There have been many recent reports that the rate of outdoor biting by malaria vectors has increased. This study examined the impact this might have on malaria transmission by assessing the association between exposure to outdoor bites and malaria infection on Bioko Island, Equatorial Guinea.Responses to questions about time spent outside the previous night from a malaria indicator survey were combined with human landing catch measurements of hourly rates of outdoor and indoor biting for the whole island to estimate the number of outdoor and indoor bites received by each survey respondent. The association between RDT measured malaria infection status of individuals and outdoor bites received was investigated.vs 17.4%, p = 0.20) and children . Malaria infection in neither adults (p = 0.56) nor in children (p = 0.12) was associated with exposure to outdoor bites, even after adjusting for confounders.The average number of bites received per person per night was estimated as 3.51 in total, of which 0.69 (19.7%) would occur outdoors. Malaria infection was not significantly higher in individuals who reported spending time outside between 7 pm and 6 am the previous night compared to those not spending time outside in both adults (18.9% Malaria vector mosquitoes in Bioko do bite humans outdoors, and this has the potential to reduce the effectiveness of vector control. However, outdoor biting is currently not a major factor influencing the malaria burden, mainly because more than 95% of the population are indoors during the middle of the night, which is the peak biting period for malaria vector mosquitoes. The majority of resources should remain with control measures that target indoor biting and resting such as LLINs and IRS. African malaria vectors have a strong tendency to bite humans sleeping indoors -4. HowevIf malaria vectors are biting more outdoors this could be as a result of intensive efforts to control them over the last decade . The majSince the 1950s, outdoor biting (exophagy) and outdoor resting (exophily) have been recognized as important factors reducing the effectiveness of IRS and its capacity to interrupt transmission . It has Anopheles mosquitoes bite humans would be at greater risk of malaria than those who do not. In this study, entomological data were combined with parasitological data from a 2013 malaria indicator survey, to estimate respondents’ exposure to outdoor biting in relation to their risk of malaria infection.If outdoor biting is a major factor in malaria transmission on Bioko one would expect that people who spend time outdoors at times when Bioko, the main island of Equatorial Guinea, has a population of approximately 250,000 and is situated 32 kilometres off the coast of Cameroon. Malaria transmission occurs throughout the year. The Bioko Island Malaria Control Project (BIMCP), funded by the Government of Equatorial Guinea and a consortium of private donors led by Marathon Oil Corporation, was launched in 2004. The project carried out island-wide IRS, the first round taking place in 2004 with deltamethrin, . This was followed by biannual rounds of the carbamate insecticide bendiocarb  from 2005 to 2012. In 2013 and 2014 a single round of a long-lasting micro-encapsulated formulation of deltamethrin  was carried out each year. IRS coverage was frequently inadequate; for example the most recent round of IRS in 2014 sprayed 55% of houses with insecticide. In 2005 intermittent preventative treatment for pregnant women (IPTp), case management using artemisinin-based combination therapy (ACT), and rapid diagnostic tests (RDT) together with the training of health facility staff were introduced as additional measures. A mass LLIN distribution took place in 2007 with 110,000 PermaNet 2.0 nets  distributed to over 38,000 households. Initially high levels of LLIN ownership and usage were achieved with 76% of two to 14 year olds reported to be sleeping under an LLIN, but coverage declined rapidly thereafter; in 2013 only 13% of two to 14 year old children were reported to be sleeping under a LLIN . MalariaAnopheles funestus and both the S and M molecular forms of Anopheles gambiae s.s. and in coastal areas by Anopheles melas. High entomological inoculation rates (EIR) of over 750 and 250 infectious bites per person per year by An. funestus and An. gambiae s.s., respectively, were recorded [An. funestus were observed and the proportion of S-form An. gambiae s.s. was reduced [. More recent studies found no specimens of either S-form An. gambiae s.s. or An. funestus [An. gambiae s.s was 8.4 bites per person per hour, compared to an indoor biting rate of 5.9 [Before the launch of the BIMCP, malaria was transmitted by recorded ,18. Afte reduced . More refunestus ,20. The funestus ,18. By 2e of 5.9 .Plasmodium falciparum using RDT , subject to informed written consent (from a caregiver in the case of children). Those testing positive for parasitaemia were provided with ACT (artesunate + amodiaquine) by a Project nurse. Those with haemoglobin < 8 g/dL or who were febrile were referred to a local clinic for appropriate treatment . Participants were asked at what time they entered the house the night before the survey, about any other time spent outside the house between 7 pm and 6 am and what time they went to bed. Behaviour during the previous night was taken as a proxy for usual behaviour, in the same way that bed net use the previous night is asked as a proxy for usual behaviour.Since the start of the BIMCP in 2004 annual household malaria indicator surveys have been conducted on Bioko -16,21,22Human Landing Catches (HLCs) were carried out monthly from January to October at six sites. These sites were all located within the system of sentinel sites used for the MIS surveys. A team of eight catchers worked through the night from 7 pm to 6 am. Four houses approximately 100 metres apart were selected in each site for conducting HLC throughout the study period. Each house had one catcher inside and another immediately outside, under the veranda if there was one. At midnight the indoor and outdoor catchers exchanged positions. Mosquitoes were stored in collection tubes labeled according to the hour and the location of capture. Two entomology field supervisors were responsible for ensuring that the volunteers stayed awake during the night. Catchers were informed of the risks involved and were offered treatment if they showed symptoms of malaria.Anopheles bites received outdoors, and πi which Killeen et al. define to be the proportion of bites occurring indoors for an unprotected individual [From survey responses, the proportion of participants indoors and outdoors at each hour of the night was calculated for each site and for the island as a whole. These proportions were multiplied by the indoor and outdoor biting rates from HLCs to estimate biting exposure in terms of the indoor and outdoor bites received at each hour of the night between 7 pm and 6 am per Bioko resident. This enabled the estimation of the proportion of dividual . This prThe association between RDT confirmed malaria infection and the number of outdoor bites received the night before the survey was assessed using logistic regression. Similarly, the effect of site level proportion of outdoor biting on individual malaria infection was investigated. Analyses were done separately for children aged two to14 and for individuals aged 15 or over. Odds ratios (ORs) were adjusted for the following site level confounders: Sero-Conversion Rate (SCR) measured in 2008 as a measure of underlying transmission intensity ; and sprThe association between site level proportion of outdoor biting and the site level prevalence of malaria infection in children aged two to14, was examined using linear regression, adjusting for the site level SCR, the proportion of children at the site who had slept under a net the night before the MIS and the proportion of houses at the site which had received IRS in the previous six months. In all analyses robust standard errors were used to account for the survey design ,28. All Ethics approval for the study was granted by the Equatorial Guinea Ministry of Health and Social Welfare and the ethics committee of the London School of Hygiene and Tropical Medicine . Informed written consent was given by each survey participant or, in the case of children, a responsible adult. In the case of participants being unable to read, the text was read and explained to them, and consent was confirmed by an independent witness identified on the consent form.The rate of indoor biting, estimated by HLCs, decreased from 39.6 bites per person per night to 3.1 over the five years from 2009 to 2013 . Infection prevalence was 27.8%  among children aged two to 14 years and 18.2%  among those aged 15 or over. Site-specific prevalence of malaria infection in children ranged from 2.4% to 55.6%.A total of 4,721 households and 21,743 individuals were sampled in the 2013 malaria indicator survey. Of these, 14,792 persons were tested for malaria infection using an RDT. Overall 21.6% tested positive for Sixty three percent of respondents were reported to be indoors between 7 pm and 8 pm the night before the survey took place. This rose monotonically over the course of the night, reaching 97% between the hours of midnight and 1 am and staying at or above this level throughout the night Table . Childrei = 0.803. This assumes that no nets are used. Data from the 2013 MIS indicate that 15.2% of respondents slept under an LLIN the night before the survey and a further 16.2% sleep under an untreated net. Assuming that no bites were received by those sleeping under a net after the reported time of going to bed, then 25.1% of all bites would occur outdoors.The outdoor biting rate obtained from HLCs was much higher than the indoor biting rate at all times of the night Figure . HoweverThe community percentage of biting taking place outdoors ranged from 13% to 24% between sites, with mean 18.5%. Individuals on average received 0.7 bites per night outdoors . On average children aged 2–14 years received 0.4 bites per night outdoors whereas persons 15 or over were exposed to 1.3 bites per night outdoors due to their greater outdoor exposure.vs 17.4%, p = 0.20) and children  (Table p = 0.56) nor in children (p = 0.12) was associated with exposure to outdoor bites, even after adjusting for confounders. There was no evidence of an association between the proportion of biting occurring outdoors at a site level and individual infection status.Malaria infection was not significantly higher in individuals who reported spending time outside between 7 pm and 6 am the previous night compared to those who did not, in both adults (18.9% p = 0.32).There was an estimated trend of a 1.1% increase in site level infection prevalence in children per 1% increase in proportion of bites received outdoors but this was not statistically significant even after adjusting for confounders  in the density biting outdoors. The indoor:outdoor biting ratio is presumably influenced not only by the mosquitoes’ intrinsic behavioural characteristics, but also by some environmental factors, especially the room used for indoor biting catches; for example ease of access via the eaves and windows, the presence of an electric light, and the possibility of some unrecorded shift over time in such environmental factors cannot be ruled out. Assuming there was a shift in behaviour, the question would then arise whether this is an evolved heritable change in behaviour and whether there is a genetically-determined subset of mosquitoes that avoid IRS by resting entirely  outdoors. This would be important because the existence of such mosquitoes has been postulated to explain the limited effectiveness of other malaria vector control programmes [The data in Table ogrammes . The behA limitation of this study is that the epidemiological data are observational, and although the analysis was adjusted for many observed confounding variables, there could still be residual confounding. This would be a limitation of any such study since it is not possible to randomly allocate communities to different levels of outdoor behaviour. It is standard practice to measure net use by asking whether interviewees used a net the night before the survey, as a proxy for their habitual use of nets . Here thAn. gambiae exists), and on the potential impact of larval source management or personal protective measures during peak periods when the population is outdoors at night.Malaria vector mosquitoes in Bioko do bite humans outdoors, and this has the potential to reduce the effectiveness of indoor vector control. However the results presented here show that it is currently not a major factor influencing the malaria burden, probably because more than 95% of people are indoors during the middle of the night, which is the peak biting period for malaria vector mosquitoes. The results of this study suggest that for the present the majority of resources should remain with control measures that target indoor biting exposure such as IRS and LLINs. To prepare for elimination, however, further research is warranted on potential shifts in vector behaviour, including outdoor biting (e.g. to identify whether an exclusively outdoor biting fraction of


