Plasmodium falciparum malaria. However, only a small number of research centres have the facilities required to perform such studies. CHMI by needle and syringe could help to accelerate the development of anti-malaria interventions by enabling centres worldwide to employ CHMI.Controlled human malaria infection (CHMI) by mosquito bite is a powerful tool for evaluation of vaccines and drugs against P. falciparum sporozoites  in 36 malaria naïve volunteers. In part A, the effect of the inoculation volume was assessed: 18 participants were injected intramuscularly (IM) with a dose of 2,500 PfSPZ divided into two injections of 10 µL (n = 6), 50 µL (n = 6) or 250 µL (n = 6), respectively. In part B, the injection volume that resulted in highest infectivity rates in part A (10 µL) was used to formulate IM doses of 25,000 PfSPZ (n = 6) and 75,000 PfSPZ (n = 6) divided into two 10-µL injections. Results from a parallel trial led to the decision to add a positive control group (n = 6), each volunteer receiving 3,200 PfSPZ in a single 500-µL injection by direct venous inoculation (DVI).An open-label CHMI study was performed with aseptic, purified, cryopreserved Four/six participants in the 10-µL group, 1/6 in the 50-µL group and 2/6 in the 250-µL group developed parasitaemia. Geometric mean (GM) pre-patent periods were 13.9, 14.0 and 15.0 days, respectively. Six/six (100%) participants developed parasitaemia in the 25,000 and 75,000 PfSPZ IM and 3,200 PfSPZ DVI groups. GM pre-patent periods were 12.2, 11.4 and 11.4 days, respectively. Injection of PfSPZ Challenge was well tolerated and safe in all groups.IM injection of 75,000 PfSPZ and DVI injection of 3,200 PfSPZ resulted in infection rates and pre-patent periods comparable to the bite of five PfSPZ-infected mosquitoes. Remarkably, it required 23.4-fold more PfSPZ administered IM than DVI to achieve the same parasite kinetics. These results allow for translation of CHMI from research to routine use, and inoculation of PfSPZ by IM and DVI regimens.Trial registration: ClinicalTrials.gov NCT01771848.The online version of this article (doi:10.1186/s12936-015-0817-x) contains supplementary material, which is available to authorized users. Malaria is one of the oldest and deadliest foes of mankind. Transmission of this parasitic disease continues in 97 countries worldwide, with 198 million cases of malaria and 584,000 deaths estimated in 2013, 90% of them occurring in Africa , human immunodeficiency virus (HIV), hepatitis B, and hepatitis C serology, urine pregnancy test, electrocardiogram and risk assessment of cardiovascular disease. Main exclusion criteria were residence in a malaria-endemic region within the previous 6 months, history of receiving an investigational malaria vaccine, positive P. falciparum serology, pregnancy, any finding that suggested a chronic condition, or that in the opinion of the study physician, could significantly increase the risk to the volunteer of developing severe malaria infection.The study was an open-label, non-randomized, controlled study in healthy adults conducted at the ISGlobal-Barcelona Centre for International Health Research (CRESIB), Hospital Clínic-Universitat de Barcelona and at the Drug Research Centre (CIM), Institute of Biomedical Research (IIB), Research Institute of Santa Creu and Sant Pau Hospital, Barcelona, Spain from December 2012 to July 2013. Volunteers 18–45 years of age were invited to participate and screened for eligibility. The main target group for recruitment was students from the Universitat de Barcelona (UB) and their close relatives and friends. Two information sessions  were held at the UB School of Medicine to explain the study and invite subjects to participate. Subsequently, interested students (groups of 4–14) were interviewed by the study physicians to provide more detailed information and answer questions. Additionally, institutional emails  were sent informing and inviting participation in the study. Eligibility was assessed by medical history, physical examination, standard haematological and biochemical tests, measurement of antibodies to asexual, erythrocytic Before any intervention  all volunteers gave written informed consent and answered correctly a questionnaire aimed to test their understanding of the study. They were requested to give three close contact phone numbers and social security numbers, to be able to search for them in case of missing follow-up visits. The study received approval by the ethics committees of Hospital Clínic and Hospital de la Santa Creu i Sant Pau together with the administrative clearance provided by the Health Department of Generalitat de Catalunya. The study followed the principles of the Declaration of Helsinki in its 6th revision (2008) as well as International Conference on Harmonization—Good Clinical Practice (ICH-GCP) guidelines. The study is registered with ClinicalTrials.gov number NCT01771848.P. falciparum strain NF54 fully susceptible to chloroquine were purified, and cryopreserved at a specified concentration at Sanaria Inc. facilities as described [P. falciparum merozoite protein 1. Membrane integrity was tested by fluorescence microscopy of PfSPZ following incubation with SYBR green and propidium iodide. Volunteers were inoculated within 30 min after thawing of PfSPZ.SPZ from escribed , 17, 20.escribed . The quaescribed . BrieflyVolunteers were assigned to six different groups Group 1–6). Three groups were inoculated in part A and three in part B, according to the order of enrolment. Additionally, back-up volunteers were screened and inoculated only if any of the initially assigned volunteers withdrew or did not fulfill the study criteria shortly before the inoculation date  and examined on the following day (Day 1). Participants were provided with a diary where they were instructed to register their daily symptoms and concomitant medication taken, as well as with a card with contact information (telephone numbers of study physicians) and a digital thermometer. Between Day 2 and Day 5 volunteers were contacted daily by telephone. In part A, twice-daily visits and thick blood smears (TBS) were performed from Day 6 until the first positive blood smear or Day 21 was reached. In part B, once-daily visits were performed between Days 6 and 9, followed by twice-daily visits from Day 10 onwards. TBS were performed with blood samples taken by venipuncture in 2-mL EDTA tubes. On the day of first parasite detection by microscopy or Day 21, volunteers started a curative anti-malarial treatment with chloroquine. When chloroquine was contra-indicated as in the case of two volunteers with psoriasis, participants were treated with atovaquone–proguanil. Later follow-up visits of volunteers were performed on Days 35 and 90 after inoculation. Every time blood was taken for TBS, an extra blood sample was drawn in a 2-mL EDTA tube and stored at −80°C for subsequent assessment of sub-microscopic parasitaemia by quantitative real time polymerase reaction (qPCR). qPCR was performed retrospectively once all follow-up visits were completed. Adverse events (AE) and clinical symptoms were reviewed daily and graded according to standard criteria of the US Food and Drug Administration (FDA) guidelines  until daSuccessful infection was defined as the appearance of asexual parasites in peripheral blood, detected by TBS microscopy. The pre-patent period was defined as the time between PfSPZ Challenge injection and first positive TBS. Quantitative TBS were prepared as described elsewhere . In brieData were double-entered using the OpenClinica™  softwareP. falciparum parasitaemia and all had mild malaria. No volunteer required hospitalization, and all were successfully cured by anti-malarial treatment, no serious AE (SAE) occurred. Twenty-three of the participants who developed malaria had a negative TBS 1 day after onset of treatment. The two volunteers who were still positive by TBS 1 day after onset of treatment became TBS negative 2 days after diagnosis.Eligibility criteria was assessed in 71 volunteers from which 36 were enrolled  and one volunteer from Group 2 . The latter scratched the site of injection immediately after the inoculation took place and who had a non-pruritic, painless 4-mm diameter erythematous and edematous area at one of the injection sites that lasted 1 day. This volunteer did not develop parasitaemia. All AEs observed during the pre-erythrocytic phase were transient and the majority were mild  after day 5 (D5) and before malaria diagnosis or D21 for those who did not develop parasitaemia; and, (2) after treatment, which was on the day of diagnosis for those who developed parasitaemia and on D21 for those who did not develop parasitaemia, through to the completion of follow-up visits on D90.No Grade 3 AEs were observed during the first erythrocytic phase after D5 and before diagnosis of malaria or D21. The most frequent Grade 2 AE attributed to malaria during this phase was headache (27%), followed by fatigue (7%). Only one volunteer developed a Grade 2 fever (38°C); this occurred one visit before malaria diagnosis. A detailed list of the AEs of moderate intensity (Grade 2) observed during this period is provided in Additional file P. falciparum infection. No SAE occurred. A summary of the frequency of volunteers that presented Grade 3 AEs in both pre-erythrocytic and erythrocytic stages by inoculation group is shown in Additional file A total of 377 AEs occurred after the day of malaria diagnosis or D21 and the completion of the follow-up visits Table . The mosTwo volunteers presented during clinical malaria with additional symptoms. One 40-years old female, who received 3,200 PfSPZ by DVI, was diagnosed with malaria with a parasitaemia of 1.25 parasites/µL 10 days after inoculation of PfSPZ Challenge. She received chloroquine treatment immediately after, with malaria symptoms lasting 24 h and with a negative TBS 1 day after onset of treatment. Between the third and the fourth dose of chloroquine, , she developed anxiety, insomnia, anhedonia and anticipatory fear. As malaria symptoms were absent and the TBS was negative; she was referred to the psychiatry department of the Hospital Clínic where she was diagnosed with unspecified anxiety disorder. She received benzodiazepines for 2 months and was safely managed as an outpatient. No anxiety was reported at D90 visit. Another female volunteer, a 20-years old, UB medical student, who received 75,000 PfSPZ IM, was diagnosed with malaria with a parasitaemia of 3.3 parasites/µL 12 days after injection of PfSPZ Challenge. She presented after the second dose of chloroquine (6 h after onset of treatment) with parasternal chest pain of moderate intensity, described as a burning sensation, accompanied by shortness of breath after moderate effort. Due to the antecedent of a cardiac AE after initiation of treatment for malaria in a CHMI in The Netherlands , she wasThirty-six healthy volunteers, 20 women and 16 men between ages 19 and 41, were enrolled out of a group of 71 volunteers who were assessed for eligibility Fig. . DemograIn part B, 18/18 (100%) volunteers developed parasitaemia. GM pre-patent periods were 11.4, 12.2 and 11.4 days for Group 4 , Group 5  and Group 6 , respectively  had an infectivity rate of 67% and a GM pre-patent period of 13.9 days; Group 5  had an infectivity rate of 100% and a GM pre-patent period of 12.2 days; and Group 6  had an infectivity rate of 100% and a GM pre-patent period of 11.4 days. Pre-patent periods compared between these three groups were significantly different  which was attributed to the reduction in the pre-patent period in the 75,000 PfSPZ dose group compared to that in the 2,500-dose group  or the 25,000-dose group   and the shortest pre-patent period (13.9 days) occurred in those volunteers administered 2,500 PfSPZ in 10 μL. As the dose was increased from 2,500 to 25,000 to 75,000 PfSPZ in a constant 10-μL volume IM, the infectivity rate increased and the pre-patent period decreased: Group 1  had an infectivity rate of 67% and a GM pre-patent period of 13.9 days (range 12.0–15.0); Group 5  had an infectivity rate of 100% and a GM pre-patent period of 12.2 days (range 11.1–13.3); and Group 6  had an infectivity rate of 100% and a GM pre-patent period of 11.4 days (range 11.0–12.0).Additionally, the findings of the UKT trial were corroborated . In a diVolunteers injected with 3,200 PfSPZ by DVI or 75,000 PfSPZ in 10 µL IM had infectivity rates and same GM pre-patent periods (11.4 days) comparable to CHMI by exposure to five PfSPZ-infected mosquito bites. This is the first clear comparison in humans between the infection rates after DVI and IM injection. It required 23.4-fold more PfSPZ administered IM than DVI to achieve the same infection rate and pre-patent period. Murine studies predicted that IV/DVI would be more efficient than IM injection, but not to this degree . IntradeP. falciparum exposure, studies that may be useful for the development and fielding of future malaria vaccines.Administration of two different quantities of PfSPZ Challenge by two different routes of administration , were safe and comparable to mosquito-administered CHMI. In consequence these inoculation regimens represent an alternative tool to mosquito-administered CHMI for researchers worldwide, especially in malaria-endemic countries where vaccine and drug efficacy trials in semi-immune and immune individuals are greatly needed. Such studies in endemic countries will also provide a unique opportunity to study the impact of adaptive immunity and innate phenotypes  on infection rates, pre-patent periods and clinical manifestations of malaria in different populations with different levels of


