Background: In April 2019, Chongqing passed the national malaria elimination assessment. However, around 30 imported malaria cases are still being reported every year, and Anopheles sinensis was widely distributed in Chongqing, meaning the risk of malaria resurgence still exists. Early diagnosis and treatment for malaria cases are effective measures to prevent malaria resurgence. The primary health institutions are the first station where potential malaria cases may seek treatment. The competency with which primary health institutions diagnose malaria will directly affect the timeliness of malaria diagnosis. Nowadays, most primary health institutions in Chongqing use microscopy to confirm malaria cases. This study assessed the microscopy competence of primary health institutions, studied and analyzed the results, and provided a scientific basis for malaria prevention and control after malaria elimination in Chongqing.Methods: According to the stratified sampling principle, four plasmodium microscopy technicians  were selected from each of the 39 districts/counties of Chongqing to test the plasmodium microscopy competence. Descriptive statistical analysis, correlation analysis, spatial self-correlation analysis, and ROC curve analysis were carried out on the test results.Result: The average of the technicians' test scores was 4.33 ± 0.47 ; The spatial clustering of the scores was significant . The test scores were positively correlated with the “level of work institutions”  but were negatively correlated with “age” . The highest Sensitivity of the technicians' microscopy was in qualitative diagnosis . The Delong's test showed that the diagnostic efficiency of the technicians' microscopy to P. falciparum was the best (P < 0.01), however to P. ovale was the worst (P < 0.01).Conclusion: The microscopy technicians in primary health institutions in Chongqing have good microscopy competency in qualitative diagnosis, but there were deficiencies in the identification of plasmodium species. Township level health institutions in Central China have weaker microscopy than those in other areas. Malaria is one of the most serious parasitic diseases. According to WHO, there were 2.28 million malaria cases and 405,000 deaths worldwide in 2018, and 93% of the cases were in Africa ” and the principle of stratified sampling means that all 39 district/county level CDCs have participated in the study. Two to three clinical medical institutions were randomly selected according to the actual situation of each district and county. The second step involved one microscopic technician being randomly selected from 39 CDCs, and three microscopic technicians being randomly selected from the selected health institutions, making up four people from each district/county to participate in the malaria microscopy competence test.The first step in the national “Malaria Elimination Assessment Program (2014 Edition)” and the WHO “Operating Manual for Microscopy and Evaluation of Plasmodium” , medium , and low (≥500 counts/ul), one P. vivax slide, one P. ovale slide, and one negative slide. The parasitemia of four P. vivax slides and four P. ovale slides were 10,072–13,280 counts/ul and 2,293–3,072 counts/ul. The positive slides were made by the malaria patients' blood which was stored in the sample bank of Chongqing CDC. The negative slides were made using a healthy person's blood. All of the blood samples were confirmed by NEST-PCR and the blood slides were double checked by technicians who had acquired a WHO malaria microscopy competency level one certification to guarantee correct diagnosis. Only the blood slides with the same diagnosis of NEST-PCR and microscopy were used in this research. When the microscopy competency test was conducted, each technician would randomly select one set, and took five blood films from the set. The microscopy of plasmodium must be completed within 1.5 h. Five points were awarded if all were correct. One point was deducted for one qualitative error and 0.5 point was deducted for one species error.The malaria microscopy competency single blind tests were conducted separately in each district/county from 2014 to 2017 with one bind. There were four sets of standard blood slides for tests that were provided by the Malaria Diagnostic Reference Laboratory of Chongqing CDC. The blood slides were made in line with the requirements of the national “smodium” . Each seThe test results and patient information were collected and sorted, and a database in the Excel 2016. R.4.02.application was used for statistical analysis. The districts and counties of Chongqing were divided into five geographical “urban areas”: “Western Chongqing,” “Central Chongqing,” “Southern Chongqing,” “Northeast Chongqing,” and “Southeast Chongqing.” One factor analysis of variance was conducted for the scores. The judgment results of each blood film were recorded and scored according to the design principles. The “Kendall” correlation analysis was carried out on the variables of “score,” “gender,” “age,” “working unit level,” and “professional qualification grade” of the technicians. The average scores of 39 districts/counties were calculated, and the “overall self-correlation” analysis was done with ArcMpa16.0, and the “Clustering Distribution Map” was plotted.The qualitative diagnosis of microscopy and sensitivity, specificity, positive predictive value, negative predictive value, and Youden index in different plasmodium determinations were calculated and the ROC curve was plotted, which was to be paired and compared using “Delong's test.” When calculating the diagnostic indexes of different species, the positive determination of the blood film of the species was considered valid, while the negative or other species determination was considered invalid.A total of 156 microscopic technicians from 39 districts/counties participated in the test, including 56 males (35.90%) and 100 females (64.10%), with a male to female ratio of 0.56; the age of the technicians was between 19 and 64 years and the average age was 34.89 ± 8.91, of which 56 (35.90%) were under 30 years old. 85 (54.50%) were at County-level medical institutions; 78 (50%) had junior technical qualifications. In the assessment results, there were 13 (8.30%) technicians with one qualitative error, 75 (48.10%) with one species identification error, 43 (27.60%) with two species identification errors, and eight (5.10%) with three species identification errors. The average score was 4.33 ± 0.47; the lowest was 3, the highest was 5, and the median was 4.5 .z = 3.618, P < 0.01). From the clustering distribution map based on the average scores of all districts/counties, we can see that the highest scores occurred in Western Chongqing, the urban area, and Northeast Chongqing, and the low scores were concentrated in the central part of Chongqing. The results showed that there were significant differences in scores among the geographical distribution regions . There was no significant difference between the “Urban area” (4.51) and “Northeast Chongqing” (4.49) , and the lowest score was 4.08 in Central Chongqing, which was much lower than that in other regions (P < 0.05), see Among the 38 districts/counties and one economic development zone, Shapingba District and Wuxi County got the highest average score of 4.875, followed by Jiulongpo District with 4.75. Dazu District got the lowest score of 3.625. The results of global spatial self-correlation analysis showed that the scores had significant spatial clustering . The highest specificity of diagnosis occurs in P. ovale, 96.20%  and the lowest in P. vivax . The negative predictive value and positive predictive value of qualitative diagnosis were the highest, respectively, 94.70 and 99.07%. The lowest negative predictive value was 78.54% for P. falciparum and 28.95% for P. ovale. The highest Youden Index was 0.9434 for qualitative diagnosis and 0.1214 for P. ovale, see The sensitivity of microscopy was the highest in qualitative diagnosis  and the lowest in P. falciparum, P. vivax, and P. ovale were, respectively, 0.9717, 0.8413, 0.7823, and 0.5607 for technician microscopy. See The area under ROC curve for qualitative diagnosis, diagnosis of P. falciparum was significantly higher than that of other species (P < 0.01), see Delong's test was used to compare the ROC curves microscopy for diagnosis of different plasmodium species. The results showed that the diagnostic efficiency of r = 0.21, P < 0.01) and negatively correlated with age . There was a positive correlation between technical qualification and age , see The variables were encoded: Gender: 0 = female, 1 = male; units: 1 = township medical institutions, 2 = county-level medical institutions, 3 = county-level CDC; qualification: 1 = junior, 2 = intermediate, 3 = senior; age group: 1 = under 30, 2 = 30–40, 3 = above 40. “Kendall” correlation analysis showed that the score of technicians was positively correlated with unit level (The results of this study showed that the overall microscopy competency was the best in qualitative diagnosis, and the sensitivity and specificity microscopy were at a high level. There were differences in scores amongst different regions. The scores in the urban area and Northeast Chongqing were significantly higher than those in other regions, and the lowest score was in Central Chongqing. The reason could be that the number of malaria cases reported in the urban area of Chongqing accounts for about 60% of the total cases in Chongqing , 19, 20,P. falciparum. The scores of the identification of P. vivax and P. ovale were quite low; the positive predictive value was only 51.60 and 28.95%. Morphological identification of P. vivax and P. ovale by microscopy has always been difficult, and requires rich experience and technical training from the technician (P. vivax and P. Ovale are basically identical (P. vivax malaria are of great significance to prevent the malaria resurgence of imported cases after the elimination of malaria in China (A. sinensis to P. ovale, and there is no clear evidence that imported P. ovale can exist in local Anopheles sinensis and infect humans. The primary doctors may neglect management of imported P. ovale; if P. vivax were misdiagnosed as P. ovale, the risk of malaria resurgence will increase. In recent years, the number of imported cases of P. ovale malaria cases has increased year on year (The results showed that the qualitative diagnostic