Plasmodium (P). falciparum was the only species identified. The proportion of patients with a clinical malaria requiring parenteral treatment was 38.5%, whereas 47.5% of outpatients had uncomplicated malaria. According to WHO classification, 14 (19.7%) infected patients had severe malaria; neurological and respiratory symptoms tended to be more frequent in case of P. falciparum infection. Anaemia was found in 51.5% adults and none had severe anaemia. Almost half of adults consulting for fever in two health centres of the urban city of Libreville have malaria. The use of insecticide-treated bed nets, the screening, and the treatment of individuals with P. falciparum microscopic and submicroscopic asymptomatic infection or clinical malaria should be emphasized to reduce the transmission.Following the observed increase of malaria prevalence among older children in Gabon, a descriptive observational study was carried out in 2012 to determine the prevalence of malaria in adults presenting with fever in two health centres of Libreville, the capital city of Gabon. Thick- and thin-blood smears for malaria diagnosis were performed in febrile individuals aged more than 15 years old. Age, use of bed nets, previous antimalarial drug treatment, clinical symptoms, chest radiography results, and available haemoglobin data were also recorded. Among the 304 patients screened, the global malaria frequency was of 42.1% ( In areas with a high level of malaria transmission, children under five years of age and pregnant women represent the most vulnerable population and the primary target of prevention strategies. Reported malaria cases in African adults are scarce. The risk of malaria attacks in residents of malaria-endemic areas decreases with age, because of sequentially acquired immunity which leads to a reduction of life-threatening disease, incidence of mild malaria among adults, and parasite prevalence , 2. HoweAfter the decline in the proportion of malaria cases in Gabonese children between 2005 and 2008, a rebound in infection rates in rural and urban areas occurred . MalariaAside from entomological and immunological surveys, measurements of malariometric indices in the exposed population are also essentials to characterize the transmission. Unrecognised parasite reservoir such as asymptomatic or submicroscopic carriers, along with undiagnosed infected adults can contribute to the sustainment of malaria transmission , 8, 9. I P. falciparum attacks clinical features at admission.The present study was designed to determine the prevalence of malaria in adults consulting for fever in two hospitals of Gabon, Central Africa, andThis is an observational and descriptive study using data collected during a prospective cross-sectional survey conducted from December 2011 to October 2012 in Gabon, at Libreville, the capital city, and at Melen, a suburban area located 11 km north of Libreville. Patients were recruited at the Centre Hospitalier Universitaire de Libreville (CHL) and the regional hospital of Melen (RHM), two sentinel sites for malaria surveys selected by the Malaria National Control Program (MNCP). In sentinel sites, febrile patients are routinely screened for malaria infection; therefore, data collection was part of the normal activities at the CHL and at the RHM. As malaria transmission is perennial without significant fluctuation throughout the year, the study team collected data over at least one rainy and one dry season in each site.Febrile outpatients and inpatients, aged more than 15 years, were included after they accepted to participate in the study. Oral informed consent was obtained to complete the demographic and medical history sections of a case report form (CRF). Tympanic temperature, history and duration of fever, age, sex, bed net use, prior self-treatment with an antimalarial drug, and clinical symptoms leading to the consultation were recorded into the CRF. In order to minimize the frequency of coincidental parasitaemia in case of comorbidity, patients with known chronic infection such as HIV, hepatitis, and tuberculosis were not included.μL of blood was layed on a 10 by 18 mm area of a microscope slide and then dried and stained. Parasitemia was expressed as the number of parasites per microlitre of blood (p/μL), and parasite species were identified in the matched thin-blood smears. Smears were read using a light microscope (×100 oil immersion lenses). Quality control of the blood smears was performed: a second microscopist, blinded to the results of the first reading, read the slides. In case of disagreement, slides were controlled by a third microscopist and the mean of the two closest readings of parasitaemia was taken. A patient was considered negative if no parasite was observed after the examination of at least 100 oil immersion fields in a thick-blood smear.For each patient, matched thick- and thin-blood smears were prepared and stained with 20% Giemsa. Thick smears were screened for the presence of malaria parasites according to the Lambaréné method . CarefulAvailable haemoglobin (Hb) measurements were used for the analysis of anaemia. According to the WHO classification, anaemia was defined as a Hb concentration below 11 g/dL and classified as severe (Hb < 5 g/dL), moderate (5 ≥ Hb < 8 g/dL), or low (8 ≥ Hb < 11 g/dL) type.According to WHO 2010 and Newton and Krishna classification of African population modes of disease presentation, malaria patients were classified into three groups: (1) severe malaria patients who strictly met the WHO 2000 criteria for severe malaria; (2) moderate malaria patients who did not have any clinical or biological features of SM according to WHO classification but required parenteral treatment and hospitalization because of symptoms such as asthenia, vomiting, convulsions; (3) uncomplicated malaria patients, that were, febrile outpatients who did not have any features of severe or moderate disease and where able to tolerate oral medication , 18.Fever was defined as a tympanic temperature > 37.5°C, dyspnoea as an observed respiratory rate ≥ 20 beats/minutes. Level of consciousness was determined using the Glasgow coma score and impaired consciousness as a GCS < 10. Any degree of impairment of consciousness or any other neurological involvement was considered as a potentially serious neurological manifestation. Chest radiography results were used for the diagnosis of pulmonary infection.The study aims were clearly explained to the ward staffs. Patients were informed about the protocol, and their oral consent was required prior to data collection. Although it was a noninvasive study, this oral consent was sought to obtain medical history and to use the demographic, clinical and biological data. Data were kept confidential. The study was approved by the Ministry of Health. As a reference laboratory for the MNCP, the Department of Parasitology Mycology (DPM) has health authorities' approval to monitor the evolution of malaria morbidity throughout the entire country through sentinel sites. Malaria diagnosis was free of charge and infected patients were treated according to the national policy. For patients aged between 15 and 20 years old, individual oral assent and oral consent of legal guardian were required prior to their inclusion.According to WHO sample size tables for prevalence studies, the sample size calculation was based on 5% precision with 95% level of confidence and an expected prevalence of symptomatic malaria of 15% . This exP value of <0.20 in the bivariate analysis as the independent variables for this analysis. The significance level of all comparisons was set at a P value < 0.05.All data were entered and cleaned using Epi-info version 3.3.2 (2005 CDC Atlanta) and analyzed with Stata. Qualitative variables were summarised as frequencies and percentages. Median with interquartile ranges (percentiles 25th and 75th) were used for continuous variables such as age, Hb, and parasitaemia. The results were compared with the Chi-square or Fisher's exact test or the nonparametric tests  as appropriate. Bivariate analysis was used to determine possible factors that could be associated with malaria. A multivariate analysis was then performed using a forward stepwise likelihood ratio logistic regression, and considering the presence of malaria parasite (Yes/No) as the dependent variable, and variables which resulted in a n = 88) were male. The majority of the patients attended the hospital after two days of illness duration (2 [2–5] days), and 15.3% (n = 30/196) of them had taken an antimalarial treatment before the consultation  were adults. Data from 304 were available and analysed. One hundred twenty patients were referred by the outpatient unit, and 184 came from the emergency ward. The median age of the patients was 25 [19–34] years, and 29%  out of the 128 infected patients had a parasite count below 1000 p/μL, 61 (47.7%) had more than 5,000 p/μL, and five (3.9%) had a count greater than 100,000 p/μL. The P. falciparum infection rate did not vary significantly with bed net use or previous antimalarial treatment (n = 71/184 inpatients), whereas 47.5% (n = 57/120 outpatients) had uncomplicated malaria (P = 0.1). P. falciparum prevalence did not correlate with age: it was 44.8% in patients aged less than 31 years, 34.6% among those age between 31 and 45 years, and 43.5% in those over 45 years.A total of 128 (42.1%) among the 304 adults had a positive blood smear, with only three harbouring gametocytes with asexual forms.reatment . Malarian = 99/128) did not present clinical and radiological signs suggestive of other infection. For outpatients, the main reasons for consultation, except fever or history of fever, were fatigue and headache. In the hospitalized group, fatigue, digestive symptoms, pallor, and respiratory symptoms (more than 25% of patients) predominated (n = 57/71) had moderate malaria. Clinical signs of severe malaria were present in 14 (19.7%) P. falciparum infected inpatients: six (42.9%) had neurological forms (OR 5.1 95%CI 1.0–26.1), three (21.4%) had respiratory distress syndrome, and five (35.7%) had repeated vomiting  had low anaemia. Hb levels and anaemia prevalence were not related to the presence of malaria parasites: 44 among 83 (53.0%) infected patients and 55 out of 121 (45.4%) had a Hb level below 11 g/dL. No case of severe malarial anaemia (Hb below 5 g/dL with positive blood smear) was observed. Five malaria patients had a Hb level below 7.0 g/dL, whereas the lowest Hb value was 7.1 g/dL among the uninfected patients.Haemoglobin levels were analysed in the subgroup of 204 patients with available data. The majority of anaemic patients , efforts have been made to obtain data on population-based prevalence and transmission of malaria in several malaria-endemic countries. These informations should help to identify priority areas for evaluation, monitoring, and improvement of implemented disease control strategies. Epidemiological studies generally focus on children, pregnant women, and asymptomatic individuals , 20, 21.ventions , 25. Thiventions , 27.Compared to the reported prevalence among children aged less than five years old 17.9%), a surprisingly high microscopic prevalence of malaria was found among febrile adults living in the capital city of Gabon, Central Africa . This pr.9%, a suμL was also noticed. The median PD was 5600 p/μL, higher than the mean PD observed in adult hospitalized patients at the