This study was part of the work to prepare for a cluster-randomized controlled trial to evaluate the effect of combining indoor residual spraying and long-lasting insecticidal nets on malaria incidence. A pilot study was done to estimate the variations of malaria incidence among villages, combined with entomological collections and an assessment of susceptibility to insecticides in malaria vectors.kebeles (the lowest government administrative unit) in 996 households was followed from August to December 2013 in south-central Ethiopia. Blood samples were collected by a finger prick for a microscopic examination of malaria infections. A multilevel mixed effect model was applied to measure the predictors of malaria episode. Adult mosquitoes were collected using light traps set indoors close to a sleeping person, pyrethrum spray sheet catches and artificial outdoor pit shelters. Enzyme-linked immunosorbent assays were used to detect the sources of mosquito blood meals, while mosquito longevity was estimated based on parity. The World Health Organization’s tube bioassay test was used to assess the insecticide susceptibility status of malaria vectors to pyrethroids and carbamates.A cohort of 5309 residents from four kebeles near a lake or river  were significantly associated with malaria episode. Only 271 (27.3 %) of the households owned insecticide-treated nets. Of 232 adult Anopheles mosquitoes collected, Anopheles arabiensis (71.1 %) was the predominant species. The average longevity of An. arabiensis was 14 days (range: 7–25 human blood index days). The overall human blood index (0.69) for An. arabiensis was higher than the bovine blood index (0.38). Statistically significant differences in Anopheline mosquitoes abundance were observed between the kebeles (P = 0.001). Anopheles arabiensis was susceptible to propoxur, but resistant to pyrethroids. However, An. pharoensis was susceptible to all pyrethroids and carbamates tested.The average incidence of malaria episode was 4.6 per 10,000 person weeks of observation. The age group from 5 to 14 years  and Anopheles between kebeles. The observed susceptibility of the malaria vectors to propoxur warrants using this insecticide for indoor residual spraying, and the results from this study will be used as a baseline for the trial.This study showed a high variation in malaria incidence and  Long-lasting insecticidal nets (LLINs) and indoor residual spraying (IRS) are the two main malaria vector control tools available today . A worldPlasmodium falciparum  and P. vivax (33 %) , n vector . The tran vector , 6, in an vector . Early dn vector . Despiten vector  and effon vector .gares , and to determine insecticide susceptibility status.In Ethiopia, IRS and LLINs are commonly used, both separately or in combination, in the same households . The indkebeles (the lowest government administrative unit). Each kebele is further divided into gares, with each gare having an average of 35 households. The geographic location of the district and the selected kebeles are shown in Fig. kebele staffed by two health extension workers, who provide comprehensive preventive services to the community, including malaria diagnosis and treatment.This pilot study was conducted in the Adami Tullu part of the Adami Tullu-Judo-Kombolcha district (hereafter referred to as the Adami Tullu district) located 160 km south of Addis Ababa, the capital of Ethiopia, and described in detail elsewhere . Brieflygares selected from four kebeles was followed from August to December 2013. The study participants were selected through the following procedure: A preliminary mapping and census of 24 kebeles (sampling frame) in the Adami Tullu district was done in March and April 2013, with four kebeles selected from the enumerated 24 kebeles based on their distance from the main mosquito breeding sites (the Zeway lakeshore and the Bulbula River) and malaria burden . Two of the kebeles, Bochesa and Anano-Shisho, were located within 5 km and the other two, Elka-Chelemo and Gallo Raphe, which were beyond 5 km from the Zeway lake-shore and Bulbula River. To make access easy for patients with clinical sign of malaria, 29 gares within a 3-km radius from the community health posts were included. All the residents (5309) in these villages were invited to participate in the baseline survey in August 2013, and were followed-up weekly for 16 weeks.A cohort of 5309 residents from 996 households in 29 ® for P. falciparum and chloroquine for P. vivax) according to the national malaria treatment guidelines [Households were visited weekly (active surveillance), and household members with fever (body temperature ≥37.5 °C and/or history of fever in the last 48 h) were identified and referred to health posts. In addition, residents were asked to visit the health posts if they developed a fever when the project staff was not available (passive surveillance). Blood samples were collected by a finger prick of all febrile cases reported to the health posts, and rapid diagnostic tests (RDTs) and microscopic slide examination were performed. Patients with positive RDT were treated at the health posts with anti-malarial drugs  from each of the three kebeles  were randomly selected for adult mosquito collections. Households were selected at random from the 36 gares, and indoor and outdoor mosquito collections were undertaken every month. For indoor host-seeking mosquito collections, the Center for Disease Control and Prevention light traps (CDC-LTs) were set in one house per gare and allowed to operate from 6:00 pm to 6:00 am. The traps were hung approximately 45 cm above the floor near the feet of occupants protected by LLINs. Indoor and outdoor resting mosquitoes were collected using standard pyrethrum spray catches (PSC) and artificial pit shelters from 6:00 am to 9:00 am, respectively. The PSC was carried out from one randomly selected house per gare, while pit shelter collections were performed from six pits per kebele from a total of 18 gares.The entomological study was conducted from June to October 2013, and a total of 36 Anopheles gambiae sibling species identification was carried out through the use of the polymerase chain reaction (PCR) method [P. falciparum and P. vivax circumsporozoite protein (CSP) by direct enzyme-linked immunosorbent assay (ELISA) [Mosquitoes were identified to species by morphological characteristics using an identification key . Anophel) method . The hea (ELISA) .Anopheles were dissected for parity using Detinova’s ovary tracheation method [Anopheles mosquito longevity and PR were used to estimate mosquito life expectancy based on the formula proposed by Davidson [An. arabiensis and An. pharoensis was made on a gc value of 3 days [Anopheles species, longevity was only estimated for An. arabiensis and An. pharoensis.The sources of mosquito blood meals were determined by the direct ELISA procedure using human and bovine antibodies . The abdn method . The parDavidson . Since tf 3 days . BecauseAn. arabiensis and An. pharoensis. The test for the former species was done in August 2013, a time when the aquatic forms are abundant. In October and November of the same year the tests for the latter species were undertaken. The WHO tube test [The larvae and pupae of mosquitoes were collected from different breeding sites, and were reared to adults in big cages. Insecticide susceptibility tests were conducted on two species, ube test  was emplAfter the morphological identification of females , 2-3-dayMalaria episodes measured by the microscopic slide examination of blood samples for the presence or absence of the malaria parasite was the response variable. Adult mosquito host-seeking and resting density were the response variable for entomological study.kebele factors). The individual factors were ITN use, age group  and gender, whereas the educational status of the head of the household and the wealth index were household factors. The kebele factors included the distance from lakeshore or river (within or beyond 5 km).The multilevel mixed effect model included covariates associated with malaria episode  and Stata 13 . Descriptive statistics including percentages, mean and standard deviations, were used to summarize the data. A multilevel mixed effects Poisson regression model was fitted to measure associations between response and predictor variables. Malaria incidence (count data) was assumed to follow a Poisson distribution based on random and independent occurrence. Hence, a three-level mixed effects Poisson model with log link was considered to account for malaria episodes, with clustering according to individuals, households and A household wealth index was constructed using a principal component analysis (PCA) . Fourteegares and the study months, were analysed using a non-parametric Kruskal–Wallis test. The human blood index (HBI) and bovine blood index (BBI) were calculated based on WHO guidelines [Variations in adult mosquito host-seeking and resting density, both within and among the idelines , and allThe study protocol and informed consent forms were reviewed and approved by the Institutional Review Board of the College of Health Sciences at Addis Ababa University, Ethiopia and by the Regional Committee for Medical and Health Research (ref: 2013/986/REK Vest), Norway. The national ethical clearance was obtained from the Ethiopian Ministry of Science and Technology (ref: 3.10/446/06). Written permission to undertake the study was obtained from the Oromia Regional Health Bureau, the East Shewa Zone Health Department and the Adami Tullu District Health Offices. Local leaders, village leaders and community elders were also informed about the purposes of the study. Participation in the study was voluntary, and informed consent was obtained from each participant above the age of 18 years. For participants less than 18 years old, consent was obtained from parents or caretakers, while verbal consent was obtained from household heads before routine mosquito collections. Patients who were positive for malaria by RDT were treated at the health posts according to the national guidelines for malaria treatment.kebeles were registered at baseline. The number of households per kebele was 325 (32.6 %) in Anano Shisho, 263 (26.4 %) in Bochesa, 210 (21.1 %) in Gallo Raphe and 198 (19.9 %) in Elka Chelemo. Three households  were lost to follow up, with an average household size of 5.3 persons. Nearly half, or 49.9 % (2651) of them were women, and the median age was 15 (IQR = 7–28) years.A total of 5309 individuals in 996 households from four Plasmodium vivax accounted for 33 (84.6 %) of the positive slides  and from 5 to 14 years age group   slides were microscopically confirmed positive for malaria infection, and 12 (30 %) of these cases were identified through weekly home visits.  % slidesLess than one-third of the households  owned insecticide-treated nets. Data on ITN use (self-report of sleeping under ITNs last night) was collected during a census at the beginning of the study and once per week during the home visit. The percentage of ITN use among households that own an ITN was 49 % (n = 657), but the percentage for all participants was low (11 %). The median days individuals slept under an ITN for the 16 weekly visits was 2 days.kebeles close to Zeway Lake and the Bulbula River had almost a 14.2 (95 % CI 3.1–64.7) times higher risk of malaria infection than those further away from the lake and river. The other variables, including gender, educational status of the head of the household, ITN use and wealth index, were not found to be predictors of malaria in the study area.The multivariate multilevel mixed effects model results Table  showed tAnopheles mosquitoes were collected over the 5 months  and the least in Gallo Raphe (18.5 %). The Anopheles abundance varied over the study months with a peak in September after the rainy season  and between the 36 gares . The same statistical test revealed that there were significant differences in host-seeking abundances (light trap catches) of An. arabiensis (P = 0.025), An. pharoensis (P = 0.001) and An. zeimanni (P = 0.015) between kebeles. However, the indoor host-seeking abundance (light traps) of An. funestus s.l. was not significantly different between kebeles (P = 0.458).kebeles and gares in the abundance of indoor resting anophelines (PSC) (P > 0.05) and outdoor resting anophelines (pit shelter) (P > 0.05).Moreover, no significant differences were detected between Anopheles tested, the overall HBI and BBI was 0.70 and 0.38, respectively  than bovines (0.29). The HBI was higher for An. arabiensis collected indoors (0.79) than for those collected outdoors (0.37). Inversely, the BBI was higher for An. arabiensis caught outdoors (0.68) compared to those collected indoors (0.27). All An. pharoensis females that had fed on humans were captured indoors, though none of the indoor- and outdoor-collected An. pharoensis females had taken blood from bovines alone. Anopheles ziemanni fed more on bovine (BBI = 0.67) than human (HBI = 0.50).Of 107 freshly fed ly Table , with thP. falciparum and P. vivax circumsporozoite proteins. Table An. arabiensis and An. pharoensis. The overall average age of An. arabiensis and An. pharoensis females was 14 days (range: 7–25 days) and 1.6 days (range: 0–6.3 days), respectively.All collected mosquitoes (n = 232) were negative for gares from three kebeles . A higher mean (four) indoor host-seeking density of Anopheles mosquito was observed in kebele (Bochesa) near a lake. In the same kebele, a higher  malaria incidence was observed , but susceptible to bendiocarb and propoxur .ur Figs. , 8. All gares, and in gares closer to the lake or river, the incidence rate was close to eight cases per 10,000 person-weeks of observation. Plasmodium vivax was the dominant species, and a higher malaria incidence was observed in a kebele with overall higher mean host-seeking density of Anopheles.This study represents one of the few descriptions from Ethiopia on simultaneous epidemiological and entomological information. The overall malaria incidence rate was 4.6 cases per 10,000 person-weeks of observation. However, the incidence varied between the The observed malaria incidence in this study was higher (4.6 versus 3.6 episodes per person weeks) than what has been reported from southern Ethiopia , which cP. vivax was the dominant species in the study area, representing about 85 % of the positive cases. The 2011 malaria indicator survey also reported P. vivax as the main (60 %) causative agent in the Oromia region [In line with previous studies from other parts of the country , 29, P. a region .kebeles were located below 2000 metres above sea level, which is defined as the threshold for being a malarious area, differences in malaria distribution were observed among the kebeles and gares. Those Kebeles near to the lake or river had more incidences of malaria and a higher mean indoor host-seeking density of Anopheles mosquito, with similar observations done in other parts of Ethiopia [Anopheles mosquitoes and of water bodies [Although all of the study Ethiopia . The perr bodies  could haComparable to other studies , childreFamilies’ welfare, as measured by the wealth index, was not associated with the probability of malaria episodes in this study. The inclusion of villages close to a health post (within 3 km), as well as weekly home visits to identify residents with clinical symptoms of malaria, could have motivated febrile cases to seek early treatment and reduce the risk of transmission to other family members in both poor and rich families. The ownership of ITNs in this study (27.3 %) was much lower than the WHO recommendations and the national goal (100 % coverage) , 34, andAnopheles arabiensis and An. pharoensis were the predominant species in Adami Tullu kebeles. These findings were consistent with Abose et al. [An.arabiensis as the primary- and An. pharoensis as secondary vectors in the area. The results also showed that the monthly average precipitation peaked in July and sharply declined from August to October, whereas Anopheles abundance rose in September and sharply dropped in October. This was expected since Anopheles population dynamics and malaria transmissions are driven by seasonal precipitation in Ethiopia [Anophelesarabiensis proliferates in rain-fed residual pools after months of heavy rain in the country [Anopheles abundance may not coincide with peak precipitation months.e et al. , who repEthiopia . Anophel country  and the  country . TherefoAnopheles density could be the rapid scale-up and intensive use of vector intervention measures, particularly ITNs and IRS in the country [Anopheles population controlling breeding and survival.Results indicate that the overall mosquito density captured by the different mosquito sampling methods was low compared to previous studies in the area . The rea country  and else country . Besides country , may havAn. arabiensis, which have behavioural plasticity in host preferences and shifts in peak biting time [The other key potential reason for the low mosquito catches could be the lack of efficient mosquito sampling tools . Efficieing time ; hence, An. arabiensis was higher than the BBI (0.38) for the same species. This finding contrasts prior studies that found a higher BBI for An. arabiensis than the HBI in the country [An. arabiensis compared to the BBI in the country. It should be noted that the present study used similar mosquito sampling methods than the previous study [An. arabiensis was higher indoors (0.73) than outdoors (0.21), but the BBI was higher when collected outdoors (0.53) than indoors (0.21). These results are generally in agreement with prior studies, which observed the opportunistic feeding behaviour of An. arabiensis [Anopheles pharoensis showed anthropophilic and endophilic behaviour in the area, but more blood-fed females should be tested to reach such conclusions. Furthermore, the average longevity of An. arabiensis ranged from 7 to 25 days in the villages, thereby implying that the vector had a sufficient longevity for malaria transmission during the study period.The overall HBI (0.69) for  country . However country , which fus study , thus thus study , that reabiensis . Anophelkebele was low. This could be due to some of the gares being located near the lakeshore in this kebele, where a higher mosquito abundance was not followed for malaria episodes. In kebeles where the two studies overlapped, high malaria episodes were observed in those with a higher indoor host-seeking density of Anopheles.Overall, the relative increase in the abundance of mosquitoes in September and the beginning of October, compared to the other study months, coincides with an increased incidence of malaria episodes in the same and subsequent months. In the entomological study, an overall high mosquito density was observed in Elka Chelemo kebele, although the malaria incidence for the Anopheles arabiensis was highly resistant to all the tested pyrethroids, including deltamethrin, but susceptible to bendiocarb and propoxur. The insecticide susceptibility study showed a resistance of An. arabiensis to the pyrethroids, which is the current insecticide of choice for the treatment of LLINs. This resistance may compromise the efficacy and effectiveness of ITNs. On the other hand, An. arabiensis is currently susceptible to the carbamates, which is useful and will be beneficial for the main trial.The use of weekly active case detection, which was supplemented with passive surveillance, would have maximized the number of cases captured by the study. In addition, the active monitoring of the occurrence and the abundance of adult mosquitoes through house-to-house surveys during the major malaria transmission season in the area is also another strength. Weaknesses of the study include a lack of efficient mosquito sampling methods for the local vectors, the overestimation of malaria incidence due to the inclusion of the major malaria transmission season and the self-report of sleeping under ITNs (difficult to observe), which may have affected the reported ITN usage.Anopheles among gares. Younger age groups and households located near lakes and rivers were significantly associated with malaria infection. Anopheles arabiensis had a high HBI (high human contact) and a sufficient longevity for malaria transmission. The observed susceptibility of the malaria vectors to propoxur warrants using this insecticide for indoor residual spraying, and results from this study will be used as a baseline for the trial.This pilot study showed a high variation of malaria incidence and


