Malaria Journal - Most viewed articles

Evaluation of light microscopy and rapid diagnostic test for the detection of malaria under operational field conditions: a household survey in Ethiopia

2008-07-03

Background: In most resource-poor settings, malaria is usually diagnosed based on clinical signs and symptoms and not by detection of parasites in the blood using microscopy or rapid diagnostic tests (RDT). In population-based malaria surveys, accurate diagnosis is important: microscopy provides the gold standard, whilst RDTs allow immediate findings and treatment. The concordance between RDTs and microscopy in low or unstable transmission areas has not been evaluated.ObjectivesThis study aimed to estimate the prevalence of malaria parasites in randomly selected malarious areas of Amhara, Oromia, and Southern Nations, Nationalities and Peoples' (SNNP) regions of Ethiopia, using microscopy and RDT, and to investigate the agreement between microscopy and RDT under field conditions. Methods: A population-based survey was conducted in 224 randomly selected clusters of 25 households each in Amhara, Oromia and SNNP regions, between December 2006 and February 2007. Fingerpick blood samples from all persons living in even-numbered households were tested using two methods: light microscopy of Giemsa-stained blood slides; and RDT (ParaScreen device for Pan/Pf). Results: A total of 13,960 people were eligible for malaria parasite testing of whom 11,504 (82%) were included in the analysis. Overall slide positivity rate was 4.1% (95% confidence interval [CI] 3.4–5.0%) while ParaScreen RDT was positive in 3.3% (95% CI 2.6–4.1%) of those tested. Considering microscopy as the gold standard, ParaScreen RDT exhibited high specificity (98.5%; 95% CI 98.3–98.7) and moderate sensitivity (47.5%; 95% CI 42.8–52.2) with a positive predictive value of 56.8% (95% CI 51.7–61.9) and negative predictive value of 97.6% (95% CI 97.6–98.1%) under field conditions. Conclusion: Blood slide microscopy remains the preferred option for population-based prevalence surveys of malaria parasitaemia. The level of agreement between microscopy and RDT warrants further investigation in different transmission settings and in the clinical situation.

Antimalarial drug use in general populations of tropical Africa

2008-07-08

Background: The burden of Plasmodium falciparum malaria has worsened because of the emergence of chloroquine resistance. Antimalarial drug use and drug pressure are critical factors contributing to the selection and spread of resistance. The present study explores the geographical, socio-economic and behavioural factors associated with the use of antimalarial drugs in Africa. Methods: The presence of chloroquine (CQ), pyrimethamine (PYR) and other antimalarial drugs has been evaluated by immuno-capture and high-performance liquid chromatography in the urine samples of 3,052 children (2-9y), randomly drawn in 2003 from the general populations at 30 sites in Senegal (10), Burkina-Faso (10) and Cameroon (10). Questionnaires have been administered to the parents of sampled children and to a random sample of households in each site. The presence of CQ in urine was analysed as dependent variable according to individual and site characteristics using a random - effect logistic regression model to take into account the interdependency of observations made within the same site. Results: According to the sites, the prevalence rates of CQ and PYR ranged from 9% to 91% and from 0% to 21%, respectively. In multivariate analysis, the presence of CQ in urine was significantly associated with a history of fever during the three days preceding urine sampling (OR=1.22, p= 0.043), socio-economic level of the population of the sites (OR=2.74, p = 0.029), age (2-5y = reference level; 6-9y OR = 0.76, p =0.002), prevalence of anti-circumsporozoite protein (CSP) antibodies (low prevalence : reference level; intermediate level OR = 2.47, p = 0.023), proportion of inhabitants who lived in another site one year before (OR= 2.53, p= 0.003), and duration to reach the nearest tarmacked road (duration less than one hour = reference level, duration equal to or more than one hour OR= 0.49, p = 0.019). Conclusions: Antimalarial drug pressure varied considerably from one site to another. It was significantly higher in areas with intermediate malaria transmission level and in the most accessible sites. Thus, P. falciparum strains arriving in cross-road sites or in areas with intermediate malaria transmission are exposed to higher drug pressure, which could favour the selection and the spread of drug resistance.

