Socio-economic and obstetrical data of mothers and neonate birth weights were documented. Peripheral blood from 201 mothers and newborns as well as placental and cord blood were used to prepare thick and thin blood films. Maternal haemoglobin concentration was measured. The overall malaria parasite prevalence was 22.9% and 6.0% in mothers and newborns respectively. Monthly income lower than 28000 FCFA and young age were significantly associated with higher prevalence of placental malaria infection (p = 0.0048 and p = 0.019 respectively). Maternal infection significantly increased the risk of infection in newborns . Haemoglobin concentration and birth weight were lower in infected mothers, although not significant. HIV infection was recorded in 6.0% of mothers and increased by 5-folds the risk of malaria parasite infection . Attendance at antenatal clinic and level of education significantly influenced the utilisation of IPTp-SP (p<0.0001 and p = 0.018 respectively). Use of SP and mosquito net resulted in improved pregnancy outcome especially in primiparous, though the difference was not significant. Malaria infection in pregnancy is common and increases the risk of neonatal malaria infection. Preventive strategies are poorly implemented and their utilization has overall reasonable effect on malaria infection and pregnancy outcome.Malaria is known to have a negative impact on pregnant women and their foetuses. The efficacy of Sulfadoxine-Pyrimethamine (SP) used for intermittent preventive treatment (IPT) is being threatened by increasing levels of resistance. This study assessed malaria risk factors in women on intermittent preventive treatment with SP (IPT More than half of the world's population is at risk of malaria and the vast majority of cases are from sub-Saharan Africa, where about 30 million pregnant women are highly exposed to the disease each year p), use of insecticide-treated nets and effective management of cases. Sulfadoxine-Pyrimethamine (SP) has been the drug of choice for malaria IPTp, in pregnant women living in malaria endemic areas p-SP) in Cameroon was adopted in 2004, with the objective of giving at least 3 SP doses between the 16th and the 36th weeks of pregnancy. However, increasing levels of resistance across South-East Asia and Africa including Cameroon have been reported p. Some studies on pregnancy associated malaria risk factors and effects p-SP as well as malaria risk factors and their effects on mothers and newborns at delivery have not been documented in the Sanaga-Maritime Division. This study therefore aimed at assessing malaria risk factors in women on intermittent preventive treatment with SP (IPTp-SP) at delivery and their effects on pregnancy outcome in the Sanaga-Maritime Division, Cameroon. The results from this study will help inform public health managers and policy makers on the situation of malaria risk factors and the impact of the IPTp-SP strategy for malaria control in pregnancy in this part of Cameroon.Malaria prevention and control during pregnancy consist of the administration of intermittent preventive treatment  are based in semi-urban areas whereas the others  are in rural areas. The Sanaga-Maritime Division is hyperendemic for malaria. The climate is equatorial, warm and humid, with a mean temperature of about 28°C. Rainfall ranges from 3000 to 4000 mm per year, and humidity varies from 80% in the dry season to 99% in the rainy season. Vegetation is made up of mangrove forest in the Mouanko coastal area, agro-industrial farms and rainforest in the inland. Vegetation is reduced in towns. The hydrographic network is highly developed with many rivers and streams. The economy relies on fishing, agriculture and timber exploitation, with an industrial complex in the town of Edéa.The study population consisted of pregnant women who consented to participate in the study and signed the informed consent forms. Pregnant women with a history of allergy to sulfonamides, HIV positive pregnant women under daily Sulfamethoxazole-Trimetoprim treatment as well as women with chronic diseases such as diabetes and high blood pressure or with immediate life-threatening medical and obstetrical conditions were excluded. A total of 201 women and their newborns were enrolled. The study was carried out for one year, from March 2011 to March 2012.Ethical and administrative clearances for this study were issued by the Ethics Committee of the Regional Delegation of Public Health for the Littoral Region, Cameroon, after approval of the protocol of this study. Pregnant women were approached during antenatal clinics or when reporting for delivery. The aim and objectives of the study were explained to them in the language they understood best (French or English), and their questions were answered. Only volunteer pregnant women who signed an informed consent form for their participation and that of their newborn were enrolled. Participants found infected were referred to clinicians of the health facility concerned for appropriate treatment. There was no difference in the care provided to pregnant women who accepted to participate in the study and those who did not.A structured questionnaire was administered to document the ages, socio-economic , obstetrical , and environmental (area of residence) data on participants. Blood was collected at delivery from finger pricks of the women as well as heel pricks of neonates. One millilitre of cord blood was collected through suction of the umbilical vein with a sterile disposable syringe. Placental blood was collected from a pool on the maternal face of the placenta Blood films were stained with 10% Giemsa and examined under the oil immersion (×100) objective of an Olympus® BX 40F light microscope . Thick films were considered positive when asexual forms (trophozoites and schizonts) and or gametocytes were present in the blood film. Slides were declared negative after observing at least 100 high power fields without detecting any parasites. Parasites were counted against 500 leucocytes and expressed as parasites per microlitre (µl) of blood, assuming a white blood cell count of 8000/µl of blood Haemoglobin concentration was measured with a Marienfeld™ Haemometer , following the acid haematin method (Sahli's method) Women were screened for HIV infection with the Alere Determine™ HIV-1/2 lateral flow immunochromatographic test . Positive samples were subjected to a confirmatory test using Colloidal Gold® lateral flow immunochromatographic test .Participants were categorized according to their age groups , parity , level of education , monthly income  and marital status . Neonates with birthweight lower than 2500 g were considered to be of low birth weight (LBW) and delivery at a pregnancy age less than 37 weeks was considered as pre-term delivery.All data were entered in an Excel sheet and analysed using SPSS version 17.0. Chi-square or Fisher's exact tests and t-test were used to evaluate differences in proportions. ANOVA, Mann-Whitney and Kruskall-Wallis tests were used to assess differences in means. Odds Ratios (OR) were calculated to compare the susceptibility of individuals or groups to different parameters. The level of significance was set at α = 0.05.A total of 201 mother/neonate pairs were recruited into the study. Data are given with ± standard deviation. The mean age of the mothers was 24.8±6.4 (range: 14–48) years. The mean number of ANCs during pregnancy was 2.3±1.4; mean haemoglobin concentration was 11.3±1.2 (range: 8.2–14.1) g/dl and mean number of deliveries was 3.3±2.2. The prevalence of HIV infection in mothers was 6.0% . A total2 = 7.6; OR = 2.2; p = 0.0057). Sixteen (8.0%) women had both peripheral and placental infections. Twenty-five (12.4%) women had only peripheral infections, while 5 (2.5%) had only placental infections. Overall, low income significantly affected the prevalence of malaria  in mothers  as shown on Overall, 22.9% (46) mothers had malaria parasite infection in peripheral and/or placental blood. Malaria parasite was found in 20.4% (41) peripheral blood films and 10.5% (21) placental blood films. Prevalence of malaria parasite infection in peripheral blood was twice as high as in placental blood (χp = 0.007) was observed in HIV infected women. The prevalence values of peripheral malaria parasite infection was 26.7%, 19.6% and 22.5% in primiparous, secundiparous and multiparous respectively while GMPDs (95% CI) were 247 (35.7–705.5) 185.6 (19.6–764.0) and 68.6 (31.7–103.7) parasites/µl respectively. Low income was significantly associated with the prevalence of malaria parasites, women earning less than 28000 FCFA being more affected . Placental infection rate was 15.6%, 10.9% and 8.3% in primiparous, secundiparous and multiparous, respectively while GMPD was 214.5 (7.0–1879.7), 176.6 (5.3–2736.6) and 161.4 (43.3–435.4) parasites/µl in the respective groups. Malaria parasite infection of the placenta was significantly associated with age and monthly financial income, women less than 20 years of age and women having monthly financial income less than 28000 FCFA being at greater risk . In both cases, GMPD was not significantly associated with any of the assessed factors.A five folds increased risk of malaria parasite infection in mothers . Placental films showed higher GMPD [181.3 (48.2–164.3) parasites/µl] than peripheral films [124.2 (45.5–343.8) parasites/µl]. This was however not significant .Proportions of low, moderate and high parasitaemia were 82.9%, 7.3% and 9.8% respectively for positive peripheral blood samples, and 76.2%, 9.5% and 14.3% for positive placental blood samples. High densities were mostly found in placental blood films; however, no significant association of parasite density with sample source was found . Eight (4.0%) newborns had both cord blood infection and peripheral blood infection. Four (2.0%) children had cord blood infection only and 4 (2.0%) others had peripheral blood infection only. Prevalence was 2.2%, 4.3% and 4.6% in newborns from primiparous, secundiparous, and multiparous respectively.p<0.0001). Haemoglobin concentration was lower in infected mothers and preterm deliveries were higher; mean birthweight of babies born to infected mothers was lower and the prevalence of low birthweight was higher in babies born to infected mothers. This was however not statistically significant, as shown on p = 0.021]. The risk of neonatal