CHL in 1991 (1000 p/μL) and the PD in asymptomatic patients from Lambaréné (<200 p/μL) [A low frequency of parasite density (PD) below 1000 p/00 p/μL) , 15. P. falciparum in patients with a fever due to other infections. However, it was recently reported that intensifying malaria control modifies the threshold of parasitaemia to be used to define P. falciparum attacks, that is, fever attributable to malaria; pyrogenic threshold levels of 1000 p/μL for adults and of 5000 p/μL in children for attributing fever episodes to P. falciparum malaria were defined in an endemic area of Senegal [ falciparum malaria. A higher frequency was reported in adults from Asia and non-malaria-endemic settings [Identifying clinical factors associated with malaria can help to conclude to an incidental parasitaemia or to provide appropriate management of febrile infected patients, at least to identify those who require intensive care unit admission. Gabonese children with complicated malaria present more frequently prostration, seizures, and pallor; the predominant signs, presented by the parasitaemic hospitalized adults, were also found in a similar frequency among uninfected individuals . Altered Senegal . Thus, t Senegal , 18. Ninsettings , 34. Stusettings –35. P. falciparum like recently reported by Newton et al. [Although this was not a study designed to analyze the risk factors for severe malaria in adults, most of the clinical symptoms presented by the patients were not found to be associated with the presence ofn et al. . Howevern et al. , 37.More than half (51.5%) of the patients had anaemia, which was not significantly related to the presence of malaria parasites. The majority of anaemic individuals had low anaemia like that reported in other settings . AccordiThis study has some limitations. First, it is health-facility-based study and it did not include patients within the community. It is important to underline that, in the case of fever, a majority of people aged more than 15 years directly obtain an antimalarial drug from a pharmacist; also some patients could have been missed by the study team although they had a daily presence at hospital. Therefore, the burden of malaria could be overestimated or underestimated. A second limitation could be the absence of molecular diagnosis of malaria, which is essential for the real estimation of malaria burden . P. falciparum infection should be promptly treated with antimalarials before further investigation on other possible causes. The use of ITNs, screening and treatment of individuals with microscopic or submicroscopic asymptomatic infection or clinical malaria should be emphasized and could reduce the transmission of malaria in the country.This descriptive study highlights the emergence of malaria in febrile adults living in an urban city of Gabon. Malaria attacks which require parenteral treatment are now more frequently described in adult patients, with a prevalence of severe malaria exceeding 10%. Whether this increased prevalence is due to high exposure or to an inadequate acquired immunity remains an important issue. Nevertheless, this population may contribute to the recent rebound of malaria observed in the country as an important parasite reservoir. Additionally, the present data highlight a challenge to control and eliminating efforts in the country. Adults with any evidence of


Background. While research on P. vivax is scarce because it is considered benign, it has become evident with implementation of molecular diagnosis that it can also cause multiple organ dysfunction and severe life-threatening disease. Objective. To study clinical presentations and complications of P. vivax malaria and mortality correlation to severity parameters as defined by WHO criteria for severe malaria. Materials and methods. This study was conducted in a tertiary care centre in Mumbai. Confirmed P. vivax cases were enrolled and studied for their clinical profile, and WHO severity parameters were tested for their frequency and association to mortality. Result. The most common presentation was fever followed by pallor. 26% of the cases satisfied one or more criteria of WHO severity parameters. 2 cases died; both had pulmonary edema and bleeding. The major predictor of mortality among these predefined severity criteria was pulmonary edema/ARDS. Patients with severe anemia, circulatory collapse, and repeated generalized convulsion had 100% survival rate. Leukopenia was present in 10% of the cases. Both cases with mortality had leukopenia. Conclusion. P. vivax monoinfection tends to have severe complications in children. There is a need to review severity criteria for P. vivax malaria. P. vivax cases . India alone contributes 80% of southeast Asia malaria burden. The risk of severe P. vivax disease in residents of endemic areas has been observed to rise with increasing transmission intensity, although the contribution of less access to care and more comorbidity in these settings is not well quantified. As a result of the slower rate of decrease in the incidence of P. vivax, many malaria control programs that are moving towards elimination need to give greater attention to the control of P. vivax, particularly in countries outside sub-Saharan Africa. Indeed, P. vivax predominates in countries in the preelimination and elimination phases [Four countries account for more than 80% of estimated cases ofn phases .P. vivax malaria has long been considered to have a benign course with multiple relapses. The typical complications seen in P. falciparum malaria are not usually found in P. vivax monoinfections. However, during the past few years, the trend in the clinical manifestations of P. vivax malaria has been changing [ P. vivax malaria [changing . Several malaria . P. falciparum malaria. However, with implementation of molecular diagnosis, it has become evident that P. vivax monoinfection could also be involved in multiple organ dysfunction and severe life-threatening disease as seen in P. falciparum infection [Although this type of malaria is an enormous burden of disease, research about the disease is scarce probably because of it being considered benign malaria compared tonfection , 5.A prospective hospital-based clinical observational study was done over 2 years in a pediatric ward of a tertiary care hospital situated in Mumbai, India. A total of 50 patients under age of 12 years were enrolled in the study.The institutional ethical committee approved the study.Children in age group of below 12 years. Plasmodium vivax malaria.Peripheral smear or rapid malaria antigen test (RMAT) positive forAvailability of a written informed consent.Nonavailability of consent. P. falciparum or positive for both P. falciparum and P. vivax.Peripheral smear positive forPatient presenting with fever  but treated empirically like malaria. P. falciparum and P. vivax malaria were established by thick and thin film of peripheral blood smear examination under oil immersion with Giemsa stain and RDT. The RDTs were based on detection of specific Plasmodium spp. lactate dehydrogenase and histidine-rich protein 2.The diagnosis and confirmation of species ofCategorization in severe and nonsevere malaria was done on the basis of WHO guidelines for severe malaria.Cerebral malaria: unarousable coma nonattributable to any other cause, with a Glasgow Coma Scale score ≤9. Coma should persist for at least 30 min after generalized convulsions.μL.Severe anemia: hematocrit <15% or hemoglobin <50 g/L in the presence of parasite count >10 000/Renal failure: urine output <12 mL/kg/24 hours in children and a serum creatinine >3.0 mg/dL despite adequate volume repletion.Pulmonary edema and acute respiratory distress syndrome.Hypoglycemia: whole blood glucose concentration <40 mg/dL.Circulatory collapse : systolic blood pressure <70 mmHg in patients >5 years of age (<50 mmHg in children aged 1.5 years), with cold clammy skin or a core-skin temperature difference >10°C.Abnormal bleeding and/or disseminated intravascular coagulation: spontaneous bleeding from gums, nose, and gastrointestinal tract, or laboratory evidence of disseminated intravascular coagulation.Repeated generalized convulsions: 3 convulsions observed within 24 hours.Acidemia/acidosis: arterial pH <7.25 or acidosis (plasma bicarbonate <15 mmol/L).Macroscopic hemoglobinuria: hemolysis not secondary to glucose-6-phosphate dehydrogenase deficiency.Impaired consciousness: arousable mental condition.Prostration or weakness.μL .Hyperparasitemia: >5% parasitized erythrocytes or >250,000 parasites/Hyperpyrexia: core body temperature >40°C.Hyperbilirubinemia: total bilirubin >2.5 mg/dL.Data regarding patient age, sex, clinical presentation, investigations, and outcome were recorded. Patients were categorized in severe and nonsevere group based on WHO guidelines for classification of severe malaria. Chi square test was performed to test statistical significance of sex distribution in different age buckets. Prevalence of symptoms, signs, severity criteria, lab parameters, and their relation to mortality were studied.Patients were treated according to WHO guidelines for malaria treatment.In this study most of cases were in the 6–12-year age group see .See Overall male to female ratio was 1.94 : 1. Male to female ratio was 1 : 1 in <1-year age group; males outnumbered female cases in the age group from 6 to 12 years  see .See See WHO has defined severity parameters for malaria, which were tested for our study in terms of their frequency and their association to the outcome in the form of mortality. 13 cases (26%) satisfied one or more criteria of WHO severity parameters and were classified as severe malaria. Clinical and laboratory profile of these cases are presented in See Among the total of 50 cases studied 2 cases died with a case fatality rate of 4%.Among the total of 50 cases studied 10 cases (20%) required ICU admission. P. vivax malaria. Age distribution among various age groups was 33.9% in 0–5 years, 30.1% in 5–10 years, and 30% in >10 years, which was almost similar in all age groups [ P. vivax malaria, as compared to our study which shows 69% males and 31% females having P. vivax malaria in similar age group of 1 to 12 years [Males were more affected than females, which is possibly due to increased outdoor activity and increased exposure to mosquitoes in males as compared to females. Kochar et al. found similar results in their study with 33.0% females affected among cases ofe groups . A study12 years .The most common presentation was fever, present in 48 out of total of 50 cases (96%). P. vivax disease even with lower parasitemia due to its recognized lower fever-threshold (around 100 infected RBCs/microliter) [High fever trends are evident inroliter) . P. falciparum and mixed infections were anemic while 29% of P. vivax infected cases had this abnormality [It was followed by pallor which was present in 31 cases (62%). Two common causes of anemia are increased hemolysis and decreased rate of erythrocyte production from bone marrow whereas the malnutrition and intestinal parasitic infections aggravate this problem in highly endemic areas. In a study about 50% of patients withMajor confounding factors in the global analysis of anemia are the local contributors to this hematological complication such as iron-deficiency anemia .None of the cases presented with renal impairment, hypoglycemia, jaundice, and hyperparasitemia.The new WHO guidelines