The prevalence of malaria parasites in adults in Africa is less well researched than in children. Therefore, ademographic surveillance site was used to conduct a household survey of adults in the malaria endemic area of Maseno division in Kisumu County near Lake Victoria.A random survey of 1,190 adults living in a demographic health surveillance site in a malaria endemic area of 70,805 population size was conducted, measuring presence of malaria parasites by slide microscopy. Data were analysed using STATA to calculate the prevalence of malaria and associated risk factors.The adult prevalence of presence of malaria parasites in Maseno was 28% (95% CI: 25.4–31.0%). Gender was a significant sociodemographic risk factor in both univariate  and multivariate  analyses. Females were 50% more likely to have malaria than men.Presence of malaria parasites is common in the adult population of this endemic area, and the rate is greatly increased in women. The presence of such an adult pool of malaria parasites represents a key reservoir factor in transmission of parasites to children, and is relevant for plans to eradicate malaria. Globally, malaria causes around 627,000 deaths in 2013, mostly of children aged under 5 years living in Africa , as wellIn Kenya, there have been two national malaria indicator surveys recently, in 2007 and 2010. The adult population acquire partial immunity, the risk of death is higher in children and pregnant women, and malaria indicator surveys tend to focus on children  and 2010The Kenya malaria survey 2007  found a This paper reports the prevalence of the presence of malaria parasites in a random household sample of adults aged 18 and above in Maseno division of Kisumu county western Kenya in 2012/2013, and its relationship to key socio-demographic variables. It forms part of a wider survey of malaria, mental health and immunity, which will be published in a series of forthcoming papers.2. The population is largely young with a mean age of 23 years. Among the population sampled, those aged 0–14 years constitutes 46%, with those aged 15–64 years and 65+ years constituting 49 and 5%, respectively.The sample frame is a sub-county in Kenya, in an area endemic for malaria, namely Maseno division within Kisumu County, Western Kenya which has a population of 70,805 (Kombewa HDSS 2012). Females constitute 53% of the population. The mean household number is four people per household with a population density of about 374 people/kmThe population is primarily black African, and the languages spoken are Dholuo (predominant ethnic group), Kiswahili and English. The area is largely rural, with most residents living in villages, which are a loose conglomeration of family compounds near a garden plot and grazing land. The majority of the houses are mud-walled with either grass thatched or corrugated iron-sheet roofs. Water is sourced mainly from community wells, local streams and the lake for those living on the shores of Lake Victoria. Most water sources are not chlorinated. Subsistence farming, animal husbandry and fishing are the main economic activities in the area.Malaria is holoendemic in this area, and transmission occurs throughout the year. The ‘long rainy season’ from late March to May produces intense transmission from April to August. The ‘short rainy season’ from October to December produces another, somewhat less intense, transmission season from November to January. This area was used for an earlier study on prevalence of common mental disorder and psychosis, and their risk factors in 2004 , 12.Figure The study sample was selected from Maseno division which is sub-divided into four locations, 17 sub-locations and 184 enumeration areas (villages) based on mapping work done earlier by the Kombewa Health and Demographic Surveillance System (Kombewa HDSS) run by the KEMRI/Walter Reed Project. The Kombewa HDSS is a longitudinal population registration system set up to monitor the evolving health and demographic problems of the study population in Kombewa and Maseno divisions . Some viMeetings were held with the community leaders to explain the purpose of the study and answer questions. The participants in the survey were approached in their own homes for voluntary written and witnessed informed consent, and then capillary blood samples were collected for preparation of thick and thin blood films (reported here) and immunity (which will be reported in accompanying papers). A structured epidemiological interview assessment accompanied the blood tests, which included detailed socio-demographic and housing variables (reported here) and additional sections on psychosocial variables (which will be reported in accompanying papers).Field staff training was undertaken in November 2012 for 5 days in the KEMRI field centre in Kisumu. Team supervisors and research assistants were trained on the rationale and methodology of the interviews, use of personal digital assistants (PDAs) to collect the interview data, and the methodology for blood samples. Prior to the field work, the communities via their community leaders received information about the study and an opportunity to discuss the project. The field work commenced on December 2012, and continued intermittently until June 2013. The research assistants were driven to the study sites, and were closely supervised by field supervisors. The questionnaires were programmed on to the PDAs and tested before the actual field work. Socio-demographic data were captured on the PDAs. They were then transferred at the end of each day to a personal computer for merging, and transmission to the statistician for analysis.Venipuncture blood samples of about 5 mL were collected aseptically into EDTA tubes from the enrolled participants before any treatment interventions. Blood smears were immediately prepared, dried and packed carefully in the field, and sent to KEMRI at Kisian, Kisumu, where staining and malaria parasite determination was performed by well trained laboratory technologists. Briefly, thick and thin peripheral blood smears were stained with Giemsa reagent and the prevalence of parasitaemia was determined by counting the asexual parasites against 300 leukocytes assuming a count of 8,000 leukocytes per microlitre of blood.The prevalence of malaria parasites was analysed in relation to a variety of socio-demographic, housing and economic variables. Predictors of parasitaemia were also examined using STATA  to calcuEthical approval was granted by the Kings College London and Kenya Medical Research Institute Ethics Review committees . Written informed consent was sought from participants to take part in the study, be interviewed and to give blood, and for the data to be analysed and published. Permission was obtained to conduct the study in households in Maseno area, which is part of the KEMRI/WRP Kombewa HDSS.1,158 participants consented to the study while 32 refused to participate in the study interviews, and 149 refused to give a blood sample (the main reasons given were the fears that the sample would either be used for an HIV test or that it would be sold for profit), thus giving an overall response rate of 91.4%. The prevalence of malaria in the total adult population in this sample was 28.1%, and its association with sociodemographic factors is shown in Table There was no significant difference in the risk of malaria with age band, or on any other socio-demographic variable, with the exception of gender . There are at least two plausible contributions to the higher prevalence in women. In the study area, the HIV prevalence is higher in women so this may contribute to the higher prevalence of malaria that we found in women, because HIV is known to cause loss of immunity and thus adults who have HIV are more likely to have malaria than those who do not have HIV , 19. In The finding of an adult prevalence of malaria of 28% in an area endemic for malaria is double the 14% microscopy prevalence found in a recent household survey of a malaria endemic area in Mozambique .Previous studies have found that in malaria endemic zones, the risks of malaria attacks declines with age between childhood and adulthood, indicating that protective immunity is acquired with increasing age up to adulthood . This stDespite earlier vigorous calls for adult malaria surveys  in orderThis study represents a contribution to the epidemiology of malaria in adults in an endemic area of Kenya. The probability sample of households and adults was drawn from a demographic surveillance site.The field work, which had been planned to last 3 months, had to be extended to 6 months to cover interruptions during the 2013 national election, due to concerns about potential election violence. Participating women were not asked if they were pregnant, and this is likely to be a major factor in the increased prevalence of malaria in women compared to men. We did not examine parasite prevalence by polymerase chain reaction (PCR), which generally finds a higher prevalence than microscopy alone.The prevalence of malaria parasites in adults in an area endemic for malaria in Kenya remains relatively high at 28%. The presence of such an adult pool of parasites represents a key factor in transmission of parasites to children, and is relevant to the malaria eradication agenda.