parasitaemia was significantly higher in children born to infected mothers than those born to uninfected mothers  as shown in p = 0.048). Newborns of mothers with GMPD higher than or equal to 500 parasites/µl of peripheral blood were at higher risk of neonatal malaria infection . This was not the case when GMPD in placental blood was considered  as shown in Malaria infection in mothers significantly increased the risk of neonatal parasitaemia  and level of education . The prevalence of malaria parasite infection was 23.9%, 20.8% and 24.5%, in mothers of zero, one and two or more SP doses groups respectively . There was no significant difference in the prevalence of maternal parasitaemia between age groups, area of residence, marital status, level of education, financial income and use of mosquito nets with use of SP. The use of SP for IPTp resulted in improved haemoglobin concentration in mothers , mean gestational age  and birthweight , as well as lower prevalence of neonatal malaria infection , anaemia in mothers  and preterm delivery  (p = 0.42] and birthweight , as well as the reduction of the prevalence of anaemia , preterm delivery 13.7% vs 16.0%, p = 0.67) and low birthweight  (The number of SP doses taken in the course of pregnancy was significantly associated with ANC attendance by the mother (χ = 0.63) . Similar = 0.77) . None ofp was mostly observed in primiparous, with gains in haemoglobin concentration  and mean gestational age . A significant reduction in the prevalence of anaemia with the use of SP was also recorded in primiparous , mean gestational age  and birthweight .Likewise, the positive effects of mosquito net use were higher in primiparous, with gains in haemoglobin concentration [0.5 (−074–1.74) g/dl, There was a reduction in the prevalence of anaemia and newborn infection in women who took their last SP dose less than 8 weeks prior to delivery although the difference was not significant. Malaria infection and other delivery parameters were not affected by the time from the last dose of SP.p-SP) at delivery and their effects on pregnancy outcome in the Sanaga-Maritime Division, Cameroon.PAM is a major public health problem in sub-Saharan Africa. HIV infection adds to its deleterious effects on pregnant women and their foetuses p policy in Cameroon. The prevalence of placental malaria parasite infection was lower than that of peripheral malaria parasite infection, which is consistent with some previous observations et al.et al.et al.var2CSA, on the surface of infected erythrocytes results in a preferential sequestration of parasitized RBCs in the placenta, with subsequent increase on malaria parasite density, even in the absence of peripheral blood parasitaemia The overall prevalence of malaria parasite infection in mothers (22.9%) was similar to findings reported in other parts of Cameroon In this study, financial income less than 28000 FCFA per month (minimum wage in Cameroon) was a major risk factor for malaria parasite infection. Women with higher income might be less exposed to malaria infection, as richer households usually have better housing conditions and protective measures. Their socioeconomic status may affect the risk of malaria parasite infection through their nutritional status, family size, and birth interval, as well as affordability and accessibility to preventive and curative measures.et al.et al.Malaria parasite prevalence and GMPD decreased with increasing parity. This agrees with other studies in Cameroon et al.et al., The prevalence of neonatal malaria parasite infection (6.0%) was lower than the prevalence reported in the South West et al.et al.et al.The prevalence of HIV infection in the study population (6.0%) was similar to the 5.6% obtained by Anchang-Kimbi et al.et al.Malaria is known to have deleterious effects on pregnancy and perinatal outcomes p. This is consistent with the results of the National Institute of Statistics Only 26.4% of women in our study received at least 2 doses of SP as recommended by the WHO for malaria IPTp-SP against maternal malaria and other deleterious pregnancy outcomes have been reported in Tanzania p-SP effectiveness in Cameroon p-SP effect is attributable to loss of SP efficacy in our study area or not. Evidence of SP failure has been reported in Cameroon, treatment failure having risen from 12.1% in 2000 to 37.5% in 2010 p effectiveness because of the negating effect of re-infection that occurs between the last dose of SP and delivery. The type of bednets used by women was not assessed in this study as women who reported use of mosquito nets could not give precise information. However, between 2005 and 2010, free Insecticide Treated Nets (ITNs) were distributed to all pregnant women as part of the focus antenatal clinic package. Furthermore, in December 2011 over 8 million of Long Lasting Insecticidal Nets (LLINs) were distributed to households all over the country. This suggests that most of the mosquito nets used by pregnant women were treated, but some ITNs might have lost their insecticidal effect as they might have expired and were not re-treated. In this study, regular use of mosquito nets resulted in improved gestational age and birthweight, as well as lower prevalence of anaemia, although this was not statistically significant. Our observations thus suggest that IPTp-SP and use of mosquito net still have overall benefits, especially for primiparous women.Many studies have shown SP to be highly effective in reducing peripheral and placental malaria parasite infection in pregnant women as well as improving pregnancy outcomes Malaria infection in pregnancy is common in the Sanaga-Maritime Division and increases the risk of neonatal malaria infection. The risk of infection is higher in younger, poorer or HIV infected women. Preventive strategies are poorly implemented but their utilization has overall reasonable effect on malaria infection and pregnancy outcome. Further studies for investigating SP resistant parasite strains infecting pregnant women in this area and research on drugs with high potential for malaria prevention in pregnancy should be carried out.


Plasmodium falciparum malaria, which can lead to poor maternal and fetal outcomes. Few data exist on the epidemiology of severe P. falciparum malaria in pregnant women.Pregnant women are more susceptible to severe P. falciparum malaria among pregnant women at the Kassala and Medani maternity hospitals, which are located in areas of unstable malaria transmission, in eastern and central Sudan, respectively. Pre-tested questionnaires were used to gather socio-demographic, clinical and obstetrical data. Suitable tests were performed for clinical and biochemical investigations.A hospital-based study was carried out to assess the pattern of severe P. falciparum malaria. These were hypoglycaemia , severe anaemia , hypotension , jaundice , cerebral malaria , repeated convulsions , hyperparasitaemia  and more than one manifestation . While the mean (SD) presenting temperature was significantly lower for women presenting with hypoglycaemia , other clinical and biochemical characteristics were not significantly different among women with different manifestations of severe P. falciparum malaria.Among 222 pregnant women diagnosed with malaria at the two hospitals, 40 (18.0%) women at mean (SD) gestational age of 29.3 (6.7) weeks fulfilled one or more of the WHO criteria for severe Preventive measures for pregnant women such as insecticide-treated bednets and chemoprophylaxis may be beneficial in areas of unstable malaria transmission. Early detection and prompt treatment of severe malaria, especially in pregnant women with hypoglycaemia, are needed. P. falciparum malaria , other clinical and biochemical characteristics were not significantly different among women with different manifestations of severe P. falciparum malaria, Table While the mean (SD) presenting temperature was significantly lower in women presenting with hypoglycaemia [38.2(0.6) versus 38.8(0.7) °C, P. falciparum malaria observed during pregnancy in this epidemiological setting. With the exception of lower temperatures, other clinical and biochemical criteria were not different among women with different criteria of severe P. falciparum malaria. Previously, severe anaemia and jaundice had been observed as the presenting manifestations of severe P. falciparum malaria in pregnant women in central and eastern Sudan [P. falciparum malaria [The main findings of the present study were that hypoglycaemia and severe anaemia were the predominant presenting manifestations of severe rn Sudan ,14. In nrn Sudan . Generalrn Sudan ,7. The grn Sudan ,17. It hrn Sudan . Thus, trn Sudan . None ofrn Sudan . Therefo malaria . Hyperin malaria ,21. Intr malaria . Compare malaria . PatientP. falciparum malaria. Thus, in such situation these patients would have received blood transfusion and artemisinins combination therapy rather than quinine treatment.In the present study, 12 30%) and 6 (15%) patients presented with severe anaemia and cerebral malaria, respectively. Cerebral malaria and severe malarial anaemia are two major syndromes causing malaria-related mortality . The pat0% and 6 P. falciparum malaria there are syndromes associated with mortality rates that are lower (e.g. severe anaemia) and higher  [P. falciparum malaria, which is higher than in non-pregnant adults [P. falciparum malaria and healthy controls.There were no maternal deaths in this study, early diagnosis; prompt effective treatment could explain this observation. These women would appear to represent a milder spectrum of disease e.g. severe anaemia and hypotension. It have been shown that, within the broad definition of severe cidosis) . We prevcidosis) ,30. Matet adults . The othPreventive measures for pregnant women such as insecticide-treated bednets and chemoprophylaxis may be beneficial in areas of unstable malaria transmission. Early detection and prompt treatment of severe malaria, especially in pregnant women with hypogylcaemia, are needed.The authors declare that they have no competing interests.AAA and EME carried out the study and participated in the statistical analysis and procedures. MMM carried out the biochemical tests. IA and MIE coordinated and participated in the design of the study, statistical analysis and the drafting of the manuscript. All the authors read and approved the final version.