Plasmodium falciparum-infected erythrocytes to endothelial cells in microvessels is a remarkable characteristic of severe malaria. The endothelial protein C receptor (EPCR), encoded by the endothelial protein C receptor gene (PROCR), has recently been identified as an endothelial receptor for specific P. falciparum erythrocyte membrane protein 1 (PfEMP1) subtypes containing domain cassettes (DCs) 8 and 13. The PROCR rs867186-G allele  has been shown to be associated with higher levels of plasma soluble EPCR (sEPCR). In this study, the association of PROCR rs867186 with severe malaria is examined in Thai population.Cytoadhesion of P. falciparum malaria  were genotyped for rs867186. To assess the association of PROCR rs867186 with severe malaria, three models  were evaluated. The rates of non-synonymous and synonymous substitutions were estimated for the coding sequence of the PROCR gene.A total of 707 Thai patients with P-value = 0.026; odds ratio = 0.33; 95% confidence interval = 0.12–0.90). Evolutionary analysis provided no evidence of strong positive selection acting on the PROCR gene.The rs867186-GG genotype was significantly associated with protection from severe malaria (The rs867186-GG genotype showed significant association with protection from severe malaria. The present results suggest that PfEMP1–EPCR interaction, which can mediate cytoadhesion and/or reduce cytoprotective and anti-inflammatory effects, is crucial to the pathogenesis of severe malaria. Plasmodium falciparum-infected erythrocytes to endothelial cells in microvessels has been considered to be involved in the pathogenesis of severe malaria ) in exon 4 and one SNP (rs9574) in 3′UTR in seven Thai patients with malaria, which suggests that there was no common non-synonymous SNP other than rs867186 in the Thai population. To confirm this, polymorphisms of the PROCR gene in Asian populations were searched using the 1000 Genomes Project database [PROCR SNPs were polymorphic in a sample set of 97 CHB subjects and 89 JPT subjects: one SNP in 5′UTR and 20 SNPs in introns  is a derived allele (a point mutation that occurred in the human lineage). Therefore, the direction of association was determined by rs867186-G. Table versus rs867186-AG and rs867186-AA) showed a statistically significant difference in genotype frequency between patients with severe and mild malaria . Thus, rs867186-GG was associated with protection from severe malaria.The genotype frequencies of rs867186 in patients with malaria are shown in Table r2 ≥ 0.8) with rs867186 in Asian populations  was predicted to be “benign”, with a score of 0.201, by PolyPhen-2 software. Although rs867186-G was statistically associated with protection from severe malaria, rs867186 may not be an SNP primarily associated with severe malaria. In other words, the significant association of rs867186 with severe malaria may come from LD between rs867186 and a causative SNP. Analysis of LD detected ten SNPs in strong LD  did not significantly differ from that of synonymous substitution (dS = 0.011), suggesting that PROCR has not been under strong positive selection. It is noted here that the values of dN were calculated for human PROCR bearing 219Ser and 219Gly, separately.The observation that EPCR acts as a receptor for DC8 and DC13 PfEMP1  raises tPROCR rs867186 was significantly associated with severe malaria in Thai adult patients. There are two possible explanations for the association of rs867186-GG with protection from severe malaria. The serine-to-glycine substitution at codon 219 in the transmembrane of EPCR may introduce a conformational change in the molecule, which prevents DC8 and DC13 PfEMP1 from binding EPCR. The rs867186-G is associated with higher levels of sEPCR [P. falciparum-infected erythrocytes to the endothelial cells of microvessels. In addition, if DC8 and DC13 PfEMP1 variants are more likely to bind sEPCR than protein C, more protein C may be allowed to bind EPCR on endothelial cells in malaria patients with the rs867186-GG genotype than in those with the other genotypes. Binding of protein C to EPCR leads to the activation of protein C. Activated protein C exerts cytoprotective and anti-inflammatory effects, which may contribute to protection against severe malaria [The of sEPCR -24, and  malaria .P. falciparum-infected erythrocytes to the microvasculature of the brain. In this study, among 341 severe malaria patients, 108 patients had suffered from cerebral malaria. When patients with severe malaria were divided into two groups: 108 patients with cerebral malaria and 233 patients with non-cerebral severe malaria, rs867186-GG was found to be significantly associated with protection from non-cerebral severe malaria , but not with cerebral malaria   of positive selection may be small. If most sites are under purifying selection, it would not be possible to detect the significant difference between dN with dS in the entire coding region. The third is that PfEMP1 subtypes containing DC8 and DC13 may have appeared recently in P. falciparum and advantageous mutations that help to escape from the binding of DC8 and DC13 PfEMP1 to EPCR have not occurred yet in human PROCR.No evidence of positive selection was found in the evolutionary analysis based on the comparison of The authors declare that they have no competing interests.IN and JO performed statistical analyses and wrote the manuscript. IN performed PCR direct sequencing and genotyping. IN, JP and HH extracted DNA from human blood samples. HI extracted DNA from western chimpanzee blood samples. IN, JP, HI, and JO participated in the design and coordination of the study. All the authors read and approved the final manuscript.A phylogenetic tree of PROCR. Based on the estimated number of nucleotide substitutions, a phylogenetic tree of 14 human sequences, six western chimpanzee sequences, and a macaque sequence of the coding region of PROCR was constructed using the neighbour-joining method. The scale bar indicates nucleotide substitutions per site.Click here for fileMultiple sequence alignment of the coding region of PROCR.Click here for fileGenotype frequencies of rs867186 in cerebral, non-cerebral severe, and mild malaria patients.Click here for file


Rapid diagnostic tests (RDT) and light microscopy are still recommended for diagnosis to guide the clinical management of malaria despite difficult challenges in rural settings. The performance of these tests may be affected by several factors, including malaria prevalence and intensity of transmission. The study evaluated the diagnostic performance of malaria RDT, light microscopy and polymerase chain reaction (PCR) in detecting malaria infections among febrile children at outpatient clinic in Korogwe District, northeastern Tanzania.Plasmodium falciparum infection using histidine-rich-protein-2 (HRP-2)-based malaria RDT, light microscopy and conventional PCR.The study enrolled children aged 2–59 months with fever and/or history of fever in the previous 48 h attending outpatient clinics. Blood samples were collected for identification of P. falciparum infection with PCR analysis provided lower sensitivity and PPV of 88.6 %  and 84.3 %  for RDT compared to microscopy.A total of 867 febrile patients were enrolled into the study. Malaria-positive samples were 85/867  by RDT, 72/867  by microscopy and 79/677  by PCR. The performance of malaria RDT compared with microscopy results had sensitivity and positive predictive value (PPV) of 88.9 %  and 75.3 % , respectively. Confirmation of Diagnosis of malaria infection is still a challenge due to variation in results among diagnostic methods. HRP-2 malaria RDT and microscopy were less sensitive than PCR. Diagnostic tools with high sensitivity are required in areas of low malaria transmission. Plasmodium falciparum transmission across sub-Saharan Africa, malaria still remains a public health problem, especially among children aged under 5 years [Despite a remarkable reduction in  5 years , 2. In l 5 years . It is cFever has been the major complaint amongst children presenting at outpatient clinics, with malaria being the possible aetiology for such febrile illnesses . IntegraP. falciparum infection in settings with limited laboratory facilities [Despite its low sensitivity and limited availability, microscopy still remains the gold standard for malaria diagnosis. Malaria microscopy is time consuming, requires skilled laboratory technicians and is often subject to unreliable results from different laboratories . With thcilities . Both micilities , 13. Polcilities , 15. As cilities , 17. NonP. falciparum malaria infection among febrile children at outpatient clinics in Korogwe District, northeastern Tanzania.The performance of malaria diagnostic tests tends to vary depending on different settings of malaria transmission. The study evaluated the diagnostic performance of malaria RDT, light microscopy and conventional PCR in detecting P. falciparum malaria transmission in Tanga region, northeastern Tanzania [P. falciparum parasitaemia among children under 5 years of age from the community in both lowland and highland villages between 2009 and 2010 was below 10 % [Korogwe District is located in an area with differing low to moderate Tanzania . The envTanzania . The preSick children presenting at KDH outpatient clinic between monday and friday of every week were assessed for study eligibility. The inclusion criteria were: children aged between 2 and 59 months presenting at KDH with a history of fever in the previous 48 h or with measured axillary body temperature >37.5 °C at presentation. The visit should be their first consultation for a present problem. Exclusion criteria included severe and chronic illnesses, intake of antimicrobial and/or anti-malarial drugs within the previous 7 days, planned admissions , and trauma/injury.Medical history and clinical examination were performed on each patient by the study clinician and information was entered into a standardized case report form. This included demographic information, clinical history, vital signs, body weight, signs of dehydration, and neurological and physical examinations . Clinical diagnosis of malaria was done according to IMCI guidelines . A maxim®f  was used for detection of malaria infection. The test detects HRP-2 antigen from P. falciparum only. The tests were performed and interpreted following manufacturer’s instructions. The malaria RDT test results were provided directly to patients and assisted the clinician on clinical decision.Histidine rich protein 2 (HRP-2)-based RDT, paraHITP. falciparum and other Plasmodium species. The blood slides were read by two expert microscopists and in case of discrepancy, a third reading was performed. Asexual parasites were counted against 200 (500 if parasite count was <10) white blood cells. A blood slide was considered negative for Plasmodium species if no parasites were seen in at least 100 oil-immersion, high-power fields on the thick film.Thick and thin blood smears were prepared (in duplicate) from the blood collected in the ethylene diamine tetra acetic acid (EDTA) tubes. The thin film was fixed with methanol and blood slides were stained with a 5 % Giemsa solution for identification and quantitation of asexual P. falciparum species-specific PCR targeting mitochondrial genome 18S as previously described by Kho et al. [Three drops, each containing 50 μL of EDTA blood were spotted on a pre-made filter paper  and allowed to dry at room temperature. The filter papers were placed in zip-locked, plastic bags containing silica gel to preserve DNA integrity and stored at −20 °C and then transported to Republic of Korea for molecular analysis. DNA was extracted from half-segment of the filter spot using QIAamp DNA Blood Mini Kit  as described by the manufacturer, and eluted in a final volume of 100 μL. The extracted DNA was analysed using o et al. . The parLaboratory investigations were carried out at Korogwe Research Laboratory of the National Institute for Medical Research (Tanzania). PCR analysis was performed at the Institute of Tropical Medicine, Yonsei University (Republic of Korea). Quality control was conducted for all laboratory methods and procedures according to standard guidelines and manufacturers’ instructions. During the study, laboratory microscopists participated in the parasitology external quality assessment programme with the National Institute for Communicable Diseases (NICD).p < 0.05 was considered statistically significant. The performance of each diagnostic test method was calculated by means of sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) using conventional PCR as a reference standard.Data were double entered and validated using Microsoft Access database. Data analysis was performed using STATA . Variables were summarized as frequencies and percentages, medians and inter-quartile ranges as appropriate. Odds ratios and 95 % confidence intervals (CI) were calculated as appropriate and the value of P. falciparum by microscopy with geometric mean parasitaemia of 37,635  parasites/μL. Dried blood spots samples on filter paper for PCR analysis were prepared and performed from 677/867 (78.1 %) patients, of which 79/677  were positive for P. falciparum. Samples from 190/867 (21.9 %) patients were not available for PCR analysis; 153/190 (80.5 %) patients did not have sufficient blood for spotting on a pre-made filter paper and 37/190 (19.5 %) patients had low yield DNA extracted from dried blood spots on filter paper. The complete flow of the performed diagnostic tests and results are outlined in Fig. A total of 1380 sick children attending the outpatient clinic at KDH from January to October 2013 were screened; 867/1380 (62.8 %) met the inclusion criteria and were enrolled. The median age was 15.1 months (interquartile range (IQR): 8.6–29.9) and girls accounted for 408/867 (47.1 %) of patients , Fig. P. falciparum parasitaemia by light microscopy  and 97.4 % , respectively, with corresponding positive and negative predictive values of 75.3 %  and 99.0 %   were confirmed not having P. falciparum species by PCR. One sample that was both RDT and microscopy negative was detected positive by PCR. The sensitivity (88.6 %) and PPV (84.3 %) were lower for RDT compared to microscopy  for the first 6 months of life, mainly due to acquiring maternal antibodies and the presence of foetal haemoglobin –24. Threpfhrp2 gene, prozone effect or other factors, which could not be established [pfhrp2/pfhrp3) in parasites are not likely to be the main cause of false-negative results [The use of HRP-2-based malaria RDT in the current study resulted in over-diagnosis of malaria infection in 15 % of patients. This might suggest the presence of recent malaria infection. When compared with expert microscopy and PCR, the sensitivity value of malaria RDT was below the ≥95 % threshold recommended by WHO. These findings are similar to those reported by Shakely and colleagues on a hospital-based study conducted in Zanzibar, an area of low malaria transmission . HRP-2-bablished –32. Howe results . Therefo results . There a results .Identification of sub-microscopic infection by PCR has demonstrated that expert microscopy can miss detection of malaria in patients having low parasite densities hence leading to false-negative results. As malaria transmission declines, cases of sub-microscopic infection in both symptomatic and asymptomatic persons is likely to increase . PCR andPlasmodium apart from P. falciparum. This could have missed a few malaria infections of other species, such as P. malariae and P. ovale that have been reported in the country [P. malariae and P. ovale occur more commonly as mixed infections with P. falciparum [The study had a number of limitations. Firstly, some of the patients may have been on anti-malarial therapy despite verbal confirmation provided by their parents/guardians on the prior use of anti-malarial drugs. This would have contributed to the false-positive RDT results. Secondly, the malaria RDT and PCR diagnostic tools used in the current study could not detect other species of  country , 39, 40.lciparum . Lastly,The prevalence of malaria infection was low among outpatient children from Korogwe District. Diagnosis of malaria infection is still a challenge due to variation in results among diagnostic methods. HRP-2 malaria RDT and microscopy were less sensitive than PCR. Diagnostic tools with high sensitivity are required in areas of low malaria transmission.


After controlling for other variables the effect of IPTp-SP remained statistically significant . These results suggest that Intermittent Preventive Treatment with Sulphadoxine-Pyrimethamine is useful in the reduction of submicroscopic malaria in pregnancy.Malaria infections undetectable by microscopy but detectable by Polymerase Chain Reaction (PCR)  are common in endemic areas like Ghana. Submicroscopic malaria has been linked with severe pregnancy outcomes as well as contributing to malaria transmission. In this cross-sectional study 872 consenting pregnant women (gestation ≥ 20 weeks) were recruited from 8 hospitals in Central Region, Ghana, between July and December 2009. Malaria infection was detected by microscopy and PCR. Haemoglobin was measured and anaemia was defined as haemoglobin lower than 11 g/dL. Majority of the women, 555 (63.6%), were Intermittent Preventive Treatment in Pregnancy with Sulphadoxine-Pyrimethamine (IPTp-SP) users while 234 (36.4%) were nonusers. The prevalence of malaria by microscopy was 20.9% (182/872) and 9.7% (67/688) of microscopy negative women had submicroscopic malaria. IPTp-SP usage significantly (odds ratio = 0.13, 95% confidence interval = 0.07–0.23,  Malaria accounts for the highest cause of mortality in Africa with 90% of the global malaria deaths occurring on this continent. It constitutes 9% of the disease burden to the people of Africa and is responsible for 25% of deaths below the age of five years . Suscept Plasmodium falciparum infected red blood cells in the placenta of pregnant women, malaria diagnosisfrom peripheral blood has been inadequate. However PCR diagnosis is effective in detecting not only parasitaemia below the threshold of microscopy but also placental infections  pregnant women participated in the study. Some health and obstetric pieces of information such as gestation, gravidity, Glucose-6-Phosphate Dehydrogenase (G6PD) status, and SP intake were obtained from the Antenatal Clinic (ANC) booklets of participants; other information was collected using a structured questionnaire administered by trained research assistants. The assistants were recruited and trained to explain the questionnaire in their own local languages. Three milliliters (3 mL) of venous blood was collected from the median cubital or cephalic veins of the arm of pregnant women into labeled vacutainers, containing Ethelene Diamine Tetra Acetic Acid (EDTA). One hundred microliters  gene. The reaction was set up in a 96-well plate to a final volume of 25 μL per well containing 1x buffer, 1.5 mM MgCl2, 200 μM dNTP mix, and 0.25 μM of each primer . One denaturing step at 94°C for 3 minutes was followed by 40 amplification cycles. Each cycle constituted a denaturation step at 94°C for 1 minute, an annealing step at 50°C for 2 minutes, and an extension step at 72°C for 2 minutes. This was followed by a final extension step 72°C for 10 minutes. This cycler condition lasted for 4 hours 30 minutes. Five microlitres of the primary PCR product was used for the second amplification using the following primers: (F′ = 5 GAA ATG ATG GAA CAA GTC TGC GAC GTT 3′) and (2F = 5′ TTA ATT TCC CAA GTA AAA CTA TTA GAG CTT3′) corresponding to codon 59–108 of the pfdhfr gene. The reaction was set up in a 96-well plate to a final volume of 25 μL per well containing 1x buffer, 1.5 mM MgCl2, 200 μM dNTP mix, and 0.25 μM of each primer. One denaturing step at 94°C for 2 minutes was followed by 40 amplification cycles. Each cycle constituted a denaturation step at 94°C for 1 minute, an annealing step at 45°C for 1 minute, and an extension step at 72°C for 2 minutes. This was followed by a final extension step 72°C for 10 minutes. This cycler condition lasted for 3 hours 30 minutes. Eight microlitres (8 μL) of each nested PCR product was separated on 2% agarose gel stained with ethidium bromide. The gels were then photographed , Secundigravida (2nd pregnancy), and multigravidae (3rd or more pregnancies). A malaria positive blood smear was regarded as microscopy positive. A microscopy negative but PCR positive sample was regarded as submicroscopic malaria. A participant was anaemic if Hb < 11.0 g/dL.p < 0.05 was considered significant.All data was entered into SPSS statistical software version 17.0 for Windows and analyzed. Frequencies and Pearson's chi-square were used to compare relationships between variables. To determine the independent effect of IPTp-SP on submicroscopic malaria, logistic regression modeling was applied. Possible confounding factors such as gestation, occupation, gravidity, G6PD, and sickling status were controlled. Odds ratio (OR) and confidence interval (CI) were calculated by using logistic regression in multivariate analyses. In the logistic regression analysis, all variables were treated as categorical except gestation and gravidity that were treated as categorical. For all statistical tests, p = 0.33) in the mean age for users 33.4 years range (20–46) and nonusers 32.1 (17–44). Women using IPTp-SP were significantly more educated (p = 0.011) and better employed (p = 0.001) than nonusers  and gravidity (p = 0.023) as more women with pregnancy experience were users than nonusers. There was no association between the two groups in terms of G6PD (p = 0.719) and sickling status (p = 0.123) (There was a significant difference between the IPTp-SP users and nonusers based on trimester (= 0.123) .p = 0.575) and gravidity (p = 0.665). More than half of the women with submicroscopic malaria were anaemic. Submicroscopic malaria significantly resulted in anaemia (p = 0.003)  .p = 0.018) preventive effect on submicroscopic malaria. The prevalence of malaria by microscopy was 20.9% (182/872) and by PCR (submicroscopic) was 9.7% (67/688) but when submicroscopic infection was added it shot up to 28.6% (249/872). IPTp-SP usage significantly reduced submicroscopic falciparum infection  (Increasing dosage of SP had a significant (= 0.005) .p = 0.006; OR = 0.28, 95% CI = 0.18–0.42, p = 0.001)  .p = 0.33) older than nonusers but weresignificantly more educated and better employed than nonusers. This should buttress the importance of education in health care; as such health education schemes for pregnant women should be intensified in rural areas. The social status of Ghanaians has often been linked to health care as people with stable income have been shown to exhibit better health seeking behavior [Eight hundred and seventy-two (872) consenting pregnant women participated in the study. All the participants were eligible to use SP but only 555/872 (63.6%) had used IPTp. This may be because the women report late for antenatal care or they do not visit regularly. Though data on ANC attendance was not collected in the present study, late first ANC clinic enrolments and fewer visits have been reported to limit IPTp-SP usage . IPTp-SPbehavior .More women with pregnancy experience were IPTp users; this might be because the women were already conversant with the routine procedures at the ANC. Thus, they reported early and regularly. More third trimester participants were IPTp users as there was a significant association between gestation and IPTp usage. This is not surprising because at the third trimester pregnant women are expected to have had several ANC visits during which the IPTp intervention should have been administered. G6PD deficiency and sickling status did not vary significantly between the two groups.The prevalence of malaria by microscopy was 20.9% 182/872) while that of submicroscopic malaria was 9.7% (67/688). Submicroscopic malaria in pregnancy may be as a result of parasitaemia below the threshold of microscopy or the sequestration of infected red blood cells in the placenta 2/872 whi. DespiteA number of studies have suggested that malaria infection of any parasite density may have a harmful effect on pregnant women and their developing fetuses , 21. Subp = 0.575 and 0.665), respectively. This is contrary to an earlier study that linked higher submicroscopic infections to primigravidae [p = 0.001). More than half (52%) of the participants with submicroscopic malaria were anaemic (Hb < 11.0 g/dL). Anaemia in pregnancy is however multifactorial and can be caused by a number of reasons including poor nutrition, intestinal parasites, and socioeconomic status which have not been measured in this study. Nonetheless, similar studies have reported the contribution of malaria to anaemia in pregnancy [ P. falciparum infection in pregnancy. These submicroscopic infections may be as a result of prevailing placenta infection, because diagnosis of placenta malaria from peripheral blood by PCR has been reported to approach 100% accuracy [The prevalence of submicroscopic malaria did not differ significantly by gestation and gravidity . Studies have reported the protective efficacy of Sulphadoxine-Pyrimethamine when used as malaria prophylaxis during pregnancy. We further indicate here that its efficacy extends beyond the threshold of microscopic to submicroscopic infections. Recent studies have reported treatment failures as well as rise in the prevalence of molecular markers of SP resistance. In Ghana, for example, prevalence of molecular markers of SP resistance was 73%; nevertheless SP remains effective in preventing Ghanaian women from malaria [p = 0.018) with increasing dosage of SP. One clinical trial in Malawi also underscored the increased efficacy of SP with increasing doses among delivering women [Due to the profound consequences of submicroscopic malaria, it is very important that the IPTp intervention should not only be effective in clearing parasite from the peripheral blood but also prevent submicroscopic and placental infections. Usage of IPTp significantly reduces the presence of malaria infection both at microscopic and submicroscopic levels , neonatal mortality (NM), and placental malaria (PM) , 25, 27.Intermittent Preventive Treatment in Pregnancy with Sulphadoxine-Pyrimethamine continues to be a useful regimen for the prevention of pregnancy associated malaria and submicroscopic malaria in pregnancy.IPTp-SP is useful in the prevention of pregnancy associated malaria in Ghana.