Ischemic stroke survivors have high risk of cardiovascular morbidity and mortality even at young age, suggesting that early arterial aging is common among such patients.We measured aortic stiffness by carotid-femoral pulse wave velocity (PWV) in 205 patients (69% men) aged 15–60 years with acute ischemic stroke in the prospective Norwegian Stroke in the Young Study. High for age carotid-femoral PWV was identified in the reference normogram.2 = 0.42, p<0.001). High for age PWV was found in 18% of patients. In univariate analyses, known hypertension was associated with a 6-fold, MetS with a 4-fold and presence of carotid plaque with a 3.7-fold higher risk for high for age PWV . In multiple logistic regression analysis higher systolic BP , history of hypertension , low HDL cholesterol  and higher serum creatinine  were associated with high for age PWV.Patients were on average 49±10 years old, 34% had a history of hypertension and 37% had metabolic syndrome (MetS). In the total study population, higher PWV was associated with history of hypertension (β = 0.18), higher age (β = 0.34), systolic blood pressure (BP) (β = 0.28) and serum creatinine (β = 0.18) and lower high-density lipoprotein (HDL) cholesterol  in multivariate linear regression analysis (multiple RHigher PWV is common in younger and middle-aged ischemic stroke patients and associated with a clustering of classical cardiovascular risk factors.NCT01597453ClinicalTrials.gov  Risks for recurrent stroke, cognitive problems, cardiovascular morbidity and mortality are high in young and middle-aged patients with ischemic stroke Carotid-femoral pulse wave velocity (PWV) is a direct measure of central arterial stiffness The prospective NOR-SYS research program at the Department of Neurology, Haukeland University Hospital, Bergen, Norway includes patients aged 15–60 years, admitted with documented acute ischemic stroke. The rationale, study design, inclusion and exclusion criteria of NOR-SYS have been previously published The study was approved by the Regional Committee for Medical Research Ethics of Western Norway, and conducted in accordance with the Declaration of Helsinki. All patients or their legal representatives signed a written informed consent.A standardized questionnaire was used to obtain the patient’s self-reported information about cardiovascular risk factors and medication. Brachial blood pressure (BP) was measured in triplets by the same investigator using a regularly calibrated aneroid sphygmomanometers and appropriate cuff size earlier on the same day of the arterial stiffness assessment 2. Venous blood samples were drawn for analysis of fasting serum lipids and glucose, serum sodium, potassium and creatinine. Hypercholesterolemia was considered present if total serum cholesterol >200 mg/dl, and/or low-density lipoprotein (LDL) cholesterol >116.0 mg/dl. Low high-density lipoprotein (HDL) cholesterol was defined as <40 mg/dl  and 50 mg/dl  Body mass index (BMI) was calculated from body weight in kilograms divided by height in meters squared. Obesity was defined as BMI ≥30 kg/mMetabolic syndrome (MetS) was defined using the modified American Heart Association/National Heart, Lung, and Blood Institute criteria requiring presence of at least 3 of the 5 following criteria: 1) waist circumference ≥102 cm  and ≥88 cm ; 2) triglycerides ≥150 mg/dl; 3) HDL cholesterol <40 mg/dl  and 50 mg/dl ; 4) systolic BP ≥130 mmHg and/or diastolic BP ≥85 mmHg measured at the time of the PWV recording; and 5) fasting blood glucose ≥100 mg/dl Carotid-femoral PWV was measured by the same investigator using a SphygmoCor device  under standardized laboratory conditions after the patients had rested for 15 minutes in supine position in a quiet examination room with a stable temperature The carotid intima-media thickness (IMT) was measured by carotid ultrasound as previously published Statistical analyses were performed using the IBM SPSS statistical program version 21 . Data are presented as mean ± standard deviation for continuous variables and as percentages for categorical variables. The study population was divided into groups with normal and high for age PWV. Comparison of groups was done by Student's t-test and Chi-squared test as appropriate. Comparison between the stroke subtypes was done by analysis of variance (ANOVA) with Scheffe’s post hoc test for PWV and a general linear model with Sidak’s post hoc test for high for age PWV. The variable serum creatinine was skewed and therefore log transformed. Univariate covariates of PWV were identified by Pearson’s correlation coefficient and univariate logistic regression analysis, as appropriate. Independent covariates of PWV were identified in multivariate linear regression analysis and reported as standardized β-coefficients and p-values. Covariates of high for age PWV were identified using uni- and multivariate logistic regression analyses and reported as odds ratio (OR) and 95% confidence intervals (CI). A p value ≤0.05 was considered statistically significant in both uni- and multivariate analyses.The total population was on average 49±10 years old and included 69% men, 37% with MetS, 34% with history of hypertension, 13% with diabetes mellitus and 11% with carotid plaques . Common In the total study population, presence of carotid plaque was associated with higher PWV . Univariate covariates of PWV in the total study population are presented in High for age PWV was found in 18% of patients, and among these 77% had a PWV >10 m/sec, the current guideline recommended cut-off value for high PWV Few studies have so far reported on arterial stiffness in ischemic stroke patients The prevalence of high for age PWV in our population was comparable to that reported from the general Danish population in subjects, and therefore lower than expected The overall prevalence of hypertension in our population was high, and hypertension was a main covariate of higher PWV in young and middle-aged ischemic stroke patients in the present study. Hypertension is a well-known risk factor for stroke and increased arterial stiffness Another striking finding in the present study was the clustering of metabolic risk factors among young and middle-aged patients with ischemic stroke, and in particular those with high for age PWV. More than 50% of patients in this subgroup had at least 3 modifiable cardiovascular risk factors. This finding points to the vast potential for both primary and secondary prevention to avoid ischemic stroke as well as recurrent stroke in young and middle-aged patients. Of note, only 58% of patients with high for age PWV and known hypertension in the present study population received antihypertensive treatment at the time of the ischemic stroke.Presence of MetS was associated with increased arterial stiffness independent of systolic BP and history of hypertension in the present study, adding to findings previously reported in older ischemic stroke patients Low HDL cholesterol was associated with a 3-fold increased presence of high for age PWV independent of hypertension and systolic BP level in the present study. In several population-based studies, lower HDL cholesterol has been associated with arterial stiffness Increased carotid-femoral PWV has also been documented as an independent predictor of mortality among diabetic patients In conclusion, high for age PWV was found in 18% in this prospective study of young and middle-aged ischemic stroke patients, and particularly associated with the presence of hypertension, MetS and carotid plaques. The clustering of modifiable cardiovascular risk factors in young and middle-aged stroke patients underline the vast potential for improving prognosis in these patients by implementation of effective secondary prophylaxis. Whether patients with high for age PWV are at particular risk for future cardiovascular events should be investigated in a larger study.