Plasmodium falciparum has been extensively studied in various parts of the world. However, limited data are available from Mauritania. The present study examined and compared the genetic diversity of P. falciparum isolates in Mauritania.The genetic diversity of Plasmodium falciparum isolates blood samples were collected from 113 patients attending health facilities in Nouakchott and Hodh El Gharbi regions. K1, Mad20 and RO33 allelic family of msp-1 gene were determined by nested PCR amplification.P. falciparum samples, 93(82.3%) harboured more than one parasite genotype. The overall multiplicity of infection was 3.2 genotypes per infection. There was no significant correlation between multiplicity of infection and age of patients. A significant increase of multiplicity of infection was correlated with parasite densities.K1 family was the predominant allelic type carried alone or in association with Ro33 and Mad20 types . Out of the 113 P. falciparum populations from Mauritania was high. Infection with multiple P. falciparum clones was observed, as well as a high multiplicity of infection reflecting both the high endemicity level and malaria transmission in Mauritania.The polymorphism of  Plasmodium falciparum, which is responsible for more than 80% of malaria cases and entomological studies show that the main vector is Anopheles gambiae[P. falciparum in this zone [Malaria remains a public health problem in Mauritania with an estimated of 250,000 clinical cases reported annually . Data res gambiae,3-7. Thrs gambiae,8. The chis zone . In the his zone . The Sudhis zone . Despitehis zone , multiplP. falciparum proteins have been proposed for use as vaccine candidate antigens, but the merozoite surface protein-1 (MSP-1) has been most studied [msp-1 gene has been identified in P. falciparum isolates worldwide [msp-1 gene, in different geographic areas for the further development of effective malaria vaccine. The gene coding the merozoite surface protein 1 (msp-1) has been widely used as a marker for genotyping parasite populations [P. falciparum, the surface protein MSP-1 (around 190 kDa) plays an important role in erythrocyte invasion by the merozoite [msp-1 gene occurs as one of three distinct allelic families: K1, MAD20 and Ro33 [Therefore, the development of an effective malaria vaccine continues to be urgently needed. However, extensive genetic diversity in natural malaria parasite populations is a major obstacle for the development of an effective vaccine against these parasites, because antigenic diversity limits the efficiency of acquired protective immunity to malaria ,12. Many studied ,14. Exteorldwide -17. It iulations -20. In Perozoite . The proerozoite  and is aerozoite . The mspand Ro33 . It has and Ro33 .P. falciparum has been extensively studied in various parts of the world, but limited data are available from Mauritania. The only study on P. falciparum population genetic structure using msp-1, msp-2 and glurp markers date back 15 years [P. falciparum isolates among febrile patients attending health facilities in Nouakchott and Hodh El Gharbi region in Mauritania, during the peak of malaria transmission, using the polymorphic gene encoding for the merozoite surface protein-1 (MSP-1).The genetic diversity of 15 years . The pre2 with four departments, . The population of HG is approximately 212,156 inhabitants [The study was conducted in Hodh El Gharbi (HG), south-east Mauritania, and in Nouakchott, the capital city of Mauritania during the rainy season in September–October 2010  patients were from Kobeni, 89(31.7%) from Tintane and 55(19.6%) from Aïoun in HG region and 18(6.5%) patients from Nouakchott. A total of 113 patients were randomly selected from the 276 P. falciparum positives patients by microscopy. A finger prick blood sample was taken from each consenting patient for thick and thin blood film and 2-3 drops were collected on Whatman® No. 3 filter paper, dried and stored in individual plastic bag until used for DNA extraction.During the study, if patient presented to health facilities with symptoms consistent with mild malaria, including fever, chills, headache, and a positive slide, they were offered standard ACT as first-line treatment. Among the patients enrolled, 276 (40.8%) were microscopically confirmed as Thick and thin smears were stained with Giemsa. Parasite density was determined by counting the number of asexual parasites per 200 white blood cells, and calculated per microlitre using the following formula: number of parasites x 8,000/200, assuming a white blood cell count of 8,000 cells per μl . Absenceet al. [Parasite DNA was extracted, from blood samples blotted on filter paper by methanol method described by Djimde et al. . Brieflymsp-1 block 2, was used for the genotyping of the P. falciparum population using the nested polymerase chain reactions (PCR) technique. The msp -1 primers sequences used in this study are shown in Table msp -1 was used . Proportions were compared for significance using the χP. falciparum patients attending health facilities in study sites, 31.8% (36/113) were from Kobeni, 34.5% (39/113) from Tintane, 17.7% (20/113) from Aïoun and 16% (18/113) from Nouakchott  than females . Patients belonging to the age group 5-19 years were the most represented with 55.8% (63/113) followed by those of 20-39 years of ages with 28.3% (32/113), patients whose ages ≥ 40 years with 12.4% (14/113) and children under five years representing 3.5% (4/113).Out of the 113 randomly selected e, 17.7% 0/113 froP. falciparum isolates with respect to msp-1 gene. K1, Mad20 and Ro33 MSP1 allele’s types were identified. The total number of different sized alleles detected in this sample was 27. Among them, nine for K1 (160-400 bp), 12 for Mad20 (140-400 bp) and six for Ro33 (160-360 bp) allele families were noted. Frequencies of different msp-1 alleles and their combinations and multiplicity of infection are shown in Table P. falciparum infected patients enrolled in Aïoun health facility (4.3 genotypes per infection) and lowest in those from Nouakchott health facilities . However, obtained MOI values were not statistically different from each other (p = 0.56). The estimated MOI of all studied area was 3.2 genotypes per infection.Allele typing revealed highly polymorphic nature of Mauritanian P. falciparum-infected patients and msp-1 block 2 allelic types is shown in Table p < 0.05) (Table p = 0.8) was noted. The distribution of K1, Mad20 and Ro33 according to parasitaemia is shown in Table p = 0.09), or between 50-499 parasites/μl and 500-4999 parasites/μl (p = 0.08). However, estimated parasitaemia and multiplicity of P. falciparum infection was significantly correlated .Age group distribution of 5) Table . Howevermerozoite surface protein-1 block 2 allelic types in P. falciparum isolates from different study sites in Mauritania. Plasmodium falciparum is thought to be responsible of nearly 80% of diagnosed malaria cases in the country [P. falciparum genotypes may be an important element for implementing malaria control strategies in the country. Data showed a relatively high polymorphic nature of K1, Mad20 and Ro33 msp-1 allelic types according to the number of band sizes  among Mauritanian P. falciparum isolates. Comparable results were found by Jordan et al. [P. faliparum isolates from malaria patients in Aïoun and Kobeni area located in southern Mauritania. The number of different msp-1 alleles observed among P. falciparum isolates is also comparable to that founded by Konate et al.[msp-1 alleles were evidenced, but less than that reported by Soulama et al.[msp-1 block 2 region in P. falciparum isolates collected from children with uncomplicated malaria infection living in Burkina Faso. The study also revealed the predominance of K1 type alleles either at study site level or throughout the parasite population compared to Mad20 and Ro33. Similar finding have previously reported among P. falciparum isolates from Aïoun and Kobeni [P. falciparum isolates from 48 Senegalese patients hospitalized for malaria showed a prevalence of 68% for K1 alleles [P. falciparum patients either at study site level (2.33-4.25) or over all the study sites (3.22) reflecting the high intensity level of malaria transmission during the study period. When they compared 63 P. falciparum positve samples taken from febrile patients in Aïoun and 110 positive samples from Kobeni, Jordan et al.[P. falciparum isolates from patients with clinical symptoms, so that the MOI may be lower than that reported in asymptomatic patients [P. falciparum-infected population in Mauritania further, particularly in children. The similarity between P. falciparum strains could be explained by population migration between study sites that may allow for exchanges of parasite population. Similar results were noted in many malaria endemic areas [P. falciparum following the work conducted by Jordan et al.[P. falciparum populations, at leat in Kobeni and Aïon, had maintained a high level of polymorphism in the msp-1 block 2 region. Studies using a larger number of blood samples collected from different geographic areas in Mauritania are required not only to determine the nationwide parasite heterogeneity and detailed malaria epidemiology but also to implement malarial control programmes in this neglected malaria country.This study was undertaken to assess the polymorphism of the n et al. ; authorste et al. in the hma et al. who found Kobeni . In Daka alleles . Most ofan et al., or by aan et al.. Furtheran et al.,35. Prevan et al.. Howeveran et al.,31,37. Aan et al.,38. Thispatients . Many reic areas -42. The Plasmodium falciparum isolates from Mauritania exhibited a high degree of genetic polymorphism in msp-1 gene and most of the infected patients carried multiple clones of parasites reflecting the high level of malaria endemicity in study sites during malaria transmission season.The authors declare that they have no competing interests.MSOAS conceived of the study, carried out molecular study and performed statistical analysis; MN, BF, OG conceived and supervised molecular analyses and participated in the paper drafting; KML, OAM, carried out the microscopic analysis and participated in statistical analyses; HB, LK, OF, AOMSB conceived of the study, participated in its design and helped to draft and critically analysed the manuscript. All authors read and approved the final manuscript.


Plasmodium vivax over Plasmodium falciparum infection, recent reports confirmed gestational malaria as a serious public health problem. Thick smear examination is the gold standard to diagnose malaria in endemic settings, but in recent years, molecular diagnostic methods have contributed to elucidate the dimension of the problem of gestational malaria. The study was aimed at exploring the prevalence of gestational, placental and congenital malaria in women who delivered at the local hospitals of north-west Colombia, between June 2008 and April 2011.The frequency of pregnancy-associated malaria is increasingly being documented in American countries. In Colombia, with higher frequency of A group of 129 parturient women was selected to explore the prevalence of gestational, placental and congenital malaria in a descriptive, prospective and transversal  design. Diagnosis was based on the simultaneous application of two independent diagnostic tests: microscopy of thick blood smears and a polymerase chain reaction assay (PCR).Plasmodium vivax caused 65% of cases of gestational malaria, whereas P. falciparum caused most cases of placental malaria.The prevalence of gestational malaria (thick smear /PCR) was 9.1%/14.0%; placental malaria was 3.3%/16.5% and congenital malaria was absent. A history of gestational malaria during the current pregnancy was significantly associated with gestational malaria at delivery. Gestational and placental malaria are a serious problem in the region, but the risk of congenital malaria is low. A history of malaria during pregnancy may be a practical indicator of infection at delivery. Women inhabiting malaria endemic areas are at variable risk of acquiring gestational malaria according to the degree of endemicity and their parity. In regions of high stable transmission, they might acquire significant clinical immunity before pregnancy, and placental malaria is often asymptomatic, but it can produce severe maternal anaemia and foetal growth restriction . In suchPlasmodium infection at the time of delivery, reported a prevalence of gestational malaria of 13% with microscopy, but the frequency increased to 32% with a polymerase chain reaction (PCR) assay [In the Americas, the problem of gestational malaria has been the subject of few reports -6. The fR) assay . In addiR) assay . The diaP. vivax and P. falciparum malaria, in pregnant subjects, with presence of organ specific complications [P. falciparum and P. vivax are the causative species in these conditions, with 65-70% of reported cases due to P. vivax[Recent evidence gathered in the country, confirmed the deleterious effect of the infection, in both ications , congeniications , and lowications . All the P. vivax,14.P. falciparum to anti-malarials is widespread in the country [nd and 3rd trimester of pregnancy were treated as non-pregnant subjects according to the place of residency, or with a 7- day course of quinine plus clindamycin if on their 1st trimester of pregancy. In 2009, the scheme artesunate plus mefloquine was withdrawn as first-line from the national treatment guidelines and artemether plus lumefantrine is used throughout the country. Vivax malaria remains sensitive to a three-day course of chloroquine [Resistance of  country ,16, and oroquine  and, in oroquine .A study carried out in three municipalities of the Uraba region (north-west Colombia) recruited and followed >2,000 pregnant women at the antenatal clinics and hospitals to obtain a measure of incidenced