efficiency of plasmodium microscopy was the highest, followed by chnician , 27. Thain China . At pres on year , 29, 30, on year –33. In 2 on year . TherefoIn the correlation analysis of technician's personal characteristics, it was found that the higher the level of work unit, the higher the score. Technicians from the township level health institutions had lower scores, and their microscopy competencies were relatively lower. The study also found that older technicians scored lower. Under normal circumstances, the technician's competency of plasmodium microscopy will increase with age; rich microscopy experience leads to better competence , 26, 35.P. malariae was not included in the test. The competency tested was limited to the microscopy technician's competence of the blood film reading, not the competence of film preparation. In this study, we failed to collect complete data for utilizing social, economic, and health resources, and did not conduct further study on the influence of these factors on the competency of microscopy in various regions.Due to limitations imposed by funds and manpower, only four microscopy technicians from three kinds of health institutions from each district/county were selected to participate in the test, and the sampling volume was small. Due to the lack of good blood samples The microscopy technicians in primary health institutions in Chongqing have good microscopy competency in qualitative diagnosis, but there were deficiencies in the identification of plasmodium species. Township level health institutions in Central China have weaker microscopy than those in other areas.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The study was reviewed and approved by the Ethical Committee of Chongqing center for disease control and prevention. All participants provided written informed consent for the study.LF conceived the study, collected and analyzed the data, and drafted the manuscript. YY and LS-S provided suggestions for improving the quality of the data. TY, ZY, and XJ-R provided the test blood slides and collected the scores. ZS initiated the study. All authors contributed to the writing of the manuscript and approved the submitted version of the manuscript. All authors read and approved the final manuscript.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Chronic immune activation persists in persons living with HIV-1 even though they are aviremic under antiretroviral therapy, and fuels comorbidities. In previous studies, we have revealed that virologic responders present distinct profiles of immune activation, and that one of these profiles is related to microbial translocation. In the present work, we tested in 140 HIV-1-infected adults under efficient treatment for a mean duration of eight years whether low-level viremia might be another cause of immune activation. We observed that the frequency of viremia between 1 and 20 HIV-1 RNA copies/mL  and transient viremia above 20 HIV-1 RNA copies/mL  over the 2 last years was higher in patients with one profile of immune activation, Profile E, than in the other patients. Profile E, which is different from the profile related to microbial translocation with frequent CD38+ CD8+ T cells, is characterized by a high level of CD4+ T cell (cell surface expression of CD38), monocyte (plasma concentration of soluble CD14), and endothelium  activation, whereas the other profiles presented low CD4:CD8 ratio, elevated proportions of central memory CD8+ T cells or HLA-DR+ CD4+ T cells, respectively. Our data reinforce the hypothesis that various etiological factors shape the form of the immune activation in virologic responders, resulting in specific profiles. Given the type of immune activation of Profile E, a potential causal link between low-level viremia and atherosclerosis should be investigated. Moreover, HIV antigens detected by specific B lymphocytes and T cells trigger an adaptive immune response. Finally, even a truncated CD4+ T cell infection may induce caspase-1 activation and IL-1β production in CD4+ T cells (Immune activation (IA)-related comorbidities are becoming a major concern in aviremic HIV-infected persons under antiretroviral therapy (ART) . For ins T cells . Thus, N T cells . LikewisYet authors looking for correlations between residual viremia and IA markers obtained contradictory results. Some authors found a link between residual viremia and inflammation , CD4+ T Recent data however argue for a role of persistent viral production in IA. First, in virologic responders, higher levels of the inflammatory markers C-reactive protein (CRP), Tumor Necrosis Factor α (TNFα), IL-6, interferon γ (IFNγ) and/or the monocyte activation marker soluble CD14 (sCD14) have been reported in non-fully adherent patients than in fully adherent patients , 19. SecKnowing whether low-level viremia is a cause of IA is particularly important at a time when 2-drug regimens rather than 3-drug ART regimens , day-on,In a previous study, we analyzed 64 soluble and cell surface markers of inflammation and CD4+ and CD8+ T cell, B cell, monocyte, NK cell, and endothelial activation in 140 adults under effective ART. A double hierarchical clustering of patients and markers unveiled that these virologic responders had 5 different IA profiles . The firThis cross-sectional observational study has already been previously described . We recrUsing flow cytometry as previously described , we deteHIV-1 RNA plasma level was quantified using the Amplicor HIV-1 Monitor test (Roche Diagnostic Systems). The test has a positive threshold of 20 copies/mL, and discriminates samples containing no detectable copies in 1mL from samples containing 1 to 20 copies/mL. We also recorded the percentage of blips, defined as isolated episodes of viremia > 20 copies/mL, within the 2 years preceding the analysis of the immune profile. The frequency of detectable viremia and blips over the 2 last years was determined on 4 to 8 measurements.Fisher’s exact test or χ2 test was used to compare qualitative covariates. For quantitative covariates, on one hand, when comparing two groups (e.g. undetectable vs detectable viremia), we compared the distributions of covariates using the Student T-test or the Wilcoxon-Mann-Whitney test as appropriate. On the other hand, when comparing profiles together for example (i.e. more than two groups), the comparison was made using Anova or the Kruskal-Wallis H test as appropriate. Correlations were evaluated by Pearson, Spearman or Kendall test as appropriate. Normality was assessed using the Shapiro-Wilk test.https://www.R-project.org/).All analyses were performed using R software, version 3.6.1 , under efficient ART for a mean (SD) duration of 7.9 (4.1) years, were recruited at the University Hospitals of Nîmes and Montpellier, France. Eighty-one percent of patients were male, with a mean age of 56 (9) years. Their pretherapeutic CD4 count and viremia were 199 (119) cells/µL and 1,4372,216  HIV RHA copies/mL, respectively. Their current mean CD4 count was 733 ± 375 cells/µL, and their CD4/CD8 ratio 1.24 (0.88). ART regimens and co-infections are given in In this study population, the frequency of residual viremia (1-20 copies/mL) at the time of study was 26%. There was no difference, neither in age , duration of infection  nor aviremia , nor in pretherapeutic CD4 count  nor pretherapeutic viremia  between patients with detectable and undetectable viremia, respectively. Likewise, no link could be established between residual viremia and the use of nucleoside reverse transcriptase inhibitors (p = 0.999), non-nucleoside reverse transcriptase inhibitors (p = 0.999), protease inhibitors (p = 0.969), or integrase inhibitors (p = 0.900).-4, -4, The percentage of samples with detectable viremia (1-20 HIV-1 RNA copies/mL) or blips (isolated viremia > 20 HIV-1 RNA copies/mL) during the two years preceding the study was available for 135 out of 140 participants. These percentages of samples with detectable viremia  activated (HLA-DR+ and/or CD38+), exhausted (PD-1+), senescent , naïve (CD45RA+CD27+), central and effector  memory CD4+ and CD8+ T cells, (ii) activated (HLA-DR+), dysfunctional (CD56-), and senescent (CD57+) NK cells. Monocyte activation was evaluated by measuring sCD14 and sCD163, and B cell activation by measuring IgM, IgG, and IgA levels. Inflammation was monitored by quantifying sTNFRI and CRP. tPA, sTM, and sEPCR were used as markers of endothelium activation, and D-dimers were used as an indicator of fibrinolysis.-4, We compared residual viremia and blip frequency, i.e. for each participant, the frequency where the participant displayed low-level viremia or blips during the two last years with each one of these markers. The only link we revealed was with D-dimers. Patients with 1-20 HIV-1 RNA copies at the time of the study presented higher D-dimer levels than patients with undetectable viremia . Duration of infection and aviremia, nadir CD4, pretherapeutic viral load and CD4:CD8 ratio, as well as age were not different between Profile E and the other Profiles . There wInterestingly, one of these profiles, Profile D, was linked to microbial translocation . We reas-4, -4, No difference in duration of infection (p = 0.191) and of viral suppression (p = 0.285), in pretherapeutic viremia (p = 0.881) or CD4 count (0.285), and in age (p = 0.138) was observed between Profile E patients and patients with other profiles (data not shown). Compared with the other patients, Profile E patients had higher CD4 counts (1567 ± 451 versus 669 ± 288 cells/mL, p < 10It is logical to assume that residual viremia should fuel immune activation in virological responders. Yet, although some authors have indeed found a link between low-level viremia and IA , 13, othThe high circulating concentrations of sCD14 that we observed in Profile E patients is in line with the link between this IA marker and residual viremia reported by other authors . This liPreviously, CD4+ T cell activation has also been found to be associated with residual viremia . Here agCompared with the other IA profiles, Profile E is also characterized by a high level of sEPCR. sEPCR results from the cleavage of the external portion of the protein C receptor on the surface of endothelial cells activated by thrombin, TNFα, IL-1 or endotoxins . An incrOne consequence of our results is that we now know that residual viremia should be sought in patients with increased proportions of CD38+CD4+ T cell, sCD14 and/or sEPCR. Moreover, in these patients, potential causes of this residual viremia, e.g., non-optimal adherence to treatment or partial resistance to the current antiretroviral regimen, should also be investigated.Globally, the present data support the idea that, depending on the etiological factor at work, microbial translocation for Profile D patients  and resiThe raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving human participants were reviewed and approved by Ethics Committee of Montpellier University Hospital, France. The patients/participants provided their written informed consent to participate in this study.MY and LK contributed to the design of the flow cytometry study, and acquired, analyzed, and interpreted cell surface and soluble marker data. CP contributed to the design of the study, the enrolment of patients, and acquired, analyzed and interpreted the data. RC, PP, and TV contributed to the design of the flow cytometry study and acquired, analyzed and interpreted cell surface markers. CR, RS, AW, and PF contributed to the design of the statistical study and acquired, analyzed, and interpreted the statistical data. CM, NA, CF, VL, CB, and AS acquired, analyzed, and interpreted clinical data. JR contributed to the design of the study and analyzed and interpreted the data. PC contributed to the design of the study, analyzed, and interpreted data, and wrote the first draft of the manuscript. All authors contributed to the article and approved the submitted version.The study was funded by MSD, MSDAvenir, and the university hospitals of Montpellier and Nîmes. These sponsors had no role in the study design, the collection, analysis, or interpretation of data, the writing of the report, nor in the decision to submit the paper for publication.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Background/Purpose: Over the last two decades, malaria has remained a major public health concern worldwide, especially in developing countries leading to high morbidity and mortality among children. Nigeria is the world most burdened malaria endemic nation, contributing more than a quarter of global malaria cases. This study determined the prevalence of malaria among children at 6–59 months in Nigeria, and the effects of individual and contextual factors. Methods: This study utilized data from 2018 Nigeria Demographic and Health Survey (NDHS) involving a weighted sample size of 10,185 children who were tested for malaria using rapid diagnostic test (RDT). Given the hierarchical structure of the data set, such that children at Level-1 were nested in communities at Level-2, and nested in states and Federal Capital Territory (FCT) at Level-3, multilevel mixed effect logistic regression models were used for the analysis. Results: The proportion of children 6–59 months of age in Nigeria that had malaria fever positive as assessed by RDTs was 35.5% , (CI: 33.9–37.1). Kebbi State had 77.7%, (CI: 70.2–83.5), which was the highest proportion of 6–59 months who were malaria positive, next in line was Katsina State with 55.5%, (CI: 47.7–63.1). The Federal Capital Territory (FCT), Abuja had the proportion of 29.6%, (CI: 21.6–39.0), malaria positive children of 6–59 months of age. Children between the age of 48 and 59 months were 2.68 times more likely to have malaria fever than children of ages 6–11 months . In addition, children from the rural area , were more likely to suffer from malaria infection compared to children from urban area. Conclusion: The study identified some individual and contextual predictors of malaria among children in Nigeria. These factors identified in this study are potential areas that need to be considered for policy designs and implementations toward control and total elimination of malaria-related morbidity and mortality among children in Nigeria. The past twenty years and up till now, malaria has persisted as a major global public health concern ,2, with Between 2001 and 2014, Nigeria has implemented four National Malaria Strategic Plans (NMSPs), with the most recent, which ended in 2020 (2014–2020), was aimed at reducing malaria-related deaths to zero by 2020 . UnfortuThe transmission of malaria parasites has its root in the socio-cultural and economic statuses of the people . StudiesEffective control of malaria in Nigeria will require strategies that identify areas and characteristics of people that are highly vulnerable to malaria infections leading to the development of plans and the implementation of policies to reach them. This study complements the findings in previous studies to show potential effects of contextual variables at both cluster and state levels ,11,18. TNigeria is a country located in West Africa sharing borders with Cameroon, Niger, Benin Republic and the Atlantic Ocean with a total area of 923,768 square kilometres ,11. The This study is a secondary analysis of two independent nationally representative cross-sectional surveys data sets, such that the 2018 National Human Development Report (known as NHDR 2018)  data setNDHS, being the primary data set for this study, samples were selected separately from each stratum using a two-stage stratified cluster design on each stratum derived from the 2006 census identified enumeration demarcation. At the first stage, 1400 enumeration areas (EAs) were selected as sampling units. At the second stage, 30 households were randomly selected from each EA using equal probability sampling, leading to a target total sample of 42,000 (30 × 1400) households used for the survey. In total, 11 EAs were excluded from being captured because of in-security. Therefore, a total of 41,668 households was earmarked for sampling, but only 40,427 households representing a response rate of 99.4% were finally captured in the survey [The target groups for the survey were women age 15–49 years from all the randomly picked households and men age 15–59 years in one-third of all randomly selected households across Nigeria . Besides(i)Rapid diagnostic tests (RDTs) were conducted on blood samples taken from pricking the finger or heal of the child using SD Bioline Ag Pf (HRP-II). The RDTs detect the Histidine-rich protein-II (HRT-II) human whole blood (antigen). The results were either classified as positive or negatives for Pasmodium falciparum (Pf).(ii)Laboratory microscopy investigation on thick blood smears was performed for a three quarter of the households where RDTs was done. Malaria results were also classified as either positive or negative.In 2018 NDHS diagnostic tests for malaria parasite were carried out for children 6–59 months of age in approximately a third of the selected households. Children in this age bracket have not developed enough immunity as such and they are more prone to contracting malaria . Two tesp < 0.0001), between these two test results. However, the microscopy laboratory test was performed essentially as a confirmatory test for the RDT that was carried out on the field [There was a strong positive correlation 0.581  corresponds to the period the child had not begun to walk, 12–23 months is another important landmark (completion of immunization), by 24–36 months, some children would have had another sibling following, 36 months and above connotes immediate preschool age. Further, sex of the child, maternal perceived birth size of the child classified into, large, average, and small categories. Birth order of the child defines a child’s rank among other children of same mother. However, the effect of this on child’s health outcome is not well established ; duratioMother’s age (year) at last birthday was classified as reported in similar studies to distinguish younger mothers (below 25 years), middle aged, and older mothers, above 34 years ,40,41. THousehold wealth status is the measure of household economic status derived as the composite score from some durable goods using principal component analysis (PCA). The wealth status was originally classified into quintiles. In this study, three categories were derived, such that poor and poorest groups were collapsed into poor, while rich and richest were collapsed into rich categories ,45; housProportion of cluster’s household with no bed net; distance to a health facility is no big problem; and proportion of low cluster wealth status. These were derived from the household characteristics. The classification into low and high was based on the cut-off point of 50th percentile (median) score for each variable .Region of residence are the six geopolitical zones in Nigeria where the child resides in. There is seasonal variation across the zones, and this can impact differently on health outcome particularly on children under-five years; place of residence is the type of place where the child’s household is located and is classified as either urban or rural; state human development index (SHDI). The human development index by each state defines the average on key indicators of human development of the communities. The higher the HDI, the more protective the children from these communities will be from diseases. These categorizations of HDI by states in this study as given in NHDR 2018 ; state mSvyset” command was used to adjust for under- and over-reporting in the survey using a weighting factor of (v005/1000000), where v005 is the sample weight [2 = 30.21, p < 0.001 for Level-2 nested in Level-3).Descriptive analysis using percentage frequencies was used to establish the prevalence, distribution, and association of the malaria status among children 6–59 months of age in Nigeria with the predictor variables considered in this study. “e weight ,48. GiveIn handling the missing values, the listwise deletion technique was applied. In the first instance, all variables having more than 20% missingness were removed, furthermore, any variable with incomplete observations, and those with responses “I don’t know” or refusal to answer the questions were deleted .i (Level-1) in community (com) j (Level-2), and in state (sta) k (Level-3) having a positive RDT for malaria. mth, the nth, and the pth coefficients associated with W (Level-1), X (Level-2), and Z (Level-3) predictors. Further, jth community in kth state, while ith child in the jth community and the kth state will be RDT malaria fever positive.The dependent variable of interest is binary and follows the Bernoulli , without any predictors. The essence is to measure the variation across the communities and the states. Model 2 included only child-related variables; Model 3, adjusted for/parental-related variables, while for Model 4, household-related variables were added to Model 3; Model 5 (full model) was derived for all the selected variables including the area-related variables. Goodness of fit was determined using Akaike’s information criteria (AIC), such that the model with the lowest AIC was chosen as the best fit [p-values and 95% confidence intervals (CIs).The measures of association  were described using adjusted odds ratio (AOR) with their corresponding The measures of variation  were captured using intra-cluster correlation (ICC), and variance partition coefficient (VPC).Intraclass correlation coefficient (ICC) represents the proportion of the total variation in the model that can be accounted for by variations across the different level of clusters. In our model (three-level model), we identified two intraclass correlation coefficients: the one pertaining to children/individuals nested in community-level, and community-level groups nested in the state-level group ,51. Therme state ,53.