already point to hyperbilirubinemia  as a weak marker of severity, unless it is followed by any other vital organ dysfunction .Two cases died; both had pulmonary edema and bleeding and 1 case had impaired consciousness.Major predictor of mortality among these predefined WHO severity criteria was pulmonary edema/ARDS with 100% mortality, whereas patients with severe anemia, circulatory collapse, and repeated generalized convulsions had 100% survival rate.The statistical significance was not applicable as there were only 2 deaths among the study group. P. vivax patients are more likely to suffer from respiratory distress syndrome as they have more severe alveolar capillary dysfunction. Sequestration of P. vivax infected erythrocytes in the pulmonary microvasculature and greater inflammatory response to a given parasitic burden in P. vivax are probably responsible for this alveolar capillary dysfunction. Small airway obstruction, gas exchange alteration, increased phagocytic activity, and accumulation of pulmonary monocytes are the other suggested mechanisms for respiratory complications [Anstey et al. suggested thatications . P. vivax and P. falciparum, respectively [ P. vivax infection to be almost equally serious in causing significant mortality in comparison to P. falciparum.Case fatality rate in this study was 4%. Most of the earlier published literature consists of few death reports or small descriptive clinical series lacking denominators. Recent study from Papua, Indonesia, reported 1.6% and 2.2% case fatality rate caused by3).Among the laboratory parameters as mentioned in Among the total of 50 cases studied 10 cases (20%) required ICU admission. P. vivax  and P. falciparum . The study included all reported cases of malaria in children of 0–14 years of age in Manaus [In a study done in Manaus a rough estimation of the risk of ICU admission per species showed similar relative risks forn Manaus . P. vivax malaria on ICU facility in hospitalized patients so as to estimate the optimum requirement of facilities to maximize the patient care.Our study population was not an ideal population representative and that may be the reason for high ICU admission rate in our study. Further study is needed to study the burden of P. vivax malaria ranging from fever to cerebral malaria, ARDS, and pulmonary edema and also emphasizes the importance of severity of P. vivax malaria and there is a need for further studies to establish mortality and severity predictors specific to P. vivax malaria.Limitations of our study were small sample size and existing confounding factors of different parameters, though the study shows the diverse clinical presentations of P. vivax malaria in pediatric age group. Since P. vivax was considered a benign disease, there are scarce reports. The study stresses that Plasmodium vivax can result in severe disease and can no longer be considered a benign condition. The present study shows that some manifestations of WHO severity criteria were not seen in severe P. vivax malaria , whereas leukopenia and thrombocytopenia which are not part of WHO severity criteria were frequently present and were associated with mortality. This implicates the need for separate severity parameters for P. vivax malaria. However, larger studies need to be undertaken to establish the specific severity parameters and poor prognostic indicators.The present study highlights the epidemiology of


Mid-upper arm circumference (MUAC) was recently endorsed and recommended for screening for acute malnutrition in the community. The objective of this study was to determine whether a colour-banded MUAC strap would allow minimally trained mothers to screen their own children for malnutrition, without locating the mid-point of the left upper arm by measurement, as currently recommended.n = 103) aged 6–59 months  using the MUAC tape.A non-randomised non-blinded evaluation of mothers’ performance when measuring MUAC after minimal training, compared with trained Community Health Workers (CHW) following current MUAC protocols. The study was conducted in 2 villages in Mirriah, Zinder region, Niger where mothers classified one of their children  and > 73% and > 98% for severe acute malnutrition . The few children misclassified as not having SAM, were classified as having moderate acute malnutrition (MAM). The choice of arm did not influence the classification results; weighted Kappa of 0.88 for mothers and 0.91 for CHW represent almost perfect agreement. Errors occurred at the class boundaries and no gross errors were made.Advanced SAM is associated with severe complications, which often require hospital admission or cause death. Mothers (with MUAC tapes costing $0.06) can screen their children frequently allowing early diagnosis and treatment thereby becoming the focal point in scaling-up community management of acute malnutrition.NCT01790815)The trial is registered with clinicaltrials.gov (Trial number  United Nations Children’s Fund (UNICEF) and World Health Organisation : the presence of bilateral pitting oedema, a weight-for-height z-score (WHZ) of less than −3, based on the WHO growth curves , or a MUMeasures of weight-for-height have been used for many years for the diagnosis of SAM. MUAC was not widely recommended until the scaling up of community management of acute malnutrition (CMAM) occurred . MUAC 33 is the Community based management of SAM often relies on Community Health Workers (CHW), who may be unpaid volunteers, to conduct the anthropometric measurements of children being screened and treated for SAM. Currently this requires training, standardisation testing, and follow-up, motivation and retention of these staff may also be problematic. In training to perform a MUAC measurement, a CHW must learn to use the left not the right arm, and to measure and mark the mid-point of the upper-arm, between shoulder-tip and elbow . The lefThe hypothesis for this study is that mothers with minimal training can measure MUAC to classify the nutritional state of their children. This was initially confirmed in an in-patient setting with children admitted with SAM with complications (data not shown). The study hypothesis was tested in two villages in rural Niger. The rationale for teaching mothers to perform MUAC is to achieve an early diagnosis of SAM, which if acted upon in a timely manner would decrease mortality and morbidity related to malnutrition, reduce program costs due shorter treatment times and lowering the proportion of children requiring expensive in-patient care for SAM with complications . Verbal, as opposed to written, informed consent was obtained from all subjects because of limited literacy, consent was witnessed and formally recorded by another CHW acting as the scribe. The trial is registered with clinicaltrials.gov .The study was performed between September 2011 and April 2012, the community meeting places in 2 villages in Mirriah, a rural district in the Zinder region in southern Niger. There were 54 mothers with one of their children in the first village (Magema), and 49 mothers with one of their children in the second village (Berberkia). It was conducted by the Alliance of International Medical Action (ALIMA) and its local non-governmental organisation (NGO) partner BEFEN (Bien Etre de la Femme et de l’Enfant). UNICEF colour-coded and numbered MUAC tapes, calibrated in 1 mm gradations, were used for all phases of the study  and this was noted down by the investigator. This was then repeated by an experienced CHW testing the right and then the left arm of each child, having measured the midpoint according to current recommendations . All theR language was used [In the statistical analysis, cross-tabulations were used to investigate the agreement between mothers’ results and the CHW reference measure. The Weighted Kappa was used as a numeric summary of inter-rater agreement between two raters or methods, beyond that which would be expected by chance. Kappa is a measure of agreement, standardized along a −1 to 1 scale, where positive numbers indicate agreement, with 1 being perfect agreement, negative numbers indicate disagreement, with minus one being total disagreement, and zero indicating agreement expected by chance ,12. The was used  for dataTable Table When classification of both arms by mothers or by CHW was assessed using Weighted Kappa  Tables  and 4, tThe observed agreement in the ability of mother’s to classify their child using either arm, with the mid-point of the upper arm ascertained by eye, compared with the CHW classification with the mid-point of the left upper arm ascertained by measurement (ie the criteria by which a child is considered for entry into many CMAM programs) Table  can be cMUAC classification errors (or discordance) occurred at class boundaries, i.e. the border between red (SAM) and yellow (MAM), and yellow and green , rather than randomly, and there are no gross discordances Figure . Thus moAlmost 50 years after an early attempt to standardise the use of MUAC tapes, with trained health workers using the midpoint of the upper left arm , the preImportantly, all children misclassified as not having SAM, were nevertheless classified as MAM, none were considered ‘normal’, thus classification errors occurred at the classification boundaries. Classification by mothers measuring the mid point of the upper arm determined by eye, showed an accuracy of 86.4% – 88.4% in GAM, and 94.2% – 95.6% in SAM, compared with the current standard of the CHW classification. Roll-out of MUAC, done by mothers in the home would involve small group learning with each mother able to practice under supervision. This would be expected further to improve the quality of the screening. There was very low inter- and intra- observer variability, and high levels of agreement achieved between the current standard (results from CHW), compared with mothers with minimal training.The study was conducted in free living village populations with a lower prevalence of SAM than a program setting. This is the environment where scaled up CMAM will occur, with mothers screening their own children for malnutrition. The prevalence of SAM in these 2 villages cannot be measured from these data, because only one child from each mother was entered into the study.The Weighted Kappa values for inter-observer variation for the interpretation of classical physical signs elicited in clinical medicine are frequently less than 0.50. For example, raised respiratory rate (K = 0.25), central venous pressure (K = 0.3), bronchial breath sounds (K = 0.32) . These eThe first recommendation in a recent consultation paper comparing MUAC with WHZ , was forSadler and colleagues  in Banglclass rather than MUAC measurement is used by mothers for active case-finding in the home. This could be facilitated by the use of broader, colour-banded MUAC straps, as suggested recently [It is proposed that MUAC recently . Numberlrecently . One advrecently  althoughThe use of numbered MUAC tapes could only be required for monitoring response to treatment in therapeutic feeding programs but this approach needs validation. Numbered MUAC tapes may be useful as well in nutritional anthropometry surveys or surveillance systems that estimate prevalence of SAM using the PROBIT method .Community leaders were keen for local women to learn the skill. In contrast men were not interested in learning the skill, while adamant that the women should learn. Mothers