from a group of 250 pregnant women recruited at delivery. Two studies explored the prevalence of gestational malaria and placental malaria at delivery in the Uraba region ,9, yet nThe current study reports on the results of a study aimed at exploring the prevalence of gestational, placental and congenital malaria in women who delivered at the local hospitals of north-west Colombia, between June 2008 and April 2011. Diagnosis was based on the simultaneous application of two independent diagnostic tests: microscopy of thick blood smear and a PCR.Plasmodium vivax was reported in 65–70% of total cases. Meanwhile, in Cordoba, during 2001–2009, in 1,433,461 inhabitants, a mean number of 37,616 cases/year were reported: 69% caused by P. vivax, 23% by P. falciparum and 1% from mixed infection. The municipalities of Valencia and Tierralta , and Puerto Libertador (south-east Cordoba) reported 90% of malaria cases in the region [The study was carried out in north-west Colombia in the localities of Turbo (Antioquia department) and Puerto Libertador (Cordoba department) Figure . BetweenSubjects for the current study were recruited at the local hospitals “ESE Hospital Francisco Valderrama”, in Turbo, and “CAMU Divino Niño”, in Puerto Libertador. In these localities, the annual mean parasitic indexes  during 2000–2009 were 46.6 in Turbo and 23.4 in Puerto Libertador ,20.The study was part of a larger project aimed at exploring the epidemiology , clinical aspects (mother and child outcomes), and immunopathology  of gestational and placental malaria in north-west Colombia, partial results have been reported on the frequency of infection and the histopathology of placental malaria ,9,21. A Plasmodium was assessed intra-partum using two independent tests: microscopy of thick smears and PCR. For this, paired blood samples were obtained from peripheral vein of the mother and from the placenta at time of delivery.A subset of subjects was selected to explore the prevalence of the conditions in a descriptive, prospective and transversal  design. A sample size of 129 pregnant women was calculated based on the following parameters: a total of 2,000 in-hospital deliveries during the 34 months of the study; 10% expected frequency of malaria ; 95% confidence interval; 5% sampling error. Subjects were selected and included in this study using a simple random sampling method from the records of the 2,000 women recruited in the main project. The prevalence of infection by Inclusion criteria were > 1 year residency in the study region, general good health and no history of serious disease, signature of the voluntary consent form and hospital delivery. The only exclusion criterion was withdrawal of the voluntary consent.The following definitions were applied: A) Low birth weight: <2,500 grams. B) Premature neonate: <37 weeks. C) Intra-uterine growth restriction: ≥37 weeks of gestation and low birth weight. D) Abortion: delivery before 22 weeks of pregnancy. E) Stillbirth: dead neonate of >22 weeks. F) Anaemia: haemoglobin <11 g/dL. G) Full term pregnancy: >38 weeks. H) Gestational or pregnancy malaria: plasmodial infection diagnosed in a pregnant woman after examination of maternal peripheral blood. I) Placental malaria: plasmodial infection diagnosed in placenta after examination of placental blood.Whole blood samples from mother´s peripheral blood and placenta were obtained at delivery rooms in the local hospitals of Puerto Libertador and Turbo. The mother`s sample was obtained by finger prick and placental blood was obtained from the lake formed following a wash with saline (0.9%) and removal of a 3x3x3 cm section in the area of the cord’s insertion on the maternal side of the organ. These samples were used to perform thick and thin smear examination and PCR as detailed below.Plasmodium was confirmed in maternal, placental and cord blood by thick smear and a nested PCR according to standard published methods [The presence of  methods ,22,23. DP. falciparum and P. vivax, according to previously published procedures [P. falciparum 3D7 and from a well characterized field isolate of P. vivax. Amplification products were resolved in a 2% agarose gel using ethidium bromide and visualized under UV light. Samples were processed once as long as controls were confirmed to operate in optimal conditions, otherwise, the assay was repeated until successful performance of controls.Diagnosis of infection by PCR was performed to whole blood samples collected onto Whatman 3MM filter paper, from which DNA was extracted using Chelex100® (Sigma™). Amplification was carried out using a nested PCR assay to detect the 18 s rRNA gene of ocedures . Positiv2. Significance was established at p < 0.05%. Data analyses were performed using EpiInfo® 6.0 and SPSS® 10.0.The prevalence of gestational malaria and placental malaria was calculated according to the results of thick smear microscopy and PCR. The association between the distribution of frequencies among two variables was identified using χThe study protocol was reviewed and approved by: a) Ethics Committee of the Sede de Investigaciones Universitarias SIU, Universidad de Antioquia  ; b) Ethics Committee of the Instituto de Investigaciones Medicas, Universidad de Antioquia ; c) Ethics Committee of Instituto de Investigaciones Medicas, Universidad de Antioquia  . Each participant gave full informed consent according to the Helsinki convention and the Colombian regulations for this type of research. Each subject voluntarily accepted to participate in the study.P. vivax infection, or, in P. falciparum, a 3-day course of artesunate plus mefloquine at 200 mg and 500 mg, respectively, per day in subjects aged >13 years (Antioquia department) or artemether plus lumefantrine (Coartem®) twice a day for a total six doses in subjects >34 kg (Cordoba department) [Women with a positive peripheral blood thick smear were treated, before hospital discharge, according to the recommendation of the Ministry of Health: a three-day course of chloroquine  plus a 14-day course of primaquine (0.25 mg/kg/day) in artment) .During the 34 months of the study (June 2008 - April 2011), a total of 121 parturient women were recruited at the local hospitals . In general, subjects were young (mean age = 21.9 ± 6.7), the mean number of gravidity, including the current pregnancy, was 3.2 ± 2.9; all (but one) had a full term pregnancy (38.8 ± 2.1 weeks), and their mean haemoglobin level was 10.6 ± 0.13 g/dL . Review of clinical records confirmed that attendance to the antenatal clinic was late, scarce and irregular with a mean number of clinical evaluations of three and < 20% of mothers receiving > 5 evaluations. In addition, application of a VDRL test during the antenatal period was performed in 70 subjects and one woman tested positive (titer 1:8). A total of 48 subjects were tested for HIV and all were negative. All participants were asymptomatic for malaria infection at delivery, and insecticide-treated nets were not used.i.e. a positive PCR with negative microscopy) was 4.9% (14.0–9.1), and in cases of placental malaria this was 13.2% (16.5–3.3). The ratio between positive microscopy and positive PCR in gestational malaria was 1:1.5, and in placental malaria this was 1:5.The frequency of gestational malaria was 9.1% (11/121) by microscopy, and 14.0% (17/121) by PCR  were P. falciparum. The opposite was observed in placental malaria: P. falciparum was detected in 65% (13/20), and P. vivax in 35% (7/20) of cases. All samples of umbilical cord blood were negative for malarial parasites by both tests.Among the 17 cases of gestational malaria diagnosed by PCR, 65% (11/17) were Concurrence of gestational and placental malaria by microscopy was absent in the 110 subjects negative by microscopy and 36% of the 11 subjects with gestational malaria evidenced placental infection. The frequency of simultaneous maternal and placental infection increased when PCR was performed: in the 104 gestational malaria negative subjects, 92% (96/104) were placental malaria free, and in the 17 gestational malaria positive subjects, 71% (12/17) exhibited placental malaria. Therefore, the presence of parasites in the peripheral mother`s blood was not always associated with placental infection, but absence of parasites in the mother`s blood did not necessarily imply that the placenta was free of infection , 78% corresponded to P. vivax, and the remaining were P. falciparum. The mean parasitaemia in P. falciparum infections was 2,771 ± 4,876 parasites/μL .History of gestational malaria was confirmed by review of clinical records in 26% (31/120); cases were diagnosed by microscopy of mother´s peripheral blood and were treated according to the Ministry of Health guidelines for malaria in pregnancy by the time of diagnosis and as detailed in the introduction section. In 87% (27/31) of cases of gestational malaria before delivery, at least one of the following was recorded: P. vivax, 18% P. falciparum, 9% mixed). In the 89 mothers without a history of gestational malaria, infection was detected at delivery in 7% . A report of gestational malaria in the current pregnancy was significantly associated (p = 0.000121) with a positive PCR test at delivery and 94% (84/89) of the women without a history of malaria were negative for gestational malaria at delivery  of the subjects with a history of gestational malaria  in Turbo and 28% in Puerto Libertador (14/50). Meanwhile, the prevalence of placental malaria was 4% (3/71) and 34% (17/50), respectively. Therefore, both gestational and placental malaria were significantly associated to the place of residency   and placental malaria was eight-fold that observed in Turbo (4% vs. 34%). Climate conditions and turmoil from violence are similar in both regions and only the application of control programmes seems to differ between the two localities. Major fluctuations in the frequency of gestational and pregnant malaria have also been reported in other endemic countries [It is important to highlight that during the recruitment of subjects for the current study, the health authorities of Uraba carried out an intense malaria control programme from 2007 until 2009 with a major impact on the frequency of malaria, as reported herein. The programme, named “Papa Luis”, consisted of massive anti-malarial administration (chloroquine), biologic control of ountries ,25.P. vivax was confirmed in 83% of cases [P. vivax was detected in 53% of them [Studies on gestational placental or congenital malaria are scarce in America in comparison to Africa -6,26,27 of cases . In a pr of them . In the  of them , probablP. vivax infection, which in theory, fails to sequester in placenta, among others. The fact that subjects recruited in this study were asymptomatic yet they presented with parasitaemia, strengthens the important role of passive transfer of maternal anti-malarial antibodies in the protection against congenital malaria. This subject is under exploration in specifically-designed ongoing studies.As for congenital malaria, the current report confirmed previous observations made by other authors on the low frequency of infection in cord blood (2.5%) in relation with higher rates of gestational malaria (9.5%) . SeveralAttendance to the antenatal clinic was inadequate in coincidence with previous reports from the region , and thePlasmodium infection during pregnancy concluded that the risk of anaemia and low birth weight infants are increased in positive cases [The results reported herein confirm the higher frequency of gestational and placental malaria detected by PCR compared to microscopy as reported previously in this and other endemic regions ,31,32. Fve cases . FollowiP. falciparum seems to remain susceptible to artemisinin-based combination therapy [P. vivax relapses and erroneous species identification (a documented limitation of microscopy) during the primary episode.The presence of a positive peripheral thick smear at delivery seems insufficient to predict the existence of placental infection, but a negative smear cannot guarantee an uninfected placenta. Therefore, due to the potential risk of malaria in the mother, clinicians should presume placental infection in all cases of gestational malaria. Of major importance in the clinical practice is the finding that a positive history of gestational malaria correlated with gestational and/or placental malaria at delivery, regardless of adequate anti-malarial treatment of the original episode. Since  therapy , possiblThe current report confirms the findings of previous researchers which report gestational and placental malaria as serious public health problems in north-west Colombia. Moreover, during the period of study, the local health authorities failed to observe the official recommendation since routine thick smear of peripheral blood was not practiced at antenatal visits, delaying diagnosis and treatment. This, combined with the social inequity faced by the women and families inhabiting the region; and the particular cultural frame and living conditions, contributes to perpetuate the problem ,37. MalaThe following conclusions were reached: 1) the problem of malaria during pregnancy and placental malaria is serious in north-west Colombia; 2) the history of gestational malaria constitutes an indicator of gestational and placental malaria at delivery; 3) the risk of congenital malaria is low; 4) measures should be implemented by regional and national health authorities to guarantee that recommendations regarding malaria testing at the antenatal clinics are fulfilled.The authors declare that they have no competing interests.OA and EA performed field work and processed blood samples. AM supervised overall design and development and wrote the manuscript, JC conceived the Project, designed the protocol and supervised overall design and development. All authors read and approved the final manuscript.