The G-6-PD deficiency has an important polymorphism with genotypic variants such as 202A/376G, 376G/542T and 376G/968T known in West African populations. It would confer protection against severe forms of malaria although there are differences between the various associations in different studies. In this study we genotyped six (06) variants of the G-6-PD gene in people with symptomatic malaria in urban areas in Burkina Faso.One hundred and eighty-two (182) patients who tested positive using rapid detection test and microscopy were included in this study. A regular PCR with the GENESPARK G6PD African kit was run followed by electrophoresis, allowing initially to genotype six SNPs . Women carrying the mutations 202A and/or 376G were further typed by real-time PCR using TaqMan probes rs1050828 and rs1050829.In the study population the G-6-PD deficiency prevalence was 9.9%. In addition of G-6-PD A- (202A/376G) variant, 376G/542T and 376G/968T variants were also detected. Hemoglobin electrophoresis revealed that 22.5% (41/182) of the individuals had HbAC compared with2.2% with HbAS and one individual had double heterozygous HbSC. There was no correlation between the G-6-PD deficiency or haemoglobinopathies and symptomatic malaria infections in this study.Plasmodium falciparum infections. As opposed to previous genotyping studies carried out in Burkina Faso, this study shows for the first time the presence of the variant A- (376G/968C) and warrants further investigation at the national level and in specific ethnic groups.Our study confirms that the G-6-PD deficiency does not confer protection against  As to the βc form, it is induced by gene mutation “transition” of the β6 globin gene (GAG to AAG) sixth codon of the first exon that resulted in the substitution of glutamic acid for lysine (β6Glu→Lys). Since the Haldane hypothesis, several studies have demonstrated the protective effect of hemoglobin S and C against severe malaria although certain mechanisms remain controversial.6The G-6-PD deficiency and haemoglobinopathies occur with high frequency in sub-Saharan Africa due to the malaria endemicity.The G-6-PD deficiency is the most common inherited enzymopathy, with over 400 million carriers worldwide.9The G-6-PD gene is highly polymorphic with over 180 mutations described and at least 35 mutant alleles with polymorphic frequencies. These polymorphisms are relatively common in different parts of the world.al.Most deficient variants G-6-PDA- are usually due to a second mutation on the G-6-PDA gene.This is a prospective study in which patients regardless of gender or ethnic group were recruited in three health centers in Ouagadougou, the capital of Burkina Faso, from September 27 to November 10, 2014. Malaria transmission is hyper-endemic and seasonal during the rainy season from June to October.The study involved 182 patients aged 1 to 72 years, attending Saint Camille Hospital of Ouagadougou (HOSCO), the Medical Center of Samandin and the Biomolecular Research Center Pietro ANNIGONI (CERBA) of Ouagadougou. Patients were sent to the laboratory when malaria was suspected, and underwent a Rapid Diagnostic Test using SD Bioline Malaria Ag Pf/Pan, after which positive individuals were included with their free and informed consent on condition that they are also positive microscopy.The samples consisted of venous blood samples (5 ml of blood per subject adult and child by blood 3ml) in EDTA tubes. Part of the sample has been used for the realization of the Complete Blood Count (CBC), hemoglobin electrophoresis and thick blood. After that, the remainder of the sample was centrifuged at 15000 rpm for 5 minutes to separate the plasma from the pellet, aliquoted and stored at −80 ° C for molecular analysis.Hematological parameters were determined from blood samples with EDTA, using a blood counter ABX Micros 60 .Hemoglobin Genotyping was made by electrophoresis in alkaline pH on a cellulose acetate tape. Tris-glycine at pH 9.5 was used as a buffer. The cells were washed and then lysed using 1% saponin. The migration was carried out for 60 minutes at 200 V on average.The blades of thick films were stained for 10 minutes in a solution of 10% Giemsa. The reading was performed using an optical microscope objective 100 under oil immersion and parasite density positive slides was calculated and expressed as the number of parasites/μL. In preparing the final parasite density, trophozoites were counted simultaneously with 200 leukocytes. Two independent microscopists did quality control by a repeated examination of the blades. In the case of difference of more than 5% between the results of three readings, the average of the two closest results was then retained.Genomic DNA was extracted from blood pellet by the standard salting-out method.PCR was performed in a reaction volume of 25 μL composed of 12.5 μL of Multiplex PCR smart mix (2x), 2 μL Primer Mixture (G6PD African), 8.5 μL of sterile water and 2 μL of ‘DNA fragment (50–100 ng) of each sample. Electrophoresis was performed at 100 V for 1 hour.Female individuals with mutations in position 202 and/or 376 were further analyzed by real-time PCR using TaqMan probes respectively  include: rs1050829, rs1050828.12al.Data were analyzed using the software Statistical Package for Social Sciences (SPSS) 21.0  and EpiInfo™ 7. Hardy-Weinberg equilibrium was determined in women according to the method described by Carter et The present study was approved by the Ethics Committee on Health Research of Burkina Faso (Deliberation No. 2014-9-128). Written informed consent was obtained from the adults and guardians of children.Our study population consisted of 50.5% (92/182) of men and 49.5% (90/182) of women aged 1 to 72 years with a mean age of 17.1 ± 13.9 years. Children under 5 years old accounted for 19.2% (35/182) of the study population noted that while 46.7% (85/182) of individuals over 15 years. Socio-demographic analysis showed that 182 patients included in this study were derived from several different ethnic groups. Mossi represented the majority ethnic group with a proportion of 76.4% (139/182) of individuals whose parents were of this ethnic group . Note thConventional PCR analysis gave more than 64% (58/90) of females carrying mutations at position 202 and/or 376. Twenty-five of them were classified as homozygous and heterozygous by real-time PCR . The G-6She had the particularity of bearing G-6-PDA- (202A/376G) on one of the X chromosome and G-6-PDA- (376G/542T) on the other X chromosome with a parasite density of 40 parasites/μL. Heterozygous females accounted for 11.5% (6.6% B/A- and 4.9% A/A-) of the study population. The prevalence of the hemizygous males was significantly higher than homozygous females (15.5% vs. 4.4% p = 0.015). The prevalence of hemoglobin genotypes was estimated to be 73.6%, 22.5% and 2.2% respectively for the genotypes AA, AC and AS. The allele frequency of HbS was 0.014 against 0.126 for HbC allele. The distribution of these genotypes was similar by sex and G-6-PD status .The mean hemoglobin level in the study population was 11.7 g/dL ± 1.9. Approximately 66.0% (120/182) of patients had a hemoglobin level greater than 11g/dL. The majority (89.9% or 29/35) of children under the age of 5 had a hemoglobin below the level of 11 g/dL. However the distribution of hemoglobin and hematocrit was similar regardless of the G-6PD status and the hemoglobin genotype.In the group of persons who have not started treatment prior to completion of thick smear, parasitaemia geometric mean was relatively lower in G-6PD hemizygous/homozygous individuals compared to non-deficient . Heterozygous females in this group had a similar parasite density than non-deficient individuals (7796.907 parasites/μL vs. 6879.702 parasites/μL). However, the correlation between the geometric mean of parasite density and G-6-PD status gave no statistically significant result .Among individuals carrying the S and/or C alleles of hemoglobin were noted a mean parasite density of 2823.703 parasites/μL against 4454.813 parasites/μL for HbAA subjects with no statistically significant difference (p = 0.362).G-6-PD has a considerable polymorphism with many genotypic variants known.15A deficient woman of ethnic Gouro (Ivory Coast) in our study shows the A- variants (202A/376G) and Santamaria (376G/542T) on both X chromosomes with very low parasitaemia. All these observations suggest that these variants exist in our populations even if they occur with relatively low frequency in some areas. The highest frequencies of the G-6-PD Santamaria were reported in Sere population in Senegal.13Our present results show that there is an underestimation of genotypes real prevalence causing the G-6-PD deficiency in Burkina Faso. The latter could explain the different frequencies of the deficit between genotyping studies and enzymatic quantification studies in our populations.17al.al.al.al.3As part of this study, patients underwent a hemoglobin electrophoresis. A major sickle cell syndrome (SC) was demonstrated in 0.5% 1/182) of patients and 2.2% (4/182) had sickle cell trait AS. The most detected hemoglobin genotype was heterozygous AC present in 22.5% (41/182) of patients with 1.1% (2/182) of CC homozygosity. The prevalence of HbAC found in our study is comparable to that 19.1%) found by Simporeet/182 of p.1% foundal.Plasmodium falciparum infections but may allow a favorable evolution of malaria.Although a reduced parasitaemia was observed in some cases , all analyses of the association between the G-6-PD status, hemoglobin genotypes, parasite density, and rate of hemoglobin or hematocrit gave no statistically significant differences. Our results are similar to those reported by Carter et The protection of the G-6-PD deficiency against severe form of malaria or malaria mortality is known, but the mechanism of protection is not entirely elucidated.22al.al.al.al. showed, comparing boys and girls a significant protection from severe malaria among G6PD c.202T heterozygous girls but no evidence for protection among G6PD c.202T hemizygous boys and homozygous girls , thus the key to protection from severe malaria could be the girls heterozygous for G6PD deficiency.29In 2009 in a study in Gambia, Clark et Our study population size was limited in deepening the analysis. Parameters such as treatment before completion of thick smears are factors that may influence parasite density and bias the association analyses.al.Plasmodium falciparum. Protection of HbAC carriers against clinical forms of Plasmodium falciparum malaria has also been reported in Mali.20In 2015 in Nigeria Igbeneghu et al.Plasmodium falciparum unlike HbAC carriers, although a strong protection was also observed in HbCC and HbSC subjects. Our results suggest that even if haemoglobinopathies S or C protect against severe forms of malaria like G-6-PD deficiency, they do not confer protection against Plasmodium falciparum infections.During the same year, Mangano et Plasmodium falciparum malaria infections. However, it shows that other variants such as T968C and probably A542T exist in our population. Further investigations are required in a larger population with well certain ethnic groups for a real estimate of the prevalence of Glucose-6-phosphate dehydrogenase variants involved in a possible association with the resistance to various kinds of malaria.Our study confirms that the G-6-PDA- variant (202A/376G), the most common in Burkina Faso, does not confer protection against