Arrival of inmigrants from malaria endemic areas has led to a emergence of cases of this parasitic disease in Spain. The objective of this study was to analyse the high incidence rate of imported malaria in Fuenlabrada, a city in the south of Madrid, together with the frequent the lack of chemoprophylaxis, for the period between 2004 and 2014. Both pregnant women and HIV risk groups have been considered.Retrospective descriptive study of laboratory-confirmed malaria at the Fuenlabrada University Hospital, in Madrid, during a 10-year period (2004–2014). These data were obtained reviewing medical histories of the cases. Relevant epidemiological, clinical and laboratory results were analysed, with focus on the following risk groups: pregnant women and individuals with HIV.Plasmodium falciparum). The annual incidence rate was 11.9/100,000 inhabitants/year. The average age was 30.8 years (SD: 14.3). Infections originating in sub-Saharan Africa comprised the 97.6 % of the cases. A total of 85.9 % were Visiting Friends and Relatives. Only a 4.3 % completed adequate prophylaxis. A total of 14.28 % of the fertile women were pregnant, and 8 cases (4.3 %) had HIV. None of them in these special groups completed prophylaxis.A total of 185 cases were diagnosed (90.3 % The incidence rate in Fuenlabrada is higher than in the rest of Spain, due to the large number of immigrants from endemic areas living in the municipality. However, the results are not representative of all the country. It seems to be reasonable to implement prevention and pre-travel assessment programs to increase chemoprophylaxis. Pregnancy tests and HIV serology should be completed for all patients to improve prophylactic methods. Malaria is the most common and lethal parasitic disease in the world and one of the most important public health problems. According to data from the World Health Organization (WHO), malaria is endemic in 104 countries, which suggests that half of the world’s population is at risk of suffering from this disease. The WHO estimates that 198 million cases of malaria occurred worldwide in 2013 and the disease led to 584,000 deaths. The worst scenery can be found in the WHO African Region, where approximately a 90 % of all of the malaria deaths occur; children under 5 years in this area account for a 78 % of all the deaths . 51.9 % (96) presented anaemia (haemoglobin under 12 g/dl in women and 13 g/dl in men), with an average of 12.35 g/dl (SD: 2.15). There were no alterations in the white blood cell series: 33 (17.8 %) presented leukopaenia (levels under 3500 leukocytes/µl). Percentage parasitaemia at diagnosis was obtained in 160 cases (86.8 %), with a range between <1 and 20 % and an average of 0.9 % (IQR: 0.9–2).Plasmodium, 90.3 % (167) of cases were P. falciparum, 3.2 % (6) were mixed parasitism , 1.6 % (3) were P. ovale, 1.6 % (3) were P. vivax, and 1.1 % (2) were Plasmodium malariae. In 2.2 % (4) of the cases, the species of Plasmodium was not identified.Regarding the type of A total of 29 patients (15.7 %) took chemoprophylaxis. Of these, eight patients (4.3 %) did it correctly. By origin, only 3 (4.1 %) of those born in Equatorial Guinea (73 patients) and 1 (1.2 %) of the Nigerians (79 patients), completed prophylaxis correctly.Treatment was received in 182 cases (98.3 %). A 84.4 % (156) received treatment with combinations of quinine or derivatives , a 12.4 % (23) with atovaquone–proguanil, and a 1.6 % (3) with artemisinin. Of those treated with atovaquone–proguanil, 7 (30.4 %) were treated with derivatives of quinine at diagnosis, but treatment was modified due to an adverse effect of quinine.No deaths resulted.p = 0.06). 6 cases (66.7 %) received quinine and clindamycin, 2 (22.2 %) received artesunate and the rest received quinine and doxycycline due to previous miscarriage. None completed proper prophylaxis . Characteristically, almost all of the pregnant women presented anaemia , with average haemoglobin values of 10.1 g/dl (SD: 1.72) compared to the 11.45 g/dl (SD: 1.88) in non-pregnant women of reproductive age (3 (IQR: 51–325). The other four had known HIV [with an average CD4 count at the time of the malaria diagnosis of 394/mm3 (IQR: 239–405)]. There was a difference between both groups, though it was not statistically significant (p = 0.29).All the cases were VFR-immigrants. None had completed chemoprophylaxis Table . Four wep = 0.10).In recently diagnosed cases of HIV, the average levels of haemoglobin were haemoglobin: 9.43 g/l (SD: 3.1) and the median levels of platelets were 92,500 , both under the levels found in the cases with previously known HIV . The differences were not significant  during the period 2004–2014. The most remarkable finding is the high incidence rate, which far exceeds those from the Community of Madrid and from the rest of Spain. In addition, it was also observed that most of the diagnosed malaria cases affect sub-Saharan patients, and that there is a high percentage of VFR. They usually attended the hospital quite quickly and did not complete prophylaxis. A significant percentage are cases within pregnant and HIV+ risk groups, which present a higher risk of severe malaria.Regarding the very high incidence rate observed in the studied area , it has been tried to obtain the most reliable values by excluding from it those cases of immigrants who have recently arrived in Spain (less than 1 year). These are usually immigrants following routes to other European countries, who stay for a short time in Spain visiting friends and relatives and preparing their trip. It is in these moments when malaria symptoms appear (mostly fever), and they go to hospital. These cases are then notified, but in many of them, there is not a clinical following up, fact that shows up when medical histories are analysed.One of the possible causes of the difference between the obtained results and the incidence rates of the community of Madrid and the rest of Spain, may be an excess of diagnostic tests in the area under analysis, where the sub-Saharan population is very important and malaria quite frequent. In fact, in the emergency department, malaria is tested in all cases with fever coming from Nigeria or Equatorial Guinea, disregarding their time of permanence in Spain (sometimes travelling details are hidden by patients). This may not be the case in other areas, where some cases of malaria are not diagnosed due to the absence of suspicion and the corresponding tests. For example in Leganés , anotherRegarding the population under study, no reliable data are available apart from those of the 2013 census, and so only registered citizens are included for the computation of the incidence rate (denominator). Of course, there is a percentage of the immigrant population which is in an extreme irregular situation, that does not allow them to even register or to get a sanitary card, but they can still be treated for free in the emergency services. These cases have been included in the numerator but, as it has been explained, not in the denominator. However, taking into account that immigrants can get registered in the census in Spain with no need of having a residence permit, the difference in incidence rate due to the non-consideration of these “extreme irregular” cases in the total population does not have a significant effect on the rate calculation.The population coming from the Sub-Saharan Africa, is mainly distributed in two areas of the community of Madrid (Madrid centre and the South Ring), with a 74.52 % of the immigrants and they tend to stay in districts by nationalities. In Fuenlabrada (within the South Ring), a 55.5 % of sub-Saharan immigrants come from Nigeria and a 27.7 % from Equatorial Guinea. In the rest of the community of Madrid, a 29.78 % come from Nigeria and a 19.39 % from Equatorial-Guinea . This poP. falciparum, which is more frequent in Nigeria and Equatorial Guinea (a former Spanish colony); this pattern was also observed in other case series in Europe [P. vivax is the prevalent species, and it is present in more than a 50 % of the diagnosed cases [The majority of the cases of imported malaria are produced by n Europe , 20 and n Europe –9, 11. Oed cases . A high ed cases , 8. The The low number of days until diagnosis (3 days) of Equatorial Guinean population compared to the average of 4.5 days for Nigerians VFR, could be explained due to the absence of a language barrier for the former (mother tongue is Spanish), who attend the hospital sooner. The median time from symptoms to diagnosis was 4 days (IQR: 2.5–7) similar to another study published in southern Madrid . In a stRegarding the high number of cases who required hospital admission 95.1 %), it is explained due to the fact that it is common practice in Fuenlabrada Universtiy Hospital to hospitalize nearly all malaria cases to check their correct evolution with the treatment, to carry out analytical vigilance (anaemia) and to follow up and make a thick blood smear after 48 h. The infrequent use of chemoprophylaxis is a well-known issue. In the presented study, the rate of properly completed prophylaxis was 4 %, similar to previous rates that range from 3 to 15 % 5.1 %, it, 13, 21.It was observed that travellers-VFR (born in Spain) completed prophylaxis more frequently (16.7 %) than immigrants VFR (born in endemic area) (2.8 %). The explanation to this result could be that parents could have gone to the Primary Care Centre with their children (for a routine revision). There the paediatrician gives some pre-travel counselling about chemoprophylaxis and others, which is followed by the children (under the supervision of their parents), but not by the parents themselves (who were born outside of Spain and who have a misperception of the possible risk).In Fuenlabrada University Hospital, after the experience with such a large number of cases, pre-travel counselling is added in the clinical report and the necessary prescription is given to the patients, as a way of increasing the correct use of chemoprophylaxis.Malaria in pregnancy is associated with increases in maternal, fetal, and perinatal morbidity and mortality , and alsThe characteristics of the cases are similar to a previous study . WeightsGiven the high risk of maternal-fetal complications and the frequent occurrence of anaemia in such patients, the recommendation that a pregnancy test be completed in all cases of malaria in women of reproductive age , could be valuable.Among the infections that affect the human population, malaria and HIV/AIDS are responsible of most of the deaths. The U.S. Centers for Disease Control and Prevention (CDC) consider malaria as an opportunistic infection in patients with HIV in areas with geographic overlap . ConsideRegarding the large number of positive HIV cases (8.9 %), although this rate is very high, it could be higher if a HIV serological test was completed in all cases of imported malaria. One of the reasons of these values may be the high HIV incidence in Sub-Saharan Africa (which is the highest worldwide). These tests are done because given the prevalence of HIV in sub-Saharan Africa and the large population of this precedence in our area, HIV detection tests should be completed as a public health measure.The