Plasmodium infections in preschool children.Helminth infections can alter susceptibility to malaria. Studies need to determine whether or not deworming programs can impact on Plasmodium infection in children aged 12-59 months. Children were randomly assigned to receive either albendazole or placebo every four months for 12 months with a follow-up at 14 months.A double-blind placebo-controlled randomised trial was conducted to investigate the impact of anthelmintic treatment on Plasmodium prevalence and mean Plasmodium parasite density was significantly higher in the treatment group (44.9% and 2319 ± SE 511) compared to the placebo group (33.3% and 1471 ± 341) at baseline. The odds of having Plasmodium infection increased over time for children in both the placebo and treatment groups, however this increase was significantly slower for children in the treatment group (P = 0.002). By month 14, mean Plasmodium density had increased by 156% in the placebo group and 98% in the treatment group but the rate of change in Plasmodium density was not significantly different between the groups. The change from baseline in haemoglobin had a steeper increase among children in the treatment group when compared to the placebo group but this was not statistically significant.320 children  complied with all the follow-up assessments. Plasmodium infection in preschool children which coincided with a reduction in both the prevalence and intensity of A. lumbricoides infections.Repeated four-monthly anthelminthic treatments for 14 months resulted in a significantly lower increase in the prevalence of Current controlled trials ISRCTN44215995 Plasmodium species [Plasmodium are mainly confined to the tropics and subtropics and this results in high rates of co-infection [Plasmodium parasite densities [Infections with multiple parasitic species are common in nature . Synergi species . Populatnfection . It has ensities  and alteensities . Helmintensities  and humaensities ,8-11. Toensities ,13.Plasmodium infections in preschool children.In 2001, the World Health Assembly passed a resolution urging member states to control the morbidity of soil transmitted helminth (STH) infections through large-scale use of anthelminthic drugs for school-aged children in less developed countries . It has A. lumbricoides and malaria, both of which have included school age children and adults [The need for well-designed longitudinal intervention studies to examine the relationship between helminths and malaria has been acknowledged . To dated adults ,6. We thA. lumbricoides (47.6%), and that repeated four-monthly treatments were successful in significantly reducing the prevalence and intensity of A. lumbricoides infections[We have previously reported that 50% of the preschool children recruited into this trial were infected by one or more helminths, the most prevalent STH being nfections. This paP. falciparum is the predominant species, present in the majority (99.5%) of Plasmodial infections, while P. malariae and P. ovale are present in 17% and 9.8% of infections respectively [The study was carried out between May 2006, and August 2007, in four semi-urban villages, Akinlalu, Ipetumodu, Moro and Edunabon, situated near Ile-Ife, Osun State, Nigeria. The dry season extends from November to March while the rainy season occurs from April to October . STHs anectively . The stuectively . InformeThe study was a double-blind placebo-controlled randomised trial. Children aged 12-59 months were randomly assigned to receive either albendazole or placebo every four months for 12 months with a follow-up at 14 months. Children who complied with all the assessments received either treatment  or placebo tablets on four occasions. Children aged one year received 200 mg of albendazole (1 tablet) and children aged ≥ 2 years received 400 mg (2 tablets) of albendazole . ChildrePlasmodium spp., Plasmodium density, and malaria attacks. The secondary outcomes were haemoglobin concentration and nutritional status. Finger-prick blood samples were used to undertake a malaria rapid test and make thick and thin blood smears for each child. Plasmodium was diagnosed using Parascreen rapid diagnostic tests . In line with local practice, on the day of the assessment, an 'uncomplicated' malaria attack was defined as a positive RDT and a fever (> 37.5°C).Children were screened for STHs and Plasmodium at baseline, 4, 8, 12, and 14 months. Stool samples were obtained before treatment was provided and stools were processed by formol-ether concentration . To mainPlasmodium parasites by microscopy of blood slides. Due to the overwhelming prevalence of P. falciparum in this region, the infections were not further divided into those with P. malariae or other species for the analysis. Slides were stained with a 3% Giemsa solution [Plasmodium density was measured by counting the number of asexual parasites against 200 leucocytes in the thick blood film and assuming an average of 8000 leucocytes/μL of blood.Children suffering a malaria attack were treated with Coartem (artemether-lumefantrine) . Data frsolution  and examAnthropometric measurements (height and weight) and nutritional assessments have been described elsewhere . HaemoglStatistical analysis was carried out in SPSS 14.01 and R v2.6.2 . Socio-eChildren in the treatment and placebo groups were compared on the basis of their baseline characteristics: age, sex, village, SES, parasitic infections and clinical indicators . The effect of treatment (treatment or placebo), village and sex were included as fixed factors, and time as a linear covariate. Data were analyzed initially for all age groups combined (1-4 year olds at enrolment) and then identical analyses were performed on each separate age group . Parameter effects in the linear mixed effects models are estimated on a linear scale as log(odds), their effects are correspondingly additive with respect to their intercept, and the presented standard errors of the estimates are symmetrical. In order to determine the proportional change in odds referred to in the text, we calculate exp(log(odds)) so that the effects on the odds scale are correspondingly multiplicative with respect to their intercept.To account for the difference in Plasmodium prevalence and Plasmodium parasite density between the treatment and placebo groups at baseline, the analyses compared the rate of change in Plasmodium prevalence, Plasmodium parasite density and haemoglobin in the treatment group with the rate of change in the placebo groups. The Plasmodium prevalence data were analysed using a linear mixed effects model using a logit function with the assumption that the observed data were binomially distributed. The analyses were run in R v2.6.2 using the function Plasmodium parasite density was measured at baseline, 4, 8, 12 and 14 months. Plasmodium parasite density at baseline was subtracted from the densities at 4, 8, 12 and 14 months to provide a measurement for the rate of change in malaria parasite density. Since the data were not independent it was analysed by repeated measures rmANOVA  with the different time points as a within-subject factor. Group, village, age and sex were chosen as the between-subject factors. The distribution of Plasmodium parasite density was not normal and therefore was log-transformed for the purposes of statistical analysis. The malaria attack data was not analyzed because the data were sparse and over-dispersed.Plasmodium parasite density. The haemoglobin measurement at baseline was subtracted from the measurement at 4, 8, 12 and 14 months to provide a measurement for the change in haemoglobin (g/dl) from baseline. This was done on an individual subject basis.Haemoglobin concentration was measured at 0, 4, 8, 12 and 14 months from the same individuals and was analysed using rmANOVA using the same procedure as for the The drug used to treat malaria infection was Coartem (artemether-lumefantrine). The difference in the total intake of Coartem, prescribed by the study doctor, between the treatment and placebo group was tested using a chi-squared analysis.Of the 1228 children, 320 (26.1%) complied with all the follow-up assessments. Figure Plasmodium and greater Plasmodium density in the treatment group when compared to the placebo group, although the infection status of the children was not known when they were allocated into the treatment groups. In the linear mixed effects model analysis children in the treatment group had approximately twice the odds of having malaria than children in the placebo group  and 1740 (S.E. 291) in the treatment and placebo groups respectively compared to 45% and 45% of the children infected with Ascaris and mean epg being 1095 (S.E. 237) and 1126 (S.E. 182) in the treatment and placebo respectively at baseline. Of importance was the observation, that it took three rounds of anthelmintic treatment before the prevalence of Ascaris dropped in the treatment group. In contrast, intensity of ascariasis dropped after one round of anthelmintic treatment [The most prevalent STH amongst the children was es Table . The efflication . However126 S.E. 2 in the Plasmodium infection had increased for the first 8 months of the study for children in the treatment group and for the first 12 months for children in the placebo group .The odds of having e Figure , howeverPlasmodium density increased from baseline reaching a plateau at 12 months in both the treatment and placebo groups  in the placebo group and by 98% (mean Plasmodium density at baseline of 2319 to 4601 at 14 months) in the treatment group. The treatment and placebo groups showed the same pattern in the rate of change in Plasmodium density throughout the study period  F2, 558 = 0.456, P = 0.628). The rate of change in Plasmodium density did not significantly differ between the treatment and placebo groups  F1, 288 = 0.025, P = 0.874).s Figure . By 14 mThe prevalence of clinical malaria attacks was low throughout the study period Table  ranging 3, 843 = 6.714, P < 0.001). The change in haemoglobin levels increased from 4 months to 8 months in both the treatment and placebo groups and while the change stabilized in the placebo group it increased in the treatment group to 12 months and decreased slightly thereafter . There was no difference in the change in haemoglobin concentration between the treatment and placebo groups . The pattern in the change of haemoglobin concentration significantly differed between the villages over time . Change in haemoglobin concentration increased from 4 to 12 months in Ipetumodu and Edunabon in both the treatment and placebo groups and decreased thereafter. The pattern of change in haemoglobin was different in Akinlalu and Moro. In Akinlalu change in haemoglobin concentration in both the treatment and placebo groups increased from 4 to 8 months, decreased from 8 to 12 months and increased thereafter (data not shown). Change in haemoglobin concentration in Moro, in both the treatment and placebo groups, decreased from 4 to 8 months, increased from 8 to 12 months and decreased thereafter (data not shown). There was no difference in the change in haemoglobin concentration between the villages .Mean haemoglobin level remained higher in the placebo group compared to the treatment group throughout the study period, except at the 12 month survey point where the haemoglobin level was similar for both groups . Mean haemoglobin level increased by 4%, from 9.54 g/dl at baseline to 9.94 at 14 months, in the treatment group and increased by 2.3%, from 9.88 g/dl at baseline to 10.11 at 14 months, in the placebo group. The change in mean haemoglobin level varied over time, increasing from -0.209 at 4 months to 0.313 at 14 months  had light Ascaris infections [The greater increase in  malaria ,6,8. Two malaria . Both stfections . The Comfections .P. falciparum parasite density in children aged < 5 years, subjects more than five years of age had a significant increase in their P. falciparum parasitaemia compared with untreated controls[P. falciparum parasitaemia. Furthermore, the