Plasmodium falciparum infection, malaria-related morbidity, use of preventive measures and treatment against malaria, and physical access to health structures among school-aged children across Côte d’Ivoire.There is limited knowledge on the malaria burden of school-aged children in Côte d’Ivoire. The aim of this study was to assess Plasmodium infection and parasitaemia determined using Giemsa-stained blood films and a rapid diagnostic test (RDT). Haemoglobin levels and body temperature were measured. Children were classified into wealth quintiles using household assets and principal components analysis (PCA). The concentration index was employed to determine significant trends of health variables according to wealth quintiles. Logistic and binomial negative regression analyses were done to investigate for associations between P. falciparum prevalence and parasitaemia and any health-related variable.A national, cross-sectional study was designed, consisting of clinical and parasitological examinations and interviews with schoolchildren. More than 5,000 children from 93 schools in Côte d’Ivoire were interviewed to determine household socioeconomic status, self-reported morbidity and means of malaria prevention and treatment. Finger-prick blood samples were collected and P. falciparum was 73.9% according to combined microscopy and RDT results with a geometric mean of parasitaemia among infected children of 499 parasites/μl of blood. Infection with P. falciparum was significantly associated with sex, socioeconomic status and study setting, while parasitaemia was associated with age. The rate of bed net use was low compared to the rate of bed net ownership. Preventive measures  were more frequently mentioned by children from wealthier households who were at lower risk of P. falciparum infection. Self-reported morbidity (headache) and clinical morbidity (anaemia) were more often reported by children from less wealthy households.The prevalence of P. falciparum and malaria-related morbidity is considerable. Furthermore, this study points out that bed net usage is quite low and there are important inequalities in preventive measures and treatment. These results can guide equity-oriented malaria control strategies in Côte d’Ivoire.Seven out of ten school-aged children in Côte d’Ivoire are infected with The online version of this article (doi:10.1186/1475-2875-14-7) contains supplementary material, which is available to authorized users. Plasmodium falciparum malaria remains a key global driver of mortality and morbidity with people in sub-Saharan Africa affected most [Anopheles gambiae is the primary vector species [ted most , 2. In Cted most . Accordi species , 5. Howe species .Besides its direct impact on health, malaria places a heavy economic and social burden on endemic countries , 8. Key Plasmodium infections. The study was carried out in late 2011/early 2012 and involved more than 5,000 children aged five to 16 years [Plasmodium infection in the school-aged population, associated morbidity, preventive and curative measures and physical access to health systems. The information will be useful for the design of equity-oriented malaria control interventions in Côte d’Ivoire.Here, results are presented from the first national, cross-sectional school-based survey pertaining to parasitic diseases in Côte d’Ivoire, placing particular emphasis on 16 years  and thusThe study protocol received clearance from the ethics committees of Basel  and Côte d’Ivoire (reference no. 09-2011/MSHP/CNER-P). Additionally, permission to carry out the study was obtained from the Ministry of National Education. Parents or legal guardians of children provided written informed consent, while children assented orally. All febrile children (tympanic temperature ≥38°C) with a positive rapid diagnostic test (RDT) result for malaria were treated with an ACT, according to World Health Organization (WHO) recommendations and national policies [The study was carried out between November 2011 and February 2012 during the dry season and covered the entire Côte d’Ivoire. The country has been stratified into three ecozones . In brieThe study was designed following a lattice plus close pairs sampling approach, as described by Diggle and Ribeiro . The aimThe survey team visited one school per day and proceeded as follows. First, the purpose and procedures were explained to school directors and other village authorities. Second, children who had written informed consent from parents/guardians were invited to participate in a parasitological examination and a questionnaire survey. Third, school geographical coordinates were recorded with a hand-held global positioning system (GPS) receiver .Plasmodium infection status, two drops of blood were collected by finger-prick, placed on a microscope slide, and thick and thin blood films prepared. Microscope slides were air-dried, transferred to nearby laboratories where they were stained with Giemsa and examined under a microscope by experienced laboratory technicians for Plasmodium species and parasitaemia. The number of parasitised blood cells was counted against 200 leukocytes, assuming a standard count of 8,000 leukocytes per 1 μl of blood. A random sample of 10% of the slides was re-examined by senior laboratory technicians for quality control. In case of discrepancies (e.g. negative versus positive results or number of parasites differing by more than 10%), a third technician re-examined the slides and results were discussed until agreement was reached. If the level of discrepancy was less than 10%, the first reading was considered as acceptable. Otherwise, all the slides were re-read. A third drop of blood was subjected to an RDT . The result of the RDT was read after 15 min according to the manufacturer’s instructions. Finally, a fourth drop of blood was employed to determine Hb levels on a portable HemoCue Hb 301 device . Anaemia was determined based on Hb levels, according to WHO recommendations [For parasitological assessment of children’s A pretested questionnaire was administered to all children to determine household socioeconomic status, self-reported morbidity, self-reported malaria , self-reported use of preventive measures and treatment of malaria. This questionnaire had been utilised in a previous school-based survey in Côte d’Ivoire . The queData were double-entered and cross-checked using EpiInfo version 3.5.3 . Statistical analyses were done in STATA version 10 . Maps were produced using ArcView GIS version 10.0 .Plasmodium falciparum parasitaemia were considered: i) <50; ii) 50–499; iii) 500–4,999; iv) 5,000-49,999; and, v) >50,000 parasites/μl of blood [P. falciparum prevalence; an individual was considered as positive for P. falciparum if either microscopy or RDT or both tests showed positive results. Microscopy results were employed to assess P. falciparum parasitaemia. Logistic and negative binomial regressions were used on P. falciparum prevalence and parasitaemia, respectively, to assess associations with different explanatory variables, including sex, age group, socioeconomic status and study setting. A multivariate regression model, adjusted for sex, age group, socioeconomic status and setting, was used to determine how self-reported morbidity, self-reported malaria, clinical morbidity (fever and anaemia), malaria preventive measures and distance from school to the nearest health facility were linked to P. falciparum prevalence and parasitaemia. In a further step, random effects at the unit of the school were introduced in the multivariate regression models.A higher detectability of the effect of the various variables was observed from categorisation, and hence these variables were categorised for subsequent analyses. Age was categorised into two groups: i) five to ten years, and ii) 11 to 16 years . The disof blood . For anat-test was used to investigate for statistically significant C-indexes.A household asset-based approach was employed to infer socioeconomic status . To weigversus 2,408; p <0.001). With regard to age, there were 3,486 children aged five to ten years, while the remaining 1,636 children were aged 11–16 years.The study aimed at 60 children in each of the 94 schools selected through a lattice plus close pairs sampling approach across Côte d’Ivoire. One school refused to participate. Overall, 5,356 children were invited to participate in the study. Complete parasitological, clinical and questionnaire data were obtained from 5,122 children (96%). All