possibility of false positives for HIV in patients with malaria cannot be overlooked (three patients in our study) .Is it important to evaluate that none of the patients had completed previous chemoprophylaxis. In a French study on imported malaria that described 190 cases of imported malaria in patients with HIV, 10.5 % had correctly completed prophylaxis . In a st3 [3, similar to the French study, with an average CD4 count at diagnosis of 299/mm3. It should be highlighted that no studies have been found that compare cases of imported malaria with concomitant diagnoses of HIV and malaria. In the presented study (even with the scarce number of cases), such cases exhibited greater immunosuppression (average CD4 count of 221/mm3). The severely affected patient with HIV infection exhibited a CD4 count of 10/mm3 (the lowest level in the entire series). The scarce number of patients with HIV may explain why there were no significant differences in any of the data analysed.In cases of imported malaria, it has been observed that there is a higher risk of severe malaria almost exclusively in patients with HIV infection and CD4 counts under 350/mm3 . In thisP. falciparum. There is a high percentage of VFR and most of them did not complete prophylaxis. The population traveller-VFR, who was not born in an endemic area, has to be highlighted. It seems to be reasonable to implement prevention and pre-travel assessment programmes, especially in VFR, to increase the number of people who correctly perform chemoprophylaxis. Regarding pregnant woman risk group, it can be recommended that a pregnancy test is completed in all cases of malaria in women of reproductive age. In the case of the HIV risk group it can be concluded that HIV detection tests could be evaluated in all cases of imported malaria to improve prophylactic methods and as a public health measure.From this study it can be concluded that the incidence rate of imported malaria in Fuenlabrada is higher than in the rest of Spain, due to the large number of immigrants from endemic areas living in this municipality. However and due to the special distribution of the population of the city, the results are not representative of all Spain or the community of Madrid. Most of the diagnosed malaria cases affect sub-Saharan patients and are due to


Although malaria in Brazil almost exclusively occurs within the boundaries of the Amazon Region, some concerns are raised regarding imported malaria to non-endemic areas of the country, notably increased incidence of complications due to delayed diagnoses. However, although imported malaria in Brazil represents a major health problem, only a few studies have addressed this subject.A retrospective case series is presented in which 263 medical charts were analysed to investigate the clinical and epidemiological characterization of malaria cases that were diagnosed and treated at Hospital & Clinics, State University of Campinas between 1998 and 2011.Plasmodium vivax and Plasmodium falciparum were responsible for 67% and 30% of the infections, respectively. The majority of patients were male (83%) of a productive age . Importantly, severe complications did not differ significantly between P. vivax  and P. falciparum  infections.Amongst all medical charts analysed, 224 patients had a parasitological confirmed diagnosis of malaria. P. vivax infections in Brazil are not benign, regardless the endemicity of the area studied. Moreover, as the hospital is located in a privileged site, it could be used for future studies of malaria relapses and primaquine resistance mechanisms. Finally, based on the volume of cases treated and the secondary complications, referral malaria services are needed in the non-endemic areas of Brazil for a rapid and efficient and treatment.Severe malaria cases were frequent among imported cases in Brazil outside of the Amazon area. The findings reinforce the idea that  Despite intense global efforts to control malaria, non-immune and semi-immune travellers living in non-endemic areas remain a highly vulnerable group for malaria infection, especially due to delayed diagnosis and increased risks of complications. Therefore, although the clinical outlook for malaria in previously healthy adults living in endemic areas tends to be mild, the absence of immunity and delayed or misdiagnosis (up to 40% ) may preApproximately 60% of malaria cases in the Americas occur in Brazil , and theThe Hospital & Clinics of the State University of Campinas (HC-UNICAMP) is one of the fourteen-referral centers for the diagnosis and treatment of malaria in the Brazilian State of São Paulo. The region was formerly endemic for malaria, with a great number of autochthonous cases in the early decades of the 20th century . In the The informed consent waiver was approved by the Research Ethics Committee of the University of Campinas (number 1283/2011).The study was designed as a retrospective case series and took place at the HC-UNICAMP. Hospital & Clinics, State University of Campinas  is a tertiary hospital with 409 beds; 471,338 medical consultations and emergency treatments were performed in 2012. The hospital has a coverage area of more than 100 municipalities in the areas surrounding Campinas, which includes a population of 5,000,000 in these municipalities [Plasmodium infection identified, from January 1998 to April 2011. PCR was not routinely performed to confirm the Plasmodium species that caused an infection; however a senior microscopist systematically performed quality control. Only patients with accessible medical charts were enrolled. A standard questionnaire was used to register data obtained from the medical charts, such as demographic profile, time of clinical disease, referred previous malarial infections, travel history, peripheral blood parasitaemia, clinical and laboratory profiles, physical examination and the prescribed anti-malarial regimen.Patients seen at HC-UNICAMP who received a confirmed diagnosis of malaria that was reported by its Hospital Epidemiology Division (NVE-UNICAMP) were selected. Diagnoses had been confirmed based on analysis of thick and thin blood films (TBF) that were examined by trained experienced staff. Patients were enrolled in this study, regardless of the species of P. vivax. Since its absence, Lacerda et al. [P. falciparum infection fits malaria severity found in P. vivax infection. Therefore, the same criteria for both species were used. Because some patients were treated for malaria at the HC-UNICAMP for two or more episodes of malaria, only the first confirmed case registered on the medical chart was considered in the analysis. Patients were divided into residents (n = 56) and travellers (n = 87) based on the time that they stayed in the endemic area; a stay of more than 12 months was characterized as residence. Differences for which P < 0.05 were considered to be statistically significant.Malaria patients at HC-UNICAMP are treated following the Brazilian guidelines for the treatment of malaria  . PatientP. vivax malaria. Relapses were defined as the cases in which, after treatment and a negative TBF, subjects presented a new TBF with a positive result more than 28 days after starting anti-malarial treatment. Moreover, a case was only considered to be a relapse if the patient did not return to an endemic area during the follow-up period.After treatment, TBF were performed to verify cure. Blood films were checked at days 15, 45, 75 and 105 after treatment for patients with P. vivax malaria received non-supervised chloroquine for three days (four pills on day 1 and three pills on both days 2 and 3) and non-supervised primaquine (15 mg daily for 14 days). In cases of true relapse, the dose of primaquine was increased to 22.5 mg/day for 14 days; if there was a second relapse, the dose was increased to 30.0 mg/day for 14 days. Patients with uncomplicated P. falciparum malaria received a single oral mefloquine dose at admission (prior to 2007) or artesunate plus mefloquine p.o. for three days (2007–2011). Intramuscular artemether was given to 18 patients with severe disease. There was no information available on chemoprophylaxis.Drug regimens followed Brazilian guidelines for the treatment of malaria  . Patientt-test was used to compare groups with normally distributed data, and data sets with non-normal distributions were compared using the Mann–Whitney test. GraphPad Prism 5® and Stata 9® software were used for these analysis.Fisher’s exact test was used for categorical data. Student’s Plasmodium vivax malaria accounted for the majority of the cases , while P. falciparum was identified in 67 patients (30%) and mixed infection  was found in only six patients. No cases of infection by other Plasmodium species were reported. The distribution of cases per species and year is shown in Figure P. vivax and P. falciparum infections  took place in Brazil and 37 cases were from other countries, those were called ‘international’ cases, representing 18% of the total. The leading foreign country regarding the number of cases was Angola , followed by Haiti and Guiana (3 cases each), French Guiana, Ghana, Congo and Mozambique (2 cases each), and Venezuela, Cape Verde, Guinea Bissau, Equatorial Guinea, Cameroon, Egypt, South Africa and Papua New Guinea (1 case each).P. vivax infections, seven cases of P. falciparum infections Therefore, 9% of the P. vivax infections and 10% of the P. falciparum infections evolved into severe disease; these proportions were not significantly different (P > 0.05). Notably, no patient with severe disease was a resident of the probable area of infection, as five months was the longest stay.Severe malaria was defined according to the WHO criteria ,10. AmonP. vivax malaria, but no significant difference for this sign between P. falciparum and P. vivax was found. Four of these six patients presented thrombocytopaenia , which is not a criterion for severe malaria according to WHO guidelines [Six of the 224 patients (3%) presented with spontaneous bleeding of the nose and/or gums. All of these patients had idelines .P. vivax infections  and two P. falciparum infections . Among the four patients who presented with type 1 respiratory failure (pO2 < 60 mmHg and pCO2 < 35 mmHg) [P. falciparum malaria and one had P. vivax malaria.From the 41 patients with available urine test data, eight subjects had haemoglobinuria. These cases included six 35 mmHg) , three hHyperbilirubinaemia  is considered to be a marker of severe disease only if it is associated with another indicator of organ dysfunction . FollowiP. vivax infections. For these relapsing episodes, the drug regimen was either maintained or the primaquine dose was increased. Among patients with relapses, four presented no symptoms during the relapse, four required hospitalization and 14 presented with fever. Thrombocytopaenia and anaemia were common findings, occurring in 69% and 60% of patients with relapses, respectively. Most of the relapses resolved after the first retreatment, but five patients (26%) experienced more than one relapse.There were 19 (12.6%) cases of true relapses amongst patients infected with 3) [Plasmodium species. Twenty-eight patients had severe thrombocytopaenia  [P. vivax malaria (15%) and 14 were patients with P. falciparum malaria (27%). The difference between these proportions was not significantly different  . Of thosOverall, 52/152 patients (34%) were found to be anaemic  . When coP. falciparum or P. vivax malaria for prothrombin time (PT), lactate dehydrogenate (LDH) and aspartate aminotransferase (AST), were slightly elevated only for LDH and AST in P. falciparum infections (Table Laboratory test results were only different between patients with ns Table . As the P < 0.0001). A significant reduction in WBC was also found, but both median values were within the reference range.As expected, a significant decrease in haemoglobin, haematocrit and red blood cell levels in the first days after the onset of treatment was detected (P. vivax accounts for nearly 85% of cases), but was very similar to what has been previously reported for this region [P. vivax infections, compared to P. falciparum infections, is different from what is observed in Europe and the USA, where most imported cases