Plasmodium vivax malaria in pregnant women can be challenging, and the pathogenesis of adverse outcomes for both the mother and the foetus is still poorly known. The authors describe the case of a 29-year-old Pakistani woman at the 29th week of her second pregnancy, who was admitted to the Hospital following the abrupt onset of fever. At the time of admission, she had been living in Italy without travelling to any malaria-endemic areas for eight months. She was diagnosed with vivax malaria after a thin blood smear revealed the presence of plasmodial trophozoites and gametocytes and treated accordingly. Due to the onset of oligohydramnios, she underwent caesarian section at the 31st week of pregnancy with no further complications. Histological examination of the placenta showed no evidence of plasmodial infection, but was inconclusive. It is unclear whether oligohydramnios is a complication of pregnancy-related Plasmodium vivax malaria. Given the long latency of hypnozoites, every febrile pregnant patient with a previous stay in an endemic area should be screened for malaria with a thick and a thin blood smear.In the Western world, the diagnosis and management of  Plasmodium falciparum is the most frequent cause of severe clinical manifestations, including maternal anaemia, prematurity, and low birth weight. However, Plasmodium vivax malaria can also cause some of the same complications as P. falciparum infection, although less commonly.Every year approximately 50 million women living in malaria-endemic areas become pregnant : it is eMost clinical manifestations are nonspecific and variable. Fever is the main sign, usually accompanied by chills and sweats. Other common symptoms include headache, myalgias, fatigue, nausea and vomiting, abdominal pain and diarrhoea. Pregnant women are more susceptible than non-pregnant women to develop complications, such as hypoglycaemia, pulmonary oedema and acute respiratory distress syndrome . Approxith + 6 week of her second pregnancy, was admitted to the Emergency Room (E.R.) of San Matteo Hospital Foundation  on the 30th of May 2012 following the abrupt onset of fever and malaise and was then transferred to the Obstetrics and Gynecology (OB/GYN) Department.A 29-year-old Pakistani woman, gravida 2 para 1, at the 29th week. On entrance, she was febrile (38°C). Her physical examination was unremarkable. Blood pressure was 120/70 mmHg and the remainder of her vital signs were normal.The woman was born and had always lived in Pakistan until eight months before admission when she moved to Italy and had been living there thenceforth. She reported having been well until the day before admission. She denied any history of previous disease. Her first pregnancy was uncomplicated, and she delivered a healthy newborn at the 409/L: neutrophils 8.2 × 109/L). She was started on ampicillin (1 g tid) and paracetamol. Fever subsided, and cardiotocography (CTG) did not reveal any signs of foetal distress. Three days after the beginning of treatment, fever with shivers recurred in association with lumbar and leg pain. Gentamicin (80 mg tid) was added, and then, on the basis of the Infectous Disease (I.D.) consult, antibiotic therapy was switched into piperacillin/tazobactam (4.5 g tid) in order to cover a possible urinary tract infection. The patient remained afebrile for one day, when blood tests showed an increase of bilirubin  and a decrease of haemoglobin . The next day the temperature rose to 39.8°C, the haemoglobin value dropped to 10.3 g/dl, and an abnormal foetal heart rate variability was recorded on the CTG. In order to rule out pneumonia, a chest X-ray was performed under a protective abdominal shield and resulted negative. A hematological consult was obtained, too, and a thin blood smear was examined, detecting the presence of Plasmodium spp. The I.D. specialist identified trophozoites and gametocytes from Plasmodium vivax, thus enabling the diagnosis of P. vivax pregnancy-associated malaria. Quinine sulphate (500 mg tid) was immediately administered, and therapy was continued for seven days.Routine blood tests showed a haemoglobin (Hb) level of 11.5 g/dl, 33.7% haematocrit (Hct) and a mild neutrophilic leukocytosis (WBC 10.6 × 10st week), an ultrasound exam showed the presence of oligohydramnios, and the amniotic fluid index (AFI) was 16 mm. As a matter of fact, four previous ultrasound exams, the first two preceding quinine administration, had shown a progressive decrease of the amniotic fluid index. The patient underwent a premature rupture of membranes (PROM) test, which was negative, and a caesarean section followed, with no further complications.During malaria treatment, the patient remained afebrile and asymptomatic. One week after the initiation of therapy, the haemoglobin level increased to 11.8 g/dl and bilirubinaemia returned to normal values . At the same time  was performed on the umbilical blood and turned out to be negative. Furthermore, the histological exam of the placenta was requested, but no pathological evidence of infection was observed. The patient was then discharged, and a follow-up appointment was scheduled to initiate the eradication therapy through the long-term administration of primaquine.P. vivax in pregnancy has traditionally been considered less severe as compared to P. falciparum malaria. This is believed to be related to the lack of placental sequestration in P. vivax infection and the parasite tropism for reticulocytes accounting for a milder form of anaemia [P. vivax infection correlates with a significant risk of adverse maternal and foetal outcomes, and a prompt diagnosis is of paramount importance to assess the prognosis quoad vitam and quoad valetudinem of both the foetus and the mother [P. vivax infection in pregnant women.Infection from  anaemia ,11. The e mother -14. ThisP. vivax and Plasmodium ovale infections may result in a long period of clinical latency due to the presence of hepatic hypnozoites, which can re-activate weeks, or even months, after the exposure to the parasite. In this case, the onset of symptoms was eventually demonstrated to be caused by P. vivax malaria nearly one year after the last exposure. Thus, the suspicion of pregnancy-associated malaria should be elicited in any febrile pregnant woman with a previous stay in a malarious region and malaria screening tests should be always performed.The diagnosis of malaria was made only one week after admission. The patient was born in Pakistan but she had not travelled to any malaria endemic areas for nearly one year. Hence, the correlation between the onset of fever and other nonspecific symptoms and malarial infection was not promptly considered. Lumbar pain and intermittent fever, despite the initiation of ampicillin therapy, skewed the differential diagnosis toward a urinary tract infection. Nonetheless, the diagnosis of pregnancy-associated malaria could not be excluded. Indeed, P. vivax malaria is chloroquine. Nevertheless, several cases have been reported describing the presence of chloroquine-resistant P. vivax isolates in a number of areas throughout Asia and Oceania, including the Indian subocontinent [P. falciparum can account for mild cases of malaria in pregnant women who left an endemic country, because the reduction of immunity related to pregnancy might result in a recrudescence of low-level parasitaemia even several months later [P. vivax relapsing infection by eradicating the dormant forms, primaquine constitutes the standard therapy. However, because primaquine can induce haemolytic anaemia in persons affected by G6PD deficiency, it is contraindicated in pregnant women given the unknown neonatal G6PD status [A second major issue of pregnancy-related malaria is therapy. First-line therapy of uncomplicated ontinent ,16. In ahs later ,18. AccoD status . Hence, P. falciparum, may be useful as a confirmation test in non-falciparum malaria, and may be predictive of adverse outcomes in the newborn [P. falciparum, P. vivax rarely correlates with pathological evidence of infection, due to its typical lack of cytoadherence to placenta [P. vivax within the placenta. In addition, the correlation between maternal infection and adverse outcomes in the newborn needs further investigation, and the effects of P. vivax malaria during pregnancy have not been fully characterized. Therefore, the progressive contraction of the amniotic fluid might be explained by an ongoing P. vivax infection, which was not detected by placental examination. Lastly, since the amniotic fluid index started decreasing before the initiation of therapy, the quinine treatment was unlikely to account for the oligohydramnios. No other maternal or placental causes of oligo-anhydramnios were found.Finally, the presence of malarial infection in the newborn must be assessed immediately at birth. Thin blood smears were performed on the umbilical and peripheral blood, detecting no parasites. Search for plasmodial antigens was negative, too. Nonetheless, it is unclear whether the oligohydramnios was a foetal adverse outcome of malaria or a pregnancy complication unrelated to the maternal infection. The histological examination of the placenta is of great significance for the diagnosis of  newborn ,21. Placplacenta , and a nPlasmodium vivax malaria is still poorly known, and the management of malaria in pregnant women can be challenging. Every febrile or anaemic pregnant patient with a previous stay in an endemic area should be screened for malaria. The long latency of P. vivax malaria dictates the inclusion of such infection in the differential diagnosis, in so far as the suspicion is supported by epidemiological data. Placental examination should be recommended upon delivery: evidence of malarial infection might provide useful insights on the pathogenesis of congenital malaria as well as the occurrence of potential complications in the newborn. However, a negative result does not exclude an active non-falciparum malarial infection. Future studies should investigate the link between oligo-anhydramnios and pregnancy-associated P. vivax malaria.The pathogenesis of adverse outcomes in pregnancy-related Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the editor-in-chief of this journal.AFI: Amniotic fluid index; E.R.: Emergency room; I.D.: Infectious diseases; Hb: Haemoglobin; Hct: Haematocrit; LBW: Low birth weight; OB/GYN: Obstetrics and gynecology; PROM: Premature rupture of membranes; SGA: Small for gestational age; WBC: White blood cells.The authors declare that they have no competing interests.NB, EB, AM drafted the paper, NB, RL, FC collected the data. All authors discussed and approved the final version of the paper.