prevalence of A. lumbricoides in this age group may have been very low in comparison to these Nigerian children considering that the prevalence in the treatment (26.2%) and placebo (27.4%) groups was moderate at entry into the study. Differences in acquired malaria immunity, owing to different transmission settings, in the Nigerian and Madagascan population may also have contributed to the contrasting results.In Madagascar, Brutus and colleagues revealed that while there was no effect of levamisole treatment on A. lumbricoides and severe malaria [A. lumbricoides had an increased risk of severe malaria. This is in line with the results of the present study which demonstrate that children infected with A. lumbricoides are apparently less able to control their malaria infections, albeit uncomplicated malaria infections. Other studies investigating the relationship between helminths and malaria, not differentiating between helminth species, have also shown comparable results to this study [An observational field-based, case-control study in rural Senegal investigated the relationship between  malaria  demonstris study ,28.Ascaris can leave these preschool children less able to control their Plasmodium infections.In the present study, as expected haemoglobin levels increased over the study period as the children increased in age . HoweverPlasmodium prevalence and parasite densities were significantly lower in the placebo group at baseline and thus it could be argued that that the placebo group had more potential for increasing Plasmodium prevalence and parasite densities than the treatment group. However, Plasmodium prevalence was comparable in the treatment and placebo groups at 8 months and while prevalence increased in the placebo group from the dry to the wet season, when malaria transmission was likely to be low, the prevalence reached a plateau in the treatment group. This trend does not support the theory that the faster increase in Plasmodium prevalence in the placebo group was due to differences in Plasmodium prevalence at baseline. Participants were not randomly selected from the community. Achieving a random sample of study participants in this field setting would prove very difficult owing to the widely dispersed nature of these semi-urban communities, and to the restricted age group being studied. Nevertheless, we believe that the moderate sample size, small age range and randomised design may compensate for the non-random selection of study participants. The majority of children (74%) were lost to follow-up. This high attrition rate may be attributed to the difficulty in retaining the participation of such young children particularly because they are not of school-going age. School-based studies provide a better infrastructure and can improve compliance considerably[The study may have some potential limitations that need to be considered when interpreting the findings. siderably. Bias caPlasmodium infection increased over time for children who received both treatment and placebo, however this increase was significantly slower in the treatment group. This observation therefore provides some evidence to suggest that infection with A. lumbricoides leaves these preschool children less able to control their Plasmodium infection.This study has demonstrated that the odds of having Plasmodium infection [Plasmodium infections demonstrated in these preschool children implies that large-scale deworming programmes may have a protective effect on malaria morbidity in these children in this particular setting.Previous research has shown that repeated two-monthly anthelminthic treatments can have a significant impact on nfection  and the nfection . The potPlasmodium infections may be prudent as interactions may vary with helminth species which is plausible as different helminths and protozoa have synergistic and antagonistic interactions[Plasmodium and helminth infection could avoid possible unforseen effects of mass distribution of anthelminthic drugs on malaria. There is still much we do not know about helminth-malaria interactions. While the results of this study provide some illumination of potential interactions between A. lumbricoides and malaria in children aged 1-4 years, we do not know what the outcome of these interactions will be in populations from different geographical settings in areas of low malaria transmission. It is crucial that this topic receives more attention, in light of a renewed emphasis on deworming and the fact that integrated control programs for malaria and helminths are not yet widespread.Recently, the potential opportunities for combined control of malaria and helminths have been recognised. Effortseractions. The intGlaxoSmithKline sponsored the drug albendazole which was used in the study. The authors declare that they have no competing interests. The authors also declare that they have no financial competing interests.CVH conceived the study and designed it with PK with input from all the other authors. SOA and TCA chose the villages and provided input for the logistics of fieldwork. PK conducted the fieldwork with SM and contributions from the other authors. PK did the stool analysis, carried out statistical analysis with ALJ and input from CVH, and drafted the manuscript. All authors contributed to the final version of the manuscript and read and approved it.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2334/10/277/prepub


During early pregnancy, the placenta develops to meet the metabolic demands of the foetus. The objective of this analysis was to examine the effect of malaria parasitaemia prior to 20 weeks’ gestation on subsequent changes in uterine and umbilical artery blood flow and intrauterine growth restriction.Data were analysed from 548 antenatal visits after 20 weeks’ gestation of 128 women, which included foetal biometric measures and interrogation of uterine and umbilical artery blood flow. Linear mixed effect models estimated the effect of early pregnancy malaria parasitaemia on uterine and umbilical artery resistance indices. Log-binomial models with generalized estimating equations estimated the effect of early pregnancy malaria parasitaemia on the risk of intrauterine growth restriction.There were differential effects of early pregnancy malaria parasitaemia on uterine artery resistance by nutritional status, with decreased uterine artery resistance among nourished women with early pregnancy malaria and increased uterine artery resistance among undernourished women with early pregnancy malaria. Among primigravidae, early pregnancy malaria parasitaemia decreased umbilical artery resistance in the late third trimester, likely reflecting adaptive villous angiogenesis. In fully adjusted models, primigravidae with early pregnancy malaria parasitaemia had 3.6 times the risk of subsequent intrauterine growth restriction  compared to the referent group of multigravidae with no early pregnancy malaria parasitaemia.intrauterine growth restriction. The findings support the initiation of malaria parasitaemia prevention and control efforts earlier in pregnancy.Early pregnancy malaria parasitaemia affects uterine and umbilical artery blood flow, possibly due to alterations in placentation and angiogenesis, respectively. Among primigravidae, early pregnancy malaria parasitaemia increases the risk of  In malaria endemic areas, the World Health Organization recommends prevention and control strategies for malaria parasitaemia in pregnancy, including case management of malaria parasitaemia and anaemia; insecticide-treated nets (ITNs); and, at least two doses of intermittent preventive treatment in pregnancy (IPTp) with sulphadoxine-pyrimethamine after the awareness of foetal movement  , but were more likely to have a low level of education and to be undernourished (data not shown). There were 6 probable recrudescent malaria episodes which occurred within 14 days of a previous infection, despite receiving treatment. Recrudescent malaria episodes were excluded from all analyses. There was no association between being a recrudescent case and parasite density as reflected by qPCR Ct-value (data not shown). Participants in the analytical sample were enrolled at a median of 18 weeks’ gestation  and were followed up for a median of 19 weeks . Study participants had a median of seven follow-up visits , with five ultrasound scans  from enrolment to delivery.Plasmodium species from dried blood spot samples and Plasmodium positive samples were speciated as previously described [Baseline data were collected in an interview ; medical examination ; ultrasound examination ; and laboratory testing  as previously described . At montscribed .Colour pulsed-wave Doppler ultrasound was used to interrogate the flow velocity waveforms in the left and right uterine arteries and the umbilical artery using standard techniques. The external iliac artery and uterine artery located medial to it were identified using colour flow settings. Flow velocity waveforms were obtained from the uterine artery near the iliac vessel prior to division of the uterine artery into branches. For left and right uterine artery analyses, Doppler indices were measured from the Doppler signal, with qualitative assessment of early diastolic notching. For the umbilical artery, the flow velocity waveform was obtained from the free flowing portion of the umbilical cord and Doppler indices and presence of absent or reversed end-diastolic flow were recorded. All ultrasound measurements were taken by a single, trained obstetrician-gynaecologist (VL) on the GE Logiqbook Ultrasound System .Plasmodium falciparum malaria parasitaemia ≤20 weeks’ gestation. Quantitative PCR of peripheral dried blood spots rather than blood microscopy was used due to the higher detection threshold of microscopy and the potential for poor microscopy sensitivity and specificity [The exposure variable, “early pregnancy malaria parasitaemia”, was a binary, time-independent measure representing whether a woman was ever qPCR positive for peripheral ificity .Outcome variables for placental blood flow included the continuous, time-dependent mean of the left and right uterine artery resistance index (RI); and, the umbilical artery RI after 20 weeks’ gestation. The RI is defined as (peak systolic velocity – end diastolic velocity)/peak systolic velocity. The resistance index was selected as the outcome for several reasons: RI values are constrained between 0 and 1; demonstrate the least variance of the Doppler indices under identical hemodynamic conditions; are frequently used in clinical settings; and, have a truncated normal distribution, making the RI amenable to parametric statistical analyses .th percentile of sonographically estimated foetal weight for gestational age in completed weeks, using Hadlock’s algorithm to estimate foetal weight [IUGR after 20 weeks’ gestation was also examined. IUGR was a binary, time-dependent outcome. At each visit, women were classified as having an IUGR episode if, at that visit, their foetus was <10 weight  and the  weight . The Joh weight  was not The continuous time metric, gestational age in weeks, was back-calculated from the first ultrasound using Hadlock’s algorithm . Ultrasovs. multigravidity), female foetal sex , and baseline maternal mid-upper arm circumference (MUAC) ≤24.3 cm   were examined. MUAC is a proxy for pre-pregnancy weight [Based on previous literature of the association between malaria parasitaemia during pregnancy and foetal growth, the potential modifying effects of primigravidity ( weight . PotentiFor linear mixed effect (LME) models, mean differences were reported and population average growth curves were plotted to describe the unadjusted and adjusted effect of early pregnancy malaria parasitaemia on uterine artery RI and umbilical artery RI. To describe the effect of early pregnancy malaria parasitaemia on IUGR, unadjusted and adjusted risk ratios (RRs) and 95% CIs were modelled using log-binomial regression generalized estimating equation (GEE) regression models with an exchangeable