come from Africa [The proportion among of Plasmodium species that caused infection in the present study cohort was different from what is observed in Brazil as a whole  probably reflects the fact that both Brazil and Angola are former Portuguese colonies. The relationship of imported cases in European countries with their former African colonies is a well-known phenomenon . NonetheThe higher proportion of infected men, a common finding among imported malaria studies ,27, resuP. falciparum and P. vivax were compared. The finding that there was no greater time interval between the onset of symptoms and treatment for cases of complicated P. vivax or P. falciparum malaria is of critical importance, as it suggests that a longer disease duration and increased parasitaemia are not sufficient to yield complications of P. vivax malaria, and the development of severe disease might also depend on other factors intrinsic to the parasite species [There was no significant difference in the time elapsed between the onset of symptoms and the initiation of treatment when cases of  species .P. vivax malaria, which is still perceived to be a benign disease [P. vivax malaria, a finding previously reported in other Brazilian studies [P. vivax malaria presented with haemoglobinuria (4% of P. vivax cases), a rate of incidence similar to what has been observed previously in a multicenter study of endemic areas [P. falciparum malaria.Of particular interest is the finding that no patients with severe malaria were residents of endemic areas, which supports the concept of greater vulnerability of non-immune patients, or those with waning immunity, to the development of severe presentations of the disease . This in disease ,30. One  studies ,32. Six ic areas , but theic areas  and prev3) [P. falciparum. From the beginning of treatment of patients with anti-malarials, there was a reduction in haemoglobin, haematocrit and red blood cells, as previously reported [P. falciparum and P. vivax malaria, and anaemia worsened both in patients that received chloroquine and primaquine or mefloquine and artesunate.Thrombocytopaenia was a common finding that affected 85% of patients analysed, a proportion comparable to other studies of imported malaria ,35. This3)  was also3) , in whicreported . This paNotably, from 2001 to 2011, there were 2391 cases of malaria in São Paulo, with 28 deaths caused by malaria in this state, a lethality rate of 1.1% ,38. ThisP. vivax relapses that we found is lower that what was previously observed in other studies of imported malaria in Brazil [Analysing the incidence of relapsing cases along with associated factors is important for preventing such events. Relapses are dangerous because of their morbidity and risk of reintroducing malaria to areas where mosquito vectors are still present . The occn Brazil ,41, but P. falciparum infection, which does not include most areas of Brazil, but it is important to highlight that prevention does not solely comprise chemoprophylaxis [There was no information about chemoprophylaxis for malaria in the medical charts. Thus, it was impossible to assess different disease severities or the presence of relapses based on this variable. The absence of such information might result from the recommendation by the Ministry of Health that chemoprophylaxis is only advised for persons travelling to areas with a high incidence of phylaxis . It is iBecause this study took place in a tertiary hospital, there may have been some bias in the selection of patients, as subclinical or mild disease may have not compelled infected individuals seek out healthcare. Retrospective case series studies tend to face gaps in the register of information and the record of symptoms is somewhat biased because denied symptoms have a greater chance of not being registered in the medical chart than referred ones. Furthermore, it was not possible to exclude, from the medical charts, the presence of concomitant dengue fever in all of the cases, and this coinfection could explain cases of bleeding. Nevertheless, it was not possible to fully assess the presence of comorbities in all patients enrolled in the study.vivax malaria. Nonetheless, TBF are systematically reviewed and a lower incidence of P. falciparum infection makes coinfection of Plasmodium species less likely.The lack of a more sensitive method for malaria diagnosis in this study, especially PCR, makes it impossible to rule out the presence of mixed infection in the cases of severe P. vivax was found to be responsible for severe cases. This finding reinforces the idea that P. vivax infections in Brazil are not benign and establishes a framework for further research on the topic. Indeed, more studies are needed on malaria in non-endemic areas in Brazil, especially with a prospective design and adequate exclusion of comorbidities and coinfection. Finally, considering the study area, the volume of cases treated and the possibility of secondary complications, the importance of referral malaria services that offer rapid and efficient diagnosis and treatment in Brazil is urgently apparent. There is also academic and scientific value in the study of malaria in non-endemic areas, because it is only in these areas that cases of relapses due to P. vivax can be studied without the interference of potential reinfections.This study has gathered much information about malaria in a region of Brazil outside of the Amazon, a subject that has received little attention by researchers. Despite the peculiarities of Brazilian culture, a concordance of the social aspects of imported malaria among the cases studied and of other studies of imported malaria in Latin America was observed. Based on the clinical and laboratory profiles of imported malaria cases in a non-endemic area of Brazil, infection with The authors declare that they have no competing interests.JCKD collected the charts, performed and analyzed the data and wrote the first version of the manuscript. RNA, CMSC, SCPL, LA, MTA, CEL and MLM helped in data analysis and in the design of the study. MVGL and FTMC designed the study, helped in data analysis and wrote the final version of the manuscript.


In 2005, the Ghana Health Service mandated malaria and helminths chemoprophylaxis during antenatal care visits. The aim of this study was to investigate the prevalence of malaria and helminth infections and their relationship with adverse birth outcomes  following the implementation of these treatments.A quantitative cross-sectional study.The study was conducted on 630 women presenting for delivery in the Komfo Anokye Teaching Hospital and the Manhyia District Hospital from July to November 2011. Socio-demographic information and medical and obstetric history were collected. Laboratory analyses for the presence of malaria and helminths were performed. Association of malaria and helminths with birth outcomes was assessed using logistic regression to obtain odds ratios (ORs) and 95% confidence intervals.Schistosoma mansoni, the odds of having an adverse birth outcome  and stillbirth  were greater than for women who were not infected.The prevalence of malaria, helminths and adverse birth outcomes was 9.0%, 5.0% and 22.2%, respectively. Compared with women who received malaria prophylaxis, women without malaria prophylaxis were two times more likely to have malaria infection . Women who were not screened for helminths were twice as likely to be infected with helminths  than women who were screened for helminths. For women infected with hookworm or The prevalence of malaria, helminths and adverse birth outcomes was lower than previously reported 9.0% vs. 36.3, 5.0% vs. 25.7 and 22.2% vs. 44.6, respectively. Helminth but not malaria infection was found to be significantly associated with adverse birth outcomes. Malaria and helminths are endemic in most sub-Saharan African countries. A study in Nigeria demonstrated that over 45% of Plasmodium infected near-term mothers also had intestinal helminths . These iPlasmodium falciparum infection [P. falciparum has been found to be a stronger contributor to pregnancy anemia especially in nulliparous women [P. falciparum. The area is also endemic for both hookworm and schistosomiasis [Ascaris lumbricoides and P. falciparum [A. lumbricoides [Pregnant women living in malaria endemic areas of Africa are at an increased risk of nfection ,5. Malarnfection ,6. The pnfection . Compareus women ,6. Malarsomiasis ,8. Prevasomiasis . Studiessomiasis . The rolsomiasis . Both sylciparum , anotherricoides . The synricoides .A 44.6% prevalence of adverse birth outcomes, 36.3% prevalence of malaria and 25.7% helminth prevalence has been previously reported among women with uncomplicated pregnancy in Kumasi . The firThe study that reported a 44.6% prevalence of adverse birth outcomes was done in 2006 and published in 2010 . In 2006P. falciparum) with two rainy seasons lasting from April to June and September to October [A quantitative cross-sectional study was conducted in Kumasi, the capital of the Ashanti Region of Ghana. Kumasi has an estimated daytime population of 1.7 million people . Kumasi has 5 health sub-metros . This study was conducted in two health facilities in Kumasi, namely, the Komfo Anokye Teaching Hospital (KATH) and the Manhyia District Hospital  from July to November 2011. KATH is a referral hospital that provides most ANC, labor and delivery services and serves the entire Ashanti Region and the bordering Brong-Ahafo, Central, Eastern and Western Regions. Manhyia District hospital covers Manhyia North and South and serves 34.6% of the Kumasi population. Kumasi has perennial malaria transmission  and stored at room temperature. Samples were analyzed at the end of the study in the parasitological laboratory of the outpatient unit at KATH. Determination of helminths was done using the Formalin-Ether concentration method. Samples were processed in conformity to the standard protocol ,22. The P. falciparum malaria in blood and serum. The assay detects the merozoite antigen that circulates in the blood and a positive result is suggestive of current or very recent infection. The ELISA test results were considered positive when the optical density was >0.2 over the negative control. The assay has been shown to detect P. falciparum parasitaemia as low as 0.001% with a sensitivity of approximately 98.8% and specificity of 100% [Peripheral blood (5 ml) was drawn by venipuncture soon after delivery into a vacutainer tube without anti-coagulant to facilitate clotting and labeled with the participant's ID number. The clotted blood samples were spun at 4000 rpm at 4ºC and the extracted serum frozen at -20ºC until analyzed for malaria antigen using the Malaria Antigen Celisa kit . The Celisa kit is a monoclonal antibody assay based on the detection of malaria antigen (HRP II) a highly sensitive marker for  of 100% .Malaria infection: Presence of malaria antigen in the peripheral blood at the time of delivery. Helminth infection: Presence of helminth eggs or larvae in stool at the time of delivery. Co-infection: Presence of both malaria antigen and any helminth infection at delivery [Severe/moderate anemia: haemoglobin level <8 g/dL of blood, mild anemia: haemoglobin levels ≥ 8 and < 11 g/dL of blood [Adverse birth outcome in this study includes any of the following outcomes; i) low birth weight defined as birth weight < 2,500 g; ii) preterm delivery (<37 weeks of gestation); iii) definition of stillbirth has been adapted for this study to mean the death of a fetus prior to, during or soon after delivery, but before discharge from the hospital (since we could not have access to the new mothers 12h after delivery). At the study site women are monitored for about 1-2h in the maternity ward after delivery. They are then taken to the “Lying Inn Ward” for further observation for 2–4h before being discharged from the hospital. delivery . Severe/of blood .