who had completed the task were observed to help other mothers perform the MUAC classification and the enthusiasm of girls (i.e. the next generation of mothers) to participate was striking. A future can be envisaged in which mothers in every home where childhood malnutrition is a risk are familiar with, and empowered to screen their children. Even in the most functional CMAM program, it is unusual for children to be screened more than once a month. Repeated screening with MUAC, if a mother is concerned about her child’s health, will increase the likelihood of early diagnosis, even if the initial screen classified the child incorrectly. Training mothers to perform MUAC could provide the most timely and proximal diagnosis of malnutrition in their young children. Furthermore programs could be designed to facilitate mothers monitoring their children once entered into a CMAM program, to reduce the number of repeat visits, often at great distance on foot, to the treatment centre, and increase retention in the program, although this approach has not yet been validated.Advanced SAM is associated with complications, which often require hospital admission or cause death ,10. Earltipping point [Giving mothers more autonomy in monitoring the nutritional status of their children may provide the ng point  in scaliIn Niger, international and more recently national NGOs (eg BEFEN and Forum Santé Niger (FORSANI)) have been running nutrition programs for more than 8 years. This may explain why mothers and communities embraced the idea of doing MUAC themselves; this may not be the case in contexts unaccustomed to nutrition programs. Widespread dissemination of MUAC tapes may be an important step in raising community awareness of malnutrition .Limitations of the study: mothers were chosen because the trial involved their village, thus they were not randomly selected. There are some missing data, which however do not change the overall highly significant results. Mothers classified first one arm then the second arm; this may have caused the results for each arm to be more alike than they were in reality.It may be that this population was unusually receptive to learning to use MUAC tapes themselves, although only when the method was explained did the community recognize the treatment implications of the MUAC classifications. Perhaps more likely, this approach may illustrate the willingness of mothers to participate as fully as possible in promoting the health of their children.The study reported here collected data on children under five years of age and the results may apply only to this age-group. The choice of arm on which MUAC is measured is likely to be important in adolescents and adults in whom the MUAC of the dominant arm is generally larger than the MUAC of the non-dominant arm. Some programs (e.g. supplementary feeding programs) admit both children aged under five years and adults (mostly pregnant and lactating women with a MUAC below a threshold between 210 mm and 230 mm). Training and supervision of program workers should continue to emphasise different procedures are used when measuring children and adults.This study suggests that with brief training, mothers from the Mirriah district of Niger were able to classify their children into one of the three colour classes on a MUAC tape. The study has demonstrated that it is not necessary to specify which arm is used nor formally to measure the middle of the upper-arm, further simplifying an already simple task. Asking mothers to determine only the colour class for their child, allows illiterate and/or innumerate women to perform this screening test on their children. Since there was no difference between the MUAC value between arms, or the mid point determined by measurement or by eye, CHW training in MUAC reading can be also simplified, allowing the use of either arm of the child, and estimating the half-way point by eye.This study demonstrates that mothers can classify their children by MUAC, and it suggests MUAC done regularly by mothers should become the focal point for efforts to scale-up CMAM.


Malaria and malnutrition are the major causes of morbidity and mortality in under-five children in developing countries such as Ethiopia. Malnutrition is the associated cause for about half of the deaths that occur among under-five children in developing countries. However, the relationship between malnutrition and malaria is controversial still, and it has also not been well documented in Ethiopia. The aim of this study was to assess whether malnutrition is associated with malaria among under-five children.A case–control study was conducted in Adami Tulu District of East Shewa Zone in Oromia Regional State, Ethiopia. Cases were all under-five children who are diagnosed with malaria at health posts and health centres. The diagnosis was made using either rapid diagnostic tests or microscopy. Controls were apparently healthy under-five children recruited from the community where cases resided. The selection of the controls was based on World Health Organization (WHO) cluster sampling method. A total of 428 children were included. Mothers/caretakers of under-five children were interviewed using pre-tested structured questionnaire prepared for this purpose. The nutritional status of the children was assessed using an anthropometric method and analyzed using WHO Anthro software. A multivariate logistic analysis model was used to determine predictors of malaria.Four hundred twenty eight under-five children comprising 107 cases and 321 controls were included in this study. Prevalence of wasting was higher among cases (17.8 %) than the controls (9.3 %). Similarly, the prevalence of stunting was 50.5 % and 45.2 % among cases and controls, respectively. Severe wasting  and caretakers who had no education  were independently associated with malarial attack among under-five children.Children who were severely wasted and had uneducated caretakers had higher odds of malarial attack. Therefore, special attention should be given for severely wasted children in the prevention and control of malaria. Malaria is one of the major health problems in sub-Saharan Africa. According to the 2013 world malaria report, malaria is a cause for about 627,000 malaria deaths worldwide. The report also indicates that 3.4 billion people were at risk of malaria. Most of these malaria deaths (90 %) occurred in sub-Saharan Africa and in children under five years of age [On the other hand, malnutrition is the underlying cause of over 50 % of child deaths in developing countries . MalnutrPapua New Guinea revealed that humeral responses to specific malarial antigens were the lowest in the wasted children [Research evidence shows that malnourished children have lower anti-malarial immunity. For instance, a study carried out by Fillol showed that both the prevalence of anti-malarial immune respondents and specific IgG Ab levels were significantly lower in malnourished children than in children who were not malnourished . In the children .P. falciparum malaria attacks also increase [Even though there are evidences that showed malnourished children have lower anti-malarial immunity, there are contradictory findings on the association between malaria and malnutrition –8. Some increase . On the increase . AbsenceA variety of intervention strategies have been used to combat malaria and this has led to a significant decline in mortality in Ethiopia. Long Lasting Insecticidal Nets (LLIN), chemoprophylaxis and prompt and appropriate case management can be mentioned as major examples of intervention strategies . No singAn un-matched case–control study was conducted among under-five children during February-April 2014 in Adami Tulu district which is located 160kms south of Addis Ababa. The district lies at an altitude between 1,500 and 1,750 m above sea level. According to the 2007 national census, the population was about 150,000 of which 17 % were under-five children . The disP.falciparum and P.vivax are the most common malaria parasites in the district. Anopheles arabiensis is considered as the main vector [.The transmission of malaria in the district is seasonal. Major transmission of malaria occurs from September to December; following the summer rainfall. n vector .Malnutrition is a very common problem in the region. The prevalence of stunting, being underweight and wasting are 41 %, 26 % and 9.7 % respectively [2. Otherwise, they are considered as rural.The study population included cases and controls from selected health facilities and community, respectively. Cases consist of children aged between 6–59 months who visited the selected health facilities and diagnosed as malaria positive. The diagnosis was confirmed by microscopy in the health centres and Rapid Diagnostic Test (RDT) in health posts during data collection period. Controls include under-five children aged 6–59 months who were apparently healthy and lived in the community where cases resided. Controls are considered to be apparently healthy if the mother/caretakers perceived the child to be healthy and declared no symptoms of disease such as fever, cough, difficulty of breathing, and diarrhoea. However, these were not confirmed by laboratory. More than 90 % of cases came from the same kebeles (community) of controls. Kebeles are categorized as urban if the population density is greater than 150 people per kmSample size was calculated using Epi-Info Statcalc version 3.5.4. The following assumption was made during the calculation: 95 % confidence interval, 80 % power, 10 % wasting in controls, Odds Ratio (OR) =2.50 , ratio oOn the other hand, controls were randomly selected from four kebeles( the lowest administrative unit) where cases were identified. Sampling of controls was done using sampling technique of World Health Organization (WHO) Expanded Program of Immunization (EPI) cluster sampling method . First, A two-day long training was given to nine data collectors and one supervisor. The training focused on the questionnaire and anthropometric measurements. The questionnaire comprised of socio-demographic characteristics of children and their care takers/mothers such as sex of the child, age of the child and mother, mean monthly family income, educational status, occupation, marital status and ethnicity of the mother. Questions on malaria prevention practice like use of LLIN and Indoor Residual Spray (IRS), anthropometry measurement and laboratory test for malaria were also included. Both open ended and closed ended questions were used. In average the interview took 30–40 min. Data collection instruments were pretested and validated.For suspected malaria cases in the health centres and health posts, blood was taken from finger prick to confirm malaria. Laboratory technicians who had at least two years of work experience at selected health centres prepared thick and thin blood films. The technicians used standard operating procedures to do the microscopy. Multi-species RDT kit was used by health extension workers (HEWs) using the Ministry of Health malaria diagnosis and treatment guideline at health posts . RegularWeight of the children was measured using a digital weighing scale in bare foot and with light clothing. Height was measured for children above two years of age while length for children below two years of age using length/height board. The measurement was rounded to the nearest 0.1 kg and 0.1 cm for the weight and