summary: International efforts to scale up malaria control have achieved considerable success and have pointed toward the possibility of global malaria eradication. Achieving the long-term goal of eradication requires effective implementation of current tools, development of new technologies, and ongoing surveillance of the successes and failures of both. As malaria transmission declines and becomes increasingly heterogeneous, a finer-grained picture of malaria burden and intervention efficacy is required. In Kenya, considerable reductions in malaria morbidity and mortality have been reported, but success has not been uniform. In Bungoma East district in western Kenya, data suggest that control efforts have not had the expected impact; despite the fact that ITN ownership exceeds 70%, malaria infection and morbidity remain high. The observation that malaria burden has not responded to control measures suggests a breakdown in effectiveness of ITN, but not due to simply to ownership, a common measure of coverage. Breakdown in prevention of malaria may be due to a number of different factors in addition to coverage, including improper use and low adherence by households, changing vector populations and reduced susceptibility of the vector. In the first phase of the proposed project, we want to answer the question of why malaria morbidity has remained alarmingly high in an area with high coverage of effective interventions. We will use the efficacy decay framework to quantify barriers to effective prevention. In the second phase, we want to apply the lessons from phase 1 towards developing a tool that can generate local, timely information in a cost-effective manner to identify and address barriers to elimination. Specific Aim 1: Quantify the efficacy decay at each step using case-control methodology. We will use a case control study to estimate the relative contribution of each step in the efficacy decay of ITNs to malaria prevention in an area where coverage is high but malaria burden has remained resistant to control measures. Specific Aim 2: Develop a rapid assessment tool that can be implemented at sentinel health facilities to identify local bottlenecks to malaria elimination. Based on the results of the efficacy decay analysis, we will develop a tool that can be used by community health workers to identify local barriers to effective prevention and stimulate local solutions.

J.N. Mangeni, D. Menya, A.A. Obala, A. Platt, W. P. O'Meara, "Development and piloting of an evidence-based rapid assessment tool for malaria prevention", Malaria Journal IN PRESS 2016 A. A. Obala, J. Mangeni, A. Platt, D. Aswa, L. Abel, J. Namae, W. Prudhomme O'Meara "What Is Threatening the Effectiveness of Insecticide-Treated Bednets? A Case-Control Study of Environmental, Behavioral, and Physical Factors Associated with Prevention Failure", PLoS One 2015 10(7):e0132778