Reduction of transmission from malaria patients by artemisinin combination therapies: a pooled analysis of six randomized trials

2008-07-09

Background: Artemisinin combination therapies (ACT), which are increasingly being introduced for treatment of Plasmodium falciparum malaria, are more effective against sexual stage parasites (gametocytes) than previous first-line antimalarials and therefore have the potential to reduce parasite transmission. The size of this effect is estimated in symptomatic P. falciparum infections. Methods: Data on 3,174 patients were pooled from six antimalarial trials conducted in The Gambia and Kenya. Multivariable regression was used to investigate the role of ACT versus non-artemisinin antimalarial treatment, treatment failure, presence of pre-treatment gametocytes and submicroscopic gametocytaemia on transmission to mosquitoes and the area under the curve (AUC) of gametocyte density during the 28 days of follow up. Results: ACT treatment was associated with a significant reduction in the probability of being gametocytaemic on the day of transmission experiments (OR 0.20 95% CI 0.16-0.26), transmission to mosquitoes by slide-positive gametocyte carriers (OR mosquito infection 0.49 95% CI 0.33-0.73) and AUC of gametocyte density (ratio of means 0.35 95% CI 0.31-0.41). Parasitological treatment failure did not account for the difference between ACT and non-artemisinin impact. The presence of slide-positive gametocytaemia prior to treatment significantly reduced ACT impact on gametocytaemia (p<0.001). Taking account of submicroscopic gametocytaemia reduced estimates of ACT impact in a high transmission setting in Kenya, but not in a lower transmission setting in the Gambia. Conclusions: Treatment with ACT significantly reduces infectiousness of individual patients with uncomplicated falciparum malaria compared to previous first line treatments. Rapid treatment of cases before gametocytaemia is well developed may enhance the impact of ACT on transmission.

Median knock-down time as a new method for evaluating insecticide-treated textiles for mosquito control

Ole Skovmand, Julien Bonnet, Olivier Pigeon and Vincent Corbel — 2008-06-27

Background: Insecticide treated bed nets are major tools for the Roll Back Malaria campaign. There are two types of Long-Lasting Insecticide-treated Nets (LNs) on the market: coated nets and insecticide-incorporated nets. Nets provided to this market need a recommendation from the World Health Organization to be purchased by donors and NGOs. During laboratory study (phase I), the first step consists in evaluating the wash resistance of a new LN product. When insecticide-incorporated nets are washed, it takes time to regenerate the insecticidal activity, i.e. insecticide must migrate to the net surface to be accessible to mosquitoes. The interval of time required for regeneration must be carefully determined to ensure the accuracy of further results. WHOPES procedures currently recommend the determination of the regeneration time by using mortality data. However, as mortality cannot exceed 100%, a LN that regenerates a surface concentration exceeding the dosage for 100% mortality, will have its regeneration time underestimated. Methods: The Median Knock Down Time (MKDT) was determined as function of insecticide dosage on an inert surface, glass, and on polyester nettings using an acetone solution or a simple emulsion. Dosage response was also established for mortality data. The same method was then applied to a commercially polyethylene netting, currently under WHOPES evaluation, to determine the dynamics of regeneration as function of repeated washings. The deltamethrin content of these nets was estimated by Capillary Gas Chromatography (GC-ECD). Results: MKDT was a linear function of log insecticide dosage on glass as on nettings. Mortality data were either 0 or 100% for most concentrations except for a narrow range. MKDT was log linear function of total deltamethrin content in a commercial polyethylene net exposed to washings. The regeneration time of this net increased with the number of washes and MKDT became higher. A new, easy and rapid method to determine MKDT is suggested.DiscussionThe MKDT is linearly correlated to log dosage on a given substrate and shows no saturation as mortality data do. It is suited to determine regeneration time of a product that is exposed to a stress, like washing or heating, where the process impacts on the bio-availability of the insecticide. Mortality data are useful for measuring product efficacy, whereas MKDT are better to measure dynamics of surface concentration like regeneration after a stressing process. Change in MKDT can be used to illustrate the loss of insecticide due to washing, but the slope of the curve is product and surface-dependent.

Full blood count and haemozoin-containing leukocytes in children with malaria: diagnostic value and association with disease severity