analyses were done on this cohort , but there was good agreement between the two tests  = 0.01). The pooled results from microscopy and RDT found 3,785 P. falciparum-infected children, hence an overall prevalence of 73.9%. Figure P. falciparum infection according to the pooled results.Microscopic examination of thick and thin blood films revealed that 94.5% of the detected P. falciparum prevalence data according to the pooled microscopy and RDT results, stratified by sex, age group, socioeconomic status and setting. Bivariate logistic regression models with P. falciparum results used as outcome variable revealed that boys were significantly more likely to be infected than girls. Furthermore, children from wealthier households were less likely to be infected, as well as children visiting schools in urban settings. Children aged 11–16 years showed a slightly higher P. falciparum prevalence compared to their younger counterparts, but the difference lacked statistical significance.Table The geometric mean parasitaemia among infected children was 499 parasites/μl of blood (95% CI: 476–524 parasites/μl of blood) and more than 60% of participants had parasitaemia <500 parasites/μl of blood. Only age was significantly associated with parasitaemia and children belonging to the older age group had significantly lower parasitaemia than their younger counterparts  were positively associated with P. falciparum parasitaemia. The fever incidence rate was 3.3 higher with increasing parasitaemia levels. After accounting for school location in the multivariate negative binomial model, self-reported vomiting, fever and anaemia still showed significant positive associations with P. falciparum parasitaemia. Additionally, self-reported malaria showed a significant negative association to parasitaemia.With regard to parasitaemia, self-reported hot body and vomiting were positively, and loss of appetite negatively associated with P. falciparum infection status and parasitaemia with preventive measures against malaria and distance to nearest health facility are shown in Table P. falciparum infection, burning leaves was associated with higher odds of P. falciparum infection. Furthermore, attending schools at distances >5 km from the nearest health facility was negatively associated with P. falciparum infection. The same findings were observed in both multivariate logistic regressions models (before and after accounting for random effects at the unit of the school) for insecticide spray and burning leaves.Results from the multivariate regression models to determine associations between Only the use of insecticide spray was associated with a significantly lower level of parasitaemia after accounting for school location in the multivariate negative binomial regression model. Children visiting schools located farther away from health facilities had, on average, lower levels of parasitaemia than their counterparts living in close proximity.Plasmodium infection patterns, malaria morbidities and people’s preventive and curative measures. The study was carried out over a four-month period in the dry season towards the end of 2011 and early 2012. This timing allowed the minimisation of logistic and operational challenges, such as high rate of school absenteeism and inaccessibility to the most isolated localities during the rainy season. Plasmodium falciparum was the predominant species with a very high overall prevalence (73.9%), despite efforts in place by the national malaria control programme. A decade of socio-political crisis, which further deteriorated an already weak health system, is likely to have played a major role in this finding [This is the first national, cross-sectional, school-based survey conducted in Côte d’Ivoire that investigated  finding .versus 66.9%) suggesting a small proportion of false negative results revealed by RDT. This result is somewhat surprising, as RDT is a device that detects malaria parasite antigen in a small amount of blood with monoclonal antibodies impregnated on a test strip [In the current study, microscopy revealed a slightly higher prevalence than RDT  and place of residence . Hence, findings reported here are in line with previous observations made elsewhere in Africa [P. falciparum infection status, which is in contrast to other studies [P. falciparum infection and parasitaemia with age [Significant differences were found in n Africa , 26–29 an Africa  and thatn Africa . No sign studies . Howeverwith age .With regard to prevention and treatment against malaria, results reported here confirm previous investigations in Côte d’Ivoire and elsewhere, as the use of preventive measures and availability of anti-malarial drugs was associated with the ability to afford the related costs –34. The P. falciparum infection and parasitaemia with self-reported vomiting was found. However, it is important to highlight that all reported morbidities observed in the current study would not necessarily result from P. falciparum infections since the self-reported data used were among all children and not only among children with P. falciparum infection. Furthermore, those who reported to have suffered from malaria two weeks before the current survey were less likely to have a P. falciparum infection or high parasitaemia suggesting that children likely followed efficacious antimalarial treatment [P. falciparum infection or high levels of parasitaemia than non-anaemic or non-feverish children. These findings are again consistent with previous studies that established a link between malaria parasite density and fever, and hence, parasite density might confirm a malaria case in the face of fever [Plasmodium erythrocyte stages lead to erythrocyte death, which can result in anaemia [Regarding self-reported and clinical morbidity, children from less wealthy households reported significantly more often morbidities such as headache and abdominal pain, and were more frequently diagnosed with anaemia. However, the significant difference in self-reported headache and abdominal pain could be due to the large sample size of the study and might be clinically less relevant. As in previous studies , 38, posreatment , 40. Relof fever , 42. Non anaemia , 44. Non anaemia –48.P. falciparum and had higher levels of parasitaemia than those going to schools where health facilities were further away. The exact reasons for these observations remain to be investigated. It might be speculated that the presence of health facilities in close proximity to schools influences health-seeking behaviour; children who go to schools that are far away from health facilities might stay at home when they are sick, while children living in villages with health facilities might seek care when sick. Geostatistical modelling for prediction of malaria risk within a Bayesian framework [Another interesting finding is that two out of three children surveyed went to a school where the closest health facility was within a 1-km radius. This means that once at school, most of these children can have access to health care. Surprisingly, children attending schools with health facilities in close proximity were more likely to be infected with ramework –51 that Plasmodium and intestinal helminths [Plasmodium infection was based on a single finger-prick blood sample per child. Multiple blood samples might have revealed higher prevalence rates. Nevertheless, a combination of microscopy and RDT was used to enhance diagnostic sensitivity. It would have been interesting to employ additional diagnostic assays, particularly polymerase chain reaction (PCR) methods that are highly sensitive [P. falciparum prevalence. It is conceivable that the overall P. falciparum prevalence among school-aged children is somewhat higher during the rainy season. Fourth, although a recall period of only two weeks was considered in the questionnaire interview, in accordance to previous studies [The study has several limitations. First, the results reported here were obtained during a larger investigation focusing on co-infection patterns of elminths . Second,ensitive , 53 and ensitive , 54, 55, studies , there mP. falciparum endemicity is high in Côte d’Ivoire. Hence, continued and stronger efforts are still necessary to reduce the intolerable burden of malaria in this West African country. Significant disparities in the prevention and treatment of malaria according to socioeconomic groups are apparent, calling for adapting current control strategies to further enhance equity. Although progress has been registered to increase net coverage in high-risk groups, only a relatively small proportion of children at school age reported to have access to preventive measures, including LLINs, and the actual number of children making regular use of nets is quite low. This calls for concerted efforts to increase access to information and preventive measures in the entire population. Furthermore, improved knowledge on the effect of a list of determinants, including climatic, environmental, socioeconomic and control interventions, on the distribution of P. falciparum infection in schools needs to be generated through rigorous monitoring platforms. Finally, geostatistical modelling and prediction of malaria risk as done in previous studies [This first national school-based cross-sectional survey confirmed that  studies , 56 is nDisparities in prevention and treatment against malaria, self-reported and clinical morbidity, and distance to health facilities across socioeconomic groups, as assessed by the concentration index (C-index).(XLS 36 KB)Additional file 1:


Plasmodium falciparum infection.As indicators of burden of malaria have substantially decreased in The Gambia, reaching a pre-elimination status may be attainable. Achieving this goal requires in-depth understanding of the current burden of P.falciparum infection, and to describe its heterogeneity and associated risk factors. Finger-prick blood samples were collected for microscopy, species-specific PCR and haemoglobin measurement.A nationwide cross-sectional survey was conducted in 2012 to determine the prevalence of P. falciparum was 16.01 % with marked heterogeneity between sites (4.32–36.75 %) and within villages in each site (1.63–49.13 %). Across all sites, 51.17 %  of infections were asymptomatic and 35.61 %  were sub-microscopic. The odds of P. falciparum infection were higher in older children; 5–15 years , adults  and participants with moderate anaemia .A total of 9,094 participants were included and medianage was 11.9 years . Overall prevalence of The current malaria control interventions are not sufficient to interrupt transmission in The Gambia as malaria prevalence is still relatively high in the eastern part of the country. New interventions aiming at interrupting transmission are needed and should be urgently evaluated. The last decade has witnessed major progress in the fight against malaria as the burden has substantially reduced, even in sub-Saharan Africa, although malaria still contributes significantly to both morbidity and mortality , 2. The As the country aims for pre-elimination status, gaining a detailed understanding of the current distribution of malaria infection, characterizing its heterogeneity across the country and further identifying asymptomatic carriers is critical as these are important elements for disease surveillance and targeting control efforts. Whereas health facility data have previously been used to describe malaria morbidity trends , this inAnopheles gambiae mosquitoes. Malaria transmission occurs almost exclusively during the rainy season and immediately afterwards, until December-January. The entomological inoculation rate varies from 0 to 166 infective bites per person per year  were females  and the median (IQR) gametocyte density (N = 225) was 80 µl .The proportion of participants that reported sleeping under an LLIN the previous night was high  across all sites while  of the participants reported having received IRS in their households the previous year. A relatively high proportion of individuals  slept out doors at night; this was more frequent in the eastern part of the country, i.e., URR-north bank , CRR-north bank  and URR-south bank  ; 95 % CI 15.27–16.78 %] with significant heterogeneity observed between sites and within villages in each site. Plasmodium falciparum prevalence was highest in the eastern part of the country, with average parasite prevalence in the URR-south bank of , ranging from [18.15 % (49/270): 95 % CI 13.84–23.38 %] in Waliba Kunda to  in Madina Samako, and  in the north bank, ranging from  in Maka Masireh to  in Jecka ; 95 % CI 48.57–53.76 %] across all sites were asymptomatic, i.e., without fever or history of fever. The relative distribution of asymptomatic versus symptomatic varied significantly by region. The proportion of asymptomatic cases ranged from  in the LRR-south bank and URR-south bank to  in URR-north bank and  in NBR. Conversely, the highest proportion of individuals positive by PCR that had fever or history of fever was in the URR-south bank  and in the CRR-north bank . Overall, only  of participants with P. falciparum infection across the six sites had documented fever. The overall prevalence of sub-microscopic parasitaemia was  with an inverse relationship between the prevalence of P. falciparum parasitaemia and distribution of sub-microscopic parasitaemia  compared to children <5 years, participants with moderate  and severe anaemia  compared to those with no anaemia whereas, sleeping under a LLIN the previous night was protective against P. falciparum infection  and women had lower odds of infection compared to males . In the multivariable analyses, with clustering with-in and between sites the odds of P. falciparum infection were significantly higher among older children  and adults (≥15 years)  compared to younger children (<5 years). In addition, females had a significantly lower odds of parasitaemia  compared to males. Plasmodium falciparum infection was also strongly associated with anaemia, with the odds of parasitaemia increasing with severity of anaemia. The odds of infection were three-fold higher among participants with severe anaemia  compared to participants with no anaemia (test for trend anaemia P = 0.002). Sleeping under a LLIN the previous night was protective against malaria infection . In NBR, sleeping outdoors at night was associated with a higher odds of P. falciparum infection . However, the association was not statistically significant in the overall uni-multivariable analyses. “Sleeping outdoors at night”, “indoor residual spraying” and “sleeping out in the fields” were not predictors of P.falciparum infection. There were no differences in the covariates predicting malaria infection when compared to the multilevel, multivariable, parsimonious model, suggesting missing data did not affect the observed trends in association  was similar to that reported from community-based surveys in 2009 [Whereas the burden of malaria in The Gambia has decreased significantly over the last 10 years , 4, prob in 2009 , implyin in 2009 , Gabon [ in 2009  or BurkiP. falciparum infection. However, the high resistance to DDT and pyrethroids observed in eastern Gambia [P. falciparum in the eastern region. A. gambiae s.s and A. arabiensis are the predominant and in general most efficient vectors in the east, while other areas of the country have less efficient vectors, such as A. melas and A. coluzzii. In addition, this region has more difficult access to health care and prompt treatment. For the latter, the eastern part of The Gambia, where the highest malaria prevalence has been observed, is the least developed and the farthest from the capital.The difference in transmission between the eastern part and the rest of the country cannot be explained by different coverage of LLINs, as their reported use is relatively high throughout the country and LLIN use reduced odds infection of n Gambia , 10 and n Gambia  could ben Gambia , 23, theThe low malaria prevalence observed in the western part of the country is consistent with earlier reports in 2008 [Identifying individuals who constitute this reservoir of infection would be extremely important for the identification of ‘hot spots’ in these villages, and designing and targeting interventions aimed at further decreasing malaria transmission. Assuming such carriers are mostly the same individuals from one transmission season to the other, because of environmental factors, such as higher exposure to infectious bites, residing in households near breeding sites, or genetic factors , targetiAs previously reported , 26, aboThe prevalence of asymptomatic parasitaemia was significantly higher in the older children and adults, possibly the result of stronger immunity, making them able to tolerate  but not When considering the distribution of malaria infection across The Gambia, two main strata can be identified: the eastern part where transmission is still relatively intense, with villages in which a third to a half of the population infected, and the western part with low prevalence. Within each stratum, there is considerable heterogeneity between villages. It is remarkable to notice that even in the low endemicity stratum and despite high coverage of preventive and curative interventions, transmission has been maintained over the years. Obviously, current interventions are not sufficient to interrupt transmission in the current context of modified human and vector behaviour and new approaches need to be urgently evaluated. The low endemicity stratum in The Gambia offers an ideal setting to test new interventions aiming at interrupting malaria transmission.


A prospective study on severe and complicated malaria was undertaken in the tribal dominated area of Bastar division, Chhattisgarh (CG), Central India, with an objective to understand the clinical epidemiology of complicated malaria in patients attending at a referral hospital.Plasmodium falciparum positive malaria cases who met enrollment criteria and provided written informed consent were enrolled under different malaria categories following WHO guidelines. PCR was performed to reconfirm the presence of P.falciparum mono infection among enrolled cases. Univariate and multivariate logistic regression analysis was done to identify different risk factors using STATA 11.0.Blood smears, collected from the general medicine and pediatric wards of a government tertiary health care facility located in Jagdalpur, CG, were microscopically examined for malaria parasite from July 2010 to December 2013. The P.falciparum associated complicated malaria  in the hospital was 6% and 0.81%, respectively. P.falciparum malaria prevalence, severity and associated mortality in this region peaked at the age of>4–5 years and declined with increasing age. P.falciparum malaria was significantly more prevalent in children than adults (P<0.00001). Among adults, males had significantly more P.falciparum malaria than females (P<0.00001). Case fatality rate due to cerebral malaria and severe malaria was, respectively, 32% and 9% among PCR confirmed mono P.falciparum cases. Coma was the only independent predictor of mortality in multivariate regression analysis. Mortality was significantly associated with multi-organ complication score (P = 0.0003).A total of 40,924 cases were screened for malaria. The prevalence of malaria and This study has revealed that the pattern of morbidity and mortality in this part of India is very different from earlier reported studies from India. We find that the peak morbidity and mortality in younger children regardless of seasonality. This suggests that this age group needs special care for control and clinical management. Plasmodium falciparum infection causes the most serious form of malaria and its presentation varies from one place to another depending on factors such as the presence of vectors, parasite species, drug resistance, socioeconomic factors, geographical areas