Plasmodium falciparum is the common pathogenic parasite and is responsible for majority of malaria associated deaths. Recently the other benign parasite, P. vivax, is reported to cause life threatening severe malaria complications. Thus, this study was aimed to assess incidence of severe malaria symptoms caused by P. vivax parasite in some malaria endemic areas of Ethiopia.Malaria is still a major health problem in some parts of the world. Presumptive malaria patients  seeking medication at the selected health facilities in Mendi town, Northwest Ethiopia, were recruited for the study. Socio-demographic, clinical and parasitological characteristics were assessed following standard procedures. Data was analyzed using descriptive statistics, chi-square test and relative risk.P. vivax mono-infection, 55 (14.3 %) of them were fulfilled at least one of the WHO criteria for severe malaria indicators. Some of these clinical manifestations were: prostration 14 (25.45 %), persistent vomiting 9 (16.36 %), respiratory distress 6 (10.9 %), hypoglycemia 5 (9.1 %), hyperpyrexia 8 (14.5 %), and severe anemia 13 (23.63 %). Differences in parasite load did not affect the frequency of some severe malaria symptoms. However, severe anemia, prostration, and persistent vomiting were significantly affected (P < 0.05) by relatively higher load of parasitemia,  respectively.Of the 384 patients enrolled in the study for P.vivax associated severe malaria symptoms observed in this study is supportive evidence for the notion that P.vivax is no longer benign parasite but rather virulent. Thus, to meet international and regional targets of malaria eradication, a holistic prevention and control approaches should be designed. P. falciparum and P. vivax have worldwide distribution, with P. falciparum being the more pathogenic. Few years back, it was indicated that about 1–3 million mortality per year, mainly in children and pregnant women, are due to severe malaria caused by P. falciparum [Malaria is one of the most important health problems in developing countries. It is estimated that about half of the world’s population are at risk of malaria , 2. P. flciparum  there welciparum .P. vivax is a rare parasite in most parts of Africa, it is an important parasite in Ethiopia. In some areas of the country the prevalence rate even exceeds 70 % of total malaria infections. This was previously reported due to the high Duffy positivity trait of most population of Ethiopia, but recently contradictory reports are coming [P. vivax parasite is increasing in the country [, frequently associated with P. falciparum, has been reported from Asia, South America and Africa for P. vivax [P. vivax infection in one of malaria endemic areas of Ethiopia.In Ethiopia malaria is unstable and seasonal. This is because of the country’s heterogeneous topography and climatic factors , 6. Areae coming –11. In a country . RecentlP. vivax –18. ThusP. falciparum and P. vivax. The main vector in the study area is A. arabiensis. Based on the 2007 Census conducted by the Central Statistical Agency (CSA) of Ethiopia, this town has a total population of 28,485 of whom 14,385 are males and 14,100 females [A cross sectional study was conducted in Mendi Town, located 567 km Northwest of Addis Ababa, the capital city of Ethiopia Fig. . Geograp females .Fig. 1MaP. vivax mono-infection (microscopy confirmed), without any chronic illness, without prior medication for the current illness, having clinical symptoms such as fever, chills, malaise, headache, vomiting, history of fever for about 48 h before admission, and volunteer to participate in the study. Accordingly, a total of 384 patients who fulfilled the inclusion criteria were included in the study.The study participants were all presumptive malaria patients seeking medication at the health center and clinic in Mendi town, during the study period from September, 2014 to June, 2015 and those who had symptoms of malaria infection. The inclusion criteria used were any patient positive for Clinical and demographic data were collected using pre-designed case record form by trained health professionals working in the two health facilities. Clinical symptoms such as fever, headache, diarrhea, hyperpyrexia, hemoglobunria, persistent vomiting, impaired consciousness, convulsion, respiratory distress, persistent vomiting, hypotension, anorexia, nausea, and rigor were assessed following criteria set on guideline for malaria diagnosis and treatment . Body teP. vivax cases [P.vivax was done by two experienced laboratory technician working in the two health facilities. To ensure data quality, the positive slides were further confirmed by certified senior laboratory technician at Jimma University. Fortunately there were no difference in their reading and the original record was used for analysis. Detailed description of the blood collection and smear preparation is as follows: a drop of blood sample was collected on clean glass slide from lancet pricked finger to prepare thin and thick blood smears in duplicate per patient for microscopic examination. Thick and thin blood smears were stained with 3 % Giemsa , while thin smears were fixed in methanol before Giemsa staining. Malaria parasite was identified by observation of the smears and the morphological appearance of the parasite in the infected red blood cells (RBCs) using ×100 microscope objective. Parasite load was calculated after counting asexual parasites per 200 white blood cells (WBC), assuming mean WBC count of 8000 count/μL using the following formula:Patients with at least one symptom of severe malaria complications set by World Health Organization (WHO) were classified as severe ax cases . PrelimiThe degree of parasitaemia was graded as mild, moderate, and severe, when a count (x) is between 1 and 999 parasite/μL, 1000–9999/μL, >10,000/μL, respectively .Senso Card Hungary) and hemoglobin (Hb) . The patient was considered anemic when Hb level is <11 g/dL (children) and <13 g/dL  and <12 g/dL dult female). Further, level of anemia was classified as severe, moderate and mild, when Hb level is <5 g/dL, between 5 and 8 g/dL, and between 8 and 11 g/dL, respectively [P.vivax following National Guideline for Malaria Diagnosis and Treatment [From the pricked finger, some drops of blood samples were taken for quantification of levels of blood glucose (Glu) . Descriptive statistic was used for analysis of some clinical, demographic and parasitological data. Associations between variables were computed using Pearson correlation. Responses were compared using chi-square test, and relative risk was used to assess strength of association between variables in groups. In all analysis, significance level was considered at 95 % confidence interval (CI).The trend of malaria cases showed an irregular declining pattern. However, the 5 years prevalence report 2010–2014) of the two health facilities showed that, the number of malaria infected patients was still higher  were due to mixed infection . The highest peak infection for P. falciparum and P. vivax was observed in November followed by October  seeking medication at the two health facilities, blood samples were collected from 4813 suspected malaria cases. Accordingly, 1434  were found positive for malaria infection. Among the positive cases, A total of 533 (37.2 %) and 851 (59.3 %) were infected with n = 202) and 47.4 % (n = 182), respectively. Among different age groups, the distribution of malaria infection with respect to sex was almost similar, except in those aged less than 5 years, where the infection was higher among male population of the same age. In terms of sex, male malaria patients  were significantly higher than that of females .In the current study, a total of 384 patients that fulfilled the inclusion criteria were clinically diagnosed and enrolled in the study. Prevalence of malaria among male and females patients were 52.6 % (Median age of the study participants was 14 years (1 month to 60 years). Mean body temperature and blood glucose levels of the study participants were 37.89 °C (35.5 to 40.8) and 104.4 mg/dL (36.8 to 180), respectively. Also, the level of Hb and geometric mean parasite counts were 12.4 g/dL (4.3–17.8) and 3745parasite/μL , respectively. The observed anemic cases were 115 (29.9 %) , aching 231 (60.2 %), chills 225 (58.6 %), vomiting 179 (46.6 %), rigor 152 (39.6 %), shivering 151 (39.3 %), cramp 150 (39.1 %), nausea 147 (38.3 %), anorexia 61 (15.9 %) and diarrhea 22 (5.72 %)  patients fulfilled at least one of the WHO criteria for severe malaria symptoms while 19 (34.5 %) had two or more overlapping severity indicators. of the later cases, 12 (63.2 %) had two combined symptoms, 5 (26.3 %) had three combined symptoms and the remaining 2 (10.5 %) had four combined symptoms.Severe malaria symptoms were observed in 55 (14.32 %) patients infected with n = 14 (25.45 %), persistent vomiting n = 9 (16.36 %), respiratory distress n = 6 (10.9 %), hypoglycemia n = 5 (9.1 %), hyperpyrexia n = 8 (14.5 %) and severe anemia n = 13 (23.63 %). Major severe malaria symptoms observed were prostration, and severe anemia, in combination with other symptoms including persistent vomiting, hyperpyrexia, and hypoglycemia. However, none had signs of confusion, coma, hemoglobinuria or discoloration of urine and hypotension  with respect to relative risk (RR) of P. vivax infected patients of different parasite load . However, severe anemia, prostration, and persistent vomiting were significantly associated (P < 0.05) with severe parasitemia , [, respectively  was 29.8 %,  (Unpublished data). The overall prevalence of malaria observed during the study period was slightly lower than the recent report from southern part of Ethiopia (31.9 %)  and muchP. vivax mono-infection has been