2008-06-12

Background: Diligent and correct laboratory diagnosis and up-front identification of risk factors for progression to severe disease are the basis for optimal management of malaria. Methods: Febrile children presenting to the Medical Research Unit at the Albert Schweitzer Hospital (HAS) in Lambaréné, Gabon, were assessed for malaria. Giemsa-stained thick films for qualitative and quantitative diagnosis and enumeration of malaria pigment, or haemozoin (Hz)-containing leukocytes (PCL) were performed, and full blood counts (FBC) were generated with a Cell Dyn 3000® instrument. Results: Compared to standard light microscopy of Giemsa-stained thick films, diagnosis by platelet count only, by malaria pigment-containing monocytes (PCM) only, or by pigment-containing granulocytes (PCN) only yielded sensitivities/specificities of 92%/93%; 96%/96%; and 85%/96%, respectively. The platelet count was significantly lower in children with malaria compared to those without (p < 0.001), and values showed little overlap between groups. Compared to microscopy, scatter flow cytometry as applied in the Cell-Dyn 3000® instrument detected significantly more patients with PCL (p < 0.01). Both PCM and PCN numbers were higher in severe versus non-severe malaria yet reached statistical significance only for PCN (p < 0.0001; PCM: p = 0.14). Of note was the presence of another, so far ill-defined pigment-containing group of phagocytic cells, identified by laser-flow cytometry as lymphocyte-like gated events, and predominantly found in children with malaria-associated anaemia. Conclusion: In the age group examined in the Lambaréné area, platelets are an excellent adjuvant tool to diagnose malaria. Pigment-containing leukocytes (PCL) are more readily detected by automated scatter flow cytometry than by microscopy. Automated Hz detection by an instrument as used here is a reliable diagnostic tool and correlates with disease severity. However, clinical usefulness as a prognostic tool is limited due to an overlap of PCL numbers recorded in severe versus non-severe malaria. However, this is possibly because of the instrument detection algorithm was not geared towards this task, and data lost during processing; and thus adjusting the instrument's algorithm may allow to establish a meaningful cut-off value.

Recent reduction in the water level of Lake Victoria has created more habitats for Anopheles funestus

Noboru Minakawa, George Sonye, Gabriel O Dida, Kyoko Futami and Satoshi Kaneko — 2008-07-03

Background: The water level of Lake Victoria has fallen more than 1.5 m since 1998, revealing a narrow strip of land along the shore. This study determined whether the recent drop in the water level has created additional breeding grounds for malaria vectors. Methods: The recent and past shorelines were estimated using landmarks and a satellite image. The locations of breeding habitats were recorded using a GPS unit during the high and low lake water periods. GIS was used to determine whether the breeding habitats were located on newly emerged land between the new and old shorelines. Results: Over half of the breeding habitats existed on newly emerged land. Fewer habitats for the Anopheles gambiae complex were found during the low water level period compared to the high water period. However, more habitats for Anopheles funestus were found during the high water level period, and they were all located on the newly emerged land. Conclusions: The recent reduction in water level of Lake Victoria has increased the amount of available habitat for A. funestus. The results suggest that the water drop has substantially affected the population of this malaria vector in the Lake Victoria basin, particularly because the lake has a long shoreline that may harbour many new breeding habitats.

Suppression of Plasmodium falciparum by serum collected from a case of Plasmodium vivax infection

2008-06-26

Background: It has frequently been reported that Plasmodium vivax suppressed Plasmodium falciparum and ameliorated disease severity in patients infected with these two species simultaneously. The authors investigate the hypothesis that immunological responses stimulated by P. vivax may play a role in suppressing co-infecting P. falciparum. Methods: Sera, taken sequentially from one of the authors (YN) during experimental infection with P. vivax, were added to in vitro cultures of P. falciparum. Cross-reactive antibodies against P. falciparum antigens, and cytokines were measured in the sera. Results: Significant growth inhibitory effects upon P. falciparum cultures (maximally 68% inhibition as compared to pre-illness average) were observed in the sera collected during an acute episode. Such inhibitory effects showed a strong positive temporal correlation with cross-reactive antibodies, especially IgM against P. falciparum schizont extract and, to a lesser degree, IgM against Merozoite Surface Protein (MSP)-119. Interleukin (IL)-12 showed the highest temporal correlation with P. vivax parasitaemia and with body temperatures in the volunteer. Conclusion: These results suggest the involvement by cross-reactive antibodies, especially IgM, in the interplay between plasmodial species. IL-12 may be one of direct mediators of fever induction by rupturing P. vivax schizonts, at least in some subjects. Future studies, preferably of epidemiological design, to reveal the association between cross-reactive IgM and cross-plasmodial interaction, are warranted.

Spatially-explicit risk profiling of Plasmodium falciparum infections at a small scale: a geostatistical modelling approach

2008-06-23

Background: There is a renewed political will and financial support to eradicate malaria. Spatially-explicit risk profiling will play an important role in this endeavour. Patterns of Plasmodium falciparum infection prevalence were examined among schoolchildren in a highly malaria-endemic area. Methods: A questionnaire was administered and finger prick blood samples collected from 3,962 children, aged six to 16 years, attending 55 schools in a rural part of western Côte d'Ivoire. Information was gathered from the questionnaire on children's socioeconomic status and the use of bed nets for the prevention of malaria. Blood samples were processed with standardized, quality-controlled methods for diagnosis of Plasmodium spp. infections. Environmental data were obtained from satellite images and digitized maps. Bayesian variogram models for spatially-explicit risk modelling of P. falciparum infection prevalence were employed, assuming for stationary and non-stationary spatial processes.FindingsThe overall prevalence of P. falciparum infection was 64.9%, ranging between 34.0% and 91.9% at the unit of the school. Risk factors for a P. falciparum infection included age, socioeconomic status, not sleeping under a bed net, distance to health care facilities and a number of environmental features (i.e. normalized difference vegetation index, rainfall and distance to rivers). After taking into account spatial correlation only age remained significant. Non-stationary models performed better than stationary models. Conclusion: Spatial risk profiling of P. falciparum prevalence data provides a useful tool for targeting malaria control intervention, and hence will play a role in the quest of local elimination and ultimate eradication of the disease.