height respectively. Weighing scale was calibrated frequently. The accuracy of weighing scale was checked by placing a weight of 2 kg iron bars on the scale. A local calendar was prepared to improve accuracy in estimating children’s age.Data were entered using Epi-Info version 3.5.4, then exported to SPSS version 21 for cleaning and analysis. For the analysis of nutritional indices the data were exported to WHO Anthro software. The WHO 2006 growth standards were used to transform children’s weight and length/height measurements into sex- and age-specific Z-scores. Children were classified as stunted, wasted, and under-weight if the HAZ, WHZ, WAZ < −2 standard deviation (SD) respectively. They were categorized as severely stunted, severely wasted or severely underweight if the HAZ, WHZ, WAZ were < −3 SD, respectively.P-value <0.2 in bivariate analyses were included for multivariate analysis. Final multivariate model was generated using enter method. In the final interpretation of results a P-value <0.05 was considered statistically significant. The adequacy of our model was tested using Hosmer-Lameshow goodness of fit test and it was found to be worthwhile (P = 0.57).Data were summarized and presented in frequency table. Associations between independent variables and outcomes of interest were estimated using both bivariate and multivariate logistic regression. Independent variables with a The proposal was reviewed and approved by the research and ethics committee of the School of Public Health, Addis Ababa University. Written informed consent was obtained from all mothers/ caretakers who participated in the study. This was done following explanation of the purpose of the study to the participants. Treatment was provided to children with confirmed malaria according to the national guideline in the respective health centres and health posts. Severely malnourished children were also linked to the therapeutic feeding centres.n = 107) were from cases and 75 % (n = 321) were from controls. As shown in Table n = 82) of the caretakers of the cases and 77 % (n = 247) caretakers of controls were rural residents. Majority of the caretakers of both cases 65.4 % (n = 70) and controls 56.4 % (n = 181) had no education.From a total estimated sample size of 441, 428 mothers/caretakers of children were interviewed (making response rate of 97 %) of which 25 % (n = 70) of cases and 55.8 % (n = 179) of controls were males. The mean age of children was 28 (SD ± 14) months for cases and 33 (SD ± 16) months for controls. Prevalence of wasting was higher among cases 17.7 % (n = 19) than controls 9.3 % (n = 30). High proportions of cases were severely wasted 13.1 % (n = 14) than the controls 3.7 % (n = 12). There was no significant difference in the prevalence of wasting among cases diagnosed in health centres or health posts. Prevalence of underweight was higher in cases 24.3 % (n = 26) than in controls 18.4 % (n = 59) and 13.1 % (n = 14) of the cases and 5.3 % (n = 17) of the controls were severely underweight.As indicated in Table n = 54) were detected in health centres using microscope and the rest 49.5 % (n = 53) were diagnosed in health posts using RDT. One quarter (n = 27) of cases and about two fifth (n = 123) of controls used LLIN the night before the interview. Regarding indoor residual spraying, 66.3 % (n = 71) of the cases and 73.2 % (n = 235) of the controls households had been sprayed within the past one year.About half of the malaria cases 50.5 % , being severely underweight , sleeping under LLIN of the child the night before the study , educational status of caretakers  were significantly associated with malaria attack in children in bivariate logistic regression. Severe wasting and educational status of the caretakers remained significant after adjusting for the following confounders using multivariate logistic model: age and sex of the child, religion, LLIN utilization of the child and IRS. WAZ was reduced from the model because there was multi-collinearity among anthropometric indicators.As shown in Table P-value: 0.025). The dose response trend between wasting and malaria was analyzed using Mantel-Haenszel chi square for linear trend and it was found to be significant (p = 0.003). Children with caretakers who had no formal education were 3 times more likely to have malarial attack than those with secondary education or above .As indicated in Table This study compared the prevalence of malnutrition in under-five children between malaria cases and controls so as to see the association between malnutrition and malaria. After controlling for possible confounders there was a significant positive association between wasting and malaria in under-five children. Severely wasted children were 3 times more likely to have malarial attack than non-wasted children.P.falciparum infection [The increased odds of malarial attack in severely wasted children compared to the non-wasted ones can be explained by the immunosuppressive effect of severe wasting. Our study is consistent with a case control study done in Nigeria which revealed high likelihood of malaria in acutely malnourished children than in healthy ones . Anothernfection .A retrospective analysis of routine programme data on forty-eight nutritional rehabilitation centres in southern Ethiopia showed that 28 % of malnourished children with fever (Temperature >37.5 °C) were positive for malaria on RDT. Even though this study did not compare malaria in malnourished and well nourished children, the study revealed a significant positive association between malaria prevalence and increasing grades of malnutrition which is consistent with our finding .n = 7) of wasted children were positive for malaria. Other than what we mentioned above, the definition of malaria in the above study was solely based on parasitemia unlike our study which is based on both fever and parasitemia.In contrast to the finding noted in the present study, a cohort study carried out in rural preschool children in Senegal revealed that wasted children had lower risk of having malaria attack . HoweverThe attempt made to understand the association between malnutrition and infection in general enhances our understanding the association between malnutrition and malaria. Malnutrition increases susceptibility to infection. On the other hand, infection has adverse effect on nutritional status. The reduced resistance to infection in malnourished children is mainly explained by the suppression of their immunity. Malnutrition affects not only the humeral and cell mediated immunity but it also affects bactericidal activity of phagocytes and complement formation . There iThe association between malnutrition and malaria is controversial , 6, 9. TAnother important reason for conflicting findings can probably be due to the difference in the case definition of malaria. In other words, some studies defined malaria based on either parasitemia or fever while others based on both fever and parasitemia. Although fever is the most important symptom of malaria, it is not unique for malaria . On the A further possible explanation for the controversy could be the fact that many studies, including the present study, do not control the effect of specific micronutrients deficiency on malaria morbidity. Micronutrient deficiency is as important as protein energy malnutrition which usually occurs together. This is to say, micronutrient deficiency determines how malnutrition is associated with malaria .In conducting case–control studies it’s crucial to minimize selection and recall bias. In this study, since exposure status was measured objectively using anthropometry recall bias is believed to be low. Comparability between cases and controls is another major concern that can affect the association between the exposure and outcome of interest. In our case, controls were randomly selected from the source population of cases which is very important to ensure the comparability.As a result of high awareness about malaria in the district (Part of the finding of this study but not presented in this paper) and proximity of the health facilities, caretakers probably brought their children within few days of occurrence of fever to the nearby health facility. Therefore, it was less likely that malaria could result in such level of malnutrition within in short period of time. This is to say that malnutrition may possibly be a risk factor for malaria. However, we can’t confirm the temporal relationship between malaria and malnutrition in this study since malaria can cause malnutrition and the vice versa.In our study, we did not include children admitted to hospitals or health centers for severe acute malnutrition. This could have an effect on our findings of the association between malaria and malnutrition. The effect however, depends on several factors like whether those children admitted for severe acute malnutrition (SAM) have super infections with pneumonia or other childhood infections. In this case, the association between malaria and malnutrition could not be affected since such children would have been ineligible to be either cases or controls in our study. On the other hand, if large proportions of children admitted with SAM have malaria, these would have been potential cases. Hence, our finding might have underestimated the actual Odds Ratio for malaria and malnutrition. Conversely, if large proportion of children were admitted for SAM without superimposed infection or malaria, they would have been potential controls. Consequently, our finding might have overestimated the actual Odds Ratio for malaria and malnutrition.One of the strengths of this study is the classification of malnutrition based on the degree of severity. The finding of higher odds of malarial attack among severely wasted children, but not moderately wasted ones, could be explained by the higher level of immunosuppression among severely wasted children compared to moderately wasted ones.Caretaker’s/mothers lack of education is another most important factor that was positively associated with under-five malaria attack. This is in line with studies done in rural Rwanda and Tanzania , 21.However this study had some limitations. The effect of micronutrients on malaria morbidity was not explored. In addition, there are also possible confounding factors such as diarrhoea, vomiting, and source of water supply that were not included in this study. Severely malnourished children who were admitted for different reason were not also included in this study. Furthermore non-random selection of cases might affect the generalizability of the study. We have recruited controls from the community because it was difficult to get apparently healthy children in the health facilities. However, the fact that we used different base populations for the cases  and controls (community) can be considered as another limitation of this study.This study revealed severe wasting and maternal education as independent predictors of malaria. Severely wasted under-five children were more likely to develop malarial attack than non-wasted children. Children with uneducated mothers/care takers were also more likely to develop malaria.Therefore, special attention should be given for severely wasted children the prevention and control of malaria. In addition, education of girls should be supported. Further research on the effects of micronutrients on malarial morbidity should be done.