® Access 2010 database and imported into SAS for coding and analysis. Cochran-Mantel Haenszel Chi-square or Fisher's exact tests were used to assess the associations between participants' characteristics by infection status, and association of ANC services received and adverse birth outcomes by infection status. Stratum specific estimates to assess effect modification by study sites were obtained. To access the validity of the self-reported data, Kappa coefficients were calculated to test the agreements between self-reported malaria prophylaxis and data abstracted from maternal antenatal record. Values of 0.4-0.6 indicate moderate, 0.6-0.8 substantial and 0.8 or higher as excellent agreement [® 9.3 .The data were single-entered in a Microsoftgreement . Logistigreement . All tesParticipation rate in the study was 99.7%. Mean age ± standard deviation (SD) was 27.9±5.7 years and ranged from 19-48 years. Approximately 38% (239/630) of participants were less than 25 years. Sixty-eight percent (427/630) of the women had a monthly income of less than GH¢500.00 (US$ 333.3). Twenty-one percent (130/629) were unemployed while 69.0% (435/629) were self-employed. Approximately 58% (252/435) of these self-employed were traders and 30.6% (133/435) were hairdressers or seamstresses. Women who were infected with malaria were more likely to be single and unemployed. Forty-three percent of the participants attended ANC more than the required minimum of 8 visits (Ghana's standard). Single women  and unemployed women  were disproportionately infected with malaria than women who were married and employed. The prevalence of helminths infection was also higher for women who earned less than GH¢500.00  compared to those who earned more than GH¢ 500.00  .Dicrocoelium dendriticum (liver fluke), Strongyloides stercoralis, Schistosoma mansoni (blood fluke) and Ancylostoma sp. (hookworm). The prevalence of malaria was higher (15.3%) in women who did not receive malaria prophylaxis than those who did (8.4%). Women who did not receive malaria prophylaxis were two times more likely to be infected with malaria  compared with women who received a complete regimen of malaria prophylaxis. The prevalence of helminth infection was also higher for women who were not screened for helminths (8.6%) than women who were screened and received chemoprophylaxis (4.0%). For unscreened women, the risk of helminths infection was two times higher compared with women who were screened  after controlling for the study site , respectively (A higher proportion of women with low haemoglobin (severe/moderate anemia) tended to be infected with malaria and helminths than women with normal haemoglobin concentration, but this trend was not statistically significant  or helminths (7.1%) compared with uninfected women . Though not statistically significant, women with malaria or helminths were 40% and 60%, respectively, more likely to experience an adverse birth outcome compared with women without these infections . HoweverMalaria and helminth infections are of serious public health concerns in developing countries especially in countries of sub-Saharan Africa. This study found a lower prevalence of malaria (9.0%), helminths (5.0%) and adverse birth outcomes (22.2%) among women in Kumasi in 2011 than previously studied in 2006 (reported 2010) . In thisP. falciparum has often been associated with anemia in developing countries [Though malaria infection was not directly associated with adverse birth outcomes in this study, a high proportion of women with malaria had severe anemia. Malaria especially ountries  and seveountries . A revieountries . The malountries . Hyperspountries . Though ountries . The timountries .S. haematobium as IPT in Gabon may provide a solution and reduce the reliance on praziquantel. In rodent models, mefloquine has been shown to have considerable activity against S. mansoni and S. japonicum the causative agents of intestinal schistosomiasis [nd and 3rd trimesters [The results from this study suggest that infection with any helminth was marginally associated with low birth weight. However, infection with any of the helminths that cause blood loss (hookworm or blood fluke) was significantly associated with stillbirth and low birth weight. A prior study in the same geographic area did not find any association between helminths infection and stillbirth . The facsomiasis . Seventyimesters  if they Brooker et al. in their review summarized that deworming and iron supplementation would have a greater impact on haemoglobin level than deworming alone especially in populations with diets low in bioavailable iron ,27. In aP. falciparum infection, it is possible that the lack of association of malaria and adverse birth outcomes could be due to mild infections. Also, it is possible that an episode of malaria early in the pregnancy could impact the outcome that could not be detected at the time of the study. However, we recommend that more studies be conducted in both urban and rural areas to determine the true prevalence of these infections in pregnant women and their association with adverse birth outcomes. The relatively low number of cases should be taken into consideration in interpreting the results. However, the small cell counts was not a problem since the adequacy of the sample size is determined by the across strata sample size [This is the first study to investigate the prevalence of both malaria and helminths in this region of Ghana since the full implementation of the changes made in the ANC protocol. This study demonstrates a lower prevalence of both malaria and helminth infections and a reduced prevalence of adverse birth outcomes among pregnant women in Kumasi. It is tempting to speculate that the changes made to the Ghana ANC delivery system are responsible for this reduced prevalence. Since we did not quantify the level of ple size  and the The prevalence of malaria, helminths and adverse birth outcomes was lower in 2011 than previously studied in 2006 . Helminth infection, but not malaria infection, was statistically significantly associated with adverse birth outcomes.


Monitoring local malaria transmission intensity is essential for planning evidence-based control strategies and evaluating their impact over time. Anti-malarial antibodies provide information on cumulative exposure and have proven useful, in areas where transmission has dropped to low sustained levels, for retrospectively reconstructing the timing and magnitude of transmission reduction. It is unclear whether serological markers are also informative in high transmission settings, where interventions may reduce transmission, but to a level where considerable exposure continues.Plasmodium falciparum antigens  at five time points for comparison against traditional malaria indices . Second, within individual post-ITN years, age-stratified seroprevalence data were analysed retrospectively for an abrupt drop in SCR by fitting alternative reversible catalytic conversion models that allowed for change in SCR.This study was conducted through ongoing KEMRI and CDC collaboration. Asembo, in Western Kenya, is an area where intense malaria transmission was drastically reduced during a 1997–1999 community-randomized, controlled insecticide-treated net (ITN) trial. Two approaches were taken to reconstruct malaria transmission history during the period from 1994 to 2009. First, point measurements were calculated for seroprevalence, mean antibody titre, and seroconversion rate (SCR) against three 19, correlated closely with trends in parasite prevalence throughout the entire 15-year study period. However, retrospective analyses using datasets from 2007, 2008 and 2009 failed to detect any abrupt drop in transmission coinciding with the timing of the 1997–1999 ITN trial.Generally, point measurements of seroprevalence, antibody titres and SCR produced consistent patterns indicating that a gradual but substantial drop in malaria transmission (46-70%) occurred from 1994 to 2007, followed by a marginal increase beginning in 2008 or 2009. In particular, proportionate changes in seroprevalence and SCR point estimates  for AMA-1 and CSP, but not MSP-1In this highly endemic area, serological markers were useful for generating accurate point estimates of malaria transmission intensity, but not for retrospective analysis of historical changes. Further investigation, including exploration of different malaria antigens and/or alternative models of population seroconversion, may yield serological tools that are more informative in high transmission settings.The online version of this article (doi:10.1186/1475-2875-13-451) contains supplementary material, which is available to authorized users. Plasmodium parasites, is another common metric of malaria risk. Parasite prevalence is not a measure of incidence, however, and its relationship with force of infection is complicated by super-infection and acquired immunity . Using a mixture model, cut-off values for seropositivity were determined separately for each antigen  during each year  to avoid direct quantitative comparison of ELISA results from samples collected by different methods . Age  and survey year were included to control for their effects, and models were adjusted for clustering of observations from the same household compound by incorporating an exchangeable correlation matrix.10–transformed antibody titre on the X-axis and the percentage of individuals having the indicated antibody titre or higher on the Y-axis , CSP OR = 3.0 [95% CI: 2.5-3.5], p < 0.001 for all). Seropositivity was also associated with positive blood film for AMA-1  and CSP , but not for MSP-119 . Females were more likely to be seropositive against MSP-119 , whereas sex had no effect for AMA-1  or CSP . Whether an individual resided in a village that received ITNs in 1997 or 1999 had no impact on seropositivity against any of the three antigens .Across all years, the likelihood of individuals testing seropositive increased with age for all three antigens , and then again between 2000 and 2007 (p = 0.002). Seroprevalence against MSP-119 and CSP also decreased steadily from 1994 to 2007, but the year-to-year differences were not statistically significant . This trend of falling seroprevalence began to reverse in 2008 for MSP-119 and in 2009 for AMA-1 and CSP, but none of these subsequent changes were statistically significant . Across the entire study period, AMA-1 seroprevalence values corresponded very closely to parasite prevalence values. Furthermore, proportionate changes in both AMA-1 and CSP seroprevalence  closely mirrored the pattern observed for parasite prevalence  were calculated to describe the increase in seroprevalence per year of age Figure A. Overalt Figure B. Within19 were higher in villages that received ITNs in 1997 (GMT = 25.4 [95% CI: 22.8-28.2]) compared with villages that received ITNs in 1999 (GMT = 19.3 [95% CI: 17.4-21.3]) (p >0.001). No differences were detected between villages receiving ITNs in 1997 vs 1999 for any other antigens. Antibody titres against all three antigens fell between 1994 and 2000 . For AMA-1, titres fell further in 2007 (p <0.001), exhibited no change in 2008 (p = 0.026 [cut-off with Bonferroni correction: p = 0.013]), and then subsequently increased in 2009 (p = 0.004). MSP-119 titres changed little between 2000 and 2007 (p = 0.148), but increased in 2008 (p <0.001) and then remained static in 2009 (p = 0.029). CSP titres did not change from 2000 to 2007 (p = 0.128), but increased in 2008 (p <0.001) and again in 2009 (p <0.001).Geometric mean antibody titres for children one to five years of age are displayed in Figure −1 for AMA-1, 0.051 yr−1 for MSP-119 and 0.073 yr−1 for CSP, based on a preliminary model fit to data from all years. Consistent with the results from young children, population-wide immune responses were strongest against AMA-1. Year-specific SCRs were roughly an order of magnitude greater for AMA-1 than for MSP-119 and CSP across the entire study period. SCRs for all antigens were highest in 1994, before ITN introduction. Although concerns have been raised that anti-malarial antibody responses in pregnant women may differ systematically from those of the general population [Results from reversible catalytic conversion models fit to data from all available age groups are presented in Figure pulation , 51, remvs 1999 , none of the age-seroprevalence curves exhibited a break point suggestive of a past shift in SCR. For each antigen during each year, the initial model with only a single SCR provided a better fit than any alternative model allowing for a change in SCR.P. falciparum exposure were useful for monitoring long-term changes in malaria transmission intensity in this highly endemic region. Patterns in point measurements of seroprevalence, antibody titres and SCRs all indicate that a gradual but substantial drop in malaria transmission (46-70%) occurred in Asembo from 1994 to 2007, followed by a marginal increase beginning in 2008 or 2009. This is consistent with previous findings based on child mortality, parasite prevalence [19) corresponded closely with trends in parasite prevalence throughout the 15-year study period.Serological markers of evalence  and EIR 19 performed poorly in Asembo; proportionate changes in MSP-119 seroprevalence and SCR overestimated changes in parasite prevalence during 2000, 2008 and 2009.AMA-1 is known to be highly immunogenic ; it was 19. In 2000 , young children from villages that received ITNs in 1997 had significantly higher MSP-119 antibody levels compared with those from villages that received ITNs in 1999. Previous investigations on short-term immunologic responses in very young children in Asembo also reported counter-intuitive results for MSP-119. During a 1992–1994 cohort study following children from birth to 2.5 years, Singer et al.