(VPC) differs, as it does not have corresponding interpretation, therefore:However, Equation (3), in terms of the variance partition coefficient munities (5)ICCstte-level .From (3), (4), and (5), gression . The valgression .All computations were performed in Stata 16 SE . In recognition of the complexity of the survey design, weight proportion as specified in Stata was used to account for over- and under-estimation. The listwise deletion, the default missing values handling technique in Stata was applied.There was a total of unweighted sample of 10,152 and weighted sample of 10,185 children 6–59 months of age in Nigeria considered in this analysis. In However, malaria status was not statistically associated with child’s sex, perceived birth size, wasting, and the presence of acute respiratory infection two weeks before the survey.The results in (b) part show the relationship between parental characteristics and malaria status of children 6–59 months of age in Nigeria, only marital status and paternal occupational status were not strongly associated with the malaria status at 5% level of significance. Whereas child’s place of delivery; preceding birth interval, maternal religious status, age group, age at first birth, educational status, working status, body mass index, anaemia status, autonomy level, ante-natal care visit, maternal ethnicity, religious status, maternal iron supplement during pregnancy, and paternal education status were all strongly associated with the child’s malaria fever status. The proportion of children with malaria fever (38%) was highest among mothers in the youngest age groups (15–24 years) compared to other age groups. More than 50% of children whose mother and father had no education reported RDT positive results.Additionally, 38%, 38%, 36%, and 32% of children whose mother had a preceding birth interval of 12–24 months, 25–35 months, 36–59 months, and 60+ months were RDT positive, respectively. In addition, the prevalence of malaria fever among children aged 6–59 months was higher for those whose mothers were underweight compared to normal and overweight mothers.On the household-related categories of predictors, (i.e. the (c) part of Accordingly, the household where only some under-five years slept under a bed net the night before the survey witnessed the highest prevalence of malaria fever among children 6–59 months of age in Nigeria when compared to the household where “no net in the house” (30%), “no child” (34%), “all children” (37%), slept under a bed net the night before the survey.In addition, (d) of Furthermore, (e) of p > 0.20. Because of this, 25 variables , were finally retained for the multilevel model building.In the first instance, all the variables that serves as proxies to nutritional status and household wealth were excluded from the multilevel analysis. Furthermore, a multicollinearity test was conducted to check for highly correlated predictors. Out of the variables included two factors: “under-five slept under a bed net the night before the survey” and “household had bed net” were perfectly correlated with variance inflation factors (VIF) of 7.08 and 11.18, respectively such that the mean VIF was 2.23. The variable “household had bed net” was dropped resulting in a mean VIF of 1.79. We used a forward stepwise variable selection procedure by entering all variables that were statistically associated with the malaria status of children 6–59 months of age in Nigeria at a 5% level of significance, and removal was by 2/3), which is fixed for logit.Model 1 is the null model (no predictors) with the fixed effect showing that the proportions of the total variations due to differences in the communities and the states were respectively, 1.266 and 0.614, while the variance due to individual level is 3.29  and intracommunity correlation coefficient of 0.3636 (95% CI: 0.318–0.412), indicating that 11.9% and 36.4% of the total variation in the odds of malaria positive were respectively due to state and community levels. The variance partition coefficient (VPC) at the state level corresponds with the ICC at the state level. However, the VPC at community level is 0.249, meaning that 24.9% of the total variance is collectively attributed to both the state and community levels. However, from the chosen model (Model 4) in The odds of a child having malaria increased as the child’s age increased. The odds of children between the age of 48–59 months experiencing malaria fever were 2.68 times the odds of children 6–11 months of age . Children who were still breastfeeding , and dewormed , had 39% and 25% reduced odds of contracting malaria infection. Similarly, children whose mother had their first birth after the age of 20 years had reduced odds of experiencing malaria fever than their counterparts whose mothers had their first birth earlier than 20 years.In addition, children whose mothers , or fathers  had secondary education and above had 33% and 21% significantly reduced odds, respectively, of being malaria fever positive. The wealthier the household , the less likely the child can be malaria positive. From among the clusters-related variables, children from a community with high proportion of mothers who said distance to the nearest health centre is “no big problem” had lower odds of malaria fever infested. The result from among the area-specific variables shows that children from south–south geopolitical zone , had 50% reduced odds to contract malaria fever when compared with children from the north central geopolitical zone. On the contrary, children from rural area , were more likely to suffer from malaria infection compared to children from urban area.Finally, the result shows that the state-level multidimensional poverty index and state human development index were not statistically significant predictors of malaria status among children 6–59 months of age in Nigeria.Pf. However, Azikiwe et al. (2012) found that RDTs and microscopy laboratory investigation of malaria Pf yield similar results with RDTs being more precise [This study assessed the prevalence of malaria across the states and the federal capital territory and examined its predictors among children 6–59 months of age in Nigeria. Some researchers use either rapid diagnostic test or microscopy thick blood smears result to classify the presence or absence of  precise . In addiet al. 202 found t precise ,22, to s precise . Further precise ,16,21. T precise . The pos precise .As the maternal age at first birth increases, the odd of child’s RDT outcome decreases. The study also found that maternal and paternal education statuses are significantly associated with child’s malaria status. The odds reduced with an increase in educational level ,13,21. HHousehold wealth plays a significant role in child’s health, children from rich household are less likely to be infected with the malaria parasite. Similar conclusions were reached in recent studies ,13,15,56A recent scoping review conducted has revealed that there are very few studies that analysed the influence of contextual factors on the risk of contracting malaria infection among children under-five years in SSA countries . This stHowever, there were some limitations: (i) The data sets were cross-sectional and could not ascertain the remote causes of RDT malaria positive among children 6–59 months of age in Nigeria. Information regarding the causes is better obtained from a longitudinal study which requires periodic follow up of participants ,48. (ii)Between 2010 when a national representative survey on malaria was first conducted to determine the prevalence of malaria among children 6–59 months of age in Nigeria, and 2018 when the current survey was conducted, the prevalence of malaria had dropped significantly by 15% from 50% in 2010 to 35% in 2018. This drop is commendable but was not enough to meet the expectations of total elimination of malaria-related death in Nigeria by the year 2020 [(i)The findings show that older children are often at risk compared to younger siblings. These children are allowed by their parents to walk about freely unattended to, perhaps to obtain more feeding opportunities elsewhere. These children have been weaned from breast feeding, nutritious foods are often not provided at home because some households cannot afford it. Most of these children scavenge about to find food. It is recommended that the school feeding program of the Government should also be extended to what may be called “community feeding program” where children of pre-school age can access food and boost their immunity.(ii)Parenting is a very serious matter in our society. The age at which most women first become a mother is often very low, thereby making them “baby-mothers”. Some of these mothers are not even mature enough to take care of themselves, particularly becoming mothers at that tender age, and not even able to care of their babies. Policies and the political will should be in place to discourage early girl-child marriage that often result into early childbirth. Girl-child education often delay the age at which most females become married and give birth. Therefore, female education should be made free and compulsory for up to secondary education. Any parent who withdraws their girl child from school for early marriage or whose daughter gets pregnant while still in school should be liable for prosecution.