Plasmodium parasites are detected mostly by microscopy or rapid diagnostic test (RDT). Although these methods contribute significantly to malaria control/elimination, they are not suitable for detecting the significant proportion of asymptomatic subjects harbouring low levels of parasitaemia, which endure untreated as potential reservoirs for transmission. Malaria prevalence was assessed in endemic regions of Colombia over a 4-year follow-up.Malaria control programmes rely on confirmation of parasite presence in patients’ blood prior to treatment administration. A series of cross-sectional surveys were conducted between 2011 and 2014 in low to moderate malaria transmission sentinel sites (SS) of Tumaco, Buenaventura and Tierralta municipalities of Colombia. A census was performed and a random sample of houses was selected from each SS prior to each survey. Inhabitants were asked to answer a questionnaire on clinical, epidemiological and demographic aspects, and to provide a blood sample for malaria diagnosis using microscopy and quantitative real time polymerase chain reaction (qPCR).Plasmodium vivax accounted for the majority (66–100 %) of cases in Tierralta and Buenaventura and for 25–50 % of the cases in Tumaco.A total of 3059 blood samples were obtained from all SS, 58.5 % of which were from women and displayed a malaria prevalence ranging from 4 % (95 % CI 3–5 %) to 10 % (95 % CI 8–12 %) in the 4 years’ study period. Almost all malaria cases  were sub-microscopic and only detectable by qPCR; 90 % of the cases were asymptomatic at the time of blood collection. While Buenaventura and Tierralta had a decreasing tendency during the follow-up, Tumaco had a rise in 2013 and then a decrease in 2014. This study demonstrates an important prevalence of asymptomatic malaria cases not detectable by microscopy, which therefore remain untreated representing a parasite pool for malaria transmission. This demands the introduction of alternative strategies for diagnosis and treatment, especially for areas of low transmission to reduce it to appropriate levels for malaria pre-elimination efforts to start. Malaria is a major public health issue with ~198 million cases and ~584,000 deaths reported worldwide in 2013 [Microscopic examination of Giemsa-stained thick blood smear (TBS) remains the gold standard diagnostic test used by NMCP before initiation of anti-malarial treatment . Public Previous cross-sectional studies carried out in Colombia showed that sub-microscopic infections were prevalent across different regions in Colombia (Buenaventura (Bv): 12 %, Tierralta (Ta): 15 %, Tumaco (Tm): 4 %) . Those rAnopheles mosquitoes [Patients with asymptomatic sub-microscopic parasitaemia have previously been shown to transmit infection to squitoes , 18 althsquitoes . Howeversquitoes . UnfortuThis study was performed in ten rural sentinel sites (SS) located in the municipalities of Tierralta (department of Córdoba), Buenaventura  and Tumaco (Nariño). These SS were selected based on the source of malaria cases reported in the Colombian National Surveillance System (SIVIGILA).Plasmodium vivax, 5.1 % Plasmodium falciparum and 0.5 % mixed infection) [Tierralta (Ta) is located in the northwest of Colombia, 51 m above sea level (masl) and ~50 km from the Colombian Atlantic coastline with a mean annual temperature of 27.3 °C. It presents 1144 mm of annual precipitations and has a mean relative humidity (MRH) of 82 % . Its popfection)  and is cP. vivax and 21.0 % P. falciparum) were reported by SIVIGILA in 2014 [Buenaventura (Bv) is a municipality located in west Colombia on the Pacific coast at 7 masl, with a mean annual temperature of 28 °C and a high pluviosity  . It has  in 2014 . Four SSP. falciparum is by far the most prevalent malaria pathogen. It reported 1309 malaria cases  in 2014 [Tumaco (Tm) is a municipality located in southwest Colombia on the Pacific coast at ~40 km from the border with Ecuador . It has  in 2014 , which pA series of cross-sectional studies were conducted to establish the variation of malaria prevalence in the SS that were considered malaria transmission hotspots, according to data from NMCP between 2011 and 2014. These surveys comprised two stages: (1) a population census was conducted via door-to-door visits with the help of community leaders, in which the amount of houses, inhabitants/house, age and gender were recorded. The sample size (n) was calculated for each SS with a confidence level of 95 % (z = 1.96), error (d) from 2 to 9 % and an estimated prevalence (P) from 2 to 15 % according to the following function Two drops of blood (~100 mL) were deposited on two different microscope slides per volunteer and stained with Giemsa as described , 24 to br18s gene as previously described [Molecular detection of malaria infections in whole blood was performed by qPCR targeting the escribed . Brieflyp < 0.05 and 95 % confidence intervals were calculated for proportions. R-3.2.2 and MATLAB (version 2011b) were used for statistical analysis. The libraries used in R were dplyr (v0.4.1), ggplot2 (v1.0.1), bitops (v1.0–6), RCurl (v1.95–4.7), Hmisc (v3.16–0), xtable (v1.7–4), maptools (v0.8–36), mapplots (v1.5), plotrix (v3.5–12) and RColorBrewer (v1.1–2).Data were captured in the field in paper forms and digitalized and backed-up in REDCap (version 4.1) as described elsewhere . DigitalA total of 1169 subjects were evaluated in 2011, 981 in 2013 and 909 in 2014. Census and randomization were performed every year in each site because the studied populations had a high rate of migration. The study did not aim to evaluate the same people at each location every year. Of the total population, 58 % (95 % IC 57–60 %) were women , 72 from 2013 , and 33 from 2014 , indicating that almost all cases (97 %) were sub-microscopic.From the total 3059 samples collected from 2011 to 2014, six were positive for p < 0.001). In contrast, < 0.2 % of the samples were positive by TBS during the whole study. Despite the overall malaria decreasing trend, the proportion of P. vivax did not change significantly between 2011 and 2013  and 56/72 , respectively); but decreased to 22/33  in 2014. The proportion of Plasmodium species varied depending on the municipality, with P. vivax accounting for the majority (66–100 %) of cases in Ta and Bv and for 25–50 % of the cases in Tm. The study sites are showed in Fig. Total malaria prevalence as determined by qPCR was 10 % (95 % CI 8–12 %) in 2011, 7 % (95 % CI 5–9 %) in 2013, and 4 % (95 % CI 3–5 %) in 2014. A significant difference between 2011 and 2014 prevalences was found (p < 0.001). In Bv and Tm people >30 years showed the highest percentage of cases, 33 % for Bv  and 44 % in Tm  with significant differences.Most cases in 2011 were detected in people > 30 years , in 2013 the majority of cases were in young adults (15–30 years/old)  and in 2014 the main age group was children five to 14 years old . There was a decreasing trend with age along the study period, however no significant differences were found. Tierralta showed the highest percentage of positive cases in children five to 14 years old, including all years  with significant differences with the other age groups  . Median parasitaemia values found per site respectively for P. vivax and P. falciparum, respectively, were: four and nine parasites/µl in Ta, five parasites/μL for both species in Bv, and 41 and 142 parasites/μL in Tm. There was a low negative correlation between age and parasitaemia for P. vivax in Bv, although not significant. Additionally, the correlation between patient-reported history of number of previous malaria episodes and current parasitaemia in P. falciparum was also low and negative. People who reported having suffered more malaria episodes had lower parasitaemia than those who reported fewer episodes. No significant differences were found between time to previous episode and parasitaemia.No significant differences were found for median parasitaemias among the study sites or throughout the follow-up Table . HoweverP. vivax, 47 for P. falciparum and five harboured mixed infections. Of the 214 cases exclusively positive by qPCR, 192 were asymptomatic . Although the asymptomatic malaria prevalence trend decreased steadily in Bv with time, in Ta and Tm it presented variations, with a decline in 2013 and a slight increase in 2014. The most common symptoms in people infected with malaria were fever, headache and chills. Eighteen individuals had parasitaemias <100 parasites/mL and presented the same symptoms, which were probably due to other etiologies, although they were not further investigated in this study. A total of 261 volunteers were symptomatic without detectable infection by qPCR. These latter volunteers were possibly infected with other agents presenting overlapping malaria symptoms.A total of 195 of the 220 positive patients (95 % CI 84–92 %) did not report malaria symptoms: 143 for P. vivax (between 67 and 78 %) in Ta and Bv; and higher P. falciparum prevalence in Tm. The different parasite species distribution is most likely due to the population structure in those regions. The population in Tm is likely to have a higher proportion of Duffy negative (Fy-) individuals, probably protecting them against P. vivax infections [This study shows a malaria decreasing trend in the study areas from 9.7 % in 2011 to 3.6 % in 2014, as determined by qPCR, despite some variability per year. Although the SS are not necessarily representative of all departments of the country, these findings reflect the overall national malaria trend for the same years, as established on NMCP records based on PCD and the use of microscopy and RDT . As expefections .Plasmodium, most of whom (76 %) were asymptomatic. However, NMCP reports in Bv indicated that only ~40 % of the malaria cases detected by PCD originated in Zaragoza [p < 0.001). This could be explained by persistence of a high proportion of asymptomatic individuals in the community and possibly the maintenance of the vector reservoir created by mining activities. Almost 99 % of the asymptomatic cases displayed sub-microscopic parasitaemia only detectable by qPCR in the three study sites, which confirms a previous report using PCR in 2006 and 2007 from Ta and Tm [The situation in Zaragoza (Bv) where the community is highly involved in illegal mining activities is alarming as compared to the other communities. In 2013, 34 % of people examined by qPCR in this SS, corresponding to 81 % of the cases found in Bv by ACD, were infected with Zaragoza . Comparia and Tm , 29; theP. vivax proportion decreased compared to that of P. falciparum, the prevalence of the latter remained low but stable. This finding is in agreement with NMCP data and also evidenced by Tm data, reporting 1019 malaria cases in 2011 by ACD, 50.5 % caused by P. vivax, while in 2014 only 1.1 % of 1309 total cases were caused by this species [P. falciparum transmission but had an important impact on P. vivax.Interestingly in other localities of Bv, such as Zacarias and Punta Soldado, as well as Candelilla in Tm, malaria has notably diminished to <1 % as detected by qPCR in 2014. These findings indicate an important step towards malaria elimination in these sites. It is noteworthy that while the  species . This suIt is also interesting that the prevalence of asymptomatic patients by ACD decreased in parallel with acutely ill patients demanding diagnosis and treatment (PCD). Even though the same volunteers were not examined at every time point, a malaria decreasing trend along with asymptomatics that are not treated led to the presence of sub-microscopic parasite pools for long periods, creating a source of infection for mosquitoes and therefore of malaria transmission. Because of the study design, the period for which these infected volunteers remained asymptomatic could not be determined. However, even if these subjects were to develop symptoms, it is highly likely that they would remain untreated, as there is no ACD in these areas and only a minor fraction of the study population that was symptomatic and qPCR positive sought care. In view of malaria elimination, it is of great concern that TBS and RDT show a sensitivity and specificity limited to 50–67 % , 30, 31.Anopheles albimanus mosquitoes. In addition it has been shown that qPCR techniques using higher sample volumes can detect cases that are missed by qPCR performed on standard filter paper stored samples or lower blood volumes [The use of molecular methods and radical cure of asymptomatics would significantly accelerate elimination, despite the fact that some individuals may remain infected with parasitaemias not detectable even by qPCR. An ongoing study at the MVDC on the infectivity of asymptomatic subjects has indicated that asymptomatic and qPCR-negative subjects living in endemic villages are able to infect  volumes . Even th volumes , in low There is prevalence of malaria in endemic regions in Colombia considered to be of low and moderate transmission. The fact that almost all (97 %) of the cases were not detectable by TBS, which is the most widely NMCP-used diagnostic method underscores the need to consider introducing molecular methods for malaria diagnosis. In addition, curative treatment should follow a positive diagnosis, even if asymptomatic, in order to effectively decrease malaria prevalence and further transmission, particularly in view of current plans to accelerate elimination activities .