[19 antibody levels. In 1998, Kariuki et al.[19 was higher in intervention villages compared with control villages 14 months after the ITN trial’s start. At 22 months after the start of the trial, however, this pattern was no longer observed. Results from the current study, together with those of Singer et al.[et al.[19 is not a reliable short- or long-term marker of changing malaria exposure in Asembo. Singer et al.[et al.[19 response. This hypothesis of ineffective MSP-1 response may also explain why MSP-1 seroprevalence, unlike that of AMA-1 and CSP, was not correlated with positive blood film, an indicator of recent infection.Examination of antibody titres also revealed an unexpected outcome for MSP-1er et al. found anki et al. reporteder et al. and Karil.[et al., indicater et al. and Karil.[et al. hypothesvs 1999, it was anticipated that differences in serological responses would be apparent in 2000 and then gradually erode with time. Interestingly, aside from the unexpected finding of higher MSP-119 antibody titres among children from villages that received ITNs earlier, no serological differences were found between the two groups in 2000 or in any other year. This finding suggests that immune challenge by malaria parasites remains high enough in this region to maintain antibodies against the three antigens examined, making it difficult to detect subtle differences in the length of population protection under ITNs using these serological markers.When comparing villages that received ITNs in 1997 et al.[The different serological outcomes analysed  all produced similar trends for reconstructing transmission history in Asembo. Of note, linear regression proved to be a useful analysis tool. The relationship between seroprevalence and age tends to be linear in young age groups, and linear regression allowed for calculation of an SCR proxy using only data from children aged one to five years. The fact that these linear regression coefficients exhibited the same pattern over time as SCRs estimated using data from all age groups supports the idea that, in regions of high malaria transmission intensity, immunological changes are most evident in young children. For example, during the classic Garki study in northern Nigeria, Cornille-Brogger et al. also fouThe reversible catalytic conversion model generated accurate population-wide SCR estimates, but did not detect retrospective changes associated with the 1997–1999 ITN trial within individual post-trial surveys. Because EIR, parasite prevalence and child mortality statistics from Asembo all indicated that malaria transmission declined drastically as a result of the ITN trial , 40, 53,Inability to detect break points in the 2007, 2008 or 2009 age-seroprevalence curves may be due to several non-mutually exclusive factors. First, the Kenya Ministry of Health has instituted a series of national interventions over the past decade, including introduction of long-lasting ITNs, revised recommendations for more effective first-line anti-malarials  and implet al.[In addition to limited sample sizes and age groups for certain years, reliance on past studies that employed different protocols presented multiple challenges. For example, serological specimens from 1994 and 2000 were collected as serum, whereas specimens from 2007 to 2009 were collected as dried blood spots. To be cautious, direct quantitative comparison of ELISA results between years was minimized by calculating different seropositivity cut-off values for each year. Unfortunately, direct comparisons could not be avoided when examining antibody titres. It should be noted, however, that Corran et al. reportedDifferent methods were also employed to measure EIRs in Asembo over time. Bed net traps, PSCs and CDC light traps differ in their sensitivity for capturing malaria vectors , 57, 58,Sero-epidemiological tools have proven valuable for quantifying long-term changes in malaria transmission in numerous different locations. From the standpoint of programmatic monitoring, serology is relatively fast and efficient; finger-prick blood samples can be quickly collected in large numbers and ELISAs are high-throughput and easily standardized , 46. In Increase in seroprevalence with age in villages that received ITNs in 1997vs1999.(DOCX 13 KB)Additional file 1:Seroconversion rates (SCRs) for 1994 dataset including and excluding pregnant women.(DOCX 14 KB)Additional file 2:Seroconversion rates (SCRs) for villages that received ITNs in 1997vs1999.(DOCX 15 KB)Additional file 3:


Detection of cerebral ischemia after aneurysmal subarachnoid hemorrhage (SAH) remains challenging, particularly in comatose patients. The aim of this study was to examine the value of cerebral microdialysis (CMD) to predict cerebral ischemia, diagnosed by perfusion CT (PCT) imaging.ischemic  vs. non-ischemic. Cerebral extracellular levels of lactate/pyruvate ratio (LPR) >40 with glucose < 1.0 mmol/L were used as thresholds for brain tissue ischemia (BTI).We analyzed 48 PCT from 20 SAH patients  monitored with CMD  as part of standard care. PCT was categorized as r = 0.70, p < 0.0001; Figure Regional CBF (around the CMD probe) correlated significantly with global CBF . BTI was more frequent in ischemic PCT . A CMD pattern of BTI had a 72% positive predicted value and an 81% negative predictive value for detecting cerebral ischemia on PCT.Ischemic PCT  showed higher CMD LPR (48 ± 37 vs. 30 ± 10 in non-ischemic PCT) and lower CMD glucose (0.9 ± 0.8 vs. 1.4 ± 0.8 mmol/L; both Cerebral microdialysis appears accurate to detect cerebral ischemia at the bedside in comatose SAH patients and may be a valid complementary neuromonitoring tool in this setting.Supported by Grants from the Swiss National Science Foundation and The Novartis Foundation for Biomedical Research.


Malaria remains a burden for pregnant women and the under 5. Intermittent preventive treatment of pregnant women (IPTp) for malaria with sulfadoxine – pyrimethamine (SP) has since replaced prophylaxis and legislation has been reinforced in the area of insecticide treated mosquito nets (ITNs) in Cameroon. Clinical malaria despite all these measures remains a problem. We compared the socio-obstetrical characteristics of women who developed clinical malaria and those who did not though in the same regimen.A 5 – year nested cohort study (2007 – 2011 inclusive) at the tertiary level hospitals in Yaounde. Pregnant women who willingly accepted to participate in the study were enrolled at booking and three doses of SP were administered between 18 – 20 weeks of gestation, between 26–28 weeks and between 32 – 34 weeks. Those who developed clinical malaria were considered as cases and were compared for socio – obstetrical characteristics with those who did not. Venous blood was drawn from the women in both arms for parasite density estimation and identification and all the clinical cases were treated conventionally.Each arm had 166 cases and many women who developed clinical malaria were between 15 and 19 years . They were of low gravidity  as well as low parity . The cases were single women  and had attained only primary level of education . Gestational ages were between 20 to 30 weeks during clinical malaria . The time between the first and second dose of SP was longer than ten weeks in the cases  and parasite density was higher also among the cases .Long spacing between the first and second dose of SP seemed to be responsible for clinical malaria in the cases. Malaria in pregnancy (MiP) generates public health concerns across the globe, particularly in malaria – endemic settings and results in adverse outcomes both for the woman and foetus -5. MalarManagement of malaria in pregnancy now combines multiple approaches -11. Someth and the 20th week or when the first fetal movements (quickening) are felt. The second dose is administered at least thirty days after the first. This interval is not fixed but is usually between the 26th and the 28th week of gestation and the last dose is between the 33rd and the 34th week. Alongside IPTp, ITNs are distributed freely to pregnant women from booking visits.A consensus that favored the use of these approaches was arrived at by the health authorities in Cameroon in the year 2004 and is still in force . Thus, pThough these procedures form a common package in our antenatal care delivery, clinical cases of malaria among pregnant women constitute about 30 to 40% of our daily hospital admissions. The aim of this study was to analyze the socio – obstetrical characteristics of cases of clinical malaria and match them against women who did not develop malaria in the same cohort.For a period of five years (2007–2011 inclusive), a cohort of 2525 pregnant women was followed-up from booking to delivery in the outpatient units of three tertiary level hospitals in Yaounde from where clinical cases of malaria and none malaria cases were recruited. These hospitals are all affiliated to the University of Yaounde I, Faculty of Medicine and Biomedical Sciences (FMBS). Women who were HIV infected and those who refused to participate freely in the study were not enrolled. We also eliminated women with fever producing pathologies such as acute pyelonephritis and other confirmed infections.Enrollment was between 16 and 20 weeks of gestation. Ethical clearance N°243/CNE/SE/2006 was obtained from the National Ethics Committee and written or verbal consents were also obtained. The women had complete clinical and paraclinical evaluations. Viable pregnancies were confirmed with ultrasound. Three doses of SP were health – provider administered based on updated WHO policy recommendations. They were provided freely with ITNs on enrollment and phone calls and or home visits were carried out to ensure that the women were sleeping under ITNs.The women were evaluated every visit for evidence of clinical malaria and those who were symptomatic for clinical malaria were hospitalized and treated. Clinical malaria was defined as an acute onset of fever, chills, anorexia, vomiting, muscular or articular pain or both and headache, all these in the absence of any concomitant pathologies such as urinary tract infection and pneumonia. Parasite densities were estimated during symptoms and compared with parasite densities from women who did not have symptoms.Previous studies indicated that about 30% of pregnant women develop clinical malaria in Cameroon . This in1‒pp0−p12.Cases of clinical malaria (exposed cases) and the rest of the cohort followed up were enrolled in the same period. For each case of clinical malaria enrolled, a pregnant woman recruited at the antenatal clinic who did not present with symptomatic malaria and who was matched for parity and gestational age was enrolled for comparism.Two weeks after the first dose of SP, thumb prick blood samples were collected for quantification of serum plasmodium densities which served as baseline values for the two groups. We assumed that these D1 parasite densities values would