and type of intervention measures used Malaria is a global public health problem and India contributes substantially to global malaria incidence In India, major studies conducted so far on severe and complicated malaria are from Rourkela and Cuttack, Orissa, East India P. vivax and P. falciparum were found as mono infections and these studies did not clearly define the clinical picture of CM from other severe forms of malaria (SM). Moreover, none of these studies used PCR to confirm mono-infection of P. falciparum.In an outbreak investigation conducted in Rajasthan, a desert zone, and a low endemic area for malaria, the mortality (34%) was found due to cerebral malaria (CM) in older children and adults (>14–74 years) P. vivax, P. falciparum, P. ovale and P. malariaeThe present study was carried out in Chhattisgarh (CG), a highly malarious state contributing 12% of malaria and the highest proportion of deaths due to malaria (17%) in the country P. falciparum percentage of 85%  and Slide Positivity Rate (SPR) of 9%. Average annual rainfall in this region is around 1400–1500 mm. The economy of the villagers residing in this tribal district is mainly agricultural and forest based.A malaria clinic of the Regional Medical Research Centre for Tribal (RMRCT) was established in a 600 bedded Maharani Hospital, which is part of the Medical College in Jagdalpur, CG, India (Coordinates 19.07°N and 82.03°E) in the year 2010 , A–C. ThP. vivax was the predominant species (58%); however, since 1979 P. falciparum showed a steady upward trend (50%) and in 2002, P. vivax came down to 28% P. falciparum percentage was 78.2. Among the known vectors are An. culicifacies, An. fluviatilis, An. subpictus, and An. varunaPrior studies carried in CG in 1975–76 revealed, The study protocol was approved by the Institutional Ethical Committee (IEC) of RMRCT, Indian Council of Medical Research (ICMR), New Delhi. Written informed consents were obtained prior to enrollment of the patients, just after the initiation of the treatment. The consent form was provided and explained in detail to the patient either directly  or to their parents or guardians . For unconscious and disoriented patients of all the age groups, consent has been obtained from parents or guardians of the participant. All the consent forms were also witnessed and signed by one more representative of the patient. This clinical investigation has been conducted according to the principles expressed in the declaration of Helsinki.P. falciparum positive malaria subjects were classified under different categories as per the clinical and laboratory characteristics i.e., mild malaria (MM), severe malaria (SM) and cerebral malaria (CM) following WHO guidelines This prospective study was carried out from July 2010 to December 2013. All clinically suspected individuals admitted in the general medicine and pediatric wards were screened for malaria parasite by microscopy. RDTs were used only in case of emergency and also when blood smears were doubtful in patients presenting semiconscious/unconsciousness or treated before in case of referral to confirm parasitological diagnosis. Microscopically confirmed P. falciparum associated unarousable coma which persisted at least for 6 hours (Glasgow coma score ≤10) or ≥3 generalised convulsions in the last 24 hours after correction of hypoglycemia (blood glucose <40 mg/dl) as per the standard guidelines Severe and complicated forms of malaria were recognized by the following definitions. Cerebral malaria (CM) – Severe malaria (SM) - Presence of any of the following complications in absence of cerebral involvement; acute renal failure - serum creatinine>3 mg/dl or insufficient urine output in adults/children, severe malaria anemia (SMA) - hemoglobin <5 g/dl, jaundice - serum bilirubin>3 mg/dl , hypoglycemia - blood glucose <40 mg/dl, hypotension - systolic blood pressure <80 mm Hg for adults and <50 mm Hg for children (<5 years), respiratory distress – laboured breathing signed by chest/intercostals muscles recession or age stratified increased respiratory rate  according to World Health Organization (WHO) definition Patients presenting none of all the above signs were defined as MM. Clinical and demographic details of subjects were extracted from the hospital records in a structured abstraction form.P. falciparum malaria patients were treated with body weight dependent doses of intravenous quinine/artesunate followed by oral quinine/artesunate – sulfadoxine and pyrimethamine tablets as per the guidelines of the National Vector Borne Disease Control Programme, Ministry of Health and Family Welfare All Few drops of the finger-prick blood was obtained, for the blood smear preparation (thick and thin) on a glass slide, estimation of hemoglobin  and random blood sugar . Filter paper blood spots were taken for PCR diagnosis.Blood smears were stained by Jaswant Singh and Bhattacharyaji stain P. falciparum (Pf), P. vivax (Pv), P. malariae (Pm) and P. ovale (Po) using the 18s rRNA gene P. knowlesi was also carried out PCR was performed to rule out mixed infections among enrolled cases for final clinical analysis. Blood spotted area was punched and put into a 1.5 ml tube. The blood spots were soaked in 150 µL TE buffer  and incubated for an hour at room temperature. After one hour incubation, tubes were placed in a dry bath at 50°C and incubated for 15 minutes and punched by pipettes tips several times. Finally the tubes were incubated at 97°C for 15 minutes and centrifuged at 8,000 rpm for 2 minutes. Supernatant was aspirated and stored at −20°C for PCR amplification. Species-specific nested PCR was carried out for the detection of P. falciparum malaria, complicated malaria and associated mortality between age groups (adults & children) and gender  as end points. Univariate and multivariate logistic regression analyses were performed for risk factor analysis with background, demographic and clinical complications as independent variable and complicated malaria and mortality as dependent variables. Prior to the regression analysis presence or absence of the risk factors under independent variables and outcomes in the form of complicated malaria (Yes/No) and mortality (Yes/No) under dependent variables were coded as 1 (Yes) or 0 (No). Variables which showed significance at the level of p ∼ 0.1, in univariate analysis were selected and analyzed in multivariate logistic regression to reveal their independent association with disease severity/outcome.Categorical variables were summarized as frequency (proportion). Chi-square or Fisher exact tests were used for comparison of categorical data  and prevalence's of malaria, th – 75th percentile distribution (IQR). These were tested for normality and analyzed by multiple comparisons ANOVA. If found normally distributed among all study groups . In case where the data deviated from the normal distribution, Kruskal-Wallis test was applied . Statistical analysis was performed using STATA version 11.0 software . Non parametric spearman correlation coefficient was used to determine the correlation between variables . Statistical significance was assumed if a null hypothesis could be rejected at p = 0.05. General malariometric characteristics were defined as follows: Malaria prevalence  =  Total number of positive cases in the hospital ×100/Total number of admitted cases; Case fatality rate (CFR)  =  in a period of time, number of cases died due to specific disease in a hospital ×100/Total number of cases diagnosed with the same disease; P. falciparum (Pf)%  =  Total number of P. falciparum cases ×100/Total number of cases positive for malaria parasite.Continuous variables were presented as median and 25P. falciparum, 340 cases were P. vivax and 11 cases were found to be mixed infections of both. Overall malaria prevalence in the hospital was 6%  and Pf% was 86.1. Among P. falciparum cases gametocyte carriage rate was 1.9% .A total of 40,924 cases in all the age groups with and without fever were microscopically screened for malaria. Of the 2,450 malaria positive cases, 2,099 cases were P. falciparum malaria in particular, was significantly more associated with children [7.9%  & 7.0% ] than adults [5.5%  & 4.7% ] . Out of the 2,110 P. falciparum (including mixed Pf+Pv) cases, 334 had complicated malaria, of which 330 were due to P. falciparum, 1 severe P. vivax and 3 cases were due to mixed (Pf+Pv) infections . An increase in malaria associated morbidity and mortality from the age <1 year to 5 years was observed followed by a decline up to the age group>45 years (Further age group wise (<15 years & ≥15 years) and sex wise analysis revealed that malaria and fections . Males w45 years .P. falciparum malaria, 238 had CM of which 90 died (CFR = 37.8%) and 95 had SM of which 18 died (CFR = 18.9%) which is significant statistically (p = 0.001). We observed complicated malaria cases throughout the year. However, malaria prevalence was significantly higher in the monsoon season  and post monsoon season  as compared to the dry season.Out of 333 complicated cases of P. falciparum mono-infection cases out of 2,099 were enrolled and categorized into different disease categories . Out of 401 cases, fourteen cases were found to be infected with mixed Plasmodium infection by PCR and were excluded from the analysis . Of the remaining 387 cases, thirteen SM were further excluded as they had only jaundice and another 22 SM were excluded due to the presence of only hyperparasitemia as a severe complication. One CM was excluded due to ambiguity in the results.A total of 401 microscopically positive P. falciparum was 32.4% (57/176) and 8.9% (5/56) respectively, which was found significant (p = 0.001).Finally we compared 119 MM with 232 complicated malaria patients (SM = 56 and CM = 176) to identify background and clinical risk factors for complicated malaria, and age group wise clinical complication patterns and prognosticators. CFR due to CM and SM among PCR confirmed mono Primary complaints