The Democratic Republic of the Congo (DRC) is one of the five countries carrying half of global malaria burden with children 0–5 years old being most at risk. Rapid diagnostic tests (RDTs) are currently routinely used for the detection of Plasmodium infection in health centres and may be a useful tool for population-based survey.This study assessed, in a stable transmission zone of Kinshasa, whether a HRP2-based RDT matches the selection criteria of the National Malaria Control Programme (NMCP), DRC and assessed the most relevant fever threshold in this context.RDTs and microscopy were concordant in 84.3% and 83.4% children in the health centre and at the community level, respectively. The sensitivity was high (>95%), but the specificity was too low and lower in the community  compared to the HC . The estimated parasitic threshold of 5,414 parasites/μl was with a sensitivity of 63.3% and a specificity of 71.8% not very discriminative, and thus not a threshold.HRP-based RDT gives a satisfactory proxy to estimate and monitor malaria endemicity, but the low specificity, far below the selection criteria of the NMCP, DRC is problematic for use in a clinical setting. Despite all control efforts in the past decade, malaria remains a major public health problem. In 2012, an estimated 207 million malaria episodes occurs worldwide and 80% of the disease burden occurs in sub-Saharan Africa. In 2013, 627,000 deaths were estimated to be attributed to malaria of whom 91% occurred in Africa. 40% of the global mortality rate occurs in only three countries: the Democratic Republic of Congo (DRC), India and Nigeria [The DRC has developed a National Malaria Control Programme (NMCP) to monitor the disease and diminish mortality and morbidity. It reported that 97% of the population lives in stable transmission zones putting nearly the entire population at risk for malaria infection. Moreover, mortality in children 0–5 years old is six to seven times higher compared to the general population and they have an average of six to 10 malaria episodes per year .The World Health Organization (WHO) has defined several control strategies, fully or partially adopted by the NMCP, such as prevention of the disease by vector control, management of insecticide resistant vectors, preventive chemotherapy and adequate and timely treatment of cases . The WHOPlasmodium falciparum, the panel detection score should be at least 75% at 2,000 parasites/μl; false positive rates should be less than 10% and invalid tests should be less than 5% [P. falciparum and other species and finally the test should detect high  and low (≥1 parasite/μl) parasitaemia [Parasitological diagnosis of malaria includes either microscopy or RDTs. Microscopy remains the gold standard although its limitations have been demonstrated . RDTs ar than 5% . The NMCsitaemia . Correctsitaemia . Especiasitaemia , 16. Consitaemia . Howeversitaemia , 19. Morsitaemia . TherefoThis study assessed whether an HRP2-based RDT, chosen as the reference by the DRC NMCP, matches the selection criteria of the NMCP in a stable transmission zone of Kinshasa, DRC. In addition, the association between peripheral parasitaemia and the presence of signs and symptoms of malaria was assessed.The Health Zone (HZ) of Mont-Ngafula1 is a stable malaria transmission zone situated in the west of Kinshasa, it has 16 Health Areas (HA) and an estimated 219,274 inhabitants. Two HA, Cité Pumbu and Kindele were randomly selected and asymptomatic children were recruited in the community from April to August 2012. Symptomatic children were recruited in the Health Centre (HC) Lisungi from December 2012 to March 2013. The minimal sample size of 280 was estimated taking the prevalence of malaria in the HZ of Mongafula1, 24%, a desired precision set at 5% and confidence level of 95%. Finally, the recruitment ratio was set to 2:1 asymptomatic and symptomatic children.P. falciparum mono-infection and mixed infections with other Plasmodium spp. The test was considered positive by the appearance of the antigen and control lines in their respective windows. Corresponding to the positions, tests were read as positive to P. falciparum infection, positive to other Plasmodium spp. or mixed infections. Negative results were recorded in case the control band was visible and results were invalid when the control band was not visible. In case of an invalid result, the RDT was repeated. To ensure the validity of the results, RDTs were read within a timeframe of maximal 15 minutes by two independent laboratory technicians.RDTs, SDBioline® Malaria Ag P.f./Pan test (batch nr 05FK60 and 0902065) were kindly donated by the non-profit organization SANRU and they were used according to manufacturer’s instructions. The test can differentiate between For microscopic diagnosis, thick and thin blood smears were collected on the same slide and stained with 10% Giemsa for 10 minutes. Thin smears were fixed with methanol prior to staining. Slides were examined by two independent laboratory technicians. The parasite density was estimated assuming 8,000 white blood cells/μl . In case2 test was applied. Results were considered statistically significant when p ≤ 0.05 or when 95% Confidence Intervals (CI) are not overlapping. The sensitivity and specificity of the RDT’s were calculated in each study group using the thick blood smears (TBS) as the reference. The optimal parasite density to discriminate symptomatic from asymptomatic children or feverish form non-feverish children were estimated with a ROC analysis. The Kappa value was calculated to measure the concordance between RDT results and fever.Data were double entered and validated in Epi Info 3.5.1. and analysed using Stata 11.1 . Age, sex and history of fever were also recorded. History of fever was reported by the parents as the presence of fever in the past 24 h. For data with skewed distribution, the median and its interquartile range (IQR) are reported. Due to a high number of negative patients in the community, children with a parasite density of 0 were excluded to calculate the median. A log transformation of the data was performed to compare the mean parasite density with the unpaired t-test. For binary data, the chiEthical approval for this study was provided by Ethical committee of the School of Public Health, Kinshasa University, DRC. Participation was entirely voluntary and written informed consent was obtained from the parents or legal guardians of the children. Confidentiality is guaranteed by restricting access to the data. Medication was given to the children when their biological profile indicated the need of therapeutic care.A total of 872 children were recruited into the study, 592 were recruited from the community while 280 children presenting fever (body temperature ≥37.5°C) were recruited in the Health Centre (HC). Median age was 35.1 months old (range: 0.7-59.9) and 53.8% of the children were male (Table versus 96.5% (95%CI: 92.5-100) in the community and HC respectively. Table Figure The children were categorized as symptomatic when attending the HC and at the community level they were categorized as asymptomatic. ROC analysis estimated 5,218 parasites/μl to be the discriminating cut-off. This cut off point had a sensitivity and specificity of 64% and 70% respectively, and the area under the curve was 0.70 Figure . Some chAccurate diagnosis of malaria infection is an important matter since in high and stable transmission zones, a high proportion of the population are asymptomatic carriers of infection. This proportion of the population might also need effective anti-malarial treatment because spontaneous resolution of untreated infections is relatively rare . The oveThe vast majority of discordant results were due to the high rate of false positive results. In the HC it was 21.1% and it was unacceptable high at the community level (40.0%) thus RDT systematically overestimated the prevalence which may be problematic (Table P. falciparum from other species (Table The NMCP of the DRC endorses the use of RDTs in Health Centres and might extend its use to monitor malaria prevalence in the general population to enhance control efforts. Based on the formulated criteria , the NMCes Table . FinallyP. falciparum infection leads to non-specific signs and symptoms and the majority of the population in endemic areas remain disease-free despite high parasitaemia [et al.[P. falciparum is not a harmless condition, it would be recommended to treat all RDT positive cases with the recommended anti-malaria drugs. However, due to the relatively high number of false positive RDT results, clinicians should still check whether there may be co-infection with other organisms. Because when a false positive results influences antibiotic prescription, it endangers the health status or even the life of the child [Clinical diagnosis of malaria illness also represents a challenge because sitaemia . Neverthsitaemia . In this [et al.. This co [et al., 19. On  [et al.. This cohe child . CliniciA limitation of the study was that sub-microscopic infections were not assessed with a more sensitive PCR assay. It may significantly reduce the number of false positive RDT results. History of fever is a subjective indicator reported by the parents. Reporting history of fever is a very useful and frequently used in several studies where presumptive malaria is evaluated , 29. PreHRP-based RDTs performed quite similarly in both the HC and overestimated the malaria prevalence systematically by almost 15% and may be a satisfactory proxy to estimate and monitor malaria endemicity but the low sensitivity, far below the selection criteria of the NMCP, DRC is problematic for use in a clinical setting and has to be further explored. The parasite density threshold seemed very variable and not discriminant and its usefulness is questionable.