Plasmodium vivax trophozoites insensitive to chloroquine

2008-05-27

Background: Plasmodium vivax is a major cause of malaria and is still primarily treated with chloroquine. Chloroquine inhibits the polymerization of haem to inert haemozoin. Free haem monomers are thought to catalyze oxidative damage to the Plasmodium spp. trophozoite, the stage when haemoglobin catabolism is maximal. However preliminary in vitro observations on P. vivax clinical isolates suggest that only ring stages (early trophozoites) are sensitive to chloroquine. In this study, the stage specific action of chloroquine was investigated in synchronous cryopreserved isolates of P. vivax. Methods: The in vitro chloroquine sensitivity of paired ring and trophozoite stages from 11 cryopreserved P. vivax clinical isolates from Thailand and two Plasmodium falciparum clones (chloroquine resistant K1 and chloroquine sensitive FC27) was measured using a modified WHO microtest method and fluorometric SYBR Green I Assay. The time each stage was exposed to chloroquine treatment was controlled by washing the chloroquine off at 20 hours after the beginning of treatment. Results: Plasmodium vivax isolates added to the assay at ring stage had significantly lower median IC50s to chloroquine than the same isolates added at trophozoite stage (median IC50 12 nM vs 415 nM p < 0.01). Although only 36% (4/11) of the SYBR Green I assays for P. vivax were successful, both microscopy and SYBR Green I assays indicated that only P. vivax trophozoites were able to develop to schizonts at chloroquine concentrations above 100 nM. Conclusion: Data from this study confirms the diminished sensitivity of P. vivax trophozoites to chloroquine, the stage thought to be the target of this drug. These results raise important questions about the pharmacodynamic action of chloroquine, and highlight a fundamental difference in the activity of chloroquine between P. vivax and P. falciparum.

Amodiaquine-artesunate vs artemether-lumefantrine for uncomplicated malaria in Ghanaian children: a randomized efficacy and safety trial with one year follow-up

2008-07-11

Background: Artesunate-amodiaquine (AS+AQ) and artemether-lumefantrine (AM-L) are efficacious artemisinin combination therapy (ACT) regimens that have been widely adopted in sub-Saharan Africa. However, there is little information on the efficacy of these regimens on subsequent episodes beyond 28 days, or on the safety of repeated treatments. Methods: Children aged six months to 14 years with uncomplicated malaria were randomly assigned to treatment with AS+AQ (n = 116), or AM-L (n = 111). Recruited subjects were followed-up, initially for 28 days, and then monthly for up to one year. All subsequent attacks of uncomplicated malaria after 28 days were treated with the same regimen as at randomization. Investigations aimed at determining efficacy and side effects were conducted. Results: Adequate clinical and parasitological response in subjects with evaluable end-points were, 97.1% (100/103) and 98.2% (107/109) on day 14, and 94.2% (97/103) and 95.3% (102/107) on day 28 in the AM-L and AS+AQ groups, respectively. Similar results were obtained after PCR correction. The incidence of malaria attacks in the year following recruitment was similar between the two treatment groups (p = 0.93). There was a high incidence of potentially AQ-resistant parasites in the study area. The incidence of adverse events, such as pruritus, fatigue and neutropaenia were similar in the two treatment groups. No patient showed signs of hearing impairment, and no abnormal neurological signs were observed during one year of follow-up. Other adverse events were mild in intensity and overlapped with known malaria symptomatology. No adverse event exacerbation was observed in any of the subjects who received multiple treatment courses with these ACT regimens during one year follow-up. Conclusion: AS+AQ and AM-L were efficacious for treatment of children with uncomplicated malaria in Ghana and drug-related adverse events were rare in treated subjects during one year of follow-up. The high prevalence of potentially AQ resistant parasites raises questions about the utility of AQ as a partner drug for ACT in Ghana. The efficacy of AS+AQ in Ghana requires, therefore, continuous monitoring and evaluation.Trial registrationNCT 00406146 http://www.clinicaltrials.gov