among enrolled subjects were, fever with chills and rigor in 90.5%, headache in 79.7%, vomiting in 63.9% and diarrhea in 20.9% cases. Anemia (Hemoglobin <11 mg %) was recorded in 46% cases.p = 0.0082). Overall, mortality was significantly higher among comatose patients compared to non-comatose patients . Median fever history of different groups was similar (p = 0.296). Duration (hours) of coma among 23 CM-NS cases and 43 of CM-S patients before hospitalization was not significantly different (p = 0.08) .Details of continuous variables investigated in this study are shown in p = 0.0001), CM-S (p = 0.0001) and non survivor group (CM-NS + SM-NS) was significantly higher (p<0.0001) than MM patients. Systolic blood pressure was significantly lower in SM-S (p = 0.0001) and higher in non survivor group (p = 0.0003) than MM but it was statistically insignificant between CM-S and MM patients (p = 0.945). Percent peripheral parasitemia was significantly higher in SM-S (p = 0.0001), CMS (p = 0.0034) and non survivors patients (p = 0.0003) than MM patients.Respiratory rate in SM-S (p = 0.0071), CM-S (p = 0.035) and non survivors (p = 0.0007) compared to MM patients. Hemoglobin level was significantly lower in SM-S (p = 0.0001), CM-S (p = 0.0003) and non survivors (p = 0.0005) groups compared to MM. Serum bilirubin levels were significantly higher in SM-S, CM-S, and non survivors compared to MM . Blood urea was also significantly higher in CM-S (p = 0.039) and non-survivors (p = 0.014) compared to MM.Pulse rate was also significantly higher in SM-S (p = 0.0001) and CM-S (p = 0.277). Patients with 2 complications (p = 0.0011) and those with ≥3 complications (p = 0.0001) had significantly higher median percent parasitemia than patients with single complication. No significant difference was found between patients with 2 and ≥3 complications. Hospital stay period of SM-S patients (p = 0.018) and CM-S patients (p = 0.0001) was significantly longer than MM cases. Complicated malaria patients with ≥3 complications also had significantly longer hospital stay than those with single complication (p = 0.05) but not double complications (p = 0.448).The multiple complication score was significantly higher in non survivors group compared to SM-S  and children (n = 50) with complicated malaria revealed that the frequency of seizures, hyperparasitemia, severe malaria anemia, hypoglycemia, respiratory distress, and blood transfusion any time during hospitalization were significantly associated with children than adults. Where as complications like jaundice and acute renal failure were significantly associated with adults than children . Coma, aUnivariate logistic regression analysis for prognostic indicators revealed that coma, jaundice, hemolysis/abnormal bleeding, respiratory distress, acute renal failure and multiple complications were significantly associated with mortality of severely ill patients . We founp = 0.0114] and ≥3 complications  compared to single complication. Mortality was significantly associated with multi-organ complication score .Patients with two complications  and ≥3 complications  had significantly higher mortality than patients with single complication . Odds of mortality also increased in patients with two complications [6.0, 95%CI (1.2–29.3), Pf + Pv) . Of these eleven cases, three had SM (27.3%) of which two died (18.2%). Additionally PCR revealed 14 mixed infections , of which mortality was recorded in 28.6% (4 cases).We recorded a total of 11 microscopically positive mixed infections  majority of them were within 12 hours of admission (62.0%) and associated with 34.5% mortality . Out of 176 analyzed CM cases (57 died), coma patterns of recovered patients were available for 101 cases (75 adults and 26 children). Children showed relatively faster recovery than adults but it was statistically insignificant at all the time intervals for first 48 hours . Of 101 2 = 6.8, P = 0.009). Children also showed similar trends.Time point wise mortality pattern  revealed that 54.8% mortality occurred between admissions to 24 hours . Among aOut of the 232 enrolled complicated malaria, seventeen cases were referred to specialty care centre in Raipur of which 29.4% died. All had CM and other associated organ dysfunctions (94%).Assessment and analysis of the local malaria situation are a prerequisite for embarking on any control and elimination program. This study was conducted to determine the clinical features in patients with complicated malaria among the predominantly tribal population. Differences in age wise pattern of severe and complicated malaria (peak observed among children>4–5 years) were noticed compared to the presentation of malaria in various other endemic settings of India and Africa Age wise pattern of malaria and associated clinical manifestations were found, which differ from prior reports from this part of the Central India. In this study the median age of children having malaria and associated morbidity was 5 years. In Cuttack, the median age of severe malaria in children was 8 years A review of the age pattern of malaria revealed that as transmission increased there was a shift of malaria towards younger age groups regardless of seasonality P. falciparum than females. However, the proportions of severity and mortality in P. falciparum malaria were independent of gender difference in adults or children. Treatment seeking behaviour, occupational activities and socio-cultural barriers may also cause differences towards treatment at higher centres between males and females Further, in this study 14.0% cases had CM that was not associated with any other complication compared to 8% reported earlier Among prognostic indicators respiratory distress, coma, multiorgan dysfunction and hyperparasitemia have already been described to be independently associated with mortality among Indian children earlier Further, there are reports in literature providing evidence of increasing severity and morbidity in patients of mixed infections In most of the previous studies complicated malaria mortality is reported to occur within first 24 hours of admission before the full dose of effective antimalarial is administered From the clinical perspective, this study has some limitations also. We could not collect data on neurological sequelae at the time of discharge of complicated malaria patients in this study. Hypoglycemia was also the limitation of this study as blood glucose could not be measured before intravenous infusion, which invariably was started immediately in the casualty unit after first clinical examination in severe cases. Upon clinical examinations, as indicated, biochemical investigations were advised by the consultant physician but this information was not available for all the cases. Hemoglobinopathy (sickling and G6PD deficiency) data was also not available. Further, it is possible that we did not capture the full burden of malaria and the complete spread of clinical symptoms in our hospital setting. It is also possible that many deaths take place at home in the villages and there is a possibility that we missed certain manifestation of malaria causing early deaths in children.Severe and complicated malaria is a challenge to the attending physician who is treating an admitted severe malaria patient at a remote health facility. This comprehensive prospective study showed that delayed referral and delay in starting parenteral therapy could be an important factor for poor outcome. To reduce malaria related mortality provision has to be made to refer the cases of complicated malaria after giving initial treatment from peripheral centre or from home by health workers. Relatively high morbidity and mortality among young children suggest that they are more vulnerable and needed special care during management. This study showed that there is need of site specific data in order to understand the clinical and epidemiological picture for developing appropriate intervention strategy and management guidelines.


Kenya launched its second National Malaria Strategy with a notably ambitious vision for a “malaria free Kenya”, but malaria remains a major health problem among communities in Lake Victoria in western Kenya.We conducted three cross-sectional surveys during the dry (January 2012) and two consecutive wet seasons (August 2012 and August 2013) among communities residing in three different settings in Lake Victoria: (1) along the mainland coast ; (2) on a large island ; and (3) on small islands . The prevalence of malaria infections and G6PD deficiency was analyzed by geography and/or season.Plasmodium falciparum, 8.5% for P. malariae, and 2.1% for P. ovale in the dry season, and 26.6%, 7.2%, and 3.3%, respectively, in the wet seasons. Prevalence of mixed infections was 8.3% and 7.1% in the dry and wet seasons, respectively. P. vivax was not detected by microscopy or PCR in any survey. Significant seasonal fluctuations in PRs were observed among children and young adolescents on islands but not in the coast. Among all settings, G6PD deficiency was found in 12.1% of males and 2.1% of females. No significant correlation between G6PD deficiency rates and PRs was observed in any settings.Overall, parasite rates (PRs) as determined by microscopy (18.9% vs 18.4%), rapid diagnostic test  and PCR (31.1% vs 28.5%) were higher in the dry season than in the wet seasons with characteristic age distribution. In both seasons, PRs were highest in the coast, then in the large island and lowest on the small islands. The highest prevalence by RDT during the dry season was observed in Ungoye: 54.4% in age group 0-5 years old, 68.4% in 6-10, 55.3% in 11-15, 13.2% in 16-30 and 11.3% in >30. Species-specific prevalence by PCR was 29.3% for Variation in malaria prevalence reflects the different dynamic of malaria transmission between the islands and the coast of Lake Victoria. Our results provide baseline data for the planned feasibility study of malaria elimination on islands in Lake Victoria.