associated with severe and fatal disease in endemic areas [P. vivax malaria [P.vivax mono infection in this study were prostration, followed by severe anemia, persistent vomiting, hyperpyrexia, respiratory distress, and hypoglycemia. As observed in our study, severe malaria symptoms commonly detected in P. vivax infected patients is severe anemia [P. vivax infection, 32 non-infected RBCs are removed from the circulation, compared to the loss of 8 RBCs for every infected erythrocyte in P. falciparum malaria [P. vivax is responsible for 87 % of severe diseases compared to 73 % of severe malaria complications that occur due to P. falciparum [P. vivax than to P. falciparum [ic areas , 24, 25. malaria , 18, but malaria . The mos malaria . Other a malaria  and phag malaria . To thislciparum . In thislciparum –32.P. vivax mono infection observed in this study (10.9 %) was higher than report from India (6.8 %) [P. vivax malaria has been proposed to be severe alveolar capillary dysfunction like in P. falciparum [P. vivax and P. falciparum infected patients [Frequency of respiratory distress due to  (6.8 %) , but com (6.8 %) . The poslciparum . This ispatients –36.P. vivax infection [P. vivax.Most of these symptoms are largely attributed to production of various cytokines such as TNF- α produced in response to the parasite and toxin products released during rupture of infected RBCs . Also, hnfection , the hypP. vivax is capable of inducing fever at levels of parasitemia lower than those causing fever in P. falciparum infection [P. vivax was 180 parasites/μL compared to 1000 parasites/μL observed in P. falciparum infection [P. vivax has a tendency to achieve and maintain lower density parasitemia as it only invades young RBCs [P. vivax infections also tend to present all parasite stages that could be visible on the peripheral blood film [P. vivax may be due to the presence of the same parasite in haemopoietic tissue than in the vascular sinus [P. vivax in peripheral blood could expand rigorously without its detection [Differences in parasite load did not affect the incidence of severe malaria symptoms among assessed patients. This was in consistence with earlier report made by Price et al. , which enfection . WHO alsnfection . This isung RBCs . In addiood film , 43. Hypar sinus . Thus, petection .P. vivax causes an acute febrile illness with no complications or death. However, recently reports on complications due to P. vivax are globally increasing [P. vivax infection are uncertain. It is assumed that, it may be due to genetic alterations of the parasite or change in vector and its biting habits, indiscriminate use of anti-malarial drugs, delayed treatment, or due to declining efficacy of chloroquine or rise in chloroquine- resistant P. vivax strains [P. vivax has implication on the current global target of malaria eradication. Using knowledge and long experience accumulated over periods on P. falciparum, all concerned bodies including policy makers, researchers and others working in the same field should characterize clinical epidemiology and economic burden of P. vivax in different geographical areas for better management of burdens due to P.vivax infection.Naturally, creasing , 45, 46. strains –49. In a strains . The incP.vivax and P.falciparium using PCR is a major limitation of this study.The lack of confirmation of absence of mixed infection due to P. vivax mono-infected individuals. This strengthens the fact that parasite. P. vivax is no longer benign. Therefore, to meet the set international targets for reduction of malarial morbidity and mortality, and regional elimination of P.vivax infection, concerned bodies should no longer neglect this parasite.Some severe malaria complications such as prostration, severe anemia, respiratory distress, hyperpyrexia and persistent vomiting were observed in


Schistosoma mansoni co-infection and associated clinical correlates in malaria patients.In Ethiopia, where malaria and schistosomiasis are co-endemic, co-infections are expected to be high. However, data about the prevalence of malaria-schistosomiasis co-infection and their clinical correlation is lacking. Therefore, the aim of this study was to assess prevalence of Schistosoma mansoni.A cross-sectional study was conducted in 2013 at Chwahit Health Center, in northwest Ethiopia. Blood film positive malaria patients (N = 205) were recruited for the study. Clinical, parasitological, hematological, and biochemical parameters were assessed from every study participant. Stool samples were also collected and processed with Kato-Katz technique to diagnose and classify intensity of Schistosoma mansoni and malaria co-infection was 19.5 %. The age group of 16–20 years old was significantly associated with co-infection. Co-infected patients with a moderate-heavy egg burden of Schistosoma mansoni had significantly high mean Plasmodium parasitemia. On the other hand, age group of 6–10 years old and moderate-heavy Schistosoma mansoni co-infection were significantly associated with severe malaria.The prevalence of Schistosoma mansoni co-infection in the study area was considerably high. Severity of malaria and parasitemia of Plasmodium were associated with certain age groups and intensity of concurrent Schistosoma mansoni. Further study is needed to explore the underlying mechanisms of interaction between malaria and Schistosoma mansoni.Prevalence of malaria and  Plasmodium.Plasmodium falciparum  and Plasmodium vivax (P. vivax) are the predominant species globally attributing to the majority of disease burden. According to World Malaria Report 2013, there were an estimated 207 million episodes and 627,000 deaths due to malaria in 2012, of which approximately 80 % of the episodes and 90 % of the deaths were in the Africa region. Approximately, 77 % of malaria deaths globally occurred among children under 5 years , medium (101–400 epg), or heavy (>400 epg)  was observed within the age group of 16–20 years old (p < 0.05) . A higher frequency of severe anemia was also observed among S. mansoni co-infected participants (35.0 %) than malaria only infected ones (25.5 %) .In this study, there was a higher frequency of fever among S. mansoni co-infected and malaria only infected participants. However, a significant difference was observed only in mean red blood cell count  and hemoglobulin level , respectively . In the Post Hoc analysis, this difference persisted only among light and moderate-heavy S. mansoni co-infected participants .There was a mean difference in malaria parasitemia among malaria only infected, light and moderate-heavy S. mansoni co-infection. Moderate-heavy intensity of S. mansoni was associated with severe malaria (p < 0.05)  of the study participants. A higher frequency of severe malaria was observed among males (65.8 %) than females 34.2 %). Patients in the age group of 6–10 years old were 6.8 times more likely to experience severe malaria (p < 0.05). Twenty-six percent of the study participants with severe malaria had .2 %. PatS. mansoni co-infection with malaria was 19.5 %. This prevalence was lower compared to a recent study carried out in southern Ethiopia, 22.6 % [Malaria and schistosomiasis co-exist in sub-Saharan African countries –6, 21. I, 22.6 % , 24.S. mansoni co-infection was observed among males and within the age group of 16–20 years old. In an earlier study from Kenya, children were 9.3 times more likely to be co-infected with schistosomiasis and malaria than adults [In this study, higher n adults . Addition adults –27.S. mansoni co-infected participants presented with fever than malaria only infected ones. Although each case of malaria and schistosomiasis could lead to fever presentation [In the current study, a higher frequency of entation , 29, schentation .S. mansoni co-infection. In an earlier animal model study, schistosomiasis co-infection prolonged lower density malaria parasitemia time and caused anemia as compared to the malaria only infected group [In this study, although significant association was found only in red blood cell count and hemoglobulin level, hematological parameters were found to be influenced by ed group .P. falciparum and P. vivax were reported to decrease hemoglobulin level, white blood cells, red blood cells and platelet counts [However, t counts . Schistot counts , 34. ThePlasmodium parasitemia was observed more frequently among malaria only infected participants than S. mansoni co-infected participants. In an earlier study, reduced Plasmodium parasitemia was reported to be associated with schistosomiasis co-infection [Plasmodium dense than malaria only positives [Plasmodium parasitemia.In this study, high mean nfection . Howeverositives . The difPlasmodium parasitemia was more frequently observed among moderate-heavy S. mansoni co-infected participants than light co-infected ones. Therefore, schistosomiasis co-infection could affect Plasmodium parasitemia, depending on the intensity of the ova. Previous studies from Mali and Senegal reported that light schistosomiasis intensity is correlated with a decrease in Plasmodium parasitemia [Higher mean asitemia , 35.S. mansoni co-infection were identified as the determining factors for severe malaria. In earlier studies, children co-infected with schistosomiasis and heavy intensity of schistosomiasis were at risk of developing severe malaria [In the current study, the age group of 6–10 years old and moderate-heavy intensity  malaria , 30, 35.S. mansoni in the study area was considerably high. Severity of malaria and parasitemia of Plasmodium were associated with certain age groups and intensity of concurrent intestinal schistosomiasis. Further study is needed to explore the underlying mechanisms of interaction between malaria and S. mansoni.Prevalence of malaria and