(iii)Most families sleep in over-crowded apartments. The governmental housing policies in some states see some buildings constructed but are never allotted to anyone until they are eventually vandalized. The Government’s policies should encourage early allocation of these buildings to those that need them to ease off over-crowding households and communities. This will reduce cross-infections in communicable diseases such as malaria(iv)Due to the problem of accessibility to most rural areas , these communities are often neglected in the distribution of scare palliatives from the Government and agencies , to addressing the issue of malaria. The Government can also invest in the use technologies available for logistics such as drone to transport these items to the hard-to-reach communities.(v)When community distance to health facility is not a “big problem” to the people, they become prompt in getting the much-needed timely medical attention for their children. Therefore, having identified areas of high malaria prevalence, the governments for these areas should among other suggestions ensure that increased proportion of the people do not travel long distances before they can access prompt medical attention. Therefore, more functional health centres are available in such localities.(vi)Lastly, the results also indicates that children from a high category among low cluster wealth areas had significantly higher proportion of malaria positive status compared to the proportion among the low category ((d) in In line with some findings in this study, we have proffered some suggestions for policy implementation.Despite the huge resources committed to eliminating malaria induced morbidities and mortalities, Nigeria has remained the most burdened malaria-endemic nation in the world. This study has identified some important individual and contextual predictors of malaria among children 6–59 months of age in Nigeria. These predictors are areas that need to be considered for policy designs and implementations toward control and total elimination of malaria-related morbidity and mortality among children in Nigeria.


Plasmodium falciparum-infected patients and malaria-negative subjects in Kosti city of the White Nile State, Sudan.Hematological abnormalities are common features in falciparum malaria but vary among different populations across countries. Therefore, we compared hematological indices and abnormalities between P. falciparum-infected patients and 200 malaria-negative subjects) were recruited in the study. Hematological indices of hemoglobin (Hb), red blood cells (RBCs), white blood cells (WBCs) and platelets were measured, and their median values were statistically compared.A comparative, cross-sectional study was conducted at the Clinical Laboratory Unit of Kosti Teaching Hospital from June to December 2018. A total of 392 participants  showed a low-level parasitemia. The median values of Hb concentration, RBC count, mean corpuscular volume (MCV), mean corpuscular Hb (MCH) and mean corpuscular Hb concentration (MCHC) were significantly lower in P. falciparum-infected patients, while the median red cell distribution width (RDW) was significantly higher in the patients compared to malaria-negative subjects. Anemia, low MCV, low MCH, low MCHC and high RDW were significantly associated with falciparum malaria, but parasitemia level was not significantly associated with anemia severity. The median total WBC count was non-significantly higher in P. falciparum-infected patients, with neutropenia being significantly associated with falciparum malaria. The median platelet count was significantly lower in P. falciparum-infected patients, with thrombocytopenia being significantly associated with falciparum malaria.The majority of Falciparum malaria among patients in Kosti city of the White Nile State, Sudan is predominantly of low-level parasitemia. It is significantly associated with anemia, low MCV, low MCH, low MCHC, high RDW, thrombocytopenia and neutropenia. However, parasitemia level is not a significant predictor of anemia severity. On the other hand, leucopenia is not useful to predict falciparum malaria. Further large-scale studies in community and healthcare settings and inclusion of patients with complicated or severe malaria and those with high parasite densities are recommended. Plasmodium falciparum, either as mono-infection or mixed infection with P. vivax [Despite intensive control efforts, malaria remains a major public health concern on a global scale, where 229 million cases and 405,000 deaths from severe malaria were estimated in 2019 with the African region accounted for 94.0% of cases [P. vivax –5.Hematological abnormalities can contribute to the pathogenesis and complications of the disease . TherefoP. falciparum mono-infection and 200 malaria-negative subjects). Those who did not give written informed consent to participate, suffered from hematological diseases, or were using medicines altering the blood picture were excluded from the study. In addition, patients co-infected with other Plasmodium species, or showing signs and symptoms of complicated or severe malaria were excluded.A comparative, cross-sectional study was conducted at the Clinical Laboratory Unit of Kosti Teaching Hospital, Sudan, from June to December 2018 to compare hematological indices of RBCs, WBCs and platelets among malaria-infected patients and malaria-negative subjects. Kosti is a major city of the White Nile State at the geographic coordinates 13°10′N 32°40′E. It lies on the western bank of the White Nile to the south of Khartoum, the Capital of Sudan  concentration, mean corpuscular volume (MCV), mean corpuscular Hb (MCH), mean corpuscular Hb concentration (MCHC), red cell distribution width (RDW), RBC count, total and differential WBC counts and platelet count were measured using Sysmex KX-21 Hematology Analyzer  at the Hematology Laboratory of the Clinical Laboratory Unit at Kosti Teaching Hospital. In this reference laboratory, the hematology analyzer is regularly checked for performance to ensure that all hematological parameters of control samples are within the precision specifications. Specific, high-quality diluents were used and SOPs were followed in all measurements of hematological indices. Internal quality control is performed twice a day in the morning and afternoon before sample testing. Moreover, external quality assessment is done three times a year.9/L, while leucopenia was defined as a total WBC count < 4.0 × 109/L [According to the criteria of WHO, anemia was defined as an Hb concentration < 11.5 g/dL in children, < 12.0 g/dL in non-pregnant women and < 13.0 g/dL in men . Thrombo × 109/L . MCV < 8 × 109/L .P-values < 0.05.Data were double entered and validated in Excel spreadsheets before analysis using IBM SPSS Statistics, Version 25.0 . Data were verified for inconsistency, missing data, or outliers to ensure their integrity and quality. Categorical variables were expressed as frequencies and proportions. Non-normally distributed continuous data of age, parasite density as well as RBC, WBC and platelet indices were expressed as median ± interquartile range (IQR). The median values of hematological indices were compared using the Mann-Whitney U test, and the association between falciparum malaria and hematological abnormalities was tested using the chi-square test. Statistical significance was considered at P. falciparum was 677.5 ± 600.1 parasites/μl of blood . The majority of P. falciparum-infected patients (64.6%) showed a low-level parasitemia, while only 1.0% of patients showed a high-level parasitemia.Table P. falciparum-infected patients compared to malaria-negative subjects. In contrast, MCV was not significantly different between both groups  were anemic compared to less than a third of malaria-negative subjects, with significantly higher proportions of low MCV (microcytosis), low MCH and MCHC (hypochromia) and high RDW (anisocytosis) among P. falciparum-infected patients. Nevertheless, the level of parasitemia was not significantly associated with anemia severity. In West Kordufan state, a lower anemia proportion was reported among approximately 21.0% of patients with falciparum malaria, which was not significantly associated with falciparum malaria but was significantly associated with low proportions of MCV, MCH and MCHC [Substantial proportions of patients with falciparum malaria and malaria-negative subjects in Kosti city were anemic. The majority of and MCHC . In agreand MCHC . Malariaand MCHC , 29–31. and MCHC  did not P. falciparum irrespective of exposure frequency or disease severity [P. falciparum-infected patients in Kosti were thrombocytopenic. Thrombocytopenia was a significant predictor of falciparum malaria, which is consistent with that recently reported for patients with falciparum malaria in West Kordufan, even though a lower thrombocytopenia prevalence of 21.3% (75/353) was found [Thrombocytopenia has been assumed to occur in the majority of patients acutely infected with severity . In lineas found . In anotas found . The sigas found –28, 35. as found . Likewisas found . In Kharas found . Severalas found , 39, 40.P. falciparum-infected and malaria-negative subjects, with comparable and non-significantly different proportions of leucopenia. This lack of significant association could be partially attributed to the low parasitemia and uncomplicated nature of falciparum malaria among the study participants. In general, low-to-normal WBC counts in malaria patients is a frequent observation that could also be explained by their localization outside the peripheral blood [The present study revealed normal total WBC counts among al blood . TherefoThe prevalence of leucopenia among patients in the present study is higher than that (6.3%) reported from West Kordufan . The lacP. falciparum-infected patients in relation to malaria exposure frequency and severity.Overall, the findings of the present study should be interpreted cautiously because hematological indices and abnormalities in malaria may differ, among other factors, with the level of disease endemicity, disease severity, nutritional and immune status of patients, iron deficiency, co-existence of hemoglobinopathies as well as demographic factors , 42–48. Falciparum malaria among patients in Kosti city of the White Nile State, Sudan is predominantly of low-level parasitemia. It is significantly associated with microcytic hypochromic anemia, low MCV, low MCH, low MCHC, high RDW, thrombocytopenia and neutropenia. However, parasitemia level is not a significant predictor of anemia severity. On the other hand, leucopenia is not useful to predict falciparum malaria. Further large-scale studies in community and healthcare settings and inclusion of patients with complicated or severe malaria and those with high parasite densities are recommended.


The Problem Areas in Diabetes (PAID) scale is a reliable and valid tool that is widely used for diabetes-distress screening, but the Arabic version of the scale lacks validity and reliability analysis in primary healthcare (PHC) patients. Our study aimed to evaluate the psychometric properties of the Arabic version of the PAID (AR-PAID) scale among Egyptian patients with type 2 diabetes mellitus (T2DM) in PHC settings.We conducted a cross-sectional study on a convenience sample of 200 patients from six rural PHC settings in the Ismailia governorate. The confirmatory factor analysis (CFA) was performed to test the goodness-of-fit to the predefined models of the PAID. Convergent construct was evaluated through correlations with the Arabic versions of the Patient Health Questionnaire 9 (PHQ-9), Generalized Anxiety Disorder Scale (GAD-7), and 5-item World Health Organization Well-Being Index (WHO-5), additionally glycated hemoglobin (HbA1c) levels. Discriminant validity was evaluated through associations with patients' sociodemographic and clinical characteristics. Reliability was evaluated through internal consistency (Cronbach's α) and test-retest reliability analysis .p < 0.001), GAD-7 , WHO-5 , and HbA1c , supporting sound convergent validity. Discriminant validity was satisfactory demonstrated. Internal consistency was excellent (α = 0.96) and test-retest reliability was stable (ICC = 0.97).The CFA demonstrated the best fit for a four-factor model. The AR-PAID was significantly correlated with the following measures: PHQ-9 (rho = 0.71, The AR-PAID scale is a valid and reliable instrument for diabetes-distress screening in primary care patients with T2DM that can be used in clinical settings and research. Further research is needed to validate short forms of the AR-PAID scale. Diabetes is a global health problem with a prevalence of 9.3% in 2019. Its prevalence in the Middle East and North Africa region was the highest age-adjusted diabetes prevalence (12.2%) of all world regions. T2DM accounts for about 90% of all diabetes cases worldwide  , and it 6% , and The PAID scale is an instrument widely used to assess diabetes-distress. It includes 20 items –14. HermInterest in diabetes-distress across countries through the previous two decades means that versions in multiple languages of the PAID instruments are not only desirable, but also necessary in order to compare the findings about diabetes-distress from different languages, cultures, and societies, in addition to the improvement of diabetic care. The original PAID has been translated into several languages successfully, and these versions of it are reliable and valid instruments –32.Previous Arabic studies evaluated the validity and reliability of the 20-item AR-PAID scale in Kuwait and Lebanon. An early study revealed that the AR-PAID was valid and reliable in older adult patients with T2DM, who were recruited from one hospital-based diabetes unit and one primary diabetic clinic in Kuwait City. Another Arabic study found that the AR-PAID had excellent reliability and an acceptable convergent with HbA1c in Lebanese adults with T2DM, but its construct validity was not assessed , 34.Venkataraman et al. displayed the abridged 16-item PAID scale as reliable, valid, and sensitive in Singaporean patients with diabetes . Hsu et In light of the burden of T2DM in Middle East and Arabic countries, increased interest in diabetes-distress, and a lack of studies in validity and reliability of the AR-PAID in primary care, this study was carried out to evaluate the psychometric properties of the AR-PAID in Egyptian patients with T2DM attending PHC settings.A cross-sectional study was conducted on a convenience sample of patients with T2DM from September 2020 to June 2021. The participants were recruited from six rural PHC settings at the Ismailia governorate, affiliated with Egypt's Ministry of Health and Population. Soper's online calculator of a sample size for structural equation models was used to estimate the sample size for a CFA model of a four-factor and the 20 observed variables of the PAID scale . The samWe included participants aged 18 years or older who were diagnosed with T2DM for at least 1 year. An informed consent was obtained from every participant. We excluded patients with a severe mental illness, cognitive impairment, or gestational diabetes. Face-to-face interviews by the second author were used to collect data. A 1-month test-retest on reliability of the AR-PAID scale was conducted on 50 participants.Our study's questionnaire consisted of several parts. The initial part included the sociodemographic and clinical characteristics, e.g., age, gender, marital status, family income, occupation, smoking diabetes duration, diabetes treatment, co-morbidities, and diabetes-related complications . The next part of our study's questionnaire included the Arabic versions of the PAID, PHQ-9 , 41, GADThe original PAID scale was written in English and consisted of 20 items rated on a 5-point Likert scale from 0 to 4, with 0 indicating no problem and 4 indicating a major problem. The PAID calculates a total score range of 0 to 100 by adding the replies to all 20 items and multiplying the result by 1.25. The higher the score, the more diabetes-distress, with a score of 40 or above indicating significant diabetes-distress , 45. TheThe PHQ-9 consists of 9 items, each with a score ranging from 0 (never) to 3 , for a total score of 0 to 27. For the detection of major depressive disorder, a cut-off value of ≥10 has an 88 percent sensitivity and an 88 percent specificity . The AraThe GAD-7 is a 7-item anxiety portion that is part of the full GAD. Each GAD item is given a score ranging from 0 (never) to 3 , for a total score of 0 to 21. GAD is indicated by a cut-off value ≥10 (89 percent sensitivity and 82 percent specificity) . The AraThe WHO-5, which was generated from the WHO-10 , is one 2. The patient's most recent HbA1c readings were recorded (<8 weeks prior or 12 weeks after the interview). Adult and older adult patients with controlled glycemic targets were identified by HbA1c levels <7 and 7.5%, respectively  and height (in cm). The BMI was computed by dividing the body weight (in kg) by the squared root of the height (in meters). Overweight participants had a BMI of 25–29.9, while obese participants had a BMI of more than 30 kg/mectively .Data management and analyses were performed using the Statistical Package for the Social Sciences (SPSS), version 25.0 . Categorical variables were tabulated as frequencies and percentages, while continuous variables were summarized by means and standard deviations . Continuous variables were tested for data normality with the Kolmogorov-Smirnov test.The AR-PAID was tested for both reliability and validity . Reliability testing was performed using Cronbach's alpha for internal consistency, as well as ICC for test-retest reliability.2] to the degrees of freedom [df] (CMIN/DF) and associated p-values; (2) the standardized root mean square residual (SRMR); (3) the root mean squared error of approximation (RMSEA); (4) the comparative fit index (CFI); and (5) the Tucker Lewis Index (TLI). The model fit acceptability was set at CMIN/DF <3, SRMR and RMSEA ≤ 0.08, and CFI and TLI ≥0.90 , in which we compared the model fit indices of previously proposed models of PAID's factor structure models: the original one-factor of the original PAID, two-factor of the Turkish PAID, three-factor of the Swedish PAID, four-factor of the Dutch PAID, and four-factor of the Spanish PAID , 24, 28.LI ≥0.90 . All CFALI ≥0.90 ].The convergent validity was established by testing for correlations between the AR-PAID and other related scales  and the level of glycemic control (HbA1C level). Spearman's correlation was used with the following coefficient values: 0–0.19 considered very weak, 0.2–0.39 considered weak, 0.40–0.59 considered moderate, 0.6–0.79 considered strong, and 0.8–1.0 considered very strong correlations .p < 0.05 were considered statistically significant at a 95% level of confidence.In regards to discriminant validity, the AR-PAID's ability to differentiate between different groups of patients was tested with the Mann–Whitney and Kruskal–Wallis tests, in which the number of groups compared was given. Total AR-PAID scores were compared across patients' groups, such as patients with major depression or generalized anxiety disorder, patients with poor glycemic control, and patients with different demographic and clinical characteristics. All Two-hundred patients with T2DM were interviewed in this study. Participants' ages ranged from 20 to 80 years, with a mean of 48.3 ± 11.4 years. Twenty-four percentage of them were younger than 40 years. Females made up 60% of all participants. The majority (76%) of the participants were married. The mean duration of diabetes was 8.2 ± 6.2 years and ranged from 1 to 30 years. Sixty-seven (33.5%) patients were on insulin-containing regimen. Most (64.5%) of the participants had one or more diabetes-related complications, which were neuropathy (50.5%), retinopathy (36.5%), foot problems (33.0%), and nephropathy (21.5%). The most common chronic comorbidities were obesity (36.5%) and hypertension (23.5%). The mean HbA1c level was 7.9 ± 0.84% and ranged from 6 to 14.5%, with only 17 patients (8.5%) having achieved good glycemic control .Five alternative factor structures were compared for the goodness-of-fit indices using confirmatory factor analysis in p < 0.001), the GAD-7 scale for anxiety , and the WHO-5 wellbeing index . The total score of the AR-PAID also showed a significant but weak correlation with HbA1c levels . The AR-PAID subscales showed significant correlations with all measures, with correlation coefficients ranging from 0.15 to 0.68. All AR-PAID subscales had their highest correlations with the PHQ-9 scale and WHO-5 wellbeing index, while their weakest correlations existed with HbA1C levels (C levels .p = 0.145). Known-group validity was confirmed