Plasmodium sp. parasites, is a leading cause of global morbidity and mortality. Cerebral malaria, characterized by neurological symptoms, is a life-threatening complication of malaria affecting over 500,000 young children in Africa every year. Because of the prevalence and severity of cerebral malaria, a better understanding of the underlying molecular mechanisms of its pathology is desirable and could inform future development of therapeutics. This study sought to clarify the role of Toll-like receptors (TLRs) in promoting immunopathology associated with cerebral malaria, with a particular focus on the understudied TLR7.Malaria, caused by Plasmodium berghei ANKA mouse model of experimental cerebral malaria, C57BL/6 mice deficient in various TLRs were infected, and their resistance to cerebral malaria and immune activation through cytokine production were measured.Using the Loss of TLR7 conferred partial protection against fatal experimental cerebral malaria. Additionally, loss of TLR signalling dysregulated the cytokine profile, resulting in a shift in the cytokine balance towards those with more anti-inflammatory properties.This work identifies signalling through TLR7 as a source of pathology in experimental cerebral malaria. Plasmodium, is a major source of global morbidity and mortality, resulting in an estimated 154–289 million infections and 660,000 deaths in 2010 [Plasmodium falciparum infection characterized by coma , presence of P. falciparum parasites in the blood, and exclusion of other causes of encephalopathy [Malaria, caused by protozoan parasites of the genus alopathy , 4. AlthPlasmodium berghei strain ANKA, reviewed in [e.g., interleukin 4 (IL4) and IL10, is thought to determine the lethality of cerebral malaria [The nature of the pathogenesis of cerebral malaria is controversial –12, but iewed in ), it is  malaria , 19. In  malaria , 21. Con malaria , 23, and malaria . However malaria , highligP. berghei[Plasmodium molecules [Plasmodium glycophosphatidylinositol [Tlr2-/- mice [Tlr2-/-Tlr4-/- mice [Toll-like receptors (TLRs) are a family of innate immune sensors that are prime candidates for initiating immune responses that promote cerebral malaria. Evidence for a TLR-dependent contribution to cerebral malaria pathology stems from the observation that mice lacking myeloid differentiation factor 88 (MYD88), a downstream adapter shared by most TLRs, are partially protected from developing cerebral malaria pathology during infection with  berghei–29  infection of the C57BL/6 mouse, in which Type I inflammation promotes a lethal infection with neurological symptoms consistent with cerebral malaria [Previous work from this lab showed that a deficiency in TLR7, which recognizes ribonucleic acid (RNA), leads to widespread immune dysfunction during arasites . Similarere seen . Similar malaria , a defic malaria , 28. How malaria . This stAll mouse work was conducted with the approval of the University of California, San Francisco (UCSF) Institutional Animal Care and Use Committee in strict accordance with the guidelines of the Office of Laboratory Animal Welfare.Tlr7−/− (Jackson Laboratories); Tlr9−/− ; Myd88−/− . Tlr7-/-Tlr9-/-double knockout mice were bred in house. All strains were confirmed to have a C57BL/6 background of greater than 95% by microsatellite genotyping.The following mouse strains were used in this study: C57BL/6 ; P. berghei strain ANKA (MRA-311) parasites, which were obtained from the MR4 stock centre and maintained in C57BL/6 mice. Blood was harvested by cardiac puncture from an infected mouse on day 5 of infection, and 106 infected erythrocytes were introduced into a new mouse by intraperitoneal injection in 100 μl of Alsever’s solution. All infections were initiated at 14.00 hours. For cytokine analysis, blood was harvested by submandibular blood collection or cardiac puncture into K2EDTA for plasma isolation.All experiments were performed using Infections were initiated as described above. Survival and signs of cerebral malaria were monitored daily, and twice daily during the peak of lethality (days 6 through 12). Animals that showed neurological symptoms, such as convulsions, ataxia or paralysis, or that died on or before day 12 post-infection, were considered to have cerebral malaria as previously described . ParasitAll plasma cytokines were measured by multiplexed cytometric bead immunoassay (Millipore) as per manufacturer instructions and detected on a MAGPIX (Luminex). Cytokine level significance was assessed using a Mann–Whitney U test (α = 0.05).Tlr7-/- mice in response to several Plasmodium sp. in a previous work [P. berghei cerebral malaria that was previously undetected. To test this, the survival of TLR7-deficient mice, as well as Tlr9-/-, Tlr7-/-Tlr9-/-, and Myd88-/- mice, infected with P. berghei parasites was monitored. As previously reported [P. berghei when compared with wild-type mice, with Tlr9-/- mice less well protected than Myd88-/- mice . Because TLR7 and TLR9 share the common signalling adapter MYD88, the possibility of a genetic interaction between these sensors was tested by generating mice lacking both sensors. As expected, Tlr7-/-Tlr9-/- mice demonstrated improved survival as compared to wild-type mice, with 24% escaping cerebral malaria. Notably, they were no more protected than mice with either deficiency alone and were also not as well protected as Myd88-/- mice. There was no significant difference in survival between females and males of any given genotype . Additionally, protected mice did not show symptoms of cerebral malaria, such as ataxia, hemi- or paraplegia, seizures or coma. This protection was not due to improved parasite restriction; all animals eventually succumbed to hyperparasitaemia after the initial escape from cerebral malaria, as observed in other immunodeficient mice [Given the reduced levels of inflammatory cytokines observed in ous work , it was reported , 28, mic malaria , 27, 29.ent mice , 47 . In order to detect the difference observed in this study, a minimum sample size of 33 mice is necessary [P. berghei pathogenesis was overlooked in the previous work.In contrast to the current findings, ent mice . In the ecessary . Based oP. berghei infection in Tlr7-/-, Tlr9-/-, Tlr7-/-Tlr9-/-, and Myd88-/- mice, the levels of cytokines that have previously been associated with susceptibility to cerebral malaria [To better understand the inflammatory response as related to lethality of  malaria , 49–52 wTlr7-/-Tlr9-/- mice on both days, as compared to wild-type mice. All of the other cytokines also followed the same trend of being reduced in Tlr7-/-Tlr9-/- as compared to wild-type mice, although they did not reach statistical significance. In contrast, none of these cytokines were significantly diminished in mice singly deficient in either TLR7 or TLR9. In fact, many cytokines were produced at higher levels in Tlr7-/- mice, including TNF, IFNG, and IL6. Tlr9-/- mice appeared to follow similar trends for these cytokines, but did not reach significance. These observations are similar to those from early P. chabaudi infection [Tlr7-/- and Tlr9-/- mice on day 3, as well as in Tlr7-/- mice on day 6. Importantly, unlike the synergistic interaction between TLR7 and TLR9 suggested by the survival data, these results are consistent with a model in which TLR7 and TLR9 signal redundantly through MYD88 to promote cytokine production during experimental cerebral malaria.Specifically, at both days 3 and 6 post-infection, IFNG, IL6, TNF, MIP1B and IL10 were all significantly diminished in MYD88-deficient mice as compared to wild-type mice. MIP1B was also significantly diminished in nfection , whereinnfection . Additior2 values for IFNG and MIP1B were above 0.5  to Type II (anti-inflammatory) cytokines is more strongly associated with severe malaria disease than any single cytokine [r) of greater than 0.8 (Figure Tlr7-/-, Tlr9-/-, Tlr7-/-Tlr9-/-, and Myd88-/- mice as compared to B6 on day 3 (with the exception of IL4/IFNG in Tlr7-/-Tlr9-/-, which did not reach significance; Figure To assess the relative contributions of each cytokine to the pathogenesis of cerebral malaria, the average plasma levels of each cytokine in each genotype were examined for correlation with the percentage of that genotype that escaped from cerebral malaria. Consistent with the discrepancy between survival and cytokine production, none of the correlations reached a p value of less than 0.1, although cytokine , 55. Givcytokine , 22, 47,P. berghei ANKA infection and protects against symptoms of cerebral malaria. Interestingly, the absence of TLR7 or TLR9 results in overproduction of multiple cytokines, but loss of both TLR7 and TLR9 results in reduced cytokine production (Figure P. berghei, whereas loss of both TLR7 and TLR9 leads to decreased cytokine production. This phenomenon leads to an apparent discrepancy between cytokine production and survival data that can be explained through the consideration of ratios of cytokines to one another, rather than analysis of any single cytokine in isolation.In this highly powered study, it has been shown that signalling through TLR7 contributes to lethality from cerebral malaria. The loss of both TLR7 and TLR9 signalling leads to cytokine dysregulation during the course of n Figure . TLR7 anP. berghei mouse model of cerebral malaria have shown that multiple pro-inflammatory cytokines, chemokines and leukocyte populations drive the observed rapid lethality [Additionally, other MYD88-dependent signalling cannot be explained by TLR7 and TLR9 Figure , indicatethality , 56–58, ethality , 58, 59.P. berghei lethality [Interestingly, one study reported that mice overexpressing TLR7 were also partially protected from cerebral malaria . Althougethality . Notablyethality , indicatethality .Plasmodium parasites, and supports the notion that immune responses to Plasmodium must be finely tuned to effect parasite clearance while minimizing immunopathology.The mechanistic study of cerebral malaria in humans is difficult, as this disease may be considerably more heterogeneous than is currently appreciated , 63. GivP. berghei infection.Loss of TLR7 signalling confers partial protection against fatal experimental cerebral malaria, while having no effect on parasite restriction. TLR7 signalling promotes lethal pathology in a manner that is synergistic with TLR9 signalling. The protection conferred by the loss of TLR7 is correlated with a shift towards an anti-inflammatory cytokine profile during