working correlation matrix. LME and GEE regression models are appropriate for longitudinal analyses as they account for the correlation between repeated measures in an individual ,22.a priori cut-off of p < 0.10). The addition of additional random effects was tested using -2LL tests with a mixed chi-square distribution (a priori cut-off of p < 0.05). In the final uterine artery RI and umbilical artery RI models random intercepts and slopes were included for each woman. For log-binomial GEE models, a crude model fitted for the early pregnancy malaria parasitaemia exposure variable was utilized. Next, simple log-binomial models with early pregnancy malaria parasitaemia, a theorized effect measure modifier, and their product interaction term were constructed. If the product interaction term was significant using the Wald test (a priori cut-off of 0.10), it was considered an effect measure modifier and was included in the multivariable model. For multivariable modelling, a fully adjusted log-binomial model was initially modelled, including the early pregnancy malaria parasitaemia exposure, the significant product interaction terms and potential confounders of the association between malaria parasitaemia and IUGR. A backward elimination approach was used to assess effect measure modification. In LME models, -2LL tests were used to assess the contribution of the product interaction terms to the model using a maximum likelihood approach; in GEE models, Wald tests were used (a priori cut-offs of p < 0.10). Potential modifiers that did not modify the association between malaria parasitaemia and the outcome were assessed as potential confounders. Covariates were considered confounders if the change in the co-efficient of the main exposure was greater than 10%, within strata of modifiers. Restricted maximum likelihood was used for final LME model estimates, as is common practice [For multivariable modelling of the effect of early pregnancy malaria parasitaemia on uterine artery RI and umbilical artery RI, a fully adjusted LME model with a random intercept was initially modelled. Linearity between gestational age and the outcome variables was considered by examining polynomial transformations of gestational age using −2 log-likelihood (−2LL) tests for nested models using maximum likelihood estimation  . Of the study participants, 27% of women were primigravidae and 22% of women had a low baseline MUAC. More than half of women (55%) were pregnant with a female foetus. Women with and without early pregnancy malaria parasitaemia had approximately balanced gravidity, foetal sex, SES and low baseline MUAC. There was a non-significant trend towards greater risk of early pregnancy malaria parasitaemia among younger women and women with less education.Individual trajectories of the continuous outcomes, uterine artery RI and umbilical artery RI, were plotted in order to examine intra- and inter-individual variability over gestational age in weeks Figure . There iThere was no crude effect of early pregnancy malaria parasitaemia on uterine artery RI  Figure , Panel AThere was no crude effect of early pregnancy malaria parasitaemia on umbilical artery RI Figure , Panel Ath percentile sonographically estimated foetal weight to capture truly IUGR foetuses than a single episode.In the unadjusted model, early pregnancy malaria parasitaemia was associated with 1.8 times the risk of subsequent IUGR during pregnancy  . VL conducted all Doppler ultrasound measurements and interpreted the Doppler data. SHL designed and implemented the study while at the Department of Epidemiology, University of North Carolina – Chapel Hill and contributed to manuscript revision while at GlaxoSmithKline. AHH assisted with statistical analyses and helped prepare the Methods section of the manuscript. AKT supervised field activities, oversaw quality control at the University of Kinshasa and interpreted the data. JMT, SJR and SRM made substantial contributions to the interpretation of results and manuscript revision. All authors read and approved the final manuscript.


Dengue and malaria are two major public health concerns in tropical settings. Although the pathogeneses of these two arthropod-borne diseases differ, their clinical and biological presentations are unspecific. During dengue epidemics, several hundred patients with fever and diffuse pain are weekly admitted at the emergency room. It is difficult to discriminate them from patients presenting malaria attacks. Furthermore, it may be impossible to provide a parasitological microscopic examination for all patients. This study aimed to establish a diagnostic algorithm for communities where dengue fever and malaria occur at some frequency in adults.A sub-study using the control groups of a case-control study in French Guiana – originally designed to compare dengue and malaria co-infected cases to single infected cases – was performed between 2004 and 2010. In brief, 208 patients with malaria matched to 208 patients with dengue fever were compared in the present study. A predictive score of malaria versus dengue was established using .632 bootstrap procedures. Multivariate analysis showed that male gender, age, tachycardia, anemia, thrombocytopenia, and CRP>5 mg/l were independently associated with malaria. The predictive score using those variables had an AUC of 0.86 (95%CI: 0.82–0.89), and the CRP was the preponderant predictive factor. The sensitivity and specificity of CRP>5 mg/L to discriminate malaria from dengue were of 0.995 (95%CI: 0.991–1) and 0.35 (95%CI 0.32–0.39), respectively.The clinical and biological score performed relatively well for discriminating cases of dengue versus malaria. Moreover, using only the CRP level turned to be a useful biomarker to discriminate feverish patients at low risk of malaria in an area where both infections exist. It would avoid more than 33% of unnecessary parasitological examinations with a very low risk of missing a malaria attack. The authors present a retrospective matched-pair study on dengue and malaria performed in French Guiana. These two infections are major public health concerns in tropical regions, especially in South America and Southeast Asia, where they affect neglected populations which makes them interesting to be published in a journal aiming to publish about neglected tropical diseases. Although the pathogeneses of these two arthropod-borne differ, their clinical and biological presentations are unspecific. During dengue epidemics, hundreds of patients are admitted weekly with diffuse pains and fever at the emergency room. Among them, it is difficult to accurately distinguish malaria attacks, which are far less frequent than dengue fever cases. Moreover, it may be impossible to provide a parasitological microscopic examination for all patients. We believe the results of the present study, based on a sample of n = 416 individual are worthwhile as they support evidence that biological factors can help to discriminate between the two, in areas where they co-exist in endemic areas. A simple prognostic score based on clinical and biological criteria was built, interesting and easy-to-use for physicians in tropical areas. Flaviridae, genus Flavivirus) and the Plasmodium parasites are widespread in American and Asian intertropical regions, where their endemic areas greatly overlap. Although their pathogeneses differ, their clinical and biological presentations are unspecific and it is difficult to distinguish the two infections.Dengue fever and malaria - the two most common arthropod-borne diseases - are major public health concerns in tropical settings 2 surface is Amazonian rain forest. The remaining 10% in the north is a coastal plain where 90% of the 215,000 inhabitants live. Cayenne is the capital and represented almost half of the population in 2009 P. vivax represented half of the total cases, but currently, the proportion of P. vivax malaria is 75%, similarly to other observations in Latin America French Guiana is a French Overseas territory located on the northeastern coast of South America. About 90% of its 84,000 kmThe main objective of the study was to identify clinical and biological criteria to discriminate malaria from dengue fever in endemic areas. The secondary objective was to build a predictive score of malaria to guide the indication of parasitological examinations in case of a dengue epidemic. Thus, this study aimed to establish a diagnostic algorithm for communities where dengue fever and malaria occur at some frequency in adults.A sub-study of a matched retrospective case-control study – designed to compare dengue and malaria co-infections to single infections – was performed between June 2004 and February 2010 at the Emergency Room (ER) of Cayenne Hospital in French Guiana Case definitions were based on compatible clinical history and positive biological diagnosis for one infection and negative for the other.The diagnosis of malaria relied on the identification of hematozoa on a thin blood film and/or on a thick blood film stained with Giemsa and a negative dengue test. During the study period, the diagnosis method for malaria diagnosis (microscopic examination by an expert microscopist) and parasitaemia evaluation remained unchanged. Thick and thin blood films were prepared within an hour of blood collection (4 ml of venous blood collected in an EDTA tube). They were stained with diluted Giemsa (1∶10). Two hundred oil immersion fields of the thin blood film and 1000 white blood cells (WBC) on the thick smear were examined before classifying a slide as negative. The screening sensitivity was ∼6 plasmodia/µl . At the time of the study period, malaria rapid diagnosis tests (RDT) were not routinely performed.Due to the evolution of the techniques between 2004 and 2010, the laboratory diagnosis of dengue relied on different methods. Before 2006, the diagnosis was based on direct virus isolation and genome detection by RT-PCR (Reverse Transcriptase-Polymerase Chain Reaction). From 2006, the hospital protocol was modified in accordance with evidence presented by Dussart et al. Individual data  were retrieved anonymously from the computerized medical charts. Data were analyzed using R version 2.13.0, the Epicalc package, and Stata 11.0 software .a priori excluded from the multivariate model. Remaining variables with p<0.20 in bivariate analyses were entered into a conditional multivariate logistic regression model. Conditional multivariate backward stepwise logistic regression was then performed to estimate the adjusted odds ratios (OR) and 95% confidence intervals (95%CI).Continuous variables were categorized following laboratory or usual cut-off values. Because of the small sample size, they were generally dichotomized in order to preserve statistical power. A C-reactive protein (CRP) level ≤5 mg/L was considered as negative. Continuous variables were compared using matched Student t-test. Categorical variables were analyzed using the Wald test in matched bivariate analysis. Statistical significance was set at p<0.05. Because of the unreliability of the data obtained retrospectively, variables obtained from anamnesis and clinical examination, and variables with >5% missing data were All significant variables of the logistic model were used to determine a preliminary predictive score of malaria versus dengue. To improve model stability, a semi-external validation was performed using a .632 bootstrap procedure The retrospective use of anonymous patient files on the site of patient care is authorized by the French National Commission on Informatics and Liberties. All the data collected retrospectively were anonymized in a standardized case report form and in the database.The 416 patients were mostly men  and had a median age of 30.7 years (interquartile range (IQR): 20.6–42.3; range: 0.4–86 years). Sixty-seven patients (16.1%) were younger than 15.P. vivax, 58 (28%) with P. falciparum, and 8 (4%) with both species.Among the 208 malaria patients, 141 (68%) were infected with In the DF group, 140 (67%) cases were early