by the statistically significant differences in AR-PAID total scores between patients with and without depression (PHQ-9 ≥ 10), patients with and without generalized anxiety disorder (GAD-7 ≥ 10), and patients with and without poor wellbeing (WHO-5 index ≤ 50).The AR-PAID scale showed the ability to discriminate between diabetes-distress among patients with different demographic and clinical characteristics . Female p < 0.001), while the ICC of the AR-PAID subscales ranged from 0.92 to 0.97  compared with other subscales. These findings might be related to the importance and relevance of the emotional problems subscale for evaluating the pivotal content of diabetes-stress , 37. TheThe total AR-PAID scale had an excellent internal consistency (α = 0.96), which was in line with the reported findings from the original, Duch, Brazilian, Icelandic, Swedish, Turkish, Norwegian, Greek, Korean, Spanish, German, Malaysian, and Polish versions of the PAID (α ranged 0.90–0.96) –30, 32. We found that the emotional problems subscale had demonstrated the highest Cronbach's alpha. This unsurprising finding might be the result of its homogenous construct, as well as inclusion of more items in this subscale: twelve items, compared to other subscales. The treatment problems subscale also had an excellent internal consistency (α = 0.94), which is inconsistent with the findings of the Korean PAID (α=0.54). Lee et al. had explained their finding as a result of the relative heterogeneity of its three items, which may be related to the presence of item 15 .The total AR-PAID scale was found to have good 1-month test-retest reliability (ICC = 0.97), indicating the stability of the scale. Previous studies reported a satisfactory stability of the total PAID scale , 25, 27,Our results provided sound support for the discriminant validity of the AR-PAID in terms of determining differences in diabetes-distress with patients' sociodemographic and clinical characteristics. We found older people with T2DM showed significantly higher diabetes-distress scores than other age groups, which might have been explained by how older people reported being usually concerned about the presence and seriousness of diabetes-related complications, dealing with complications, and controlling diabetes, as well as being anxious and having guilty sensations if they are not able to achieve good glycemic targets. However, other studies found that younger patients had higher scores on the PAID , 24, 32.In the current study, patients with longer disease duration and those who are on insulin-containing regimen reported significantly higher AR-PAID scores, which was similar to the findings of a Greek study . PatientTo the best of our knowledge, this is the first study that assessed the validity and reliability of the AR-PAID among PHC patients in the Middle East and North Africa region. Our study included only PHC patients with T2DM, which limited our ability to generalize the results to patients with type 1 diabetes. Our study included a relatively small number of patients who were able to achieve good glycemic control, which restricted the group validity on this clinical variable. Lastly, the cross-sectional design of our study could not assess the responsiveness of this instrument.The AR-PAID scale is a valid and reliable instrument for assessing diabetes-distress among Egyptian PHC patients with T2DM. Further studies are needed to assess the responsiveness of the AR-PAID, to assess cultural adaptations of the AR-PAID in other Arabic-speaking patients with diabetes, and to assess the validity and reliability of short forms of the AR-PAID.The raw data supporting the conclusions of this article will be made available by the authors, upon reasonable request.The studies involving human participants were reviewed and approved by Ethics Committee of Faculty of Medicine, Suez Canal University, Ismailia, Egypt (Ref No. 4277/2020). The patients/participants provided their written informed consent to participate in this study.HS commenced the idea of this study, participated in the designing the study, wrote the manuscript draft, and approved the final version of the manuscript. SM participated in the designing of this study, collected the data, revised the manuscript, and approved the final version of the manuscript. SE participated in the designing of this study, analyzed the data, revised the manuscript, and approved the final version of the manuscript. MM and JS participated in the designing of this study, revised the manuscript, and approved the final version of the manuscript. AF designed this study, analyzed the data, revised the manuscript, and approved the final version of the manuscript. All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Plasmodium parasites, the etiological agents of malaria, are transmitted to their mammalian hosts by Anopheles mosquitoes. Despite decades of collective efforts, malaria remains one of the most devastating infectious diseases in the globe, with more than half of the world’s population at risk of infection and more than 400 thousand annual deaths. Malaria is a complex disease with a broad spectrum of symptoms, ranging from mild forms to severe pathology, the latter occurring in patients with life-threatening anemia, cerebral malaria, metabolic acidosis, and multiorgan system failure. In order to provide new insights into the complex interplay between the parasite and its mammalian host during the liver or blood stages of Plasmodium infection, the identification of key parasite or host molecules that interact with each other or that critically influence the outcome of infection, and the understanding of immune responses to infection, remain a priority , recently shown to play an important role in the regulation of various physiological processes related to malaria pathogenesis. S1P is a bioactive lipid intermediate of sphingolipid metabolism that exists in intracellular (such as red blood cells and platelets) and circulating extracellular pools, with each pool having a different function. In this review, the authors summarised the significance of each of these pools in the context of malaria. They also discussed how the S1P content in the erythrocytes could be channelled towards future therapeutic opportunities for malaria.Plasmodium berghei quiescin sulfhydryl oxidase (PbQSOX), which is present in various eukaryotic species and catalyses the insertion of disulphide bonds into unfolded and reduced proteins. Zheng et al. show that PbQSOX is most abundantly expressed in ookinetes, and localizes in the cytoplasm and surface of ookinetes. Further, the authors showed that mosquitoes fed on Δpbqsox parasite-infected mice displayed a significant reduction in ookinete and oocyst numbers compared to those fed on wild-type parasite-infected mice. Furthermore, both polyclonal antisera and a monoclonal antibody against recombinant PbQSOX exhibited substantial transmission-blocking activities in vitro and in the mosquito feeding assays. These findings identified QSOX as a potential target for blocking parasite transmission.An original research article revealed the role of the Plasmodium falciparum (Pf) parasites expressing the P. vivax (Pv) circumsporozoite protein (CSP) as a tool for the investigation of vaccines against Pv. Chimeric rodent malaria parasites expressing Pf and Pv CSP have previously been used in the preclinical evaluation of CSP-based pre-erythrocytic vaccines. Miyazaki et al. have now generated chimeric P. falciparum parasites expressing both the endogenous PfCSP and the heterologous PvCSP. The authors showed that immunization of mice with these Pf-PvCSP sporozoites elicited the production of antibodies against the repeat regions of both PfCSP and PvCSP, supporting the use of the newly generated parasite line in the optimization of vaccines targeting PvCSP.Another article discussed the potential of chimeric He et al. discussed the ‘conflicting’ roles exhibited by type I interferons (IFN-ls) during malarial infections. IFN-Is are important cytokines that play a role in various infections, autoimmune diseases, and cancer. Both the liver and the blood stages of malaria parasites can stimulate IFN-I responses in their vertebrate host. The host’s genetic background greatly influences IFN-I production during Plasmodium infections as well. Consequently, the effect of IFN-Is on parasitemia and disease symptoms are highly variable, depending on the combination of the parasite species/strains and the host. This review also summarized the major findings and progress in ligand recognition, signalling pathways, functions, and regulation of IFN-I responses during mammalian infections by Plasmodium parasites.A review by Ito et al. showed that novel proteins of apical organelles in merozoites are involved in erythrocyte invasion by Plasmodium falciparum. The authors generated a panel of monoclonal antibodies against P. falciparum schizont-rich parasites and screened the antibodies using immunofluorescence assays. Five of the monoclonal antibodies were then used in immuno-affinity experiments to purify their target antigens. Afterwards, liquid chromatography-tandem mass spectrometry (LC-MS/MS) was used to identify these antigens. The authors further expand on a novel complex that was identified by immunoprecipitation, composed of P. falciparum rhoptry-associated membrane antigen (PfRAMA) and P. falciparum rhoptry neck protein 3 (PfRON3) and identified a region spanning amino acids Q221-E481 of PfRAMA that can associate with PfRON3 in the immature schizonts.An article by Plasmodium parasite and its mammalian host. Voorberg-van der Wel et al. zoomed in on new technologies using monkey malaria and other malaria parasite model systems that can provide the tools necessary to investigate host-parasite interactions of relapsing parasites. The authors proposed that learning more about hypnozoite and host cross-talks should help identify factors that promote the activation of these dormant parasite reservoirs, leading to disease relapses, and may contribute to the identification of new tools aimed at eventually achieving malaria eradication.A mini-review provided exciting new insights on the cross-talk between the Oresegun et al. discussed underlying pathophysiological processes leading to a serious malaria infection. The authors described zoonotic malaria caused by P. knowlesi and proposed the use of this parasite as a model system