be low after treatment. Subsequently, smears were prepared from the women with clinical malaria as well as those who did not (D2 parasite densities) and compared with D1 values.Thick blood smears each measuring about 6 μL were stained with 10% Giemsa and examined under the ×100 oil immersion objective lens using Olympus CH30 microscope by two blinded laboratory scientists. Parasite densities were calculated from these thick smears and the thin smears served to differentiate Plasmodium species. The number of asexual parasites was estimated against 200 leucocytes using an average leucocytes count of 8, 000/μL as recommended . A smearParasite densities (parasite/μL of whole blood) were a ratio of parasites to WBCs in the Giemsa – stained thick smears. Parasites (Plasmodium specy) were counted against 200 WBCs. Calculation was as follows:= N° of parasites counted/WBC counted × WBC count/μL of participants’s whole blood .Confirmed cases were hospitalized for treatment with Quinine Sulphate at 25 mg/kg/24 hours. Three equi – doses were administered daily but not exceeding 1.5 g/24 hours irrespective of body weight or body mass index (BMI). Administration was parenteral during the first 72 hours in combination with paracetamol at 60 mg/24 hrs as adjuvant treatment. From the fourth day, both drugs were administered orally maintaining the same doses for a total duration of treatment of seven days.P – values whereby smaller P – values (less than 0.05) were considered statistically significant.Data were entered into spread sheets and analyzed using EPI-Info™ version 3.5.1. Parasite densities were calculated based on the hypothesis that parasite densities during clinical malaria (D2) were higher than the initial densities (D1) which were considered as parasite densities before clinical malaria. We calculated odds ratios (OR) and 95% confidence intervals (C1) for the various variables we cross-tabulated that needed comparison between the exposed and unexposed cases. Kruskal-Wallis test was used to estimate the Ethical clearance was obtained from the national Ethics Committee and authorization was obtained from the hospital administrations. Data collection did not require any expenditure by the women enrolled and both handling and analysis of data conformed to strict confidentiality.A total of 2525 pregnant women were followed up during the study period out of which 166 developed clinical malaria. We selected 166 pregnant women from the same cohort who did not develop clinical malaria and compared their socio-demographic characteristics.An equal number of clinical cases were matched against those who did not have symptoms 166 vs 166). Greater proportions of cases were between 15 and 19 years  and were of low gravidity  as well as low parity . The cases were single mothers  and educated only at primary level . Gestational ages at the time of attacks were between 20 to 30 weeks in the cases . Time interval between the first and second dose of SP was greater than ten weeks in the cases   infection during pregnancy. The reason for this remains unclear, but changes in cell-mediated immunity are thought to be involved. Enhanced susceptibility to malaria infection means that when a woman becomes pregnant, she is most likely to develop malaria especially due to PF -28.Clinical symptoms of malaria include fever, chills, sweats, nausea and vomiting ,30. All The effect of P. falciparum malaria on pregnant women has been assessed in many African countries -34. All Among the one hundred and sixty six (166) women who developed clinical malaria in this study despite IPTp and ITNs, 64 (38.55%) were between 15 and 19 years and 58 (34.94%) were in their first deliveries as against 21.69% and 18.07% respectively in asymptomatic cases. Both parity and length of gestation have an impact on susceptibility to malaria infection. The susceptibility to infection among non-immune women is similar in all parities . Many arEducation plays a role as women who are not well educated are most likely to live in disadvantageous neighborhoods. A good number of women among the cases were educated at primary school level only (45.73% versus 28.92%) and gestational age during clinical malaria was between 20 – 30 weeks (45.58% versus 20.48%). The level of education did not influence significantly malaria morbidity among the cases and the controls after primary level. The occurrence of malaria among women who had attained secondary level of education was similar , to those who had university education . One would have expected to find many women within the secondary level of education to have more episodes of clinical malaria as with primary level. However, in a country like ours where 40% of the population lives below poverty level, our neighborhoods are shared by a population mix where one finds the highly educated alongside those who have not been to school.Malaria has always been a major public health problem in Yaounde, Cameroon where many cases of P. falciparum malaria occur every day. The prevalence of vector transmission varies from one micro-ecological area to another, resulting in variable levels of transmission .th and the 28th week of gestation while in some others; administration was between the 28th and the 30th week of gestation. Be it as it may, the interval between the first and the second dose was rather too long allowing for the effects of the drugs to fade out exposing the women to infection.Most of our patients came from the periphery of Yaounde, areas plagued with swampy waters. The bulk of our patients received the second dose of SP at intervals greater than ten weeks. This may be explained by the fact that the second dose of SP was not administered in a uniform manner by our health care providers. In some of the sites, the second dose was administered between the 26The number of cases with clinical malaria declined with increasing gestational age. The prevalence of infection was higher in the first and second trimesters of pregnancy and decreased progressively in the third trimester until delivery as described in literature ,26. MalaWe conclude that primiparity and long intervals between the first and second dose of SP are responsible for acute bouts of clinical malaria observed among pregnant women who sleep under ITNs in our environment. Young age, low level of education and pregnancies in the first half of gestation also contribute.The authors declare that they did not have any competing interests.REM and HJF conceived and designed the study, drafted the protocol, obtained ethical clearance and authorizations to conduct the study in the university affiliated hospitals. FYF and FTN worked with the hospital laboratories, analyzed data, interpreted results and wrote the various portions of the manuscript. RT and WAT were principal investigators respectively in two of the hospitals where the study was carried out. All the authors read and approved the final version of the manuscript and its intellectual and scientific content.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1472-6874/14/68/prepub


Young infants have reduced susceptibility to febrile malaria compared with older children, but the mechanism for this remains unclear. There are conflicting data on the role of passively acquired antibodies. Here, we examine antibody titres to merozoite surface antigens in the protection of children in their first two years of life in two settings with differing malaria transmission intensity and compare these titres to previously established protective thresholds.Plasmodium falciparum recombinant merozoite proteins  were measured by enzyme-linked immunosorbent assay at 1–6, 9, 12, 15 and 18 months of age and compared with the protective thresholds established in Kenyan children.Two cohorts of children aged four to six weeks were recruited in Banfora, Burkina and Keur Soce, Senegal and followed up for two years. Malaria infections were detected by light microscopic examination of blood smears collected at active and passive case detection visits. The titres of antibodies to the Antibody titres were below the protective thresholds throughout the study period and we did not find any association with protection against febrile malaria. Antibodies to AMA1 and MSP1-19 appeared to be markers of exposure in the univariate analysis (and so associated with increasing risk) and adjusting for exposure reduced the strength and significance of this association.The antibody levels we measured are unlikely to be responsible for the apparent protection against febrile malaria seen in young infants. Further work to identify protective antibody responses might include functional assays and a wider range of antigens. These studies have yielded inconsistent associations between anti-malaria antibodies and immunity to malaria We recently conducted a study in Burkina Faso examining the impact of maternally-acquired antibodies against synthetic GLURP and MSP3 on the risk of malaria. We found associations between increasing antibody levels and increasing risk of malaria, and no evidence of protective antibody responses. Limitations of this previous study were the limited number of antigens that were examined, and the lack of standardised controls that meant we could not estimate relative antibody concentrations and therefore could not determine how close these antibody levels were to the protective thresholds.P. falciparum febrile malaria.The present malaria sero-epidemiological study expands the range of antibodies examined and includes standardised controls. Furthermore we describe below how antibody levels vary during the first 18 months of life in two settings with differing transmission intensity and we present the results of the analysis testing the hypothesis of an association between total IgG to merozoite antigens and protection against 22.1The ethical approval for the work in Burkina Faso was obtained from the Institutional Review Board of Centre National de Recherche et de Formation sur le Paludisme (CNRFP) in Burkina Faso. In Senegal, the study was approved by the National Ethics Committee. The parents of each child were informed and an individual written consent obtained prior to performing any study-specific procedure on the child. The studies in both settings were conducted according to the principles of the Declaration of Helsinki.2.2The study was conducted in Banfora, Burkina Faso and in Keur Soce, Senegal.The Banfora site is described elsewhere 2.3In both sites, febrile malaria cases were detected using a combination of active and passive monitoring as detailed elsewhere 2.4The identification and quantification of malaria parasites were done as described elsewhere 2.5For a subset of 40 children in each site , samples at baseline, 2, 3, 4, 5, 6, 9, 12, 15 and 18 months were analysed to compare antibody dynamics. The samples of the remaining children in the Banfora cohort were analysed only at baseline, 3, 6, 9, 12 and 18 months and included in the analysis of the association between antibody levels and risk of clinical malaria in that cohort.2.6The following four recombinant merozoite antigens were tested in this study: the His-tagged AMA1 of the 3D7 allelic form 2.7Serum total IgG titres were measured as described elsewhere 33.1P.f. merozoite antigens between both the sites at baseline. Fractional polynomial regression models were constructed to fit the non-linear relationship between anti-malaria antibody titre and age. The protective thresholds  displayed in the graphs have been taken from the results of studies conducted by Murungi et al. in the Kenyan Coast We used Pearson correlation test on log-transformed values to measure how strong the relationship is between antibody levels to a given antigen from one time point to the following one and between antigen-specific antibody titres. To estimate the overall decline of antibodies, we used a Random-Effects regression model of antibody titres on age to account for between and within-infant variability of antibody titres. We calculated the cut-off value for seropositivity as the mean OD of negative controls plus 3 standard deviations. Fisher's Exact test was used to compare seroprevalence of antibodies to the 3.2The outcome measure, febrile malaria, was defined as the