diagnosis  and 68 (33%) were delayed diagnosis (IgM). The results of serotyping were available for 91 patients, among whom 25 were infected by the DENV-1 (27.5%), 25 by the DENV-2 (27.5%), 28 by the DENV-3 (30.8%), and 13 by the DENV-4 (14.2%).Patients with malaria were significantly older than those with dengue (35.3 years (±15.4) vs. 28.0 years (±17.85) respectively; p<0.001). Variables significantly associated with malaria were age ≥15 years, male gender, recent journey in the forest, and previous history of malaria. Residency on the coast was associated with dengue.Eventually, the clinical outcomes were favorable in both groups, as no deaths were reported. The malaria patients arrived in the ER later than those with dengue (duration of the symptoms 5.1 days (±3.9) vs. 3.7 days (±2.4), respectively; p<0.001) and were more often hospitalized.Tachycardia >90 bpm, fever ≥40°C, chills, malaise and/or dizziness, and splenomegaly were more frequent in malaria patients. Conversely, retro-orbital pain, ENT symptoms , and rash were associated with DF. However, there were no differences between the two groups in terms of blood pressure, signs of shock, fatigue, headaches, arthromyalgia, digestive disorders, dehydration, pallor, or jaundice.9/L (±93)) than in those with malaria (110.109/L (±55)) respectively; p<0.001).The mean platelet count was higher in patients with DF  and hyperbilirubinemia were significantly more frequent in malaria patients than in those with DF. An elevated CRP (>5 mg/L) was significantly associated with malaria (p<0.001). The proportion of patients with CRP>50 mg/L was 69.0% in P. falciparum infections, 58.7% in P. vivax infections, and 65.5% in patients infected with both species. There was no significant difference between the Plasmodia association and P. falciparum alone nor or between P. vivax and P. falciparum (p = 0.420 and 0.170 respectively with Fisher's exact test) for the proportion of high CRP level.Thrombocytopenia <100.10Biological variables significantly associated with dengue fever were prolonged activated partial thromboplastin time (aPTT), and elevated ALT levels. Finally, anemia, neutropenia, or lymphopenia did not differ between dengue and malaria patients.In matched multivariate analysis, male gender, age>15 years, tachycardia, anemia, thrombocytopenia and CRP>5 mg/l remained independently associated with malaria as compared to DF .After 1000 resampling using a .632 bootstrap procedure, the median β coefficients matching these prognostic factors were estimated. The median AUC was 0.86 , which indicates good model discrimination. The construction of the score is detailed in Considering the large weight of the CRP>5 mg/L, sensitivity and specificity for this coefficient alone were estimated . The senIn the present study, the clinical presentation was more severe and biological abnormalities were more frequent in patients with malaria than in those with dengue fever, despite that DF and DHF were both included and pooled in the study. However this might be partly due to the fact that patients with dengue presented early after the onset of symptoms, when thrombocytopenia and DHF features generally occur later in the evolution of the disease.P. falciparum is the most likely Plasmodium specie to cause severe malaria, there is growing evidence in the literature that P. vivax can also cause severe complications Plasmodium species in Karen children living in another area of low transmission, in Thailand If it is usually assumed that 9/L) was more frequent in patients with malaria than in those with dengue. A study comparing the biological features of dengue, malaria and leptospirosis in India showed similar results, observing that thrombocytopenia was a predictor of malaria A low platelet count is classical in both infections. In many tropical regions, fever with thrombocytopenia is assumed to be malaria attack, and fever with thrombocytopenia and negative blood smear is considered to be dengue fever P. falciparum malaria from Africa showed that the CRP had a better positive predictive value than the erythrocyte sedimentation rate P. falciparum malaria imported in Sweden, only 1 out of 58 patients had a normal CRP The CRP is a protein found in the blood that is synthesized by the liver. It is mainly used as an inflammation biomarker, and particularly for bacterial infections. We found that an elevated CRP level was independently associated with malaria. Few reports have been published about the values of CRP in malaria patients, and generally showed that it is elevated, as reported in a Zambian study Previous studies already aimed to establish criteria to differentiate malaria attacks from other endemic infections such as dengue fever. A study performed in southern India compared malaria to other infectious causes of fever (including dengue), and the arguments for malaria attack were normal WBC, moderate to severe thrombocytopenia, renal failure, splenomegaly, hyperbilirubinemia and cytolysis; meanwhile criteria for DF were having a rash, hemorrhagic manifestations, normal to low WBC, moderate to severe thrombocytopenia, and hypertransaminasemia During dengue epidemics, more than 500 people may consult weekly at the Cayenne ER for febrile syndrome, resulting in up to 130 biologically confirmed dengue and 5 to 25 malaria cases . The ER In French Guiana, dengue is classically found on the coast and settled in urban areas To our knowledge, if criteria were investigated to differentiate malaria or dengue fever from other diseases, no predictive score had been established . The aimHere this therapeutic attitude could be proposed with a score ≥+10, which corresponds to a CRP level greater than 5 mg/L associated to any one criteria among: male gender, age>15 years, tachycardia, anemia, or thrombocytopenia.Considering the score results, using the CRP level alone is more useful on several levels. First, tachycardia, age, thrombocytopenia and hematocrit have a very low weight (1 to 2) in the score compared to the CRP level that is affected by a weight of +9, which is very close to the cut-off. Furthermore, the complete score uses parameters that are quite specific of the local Guianese epidemiology . In this regard, using only the CRP level would allow better extrapolation of this score to other areas. The sensitivity of the CRP does not significantly differ from the previous score, but its specificity is lower. Nevertheless, the aim of the present study was to find a way to avoid a large number of unnecessary parasitological examinations without failing to diagnose malaria attacks. Using the CRP level with a cut-off inferior to 5 mg/L to challenge the indication of the thick smear induced a reduction of 35% of the unnecessary parasitological tests, and led to only one misdiagnosis of malaria attack out of 205. The rising availability of rapid tests for dengue and malaria may diminish the interest of CRP to differentiate these two major diseases. Nevertheless, the use of the CRP, and maybe, the use of CRP RDT, can also help to differentiate dengue from bacterial infection. Thus, a study was published in a pediatric cohort, showing the great interest, in terms of avoiding useless tests, of using CRP RDT (microCRP) for the diagnosis of bacterial infection in children Finally, the CRP level was a useful, sensitive and simple tool to identify patients at low risk of malaria during DF epidemics and to guide the decision of parasitological examination, without replacing the thick smear. Nevertheless, an external validation is necessary in further prospective studies, as is the comparison of cost-effectiveness of the CRP level vs. the RDT which are widely available worldwide but were not used in the present study.In many tropical areas malaria and DF coexist. Due to the challenge posed by their similar clinical pictures in case of massive influx of patients with “dengue-like” syndrome during an epidemic of DF, a predictive score was built to target the patients with a high risk of malaria and who needed parasitological examination.To our knowledge the present study is the first to propose a simple and sensitive tool, the CRP level, to discriminate malaria from dengue fever. If it does not replace the microscopic examination, it helps to avoid one third of the unnecessary parasitological tests for patients at very low risk of malaria. In case of documented dengue, an elevated CRP level may lead to seek an associated diagnosis such as malaria or bacterial infection.Checklist S1STROBE checklist.(DOC)Click here for additional data file.


Plasmodium vivax malaria with that of P. falciparum malaria, we conducted a retrospective cross-sectional study of 356 adults hospitalized with malaria (2009–2011) in Pakistan. P. vivax and P. falciparum accounted for 83% and 13% of cases, respectively; 79.9% of patients with severe malaria were infected with P. vivax.To compare the severity of  Plasmodium vivax and P. falciparum, respectively  who were hospitalized with malaria during January 2009–December 2011. Reasons for hospitalization included intravenous antimalarial therapy, management of associated diagnoses, and complications. The following data on patients were retrieved through the hospital’s electronic and file records: age, sex, infecting Plasmodium species, malaria diagnosis methods, co-existing conditions, results of biochemical and microbiological investigations, radiographic findings, complications, hospital course, and outcome.We conducted a retrospective cross-sectional study using convenience sampling at the Aga Khan University Hospital in Karachi, Pakistan. Participants were all adult patients , or both, were used for malaria diagnosis. The RDT used antibodies against http://www-01.ibm.com/software/analytics/spss/). Averages, χ2 test of independence, odds ratios with 95% CIs, and analysis of variance were computed when applicable.Statistical analysis was performed by using SPSS version 20 , respectively. Baseline patient demographics are given in P. vivax infection among hospitalized malaria patients increased from 75.0% in 2009 to 87.7% in 2011 (p<0.02)  were hospitalized in the Aga Khan Hospital during 2009–2011. Among these, 296 (83.1%), 47 (13.2%), and 13 (3.7%) were found to have (p<0.02) , panel AP. vivax infection. In 24 (51.0%) cases of P. falciparum infections and in 111 cases (37.5%) of P. vivax infections, respectively, severe malaria developed (p = 0.077). As shown in P. vivax patients increased from 24.1% in 2009 to 43.2% in 2010 and 39.5% in 2011 (p = 0.02).One hundred thirty-nine (39.0%) patients had at least 1 complication by World Health Organization criteria  and those with mixed infections .The most common complications in the patients are shown in P. falciparum patients, 3.6 days for P. vivax patients, and 2.9 days for patients with mixed infections. Three P. vivax malaria patients experienced fatal acute myocardial infarctions. One patient, who had metastatic myeloma and P. falciparum malaria, died. The mortality rate was 2.1% for P. falciparum patients and 1.0% for P. vivax patients (p = 0.50).The mean hospital stay was 4.1 days for P. falciparum infection, 189 (83%) had P. vivax infection, and 10 (4%) had mixed infection . Shock and secondary bacterial infections were no longer associated with P. falciparum infection. All other statistical associations held, although the strength of association varied.Analysis was repeated after all patients with comorbid conditions were excluded , which lnfection , panel BP. vivax and 46.5% by P. falciparum, with mortality rates of 1.5% and 2.0%, respectively , which was not unexpected because of the decreasing number of P. falciparum cases during the study period. Despite this high incidence of P. vivax malaria, the mortality rate found in our study is reassuring and stable at 1.0%.A study of hospitalized malaria patients at the Aga Khan University Hospital during 1997–2001 showed that 51.8% of cases were caused by P. falciparum. P. vivax has been reported elsewhere to cause a similar degree of anemia as P. falciparum  and death.