specifically for severe malaria. Subsequently, a method to generate long-read third-generation Plasmodium genome sequence data from archived clinical samples was developed using the MinION platform. This research then developed a representative translational model for severe malaria that was informed by clinically relevant parasite diversity due to its ability to exploit the duality of P. knowlesi as a laboratory model and human pathogen.A perspective topic authored by Taku et al. discussed how the transport protein N-myristoylated adenylate kinase 2 (PfAK2) is transported and regulated by Rab GTPases from the endoplasmic reticulum (ER) to the cell’s surface. Previously, the same group reported that the export of PfAK2, which lacked the PEXEL (Plasmodium export element) motif, was regulated by PfRab5b GTPase  from heterozygous S carriers (HbAS) and homozygous non-mutant (HbAA) donors. The authors identified proteins whose quantity or phosphorylation state varied according to infection status and/or host haemoglobin genotype. Changes due to the S trait, to P. falciparum infection, or both were highlighted. Proteins identified included erythrocyte membrane transporters, skeletal proteins, and parasite proteins such as RESA or MESA. Phosporylation state may influence multiple functions such as membrane interactions, nutrient transport, cytoadherence. This is the first report of phosphorylation patterns in HbAS RBCs, infected or uninfected, and thus provides clues to understanding the molecular mechanisms of malaria resistance and importantly also identified alterations in phosphorylation state solely due to the carrier status.The molecular mechanisms underlying the protection against malaria offered by the heterozygous carriage of the haemoglobin S mutation (HbAS), or sickle cell trait, are still poorly understood. The original article by Ikeda et al. employed a novel genetic tool, P. berghei mutator (PbMut), whose base substitution rate is 36.5 times higher than that of wild-type parasites, to analyse a mutant parasite line (PbMut-PPQ-R-P9) with reduced susceptibility to piperaquine (PPQ), unveiling a new mechanism of drug resistance in malaria parasites. Whole-genome sequence analysis of PbMut-PPQ-R-P9 clones revealed that eight nonsynonymous mutations were conserved in all clones, including N331I in PbCRT, which encodes the chloroquine resistance transporter (CRT). Furthermore, the PPQ susceptibility and growth rates observed in genome-edited parasites (PbCRT-N331I) were significantly lower than those of PbMut-PPQ-R-P9, implying that additional mutations in PbMut-PPQ-R9 parasites compensate for the fitness cost of the PbCRT (N331I) mutation and contribute to reduced PPQ susceptibility. In summary, PbMut served as a novel genetic tool for predicting gene mutations responsible for drug resistance. Nevertheless, further studies on PbMut-PPQ-R-P9, which are likely to reveal genetic changes that compensate for fitness costs owing to drug resistance acquisition, should be conducted.The original research article by Plasmodium’s mechanism of mRNA quality control and export using RNA-binding proteins of malaria parasites. Previous research had shown that nuclear poly(A) binding protein 2 (NAB2), THO complex subunit 4 (THO4), nucleolar protein 3 (NPL3), G-strand binding protein 2 (GBP2), and serine/arginine-rich splicing factor 1 (SR1) are involved in nuclear mRNA export  domain-containing protein, which plays a role in translational repression. Alternatively, NAB2 interacts with transportin and binds directly to 143 mRNAs, including those encoding 40S and 60S ribosomal proteins.This original research article clarifies A export . NiikuraIn summary, the articles in this Frontier’s Research Topic “Malaria Targeting Toolkit: Host-Parasite Interactions” bring important new data as well as thoughtful insights about host-parasite interactions, parasite virulence, immune responses and molecular mechanisms of host resistance to parasites, and parasite resistance to drugs. Novel tools and methodologies are being developed, state-of-the-art techniques expanded, and many new insights gained, which will inform future malaria drug and vaccine development efforts.TAr and TAn prepared the draft. TAr, JL, MP, DC, and TAn revised the draft and approved the final version of the draft. All authors contributed to the article and approved the submitted version.This work was supported in part by a grant for Research on Emerging and Re-emerging Infectious Diseases from the Japan Agency for Medical Research and Development (AMED) , a grant from the Japan Society for the Promotion of Science (JSPS) (KAKENHI JP21K06999 to TAn) and a grant from The Chemo-Sero-Therapeutic Research Institute (90011100) to TAn. This work was supported in part by the National Natural Science Foundationof China (No. 31800772) to J-wL.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Information on cardiopulmonary complications in clinical malaria is sparse and diagnosis may be difficult in resource-limited areas due to lack of proper diagnostic tools and access to medical care. A case of pericardial effusion and pulmonary alterations assessed by ultrasound in a patient with uncomplicated mixed malaria infection is described.Plasmodium vivax and Plasmodium falciparum by peripheral blood smear. The patient presented with mild malaria symptoms without signs of severe malaria, but reported moderate chest pain and shortness of breath. Laboratory analyses revealed thrombocytopenia and anemia. The electrocardiogram had PR depressions and bedside ultrasound of the cardiopulmonary system showed pericardial effusion (18 mm) accompanied by multiple B-lines in the lungs, identified as vertical artifacts extending from the pleural line. Cardiac biomarkers were normal. The patient was treated according to national guidelines for malaria and suspected pericarditis, respectively. At follow-up on day 5, the pericardial effusion (9mm) and B-lines had markedly decreased. By day 21 the patient was asymptomatic, had completed the treatment, and the electrocardiogram and ultrasound findings had normalized.A previously healthy 23-year-old male from the Amazon Basin was diagnosed with mixed infection of This case report highlight the usefulness of bedside ultrasound to identify cardiopulmonary involvement in patients with uncomplicated malaria and relevant symptoms. Plasmodium vivax and Plasmodium falciparum [Information on cardiopulmonary complications in malaria is limited and only sporadically reported in clinical studies , 2. Adeqlciparum –11, but lciparum  and one A case of pericardial effusion and B-lines in a patient with uncomplicated mixed malaria infection, who presented with chest pain and shortness of breath is reported. The aim of this case report is to describe the potential usefulness of ultrasound for identifying cardiopulmonary complications in relevant patients suffering from uncomplicated malaria.P. vivax and P. falciparum by peripheral blood smear (16560 parasites/µL) in the emergency care unit . 48 days earlier he had completed treatment for mono-infection of P. vivax  with primaquine 30 mg (7 days) and chloroquine 600 mg (day 1) + 450 mg (day 2 and 3). The patient now presented with headache and chills and reported onset of stabbing chest pain and shortness of breath 3 days prior to examination.A 23-year-old Brazilian male with no prior history of cardiopulmonary disease was diagnosed with 3) and moderate anemia (hemoglobin 9.2 g/dL). Liver function was slightly affected (aspartate aminotransferase 47 U/L). Cardiac biomarkers were all within normal range . The electrocardiogram (ECG) showed PR-depressions in lead I, II, aVF and V1–V6. Ultrasound revealed pericardial effusion (18 mm) and 24 B-lines by LUS , auscultation of heart and lungs was normal. Axillary temperature was < 37.5 °C. Laboratory results showed inflammation (C-reactive protein 96 mg/L), thrombocytopenia  and peripheral blood smears were negative for Follow-up day 21: The patient reported to be free from all symptoms and peripheral blood smears were negative. Ultrasound displayed no significant pericardial effusion (< 5 mm) and 0 B-lines.P. vivax infection (n = 26 outpatients) was associated with subclinical right ventricular function  in the symptomatic phase of the malaria infection [ This case report has two principal findings: (i) Malaria patients who present with cardiac complaints may suffer from unrecognized cardiopulmonary complications, and (ii) bedside ultrasound examination may be a useful method to identify such cardiac disturbances. Recently, a meta-analysis by Holm et al. found that cardiovascular complications in malaria are only sporadically reported and may be underestimated . Specifinfection . In thisnfection , 16. Colnfection  and relenfection , 19. DesP. vivax and P. falciparum, however, occurs more frequently in mixed malaria infections [P. vivax followed by a superinfection of P. falciparum, increasing the risk of pulmonary involvement. Consequently, multiple B-lines by LUS were observed, indicating presence of extravascular lung water [Inflammatory changes also occur in the lungs during malaria , 21. Altfections . In the ng water . One prihigh-risk group, who may benefit from ultrasound of the cardiopulmonary system as part of the early clinical assessment. Furthermore, B-lines demonstrated a dynamic nature throughout the follow-up examinations and could, on a hypothesis-generating basis, be used for monitoring of pulmonary involvement in malaria; similar to what has been reported in other patient groups such as heart failure and sepsis [During the follow-up examinations, the patient reported a relief in cardiac complaints which was accompanied by a concomitant decrease in pericardial effusion and B-lines. This indicates a correlation between cardiac symptoms and cardiopulmonary findings by ultrasound. Malaria patients presenting with key cardiac symptoms  could potentially constitute a d sepsis , 12, 23.Bedside ultrasound examination represents an easily applicable diagnostic tool, which may provide accurate information for diagnosis of cardiopulmonary involvement in clinical malaria cases. LUS may be particularly useful as it can be applied by non-medical personnel with high sensitivity and specificity , and eveThis case report highlights the usefulness of bedside ultrasound to identify cardiopulmonary involvement in patients with uncomplicated malaria and relevant symptoms.