association of fever (axillary temperature ≥37.5 °C and/or reported fever in the past 24 h) plus asexual parasitemia ≥10,000/μL 44.1The characteristics of the Banfora infant cohort, follow up and malaria morbidity are described in detail elsewhere 4.2At baseline, the seroprevalence of the merozoite antigens was significantly higher in the Banfora cohort compared with Keur Soce cohort except for antibodies to MSP1-19 (Table S2). After a steady decline in the first six months of life regardless of the transmission intensity, the seroprevalence to all the antigens tested held below 20% for the remaining monitoring period in Keur Soce, the low transmission area. In Banfora where the transmission is higher, the seroprevalence peaked after six months for MSP1-19 and MSP3-3D7 . Only anti-MSP2 antibodies increased appreciably from month 9 . No confr, 0.86–0.98 in Keur Soce, 0.86–0.91 in Banfora for AMA-1) . After the first 6 months of life, antibody titres were weakly to moderately correlated to each other in Keur Soce  but not correlated in Banfora (−0.21 to 0.03).Antibody titres to AMA1-3D7, MSP1-19, MSP2-Dd2, MSP3-3D7 were strongly correlated from time point to time point during the first six months of life in both settings regardless of the transmission intensity (4.34.3.1p = 0.002) and MSP1-19  were significantly associated with a higher risk of febrile malaria but season was the strongest significant risk factor for febrile malaria . The results of the event count analysis were similar except for anti-AMA1-3D7 antibodies that appeared as significantly associated with protection against febrile malaria episodes . Children with haemoglobin CC type had lower risk of febrile malaria compared with haemoglobin AA children. Age was a significantly associated with risk of febrile malaria (Table S4). In both models, the highest level of education was significantly associated with protection and children born in the last quarter of the year had significantly lower risk of febrile malaria compared with those born in January as previously described This analysis applies to Banfora only. In the time-to-event univariate analysis none of the antigen-specific antibodies, in terms of levels or seropositivity, was associated with protection. Antibodies to AMA1-3D7 . Season remained the strongest risk factor , and exposure index was associated with a risk of malaria . There was a tendency of anti-MSP1-19 antibodies to be associated with higher risk of febrile malaria , but overall the correlation between antibodies and increased risk of malaria was reduced by adjusting for exposure and season. There was no significant deviation from the proportional hazards assumption (p = 0.042) in the event count analysis.There was only limited collinearity between the different antibody titres . In the multivariable time-to-event analysis, foetal haemoglobin rate was weakly but significantly associated with protection  were rather a maker of exposure to malaria, evidenced by the association with risk and the fact that this association was diminished after adjusting for the exposure index.The titres of antibodies to all the four antigens tested were below the protective thresholds except for a few outlying results. After a consistent decline up to six months of age, only antibodies to MSP2 showed a steady increase up to month 18 in the high transmission setting (Banfora). Overall, we did not find any protective effect in the investigation of the association between antibodies to Average antibody decay rates were similar in both settings only for antibodies to MSP1-19. Reduced exposure to infectious bites during the first six months in the high and seasonal transmission setting (Banfora) is a likely explanation of this similarity since only five malaria infections were detected during this period in Banfora, of which three occurred in the first rainy season in children aged above five months. The lack of acquisition of antibodies and the strong correlation of antibody levels between time points in Keur Soce indicates lack of exposure throughout the monitoring period. However in Banfora antibody levels were more variable from time point to time point, indicating that exposure to malaria was stimulating antibody production in some children, and furthermore that increases in antibody titres were often transient .Few studies have examined the role of anti-malaria antibodies in infants. We found that anti-AMA1-3D7 antibodies appeared as a marker of exposure  in our univariate analysis, which is consistent with the conclusions of Riley et al. The apparent variation in results between infants and older children may be explained by the presence of a protective threshold. Murungi et al. and Rono et al. have analysed two independent cohorts of children and established protective threshold concentrations for some merozoite antigens The possibilities are that other antibodies not measured in our work are related to protection 6P. falciparum merozoite antigens  remained low compared with the previously established protective threshold concentrations. In addition, the antibodies were not significantly associated with a reduced risk of malaria raising more questions on the basis of the early apparent protection against febrile malaria.Even at high intensity of malaria transmission, antibody levels to the tested However, these results should be interpreted with caution because of the limitations of this study. The protective thresholds used in the present study have been established in cohorts including children more than 2 years old in addition to infants. In our cohort, the lack of any protective effect did not allow us to determine specific thresholds for this age group. Furthermore, the timing of the study, in which the first few months of life overlapped with the low malaria transmission season, was not ideal to assess the role of maternal antibodies at the higher titres seen in the first few months of life. However, if antibody thresholds are related to real biological phenomena than we would expect, the thresholds should be similar across study sites and age group. Hence the main contribution of our work is the demonstration that antibody levels in infants to selected merozoite antigens are well below previously defined protective thresholds, and therefore that these are unlikely to be responsible for mediating protection in vivo. Further work to identify protective antibody responses might include assessment of antibodies to other targets including red cell surface antigens, and functional assays in which the interaction of antibodies with immune cells is taken into account


There is a remarkable dearth of literature on less pronounced outcomes in malaria, namely prolonged hospitalization and intensive care requirement. Limitations on routine clinical applicability of the World Health Organization’s (WHO) guidelines for determination of severity in malaria does result in underestimation of the true burden of clinicians’ perceived severity in malaria. This study was conducted to evaluate the clinico-laboratory and malarial severity features to determine their association with mortality, prolonged hospitalization and requirement of intensive care outcomes.A tertiary care hospital based retrospective study was conducted from the year 2007 to 2011 among microscopically proven adult malaria patients. Logistic regression analysis was performed to determine the factors associated with mortality, more than seven days hospitalization, intensive care and other supportive requirements.Plasmodium falciparum infection, more than three days of history of fever, haemoglobinuria, renal failure, shock, leucocytosis, severe thrombocytopaenia and every 10 mmHg fall in systolic blood pressure were the independent predictors of more than seven days of hospitalization. More than three days of history of fever, cerebral malaria, PE/ARDS, renal failure, metabolic acidosis, hyperparasitaemia, leucocytosis and severe thrombocytopaenia were independently associated factors with intensive care requirement.Of a total of 922 malaria cases studied, more than seven days of hospitalization was the most frequent outcome (21.8% (201), 95% CI = 19.1-24.5%) followed by intensive care requirement (8.6% (79), 95% CI = 6.8-10.4%) and in-hospital mortality (1.2% (11), 95% CI = 0.5-1.9%). Odds of mortality were significantly higher with cerebral malaria, pulmonary oedema/acute respiratory distress syndrome (PE/ARDS), liver dysfunction, severe anaemia, renal failure, respiratory distress, metabolic acidosis and leucocytosis. More than seven days hospitalization had inverse association with mortality. Plasmodium vivax may result in mortality, whereas multiorgan involvement is common in P. falciparum related mortalities.For routine clinical settings, severity definition for malaria needs to be redefined or modified from the existing WHO guidelines. Leucocytosis and severe thrombocytopaenia should be identified as severity determinant in malaria. Patients having more than three days history of fever, leucocytosis, severe thrombocytopaenia and renal failure are more likely to require either prolonged hospitalization and/or intensive care. PE/ARDS alone in The online version of this article (doi:10.1186/1475-2875-13-370) contains supplementary material, which is available to authorized users. Plasmodium falciparum malaria. There is no report exclusively describing the less pronounced malarial outcomes together with mortality in adult malaria, except one study , as the probability decreased with time after admission, Figure Mortality occurred with 2 (2%), 7 6.1%) and 2 (16.7%) severe % and 2 ] with respect to severe P. vivax for more than seven days hospital stay on univariate logistic regression but, it did not figure in the multivariate logistic regression analysis.In severe subgroup, haemoglobinuria , renal failure [2.4 (1.1-4.8)] and leucocytosis [2.6 (1.1-6.0)] were the independent predictors of more than seven days of hospitalization. However severe P. falciparum infection [7.6 (1.4 – 42.4)] and every 10 mmHg fall in systolic blood pressure [0.6 (0.3-0.9)] were the independent predictors of more than seven days of hospitalization.In non-severe subgroup, P. falciparum was more likely to result in intensive care need in both the malaria cohort [4.0 (2.41-6.62)] and the severe malaria subgroup [2.1 (1.1-3.8)] in univariate logistic regression analysis. Intensive care support was needed among substantially less proportion i.e. 1.6% (11/696) of non-severe subgroup.In malaria cohort, over three days of history of fever, cerebral malaria, PE/ARDS, renal failure, metabolic acidosis, hyperparasitaemia, leucocytosis and severe thrombocytopaenia were independently associated with intensive care Table . In seveP. falciparum showed significantly higher odds for inotrope [4.17 (1.44-12.11)], blood transfusion [4.94 (3.20-7.61)], mechanical ventilation [3.40 (1.48-7.78)] and dialysis [17.55 (4.05-76.13)] than P. vivax ], mechanical ventilation [5.10 (2.37 - 10.96)] and dialysis [11 (4.28 - 28.28)] in malaria cohort. Likewise, patients with intensive care support were significantly more prone to have inotrope [15.13 (5.78 - 39.57)], blood transfusion [16.15 (9.68 - 26.94)], mechanical ventilation [129.48 (37.89 - 442.42)] and dialysis requirements [24.46 (10.00 - 59.87)]. On inter-species comparison, Global health care diligence intends to avert malaria exclusively. However, its untoward occurrences and aggravations invariably results in extensive resource utilization to try reverting the ailment. Aftermaths of malaria, namely prolonged hospitalization, intensive care requirements and most unfortunate ‘mortality’ , are the sheer reflection of underlying disease severity and extensive resource utilizations. Here, few determinants of these unpleasant outcomes in adult malaria at a tertiary care setting have been identified. Considering clinico-pathophysiological parameters as the independent determinants of the disease severity and the outcomes, those were analysed across malaria cohort, severe and non-severe subgroups of total cohort.P. vivax infected mortality was due to PE/ARDS and respiratory distress only, whereas other mortalities were due to multiorgan complications Additional file 1: