The transmission of malaria by blood transfusion was one of the first recorded incidents of transfusion-transmitted infections (TTIs). Although the World Health Organization (WHO) recommends that blood for transfusion should be screened for TTIs, malaria screening is not performed in most malaria-endemic countries in sub-Saharan Africa (SSA). The transfusion of infected red blood cells may lead to severe post-transfusion clinical manifestations of malaria, which could be rapidly fatal. Ensuring that blood supply in endemic countries is free from malaria is highly problematical, as most of the donors may potentially harbour low levels of malaria parasites. Pre-transfusion screening within endemic settings has been identified as a cost-effective option for prevention of transfusion-transmitted malaria (TTM). But currently, there is no screening method that is practical, affordable and suitably sensitive for use by blood banks in SSA. Even if this method was available, rejection of malaria-positive donors would considerably jeopardize the blood supply and increase morbidity and mortality, especially among pregnant women and children who top the scale of blood transfusion users in SSA. In this context, the systematic prophylaxis of recipients with anti-malarials could constitute a good alternative, as it prevents any deferral of donor units as well as the occurrence of TTM. With the on-going programme, namely the Affordable Medicine Facility - Malaria, there is an increase in the availability of low-priced artemisinin-based combination therapy that can be used for systematic prophylaxis. It appears nonetheless an urgent need to conduct cost-benefit studies in order to evaluate each of the TTM preventive methods. This approach could permit the design and implementation of an evidence-based measure of TTM prevention in SSA, advocating thereby its widespread use in the region. Plasmodium  [Plasmodium species in transfusion-related malaria cases, and the clinical impact of parasitaemic blood in recipients, particularly young children and pregnant women who are the highest consumers of blood transfusions in sub-Saharan Africa (SSA) [Malaria is a protozoan parasitic infection of humans resulting from one or more of the five species of the genus nowlesi) . It is onowlesi) ,3. But, nowlesi) . As a reca (SSA) ,5. When ca (SSA) ,3.The incidence of transfusion-transmitted malaria (TTM) among people residing in endemic areas is unknown. As a matter of fact, a substantial proportion of the population in malaria-endemic countries has asymptomatic parasitaemia, making it difficult to be sure whether malaria occurring after blood transfusion was acquired from the transfusion or not ,6. NonetOther transfusion guidelines suggest that transfusion recipients should be given systematic anti-malarial prophylaxis ,5,6. ForFortunately, a new programme, the Affordable Medicines Facility - Malaria (AMFm), has recently been put in place with satisfactory results. This is a pilot supra-national subsidy programme that aims to increase access and affordability, therefore, reducing the price of ACT to levels similar to that of less effective anti-malarials (such as sulphadoxine-pyrimethamine and chloroquine). The evaluation of this programme shows that there is an increased availability of low-priced ACT with no significant variation in availability based on remoteness . Its impMalaria remains a major public health hazard in SSA owing to its high morbidity and mortality despite being the focus of significant financial support and research. According to the latest World Malaria Report summarizing data received from 104 malaria-endemic countries and territories, there were about 219 million cases of malaria and an estimated 660,000 deaths, 90% of which occurring in SSA .Malaria exacts a heavy toll of illness and death among children specifically the under fives, and on pregnant women . In factin utero[Malaria in pregnancy is widespread. Pregnant women are highly vulnerable because of iron deficiency, a major problem in malaria-endemic areas. It endangers the health of women as well as that of the newborn. Malaria causes anaemia and low birth weight as a consequence of the loss of previously existing immunity . Malariain utero. An estiin utero.P. falciparum is the most virulent [Plasmodium falciparum causes severe complications, such as cerebral malaria, severe anaemia, acute renal failure, hypoglycaemia and pulmonary infection [A contributing factor to the malaria problem in SSA is the diversity of the parasite that infects humans. Five species infect man of which virulent . These mvirulent . Plasmodnfection . Severe Every second, someone in the world needs blood . In everMany patients, particularly in SSA, do not have access to blood when they need it. Of the estimated 80 million units of blood donated annually worldwide, only 38% are collected in the developing world where 82% of the world’s population lives . Up to 1Despite the fact that blood transfusion can be life-saving, there are associated risks, particularly the transmission of blood-borne infections. Screening for TTIs, to exclude blood donations at risk of transmitting infection from donors to recipients, is a critical part of the process of ensuring that transfusion is as safe as possible. Effective screening for evidence of the presence of the most common and dangerous TTIs can reduce the risk of transmission to very low levels . AccordiPlasmodium species respond to all the aforementioned criteria [To be transmissible by blood, the infectious agent must have the following characteristics: (i) presence in the blood for long periods, sometimes in high titers, (ii) stability in blood stored at +4°C or lower, (iii) long incubation period before the appearance of clinical signs, and (iv) asymptomatic phase or only mild symptoms in the blood donor, hence not identifiable during the blood donor selection process . Plasmodcriteria . Malariaet al. reported that the history of TTM dates back to 1882, when Gerhardt empirically demonstrated the transmission of malaria in humans by infected blood [Batista-dos-Santos ed blood .Plasmodium species are the most prevalent transfusion transmissible pathogens especially in SSA [The prevalence of malaria parasitaemia in African donors depends on the local endemicity and transmission season and varies from 0.67% in Nairobi, Kenya, a non-endemic area, to over 55% in highly endemic northern Nigeria  . Plasmody in SSA . In facty in SSA .Given that asymptomatic carriage of malaria parasites is common in malaria-endemic countries , parasitet al.[P. falciparum by polymerase chain reaction (PCR). The parasite density in the blood unit that caused the TTM was 280/μL [Anecdotally, Owusu-Ofori et al. conductes 280/μL . Anothers 280/μL , claiminTransmission of malaria has been reported to occur mainly from single-donor products . Any bloet al., as few as ten parasites are sufficient to initiate fulminant malaria in humans [Additionally, in cases of TTM, depending on the number of parasites in the inoculum, the symptoms of malaria may begin days or weeks after transfusion , presentn humans .The majority of recipients of blood transfusions living in malaria-endemic areas are semi-immune to malaria , but theThe risk of TTM has been associated with the difficulty in identifying infected potential donors, mostly those with a low number of parasites circulating in their blood, as well as the ability of this parasite to remain viable in stored blood units, even after the storage process ,28. ThusThe ability to screen blood donations, as well as donors, can significantly decrease any risk of TTM . LaboratPlasmodium detection in malaria-endemic areas [In routine practice, the “gold-standard” technique, optical microscopy in thick blood smears, is the most often used for ic areas . This teic areas . Its senic areas ,36. Furtic areas . But desic areas ,27. In aic areas ,38. Thisic areas . Microscic areas .Plasmodium antigens or antibodies directed against the Plasmodium. The detection of malarial antigen with rapid diagnostic tests (RDTs) was originally intended as a more rapid and objective alternative to direct microscopy [Plasmodium-specific parasite proteins, such as pan-malarial lactate dehydrogenase (pLDH), and P. falciparum specific histidine-rich protein 2 (HRP2). Most of these assays are in a ‘dipstick’ format that can be used with minimal training, are field applicable, and provide a result within 10-20 minutes [P. falciparum, or they cannot distinguish between the parasite species present [et al. using a RDT CareStart pLDH showed for instance that overall sensitivity for P. falciparum and P. vivax was good, but poor for P. ovale and P. malariae[Plasmodium species, it has been proposed a combined HRP2/pLDH-based RDT [et al. showed on another hand that false-negative results mainly occurred at parasite density less than 100/μL [et al. claimed that the pLDH-based RDT can exhibit a detectability threshold of 1 parasite/μL, lower than that of the other methods, with the exception of PCR, and that unlike HRP2-based tests, false positives are exceptional with pLDH-based RDTs [Plasmodium species could be an interesting tool for blood donation qualification in order to ensure blood safety in malaria-endemic areas [Alternative methods have been developed for the screening of malaria for use both in areas where malaria is endemic and in areas where it is not, detecting specific croscopy . RDTs de minutes ,33,39. H present . Heutmek malariae. In ordeased RDT . Heutmekn 100/μL . Atchadesed RDTs . Based oic areas ,42. It hPlasmodium species, the immune response results in the formation of specific antibodies not necessarily protective, and not necessarily indicating that the person is harbouring malaria parasites as well [et al. showed that the latter was more sensitive and specific than the former, with a possibility of automation, fulfilling thereby the criteria of a satisfactory and reliable malaria screening test [P. ovale and P. malariae may not be detected by P. falciparum and P. vivax antigen-based assays [Following infection with  as well . Antibod as well . After hing test . Howeverd assays . Given td assays . Malariad assays ,42. ThisPlasmodium by PCR, such as the nested PCR [et al. have described real time PCR as a necessary, appropriate and inexpensive method, with higher sensitivity and specificity compared to those previously described, which can be adopted as part of the laboratory screening in haemotherapy centres, especially in malaria-endemic areas [Methods based on molecular biology have been used to detect different types of sted PCR . This tested PCR ,46,47. Tsted PCR ,46,47. Hsted PCR ,23,27, rsted PCR ,47-49. Rsted PCR ,38,48,50ic areas . Owing tic areas .et al., the accuracy for malaria diagnosis using automated haematology analysis may vary according to species, parasite load, immunity and clinical context where the method is applied [A recently available technique based on detection of haemozoin pigment in white blood cells by automated haematology cell counters has been described as a convenient, less costly and objective malaria screening method ,51. AccoApart from laboratory screening, donor questioning has also been proposed as another tool for malaria screening in order to lessen the risk of TTM. It aims at deferring all potential blood donors who have experienced a febrile episode at least three months before blood donation. But this strategy lacks the capacity of eliminating asymptomatic but malaria-parasitaemic blood donors ,42. To bOverall, a number of factors need to be considered in selecting the most appropriate assays. In general, a balance has to be found between screening needs and the resources available, including finances, staff and their level of expertise, equipments, consumables, and disposables . Each scet al. after performing thick blood films, RDT, enzyme immunoassays and real time PCR for malaria screening of blood donor units concluded that none of these four tests would be ideal for African blood banks to be used for the prevention of TTM, as they were either insufficiently sensitive or too sensitive for malaria parasites detection in blood donor units [According to WHO guidelines, the minimum evaluated sensitivity and specificity levels of all assays used for blood screening should be as high as possible and preferably not less than 99.5% . But, weor units .Plasmodium transmission particularly in critical patients, such as children and pregnant women [The transfusion practice constitutes a major challenge in malaria-endemic areas because many potential blood donors are infected. Identifying low-risk individuals is virtually impossible. International policies recommend that all blood donations should be screened for malaria where “appropriate and possible , but thint women ,52.Plasmodium species, must be rapid and less costly. Moreover, it must enable a reduction of TTM risk as well as that of falsely deferred blood donors [et al. found that it was less clear if replacing microscopy with RDT-based diagnostics should be recommended on cost-effectiveness grounds [A good screening tool for malaria detection in blood units must have a high sensitivity, a high positive predictive value; it must be capable of recognizing all the d donors ,30. But,d donors ,20,24. Sd donors . But the grounds .et al. note however that the feasibility of rejecting positive blood donations with regard to blood availability in malaria-endemic areas remains a serious problem [et al. have shown that if malaria-positive donor units were to be excluded from the Kenyan national blood supply, an estimated 5% of blood units  would be wasted [So, there is not any current “realistic” and suitable method to screen for malaria parasites in blood units. And even if this method was available, there is no evidence-based policy indicating what action should be taken if the donated blood is tested positive, bearing in mind that in some regions almost 55% of blood units contain malaria parasites . Thus, r problem . Such re problem . For inse wasted . The wase wasted .Pre-transfusion screening will lead thus to the detection of malaria-positive blood units that will be afterwards unfortunately rejected. In order to prevent unnecessary deferral of potential blood donors as well as rejection and substantial wastage of malaria-positive donor units, many authors, as well as WHO, advocate appropriate and effective malaria prophylaxis to be administered with every transfusion especially in highly endemic areas ,23,24,27et al. in 2005 showed a cost per case prevented of US$1.4 in adults and US$0.69 in paediatrics for the option of recipient prophylaxis using a SP-based drug. The cost escalated to US$7.79 in adults and US$5.84 in paediatrics if the prophylaxis was upgraded to the recommended ACT. For the option of pre-transfusion screening using an automated technique, the cost was US$0.03 [et al., based on the low incidence of TTM they found, concluded that malaria transmission occurs infrequently, suggesting that routine treatment for all recipients of blood transfusion may probably be unnecessary [There have been some claims that the cost per case prevented of transfusion-associated malaria is considerably higher for recipient anti-malarial prophylaxis than pre-transfusion screening using an automated flow cytometry technique . Anecdot US$0.03 . However US$0.03 . Likewisecessary  whilst cecessary .Happily, there is an emerging programme that can help to reinforce the practice of malaria prophylaxis by considerably lowering the price of ACT. This is the AMFm. It is a “factory-gated” subsidy for ACT launched in 2010 and currently being piloted in seven African countries. The goals of the AMFm are to increase the availability and reduce the prices of ACT to levels similar to that of less effective anti-malarials, and to displace artemisinin monotherapy whose widespread availability and improper use threaten to accelerate parasite resistance to artemisinin. A recent evaluation of this programme in Tanzania showed that average ACT prices for an adult dose fell from US$1.03 to 0.81 within six to eight months (this price being cheaper for paediatric doses), as well as it has led to a large increase in availability of the drugs with no significant variation in availability based on remoteness .Furthermore, governments of some SSA countries such as Cameroon have decided to give ACT to children under five years old free of charge, and have subsidized adult doses. This strategy could also contribute in reinforcing malaria prophylaxis for blood recipients as an affordable policy given that most of the recipients in SSA are young children. In parallel, a recent study showed that almost 50% of blood recipients have received a malaria treatment with their blood transfusion, 84% of which were children, and in almost 80% of cases the anti-malarials were prescribed at the same time as the blood transfusion . In malaet al. in Pakistan is mainly based on the aforementioned strategy [P. falciparum being highly sensitive to inactivation by photochemical treatment with amotosalen and long wavelength ultraviolet light [Alternatives to donor screening for reducing the burden of TTM have been published (see Table strategy . Finallyet light . But thiHowever, it is worth emphasizing that despite the different strategies adopted, it is virtually impossible to safeguard the blood supply from malaria in endemic countries, and often the transfusion of blood, together with the judicial use of anti-malarial drugs, is necessary to minimize the occurrence of TTM in the recipient. In addition, promoting the appropriate clinical use of blood has a role in minimizing TTM by ensuring that patients receive blood only when needed and, therefore, are not exposed unnecessarily . FinallyThe critical lack of evidence about the clinical impact of TTM and the absence of an effective and feasible screening method are impediments to rational decision-making about when and how to screen blood for malaria. There are no screening tools for malaria that are practical, affordable, and suitably sensitive for use by blood banks in SSA. The prevalence of malaria in blood donors is variable but can reach 55% in some parts of West Africa. Implementation of any policy that advocates deferral of all such donors will have a significant negative impact on the availability of blood for transfusion, will undoubtedly increase mortality particularly among pregnant women and children, and must be underpinned by robust evidence. With the availability of subsidized and low-priced ACT, the anti-malarial prophylaxis with every transfusion appears a practical alternative strategy to lessen TTM in SSA. However, cost-benefit studies should be conducted to point out the most suitable method to be used for the prevention of TTM. One should however bear in mind that complete prevention of TTM may not be attainable, so malaria must always be considered in any patient with a febrile illness post-transfusion.ACT: Artemisinin-based combination therapy; AMFm: Affordable medicines facility-malaria; DNA: Deoxyribonucleic acid; ELISA: Enzyme-linked immunosorbent assay; PCR: Polymerase chain reaction; RDT: Rapid diagnostic test for malaria; RNA: Ribonucleic acid; TTIs: Transfusion-transmissible infections; TTM: Transfusion-transmitted malaria; SSA: Sub-Saharan Africa; WHO: World Health Organization.The authors declare that they have no competing interests. They have not benefited from any sponsorship and funding.JRNN conceived the review, took part in the compilation of background material, drafted and revised the manuscript. JJNN conceived the review, conducted the compilation of background material and contributed to the manuscript drafting and revision. SNT, AFZM and CGM critically reviewed and revised the manuscript. All the authors approved the final version of the manuscript.


Dear Editor in Chief Iranian J ParasitolPlasmodium falciparum. Hematological changes are nearly common in malaria infection but severe thrombocytopenia is rare in P. vivax , 11 cases had a platelet count less than 50000 and among them 7 patients had a platelet count below 20000, 2 cases between 10000 to 20000 and 5 cases less than 10000. Patients who had platelet count less than 10000 had small hemorrhages under the skin and they underwent platelet transfusion.We evaluated all patients who were referred to our hospital in Zahedan because of vivax malaria during 2 years, from Aug 2007 to Sep 2009. Out of the 34 patients with vivax malaria. It may be due to a new genotype of P. vivax. Non-immunological or immunological destruction of platelets are given reason for causing thrombocytopenia in such cases but the exact mechanisms involved are still not completely clear (P. vivax.Although, severe complications including profound thrombocytopenia are common due to falciparum malaria , 4 but, ly clear . Further


Plasmodium infection and malaria outcomes. Further studies should include a larger number of individuals, refined parameters and a fine-scale map obtained through DNA sequencing to increase the knowledge of the Amazonian population genetic diversity.The Brazilian Amazon is a hypo-endemic malaria region with nearly 300,000 cases each year. A variety of genetic polymorphisms, particularly in erythrocyte receptors and immune response related genes, have been described to be associated with susceptibility and resistance to malaria. In order to identify polymorphisms that might be associated with malaria clinical outcomes in a Brazilian Amazonian population, sixty-four human single nucleotide polymorphisms in 37 genes were analyzed using a Sequenom massARRAY iPLEX platform. A total of 648 individuals from two malaria endemic areas were studied, including 535 malaria cases  and 113 health controls with no history of malaria. The data revealed significant associations (p<0.003) between one SNP in the IL10 gene (rs1800896) and one SNP in the TLR4 gene (rs4986790) with reduced risk for clinical malaria, one SNP in the IRF1 gene (rs2706384) with increased risk for clinical malaria, one SNP in the LTA gene (rs909253) with protection from clinical malaria and one SNP in the TNF gene (RS1800750) associated with susceptibility to clinical malaria. Also, a new association was found between a SNP in the CTL4 gene (rs2242665), located at the major histocompatibility complex III region, and reduced risk for clinical malaria. This study represents the first association study from an Amazonian population involving a large number of host genetic polymorphisms with susceptibility or resistance to  Malaria is a life-threatening parasitic disease transmitted by mosquitoes. Despite major efforts aimed at controlling the spread and impact of the disease, it still persists as a major health burden, being responsible for over a million deaths each year, mainly children in Sub-Saharan Africa. In Brazil, there were over 300,000 recorded cases of malaria in 2010, almost exclusively (99.8% of the cases) restricted to the Amazon Basin region Malaria is a complex disease with many genetic and environmental determinants influencing the observed variation in response to infection, progression and severity. Several factors important for these different phenotypes include the parasite genetic make-up and host age, state of immunity and genetic background Plasmodium infection (see NOS2A) genes , southeast asian ovalocytosis and the Duffy-negative blood group are examples of the general principle that different populations have selected different genetic variants to protect against tion see , and ABOtion see , Toll-lition see , and theP. vivax malaria has been observed in five endemic states of the Brazilian Amazon P. falciparum infection in individuals from an endemic area in the state of Amazonas P. falciparum infections P. vivax infected patients may be unaltered by polymorphism in the promoter region of IL-10 gene Previous genetic studies in Brazilian Amazonian populations have demonstrated different malaria protective effects from blood-related polymorphisms  malaria in a population of the Brazilian Amazon. We genotyped 64 single nucleotide polymorphisms (SNPs) in 37 human host genes, including loci related with erythrocytes receptors and immune response. Our study is the first to comprehensively survey important malaria candidate polymorphisms (including HbS and ABO) in a Brazilian population from the Medium Negro River Basin in the Amazon. This setting provided an excellent field to test hypotheses on the generalization of established malaria-genetic associations, particularly for low endemic areas. It also provided a mean to find other associations related to either different mechanisms or by linkage disequilibrium with putative markers associated with susceptibility/resistance to Plasmodium infection Here, we investigated the association of a larger number of host candidate genes polymorphisms with susceptibility/resistance to Approval for the recruitment of participants, collection of blood samples, DNA preparation and DNA genotyping was provided by the relevant research ethics committee  and an informed consent was obtained from each participant.Potential participants were engaged between January 2002 and October 2006 from an ongoing epidemiological study of malaria in the cities of Barcelos (n = 596) and Santa Isabel do Rio Negro (n = 52), which are 350 km apart. The municipalities are located within the Negro river micro region in the state of Amazonas and display similar demographics. In 2006, the Annual Parasite Index (API) was 264.4 cases per 1000 inhabitants in Barcelos The individuals included in this study had lived in the study area for at least five year with similar social and genetic backgrounds. The population of both municipalities is predominantly of Amerindian descent from Tukano-Oriental speaking societies Plasmodium-infected cases were defined as an individual without symptoms for malaria within 30 days before or after the blood collection, but with a positive thick smear and/or PCR, following the recommendations of the Brazilian consensus group for studies of asymptomatic individuals.Three definitions of malaria cases were used for the association analysis: clinical malaria , asymptomatic infected individuals (n = 122) and individuals with a previous history of mild malaria (non-asymptomatic infection), but not infected at the moment of blood collection (n = 300). Clinical malaria was defined in accordance to the guidelines of the World Health Organization (WHO) for the American region and the Brazilian National Malaria Control Programme (PNCM) including symptoms associated to malaria  and a positive thick smear or rapid diagnostic test (RDT). Asymptomatic Plasmodium species was identified by PCR according to published protocols P. falciparum and P.vivax  The sample collection consisted of 535 cases  and 113 healthy controls with no previous history of malaria . DNA samples were prepared by extraction from 300 µl of total blood using a commercial kit following the manufacturer’s protocol (Promega®). Genomic DNA samples underwent whole genome amplification by Primer Extension Pre-amplification (PEP) before genotyping on a Sequenom® MassArray genotyping platform  with the never_malaria group (control); b) clinical_malaria group  with the never_malaria group; c) asymptomatic infection group with the never_malaria group and d) clinical_malaria group  with asymptomatic infection group.Association studies were performed comparing different groups: a) P-values from these correlated tests are reported. Haplotypes were estimated using an expectation-maximization algorithm 2 and D-prime metrics.Genotypic deviations from the Hardy-Weinberg equilibrium (HWE) were assessed using a chi-square statistical test. SNPs were excluded from the analysis if there was at least 10% of the genotype calls missing or a significant deviation from the HWE (p<0.0001). A case-control association analysis using SNP alleles and genotypes was undertaken by logistic regression and included site (Barcelos or Santa Isabel do Rio Negro) and gender as covariates. In this approach, the SNP of interest was modeled assuming several related genotypic mechanisms  and the minimum Fst metric Population structure or differences in allele frequencies between sub-populations can lead to false positive associations. Differences in allele frequencies were estimated between Barcelos and Santa Isabel do Rio Negro using an http://www.r-project.org). Performing multiple statistical tests lead to an inflation in the occurrence of false positives and, by using a permutation approach that accounted for correlation between markers and tests, the estimated p-value cut-off of 0.003 was considered statistically significant.Statistical analysis of SNPs on the X chromosome was performed for each gender separately and, where applicable, the results were pooled using meta-analytic techniques. All analyses were performed using the R statistical package  or due to a high rate of missing genotype calls . any_malaria versus never_malaria group: rs1800896– IL10-1082 , rs2706384 - IRF1 , rs2242665 - CTL4 , rs4986790 - TLR4  and rs909253 - LTA+252  , rs2242665 - CTL4 , rs4986790 - TLR4  and rs909253 - LTA+252 . When analyzing clinical_malaria versus asymptomatic infection group, associations were observed with the TNF-376 promoter SNP , previously associated in a number of other malaria studies. , rs1800896 - IL10-1082 , rs3024500  and rs1800890 - IL10-3533 . There was a high linkage disequilbrium (LD) between the three IL10 polymorphisms (minimum pairwise D’  = 0.85). A haplotype analysis of these three polymorphisms  revealed that those with the GCT allelic combination (∼10% frequency in population) were at a lower risk of any form of malaria  when compared to the common ATA combination  see . Four of−, which is a deficiency surrogate that occurs at a low frequency in our population (<3%). Two other candidate polymorphisms with a strong presence in the malaria literature, type HbS and B blood groups, were present at low frequencies in our population (<4%) and, therefore, lacked the power to detect an association  located in the CTL4 gene, displayed a significant association with reduced risk for clinical (mild) malaria. This gene encodes for a possible sodium-dependent transmembrane transport protein involved in the uptake of choline by cholinergic neurons. As the MHC class III region has a complex haplotype structure with long-range LD patterns, this finding could arise from a functional variant in high linkage with this SNP.Plasmodium infections.Polymorphic variability in the innate immune response gene IL-10 also showed a strong haplotype risk association  and beta (LT-ß/LTB) genes, which are closely related. The TNF and LTA genes are implicated in the host defense and pathogeneses of severe malaria In addition, the TNF-376 promoter SNP (rs1800750) was identified to have an association with clinical malaria . An assoP. falciparumP. falciparum infection both in healthy adults and children displaying severe and uncomplicated malaria P. falciparum infection levels Other cytokine-related findings include one SNP (rs2706384) in the Interferon Regulatory Factor 1 gene (IRF1), which was associated with an increased risk for clinical malaria. IRF1 is a critical mediator of IFN-γ activity and is crucial in both innate and adaptative immune responses against Finally, a polymorphism was seen in the TLR4 gene (rs4986790) that was associated with reduced risk for clinical malaria. Previous studies in an Amazonian population reported no association between TLR4 and mild malaria Plasmodium infection and malaria outcomes. To understand which are the real causal variants, re-sequencing of LTA, TNF and CTL4 genes and the surrounding MHC class III in a range of populations will be necessary to assist the design of large scale epidemiological studies. Previous candidate polymorphisms have arisen mostly from studies in an African setting, where the linkage disequilibrium or correlation structure between SNPs, the absence of Plasmodium vivax, endemicity, and disease severity complicate their relevancy to Amazonian populations. For example, the data analysis from our study revealed no significant associations for gene polymorphisms of the sickle-cell trait, blood-related polymorphisms and G6PD A- surrogate, which display inherited innate resistance to malaria. These results were not unexpected, given that the low frequencies of these alleles in the Brazilian population together with the current sample size that restricted the resolving power of the analysis to detect associations.Overall, this study represents the first association study from an Amazonian population involving a large number of host genetic polymorphisms with susceptibility or resistance to The issue of malaria disease association mapping and its implications for disease management in multiple geographic locations remains a major challenge confronting the field. The differences highlighted here and the association of specific SNP polymorphisms with clinical malaria in the Amazon basin support the need for additional studies. The results suggest a need for associations studies with more dense mapping of candidate genes, especially CTL4 and IL-10, along with other genes from the major histocompatibility complex region to identify additional functional variants most relevant for malaria in Amazonian populations.Table S1List of all polymorphisms genotyped in this study.(XLS)Click here for additional data file.Table S2X chromosome analysis.(XLS)Click here for additional data file.Table S3Allele frequencies differences between Santa Isabel do Rio Negro and Barcelos.(XLS)Click here for additional data file.Table S4Allele frequencies and test of association - Any_malaria versus never_malaria group.(XLS)Click here for additional data file.Table S5Allele frequencies and test of association - Asymptomatic versus never_malaria group.(XLS)Click here for additional data file.Table S6Allele frequencies and test of association - Clinical_malaria versus never_malaria group.(XLS)Click here for additional data file.Table S7Allele frequencies and test of association - Clinical_malaria versus asymptomatic group.(XLS)Click here for additional data file.


Malaria is a leading cause of ill health and neuro-disability in children in sub-Saharan Africa. Impaired cognition is a common outcome of malaria with neurological involvement. There is also a possibility that academic achievement may be affected by malaria with neurological involvement given the association between cognitive ability and academic achievement. This study investigated the effect of malaria with neurological involvement on cognitive ability, behaviour and academic achievement.This prospective case-control study was carried out in Kampala City, Uganda between February 2008 and October 2010. Sixty-two children with a history of malaria with neurological involvement were followed up and given assessments for cognitive ability , behaviour  and academic achievement  three months after the illness. Sixty-one community controls recruited from the homes or neighbouring families of the cases were also given the same assessments. Tests scores of the two groups were compared using analysis of covariance with age, sex, level of education, nutritional status and quality of the home environment as covariates. This study was approved by the relevant ethical bodies and informed consent sought from the caregivers.Children in the malaria group had more behavioural problems than the community controls for internalizing problems , = -6.34 to -1.08, p = 0.007). There was marginal evidence of lower attention scores . However, excluding one child from the analyses who was unable to perform the tests affected the attention scores to borderline significance . No significant differences were observed in other cognitive abilities or in academic achievement scores.Malaria with neurological involvement affects behaviour, with a minimal effect on attention but no detectable effect on academic achievement at three months post discharge. This study provides evidence that development of cognitive deficits after malaria with neurological involvement could be gradual with less effect observed in the short term compared to the long term. Plasmodium falciparum, is one of the most commonly occurring infections in children in sub-Saharan Africa with approximately 515 million clinical episodes annually [Malaria, caused by annually . One of annually . In addiannually . Two proannually . ImpairmIn a Kenyan study, malaria with impaired consciousness was associated with deficits in attention at three years post illness with 14% impaired . A similet al also observed that both cerebral malaria and malaria with complicated seizures led to deficits in non-verbal functioning and speech and language in Kenyan children [Carter children . These cchildren . Cerebrachildren .Working memory and attention deficits, which are commonly reported outcomes in the above studies, have been associated with poor reading and arithmetic achievement in children -19 implyLower grades in school have also been reported among children exposed to infection with non-severe malaria ,24 suggeThere is also inconclusive evidence on whether malaria with neurological involvement may result in dysfunctional behaviour in children. Studies that have assessed behavioural outcomes of cerebral malaria were either case studies ,28 with This study assessed cognition, behaviour and academic achievement in Ugandan children three months after an episode of malaria with neurological involvement.Plasmodium falciparum on blood smears) and either one or more of the following; 1) convulsive seizures lasting over 15 minutes or repeated seizures observed by the parent or during admission at the hospital, 2) impaired consciousness , or 3) coma . A physical examination and medical history were done on admission.Children were recruited from Mulago Hospital, the National Referral Hospital of Uganda, and from Nsambya, Rubaga and Mengo Hospitals, all located in Kampala, Uganda's capital city. The latter three are large private mission hospitals. Participants were children aged five to 12 years presenting with malaria  to detect differences of 0.71 in attention, 3.76 in working memory, 4.05 in arithmetic, 4.99 in reading, 3.75 in internalizing problems and 5.13 in externalizing problems.This study set out to examine in children, the effect of malaria with neurological involvement on cognitive ability, academic achievement and behaviour three months after infection. Malaria with neurological involvement was associated with increased behavioural problems and a minimal effect on attention but did not affect academic functioning.et al [et al [et al [This is the first study to use standardized measures to assess both the behavioural and academic outcomes after malaria with neurological involvement. Recent studies from Uganda show that malaria with neurological involvement is associated with severe behavioural problems like hyperactivity, aggressive behaviour, autism spectrum disorders, internalizing problems (withdrawn/depressed and thought problems) and externalizing problems  ,30. The et al  in a clil [et al  reviewedl [et al  were frol [et al  report svs 7% at three months [Both retrospective and prospective studies have shown that severe malaria does affect cognition with rates of impaired cognition ranging between 14 to 26% ,32. The e months . What iset al [et al [This implies that much as malaria with neurological impairment has been associated with cognitive impairment, there seems to be a gradual development of these deficits, which become more pronounced and severe, as was shown at the 24-months assessments by John et al . This mal [et al  study coet al [et al [In a re-analysis of cognitive test scores from John et al  and Boivl [et al  using a et al [et al [The heterogeneous nature of the malaria group may be another reason why minimal group-average effects were seen in the current study. Of the sixty-two children with malaria in this study, nine had cerebral malaria, 34 had seizures, and 19 had impaired consciousness but no coma. The study by Boivin et al , which al [et al  and BergSimilarly, absence of an effect on the academic achievement scores could also be attributed to the heterogeneous sample and assessment at three months, which is too early to see any effect. This contrasts with studies in which effects on academic performance were seen at two weeks after infection with less severe forms of malaria . Other sThis study adds to the body of knowledge that malaria with neurological involvement does affect behaviour and cognition, highlighting the need for intervention among child survivors. The observation that these deficits may become more evident with time also necessitates interventions to arrest this trend. It has been previously shown that computerized cognitive rehabilitation training does improve cognition and behaviour after severe malaria infection ,45.However, there are several limitations in this study that necessitate caution when interpreting the results. The case-control design used is not sufficient to test causality especially with the limited follow-up time and demographic differences in the cases and controls. The observed effects could also include artefacts of these differences. The heterogeneous sample of the malaria group may affect outcomes since risk factors for cognitive deficits like coma, seizures, neurological signs, hypoglycaemia and malnutrition ,6,32,46 Malaria with neurological involvement results in behaviour problems, affects cognition minimally but may not affect academic achievement at three months. Understanding the burden of malaria with neurological involvement on cognition, academic achievement and behaviour can best be achieved with large long-term prospective studies. Despite the minimal effects in this study, interventions planned early may improve the lives of these children.The authors declare that they have no competing interests.PB conceived the study, participated in the data collection, analysis, interpretation and writing of the manuscript. PA, MJB, CCJ, AE and SM participated in the interpretation and writing of the manuscript. TLB participated in the analysis, interpretation and writing of the manuscript. All authors read and gave approval of the final version to be published.


In Ethiopia, light microscopy is the gold standard for malaria diagnosis although it is not available in most peripheral health facilities. It is time consuming, requires trained personnel and needs careful preparation and application of reagents to ensure quality results. This study was aimed at testing the diagnostic performance of CareStart™ malaria rapid diagnostic test (RDT) with reference to light microscopy for the diagnosis of falciparum and vivax malaria in Ethiopia.Blood samples were collected from 254 patients suspected to have malaria at Kola Diba Health Center in the late malaria transmission peak season from November 2011 to December 2011. The samples were examined immediately by light microscopy and the RDT . Statistical analysis was performed using SPSS version 16 and the JavaStat two-way contingency table analysis.TM RDT was found to be 95%  and 94.2% , respectively. The sensitivity of the CareStartTM RDT for Plasmodium falciparum or mixed infection was calculated to be 92.9%  while a sensitivity of 90.9%  was found for non-falciparum species. The specificity for P. falciparum or mixed infections was found to be 95.4%  while it was 97.3%  for non-falciparum species. There was an excellent agreement between the two tests with a kappa value of 0.918.The overall sensitivity and specificity of CareStartTM RDT test showed good sensitivity and specificity with an excellent agreement to the reference light microscopy. The RDT could therefore be used in place of light microscopy, which in poor set-ups cannot be used routinely.The CareStart Plasmodium falciparum and Plasmodium vivax are the major parasites accounting for about 70% and 30% of infections, respectively, during peak transmission periods [Malaria is ranked as the leading communicable disease in Ethiopia, accounting for about 30% of the overall Disability Adjusted Life Years lost. Approximately 68% of the total population of 78 million lives in areas at risk of malaria . Accordi periods ,3.The malaria transmission pattern in Ethiopia is highly seasonal and unstable . BecauseIn the prevention and control of malaria, prompt and accurate diagnosis is the key to effective disease management . HoweverP. falciparum and other species have been used by health extension workers (HEWs) at health posts in Ethiopia since 2005 [Malaria rapid diagnostic test (RDT) was introduced in the 1990s and has undergone many improvements [nce 2005 -14. It iThis study was conducted to evaluate the sensitivity and specificity of CareStart™ rapid malaria test in reference to the conventional LM in north-west Ethiopia.2. The altitude of the district ranges between 1,750 and 2,100 m above sea level. It has a population of more than 300,000 and the majority of its population depends on subsistence farming. Kola Diba Health Center is one of the health centres in the district where people with symptoms suggestive of malaria obtain free services for diagnosis and treatment. Despite the presence of different control activities in the area, it remained endemic for both P. vivax and P. falciparum malaria despite a strong control effort.The cross-sectional study was conducted at Kola Diba Health Center in Dembia District from November to December 2011, which was a peak transmission season in Ethiopia. The district is malarious and covers an area of 1,270 kmTwo hundred and fifty four malaria suspected patients attending the medical and paediatric out-patient departments of Kola Diba Health Center during the study period were included and screened for malaria infection using LM and the CareStart™ RDT. Patients who had received anti-malarial drugs during the past four weeks and critically ill patients who were unable to give blood were excluded from the study.The socio-demographic characteristics and clinical data of the participants were collected using a structured and pre-tested questionnaire. Finger-prick samples were collected and placed in a grease-free, clean, glass slide. The same finger-prick blood sample was used to carry out the RDT in parallel, following manufacturer’s instructions. In a single slide, both thick and thin films were prepared. The thin films were fixed in methanol after air-drying, the slides were stained in 10% Giemsa solution for 15 min. Thin and thick films were read at the health centre by an experienced laboratory technician and the result was considered negative if no parasites were seen after examination of 200 fields at 1,000x magnification. The technician was blinded to the results of the RDT. All blood films were re-read a second time by an experienced microscopist at Gondar University Hospital laboratory who was also blinded to initial microscopy and RDT results. In cases where the results were discordant, a third expert reader was used. The results of the third expert reader were considered final. All the microscopists were from Gondar University Hospital laboratory. The laboratory is labelled as three star laboratory during the national pre-accreditation assessment by the Ethiopian Health and Nutrition Research Institute (EHNRI) which is on the final stages of accreditation by the WHO-AFRO. The laboratory is involved in external quality assurance (EQA) at EHNRI and the Amhara Regional Research and Diagnostic Laboratory. All the microscopists involved in the study had pre-study training and were qualified.P value of less than 0.05 was considered significant in all comparisons.The collected data were computerized using Excel program, exported and analysed by SPSS version 16 and JavaStat two-way contingency table analysis. Sensitivity, specificity, and positive and negative predictive values were determined for both tests and compared with one another. Kappa value was determined to see the consistency of the results among the diagnostic tools. A Ethical clearance was obtained from the Institutional Review Board (IRB) of the University of Gondar, College of Medicine and Health Sciences. Verbal consent was taken from all study participants and mothers/guardians of all children under 18 after explaining the purpose and objective of the study. Participants who were diagnosed to have malaria were given the appropriate treatment at the health centre.A total of 254 malaria-suspected patients were included in the study. The male to female ratio was 1.57:1 while the mean age  of the participants was 21.4 years . Most of the participants were from rural areas of the district (77.2%). Table P. falciparum, 58 (22.8%) for P. vivax and six (2.4%) for mixed infections. Using the CareStartTM RDT, the overall parasite positivity was 100 (39.4%): 50 (19.7%) for P. falciparum, 24 (9.5%) for P. vivax and 26 (10.2%) for mixed infections (Tables P<0.001). The difference of in detection of P. falciparum parasite using either tests was also insignificant (P<0.001). However, difference in detection of P. vivax using the LM and RDT was found to be significant (P<0.001). Considering mixed infection as P. falciparum, the difference of detection was found to be significant (P<0.001).The overall parasite positivity using LM was 104 (40.9%): 40 (15.7%) for  was 100 9.4%: 50 TM RDT was found to be 95%  and 94.2% , respectively. The positive predictive value (PPV) and the negative predictive value (NPV) were found to be 91.3%  and 96.7% , respectively. There was an excellent agreement between the LM and CareStartTM RDT with a Kappa value of 0.918   to “Pf plus PAN” (by RDT) were compared, whilst non-falciparum infections detected by LM were compared directly to the “PAN only” RDT results  while a sensitivity of 90.9%  was found for non- falciparum species. The specificity for P. falciparum or mixed infections was found to be 95.4%  while it was 97.3%  for non-falciparum species  [This study had also tried to evaluate the performance of the CareStartEthiopia . The sen (78.5%) . However (78.5%) , south E (78.5%)  and Mada (78.5%) . These d (78.5%) .TM in the present study for P. falciparum or mixed infections was higher than the reports from Oromia Regional State in Ethiopia and Madagascar [falciparum species in the current study was comparable to the reports of some studies [The specificity of the CareStartdagascar ,17 and ldagascar  and soutdagascar . The spe studies  and lowe studies ,12. The  studies .The RDT had high NPV, meaning that it was reliable in ruling out malaria. Similarly, the higher PPV means that patients will be correctly diagnosed as positive for malaria and avoids unnecessary treatment.TM RDT (39.4%) or the LM (40.9%). The result was higher than the report from Oromia Regional State in Ethiopia (23.2%) [The overall prevalence of malaria in the study area was very high, as detected by either the CareStart (23.2%)  while it (23.2%) . The hig (23.2%) . On the  (23.2%) . The kno (23.2%) . However0c) was the most common presenting symptom by the participants (Table Current subjective or objective fever (axillary temperature of >37.5ts Table . Fever dTM RDT test showed good sensitivity and specificity with an excellent agreement to the reference LM. The RDT could therefore be used in place of LM, which in poor set-ups cannot be used routinely.The CareStartCI, Confidence Interval; HEWs, Health Extension Workers; HRP-2, Histidine-Rich Protein 2; IRB, Institutional Review Board; LDH, Lactate Dehydrogenase; LM, Light Microscopy; NPV, Negative Predictive Value; OR, Odds Ratio; PPV, Positive Predictive Value; RDT, Rapid Diagnostic Test; WHO, World Health Organization.The authors declare that they have no competing interests.BM was involved in the study conception and design, data analysis, and drafting the manuscript. AK, AM BA, YB and ZT were involved in study conception and design and drafting the manuscript. MG, AG and DW were involved in data collection and reviewing the manuscript. All the authors have read, edited and approved the manuscript.


The World Health Organization recommends discharging children admitted to nutrition programs treating severe acute malnutrition, with a low mid-upper arm circumference (MUAC <115 mm) when weight gain is >15%. When this recommendation is followed, the most severely malnourished children receive a shorter treatment compared to children that are less severely malnourished. This study assesses whether using MUAC >125 mm as discharge criteria eliminates this effect.p = 0.000) and also a higher percent weight gain (p = 0.000) than children with higher MUAC. Similar results with weight-for-height z-scores categories were shown with both duration of treatment (p = 0.000) and percent weight gain (p = 0.000).Data from 753 children cured from a Médecins Sans Frontières outpatient nutrition program in Gedaref, North Sudan were analyzed. MUAC >125 mm was used as discharge criteria. Length of stay and percent weight gain of children were compared in relation to nutritional status on admission. Children with low MUAC on admission had a longer duration of treatment (This study shows that using MUAC as the discharge criteria eliminates the effect of shorter treatment in most severely malnourished children compared to least severely malnourished, as is observed with percent weight gain. The findings directly address the main concern that has been identified with the current WHO recommendation of using percent weight gain. MUAC could be used as discharge criteria, instead of percent weight gain, as having a longer duration of treatment and a higher percent weight gain for the most malnourished is highly desirable. The commonly used approach of the community management of acute malnutrition model (CMAM) includes both inpatient care in stabilization centres (SC) and/or outpatient care in outpatient therapeutic programs (OTP) depending on the presence or absence of complications Nearly 20 million under-5 children worldwide suffer from severe acute malnutrition (SAM) which contributes to the death of an estimated 1 million children per year In 2009 the World Health Organization (WHO) and United Nations Children’s Fund (UNICEF) provided new guidance on the admission criteria for programs treating SAM advising to include children less than -3 z-scores from the median weight-for-height z-scores (WHZ) of the WHO 2006 growth standards or a mid-upper arm circumference (MUAC) of less than 115 mm, and/or oedema Since the establishment of CMAM programs many organizations have started using MUAC for admission into their community based nutrition programs In addition to guidance on admission criteria for nutrition programs, the WHO and UNICEF 2009 Joint Statement also gave some guidance regarding discharge criteria in nutrition programs using MUAC on admission, recommending to discharge children after reaching a 15–20% weight gain Using percent weight gain as discharge criteria has the disadvantage of requiring a smaller absolute weight gain to meet discharge criteria for children with the lowest initial weight, . This leads to shorter duration of treatment for the most malnourished children as weight gain is higher in the most wasted children receiving appropriate treatment Based on the difficulties with the current recommendation of percent weight gain for discharge and on evidence that MUAC and weight respond to treatment in similar ways The objective of this paper is to evaluate the policy of using MUAC as discharge criteria in outpatient therapeutic programs and more specifically to see whether it eliminates the effect of shorter treatment duration in most severely malnourished children as observed with percent weight gain.Written consent was not obtained from the caretakers for storing data used for this analysis in the MSF database as these data were collected as part of routine patient monitoring and program evaluation. Furthermore, these data were entered anonymously before being used for this analysis. Ethical approval for the study was given by the Ethical Review Board of Médecins Sans Frontières.In July 2010 MSF Switzerland, in collaboration with the Ministry of Health, launched an emergency nutrition program in the localities Gala Alnahal and Al Guiresha in Gedaref, North Sudan. The total estimated population of children less than 5 years for the two localities was around 25 000. Gedaref is a state known normally for its strong crop production producing sorghum and sesame for the entire country. During the years of 2008–2010 Gedaref experienced poor rainfall and thus decreased crop production. As a result, there were a large number of small farmers and agricultural workers that experienced notable reduction of their income and food sources particularly among the lower socio economic groups who were already quite vulnerable to economic shocks.The program treated malnourished children in a community-based therapeutic feeding program in 4 SCs and 77 OTPs. Children aged 6 to 59 months with MUAC <115 mm and/or mild oedema had an initial assessment by a physician or medical assistant for the presence of diarrhea, vomiting, anorexia, anemia , and fever. The children were also checked for malaria parasitemia using a rapid diagnostic test, specifically Paracheck Pf ®, and whether they had previously been immunized against measles. Children with good appetite and no severe medical complications  were classified as having uncomplicated SAM and admitted to the OTP. Children in the OTP received Ready to Use Therapeutic Food as per WHO guidelines All children in the program had their height, weight, MUAC and oedema checked at admission; weight, MUAC and oedema were checked at each visit; weight and MUAC were checked at discharge.Pediatric height boards of standard design were used to measure height as per MSF nutritional guidelines The following criteria for discharge were required: MUAC >125 mm for 2 consecutive measurements plus stable weight or continuing weight gain; absence of bilateral oedema for 4 weeks; clinically well and with good appetite. MUAC cut off for discharge was set at 125 mm based on evidence that there is very low mortality in children with MUAC above 125 mm All children aged 6–59 months with a MUAC <115 mm on admission who were discharged as cured from the OTP were included in the study. The study was limited to children admitted directly to the OTP as duration of treatment and weight gain during the stabilisation phase is mainly influenced by associated medical complications and largely unrelated to response to therapeutic feeding. This also excluded from the analysis children with severe oedema who were treated initially in SC. These children receive a low-protein low-energy diet at the beginning of treatment which does not allow for new tissue synthesis and weight change during these initial days and is more related to body water elimination than to synthesis of new tissues The decision to use MUAC as discharge criteria was made by MSF for programmatic reasons. This analysis was carried out only with data routinely collected to monitor the program according to current MSF guidelines and thus individual written consent was not obtained. All data entered into the database was done anonymously.Children were admitted into the program from July 12, 2010 to December 11, 2010, the last patient was discharged from the program on December 22, 2010. Anthropometric data of all children in the program were recorded in the study database. The initial number of children meeting the inclusion criterion (MUAC <115 mm) who were cured in the OTP was 1022. The following children were excluded from the study: i) missing admission data or discharge data; ii) a percent weight gain <0 or percent MUAC gain <0 with no oedema on admission; iii) a length of stay less than 14 days. The flowchart describes exclusion of these children from the study sample .Children were classified into different categories based on admission MUAC and WHZ. Duration of treatment and percent weight gain were compared across these categories. Percent weight gain was also compared for different height categories, height being used as a proxy for age in this population where accurate ascertainment of age is difficult.Statistical analysis was done by using MYSTAT . WHZ was calculated using the WHO Anthro (version 3.2.2 January 2011) software. The Kruskal-Wallis non parametric test was used for comparisons of lengths of stay and percent weight gain by categories of MUAC at admission, height at admission, and WHZ at admission. This non-parametric procedure was used because it is robust to deviations from normality and because median length of stay is a more useful measure of the average length of treatment episodes than is the mean length of stay which can be influenced by extreme values from (e.g.) a handful of complicated cases. The null hypothesis for the Kruskal-Wallis test is that the populations from which the sample originates have the same median. Cochran’s test for linear trend was used to look at the association between ordered and contiguous MUAC categories and the proportion of children achieving a weight gain of at least 15%. The null hypothesis for Cochran’s test for linear trend tells us that the slope of a regression line across the proportions is zero.753 children were included in the analysis. 52% of the children were female and the median age was 16 months. 88% of the children in the program were between 6 months and 29 months. The profile of the study population by age and sex is shown in Outcomes of the children in the OTP were within SPHERE standards The overall median length of stay of all children in the study was 60 days (inter-quartile range (IQR) = 43; 81). Children with lower MUAC at admission had longer durations of treatment , with median durations of treatment in the lowest MUAC group of 75 days  and highest MUAC group of 56 days . The overall percent weight gain of all children in the study was 21 . Children with low MUAC also had higher percent weight gain , with median percent weight gain of 37 in the lowest MUAC group  and 17 in the highest MUAC group   and 4. RThe majority of children in all MUAC categories gained more than 15% of their weight at admission, with the highest proportion among those with the lowest MUAC  .Similar results for WHZ to those for MUAC categories on admission were found, with both duration of treatment  and percent weight gain  decreasing as WHZ categories increased  and 7.This study shows that using MUAC as discharge criteria eliminates the effect of shorter treatment in most severely malnourished children and longer treatment for least severely malnourished, as observed with percent weight gain. The findings directly address the main concern that has been identified with using the current WHO recommendation of percent weight gain.The study also shows that as a result of the longer treatment, the most severely malnourished children such as those with the lowest MUAC on admission achieve a higher percent weight gain than the recommended 15%. Consistent results were obtained when children were classified according to their weight-for-height z-scores. Again the length of stay is longer and percent weight gain is higher for the most severely malnourished.One limitation to the study is the number of children who were excluded from the analysis. Most exclusions (81%) were due to missing admission and discharge measurements, mainly due to missing height data. These missing measurements were unavoidable since we were working with routine program data from an emergency nutrition program. They also occurred randomly and are unlikely to have biased our results. In this regard, admission MUACs were compared in the dataset prior to these exclusions and no significant differences were found from the final results so biases from the exclusions seem unlikely.Since MUAC has been accepted as independent admission criteria for SAM treatment, criteria for discharge have remained debated. WHZ, the nutritional index which was previously recommended as discharge criteria for more than 20 years could not be recommended, as there is an imperfect match between MUAC and WHZ and some children may qualify for discharge shortly after admission or even on admission. For simplicity, it would be easier to use the same criteria for admission and discharge however MUAC has not been used so far as there is little data on response to treatment of this anthropometric measure. Percent weight gain was recommended, despite the expected undesirable effect of having shorter duration of treatment for the most malnourished children. Our results suggest that MUAC responds to treatment and that using MUAC as discharge criteria leads to an average similar percent weight gain to the 15–20% recommended by WHO. Our results also show that the duration of treatment and percent of weight gain are higher in the most malnourished children.A formal cost comparison of using MUAC versus percent weight gain as discharge criteria in nutrition programs is beyond the scope of this paper. However we did look at the length of stay which is a major determinant of the cost of treatment. We compared this Gedaref program that used MUAC as discharge criteria with the 2009 MSF program in Burkina Faso that used 15 percent weight gain as their discharge criteria. The average lengths of stay in these programs for children admitted with a MUAC less than 115 were 64 We suggest using MUAC as discharge criteria, instead of a uniform percent weight gain, as having a longer duration of treatment and a higher percent weight gain for the most malnourished is highly desirable. Furthermore, the feasibility of using MUAC is less complicated than using percent weight gain and more transparent for mothers to understand.Our study suggested that using MUAC >125 mm was feasible and led to acceptable durations of treatment and weight gains in our setting. It is not possible from our data to assess whether this discharge criteria was optimal or whether it would be applicable to other settings. A follow-up of children discharged with a MUAC >125 mm with close monitoring of relapse and risk factors would be useful to confirm its validity. In addition, the validity of this cut-off should be confirmed in other settings.


Plasmodium vivax and Plasmodium falciparum parasites isolated from peripheral and placental blood in pregnant women living in North-west Colombia, and compared with parasites causing acute malaria in non-pregnant populations.Placental malaria is the predominant pathology secondary to malaria in pregnancy, causing substantial maternal and infant morbidity and mortality in tropical areas. While it is clear that placental parasites are phenotypically different from those in the peripheral circulation, it is not known whether unique genotypes are associated specifically with placental infection or perhaps more generally with pregnancy. In this study, genetic analysis was performed on P. vivax or P. falciparum. Five molecular markers per species were genotyped by nested PCR and capillary electrophoresis. Genetic diversity and the fixation index FST per species and study group were calculated and compared.A total of 57 pregnant women at delivery with malaria infection confirmed by real-time PCR in peripheral or placental blood were included, as well as 50 pregnant women in antenatal care and 80 men or non-pregnant women with acute malaria confirmed by a positive thick smear for P. vivax molecular markers ranged from 0.765 to 0.928 and for P. falciparum markers ranged from 0.331 to 0.604. For P. vivax infections, the genetic diversity was similar amongst the four study groups and the fixation index from each pairwise comparison failed to show significant genetic differentiation. For P. falciparum, no genetic differentiation was observed between placental and peripheral parasites from the same woman at delivery, but the parasites isolated at delivery showed significant genetic differentiation compared with parasites isolated from subjects with acute malaria.Almost all infections at delivery were asymptomatic with significantly lower levels of infection compared with the groups with acute malaria. Expected heterozygosity for P. vivax parasites have high genetic diversity that is equivalent in pregnant and non-pregnant populations as well as in symptomatic and asymptomatic infections. For P. falciparum, the overall genetic diversity is lower, with specific genotypes associated with asymptomatic infections at delivery.In North-west Colombia,  Plasmodium falciparum and Plasmodium vivax infections cause adverse pregnancy outcomes, however only P. falciparum has been studied extensively [1 − Σpi2, where n is the number of isolates analyzed and pi is the frequency of the ith allele in the population. The FST index[ST value was tested to determine whether it was statistically different from 0, involving 10000 random permutations of the data. Kruskal-Wallis and Chi-squared tests were used for comparison of continuous and categorical variables, respectively. Significance was set at p <0.05.Microsatellite analyzer version 4.05 was usedST index with paiPatients or guardians, in case of <18 years of age, signed a voluntary consent form. The study involved minor risk and approval was granted by the Comité de Ética of Instituto de Investigaciones Médicas, Facultad de Medicina, Universidad de Antioquia  and the Health Research Ethics Board of the University of Alberta.P. falciparum was detected in 47% (41/88) of infections, P. vivax in 43% (38/88) and 10% (9/88) were mixed infections. Almost all women in the delivery group were asymptomatic; only seven women (12%) had symptoms associated with malaria.Women with malaria infection at delivery (delivery group) had a mean age of 23 ± 6 years (range of 14 to 38 years) and 31% were primiparous. Of the 57 women in this group, 31 (54%) had a plasmodial infection detected by qPCR in both peripheral and placental blood, 17 (30%) had infection only in placental blood, and 9 (16%) were only positive in peripheral blood, for a total of 88 infections at delivery. P. vivax monoinfection in all 30 samples diagnosed by thick smear, while P. falciparum monoinfection was confirmed in 19 out of 20 samples, with one sample diagnosed as P. falciparum by thick smear but with a mixed infection detected by qPCR.The mean age of pregnant women attending antenatal care  was 22 ± 6 years (range of 13 to 38), 16% were in their first trimester of pregnancy, 59% in the second trimester and 25% in the third. The qPCR test confirmed Plasmodium falciparum monoinfection was confirmed by qPCR in 38 of 40 samples, P. vivax monoinfection in 39 of 40, and there were three mixed infections. Individuals in both antenatal and non-pregnant groups had symptomatic malaria and received the treatment recommended by the Colombia health authorities based on the thick smear result.The mean age in the non-pregnant population group (non-pregnant group) was higher than the other two groups , but statistically similar (p = 0.2509). P. falciparum infections  or qPCR (DNA copies/μL template) was significantly lower in the delivery group, particularly for ns Table. The lowPlasmodium vivax showed significantly higher genetic diversity than P. falciparum  of P. vivax samples, and only 17% (19/113) of P. falciparum samples.um Table. The numHe was similar for P. vivax in all study groups yet for P. falciparum, the delivery samples had a higher He than the antenatal and non-pregnant groups  for P. vivax infections did not show significant genetic differentiation  and significant differentiation was detected when parasites isolated from peripheral and placental blood of pregnant women at delivery were compared with parasites isolated from antenatal and non-pregnant subjects. The highest genetic differentiation was observed between parasites from the delivery (periphery or placenta) and non-pregnant groups. The comparison of peripheral and placental parasites within the delivery group did not display significant genetic differentiation. In addition, a comparison of the predominant alleles revealed that only one of five markers from the placental parasites were shared with those from the antenatal and non-pregnant groups, while peripheral parasites at delivery shared 3 of 5 markers  or the compartment from the same subjects . However, polyclonal infections were significantly more common in antenatal and non-pregnant than in delivery in both peripheral and placental infections. A similar finding was observed for P. falciparum infections; higher genetic diversity and fewer polyclonal infections were detected in the delivery group compared with the antenatal and non-pregnant groups. This can be explained by the low level of parasitaemia and parasite DNA copies detected in women of the delivery group, consistent with asymptomatic infection. Other authors also reported an association between low parasitaemia and low complexity infections[The number of different alleles detected and fections-48.P. falciparum and P. vivax infections. This finding agrees with previous reports from Colombia that both P. vivax and P. falciparum uncomplicated malaria patients have low parasitaemia [P. vivax infections[P. vivax exclusively invades reticulocytes[The selection criteria used in this study likely explains the differences in parasite density observed across the study groups; all parturient women included here (delivery group) were part of a larger prevalence study on malaria infection at delivery, whose plasmodial infection was detected only by PCR (submicroscopic infection) in most cases. In contrast, selection of subjects included in the other two groups  was based on a positive thick smear (microscopic infection). Interestingly, in both groups with microscopic infection , the level of parasitaemia was similar for ites/μL)-51. Howefections-54 attriulocytes,56.P. falciparum infections showed specific parasite genotypes associated with delivery vs. non-pregnant populations. Two hypotheses could explain this finding. First, different parasite genotypes can be associated with low vs. high levels of parasitaemia. Previous studies in non-pregnant populations have reported association of specific genotypes with low parasitaemic and asymptomatic infections[P. falciparum may segregate differentially to peripheral and placental blood. Other authors have compared P. falciparum clones isolated from matched peripheral and placental blood using genes that encode surface proteins such as msp1 and msp2[dhfr, dhps[pfcrt[dhfr-dhps studies failed to find an association of specific genotypes per compartment, the msp1-msp2 and pfcrt studies did identify specific genotypes present exclusively in the placenta.One of the most significant findings in this study is that fections, as wellfections. Second, and msp2-16 or gehfr, dhps,60, and hps[pfcrt,62. AlthP. falciparum infections suggests that different strains or parasite genotypes share the phenotypic property of adherence to placental tissue. Genetic characterization of placental parasites should therefore be considered in the development of a pregnancy-associated malaria vaccine to ensure maximum cross-protection against genetically different strains.The genetic diversity and differentiation of placental parasites in P. vivax parasites have high genetic diversity, which is conserved in pregnant and non-pregnant populations as well as in symptomatic and asymptomatic infections. For P. falciparum, the genetic diversity is lower compared with P. vivax with specific genotypes that are associated with low-level, asymptomatic infections at delivery.This study affirms that in North-west Colombia P. falciparum–infected red blood cells; CSA: Chondroitin sulfate A; PfEMP1: P. falciparum erythrocyte membrane protein 1; qPCR: Quantitative real-time polymerase chain reaction; Ct: Cycle threshold; RFU: Relative fluorescence units; He: Expected heterozygosity; bp: Base pairs.Pf-iRBCs: The authors affirm that they have no commercial or other association that might pose a conflict of interest.EMA participated in the study design, carried out the molecular genotyping and statistical analyses and wrote the manuscript. RS participated in the molecular genotyping. OMA participated in the collection of field samples. JCF participated in the study design, statistical analyses and preparation of the manuscript. AM and SKY participated in the study design, coordination and preparation of the manuscript. All authors read and approved the final manuscript.


Utility of sonographic assessments of renal changes during malaria illness are rarely reported in African children in spite of the high burden of malarial-related kidney damage.In this case–control study, renal sizes, cortical thickness and volume of the kidneys of 131 healthy children and 170 with acute falciparum malaria comprising 85 uncomplicated malaria (UM) and 85 complicated malaria (CM) cases, measured within 24 hours of presenting in the hospital were compared.3 for right and by 5.79 cm3 for left kidneys respectively; in the UM group by 9.31cm3 for right and 8.87 cm3 for left kidneys respectively.The mean age of children with UM, CM and control groups was 49.7 ± 26.2 months, 50.7 ± 29.3 months and 73.4 ± 25.5 months, respectively (p < 0.001). The mean right kidney length of CM group was higher than control by 0.41cm  and UM by 0.32 cm . Similarly, mean left kidney length of CM was higher than control and UM by 0.34 cm  and 0.41cm , respectively. Estimated mean renal volume of the CM group was significantly higher than control group by 7.82 cmPlasmodium falciparum infection, which worsened with increasing severity of malaria morbidity. Ultrasonography provides important information for detecting renal changes in children with acute malaria.There was a marginal increase in renal size of children with  Plasmodium falciparum infection is responsible for almost all the morbidity and mortality.Malaria remains a public health problem with significant morbidity and mortality posing major economic and developmental challenges in sub-Saharan Africa . MalariaP. falciparum infections can also result in nephron loss leading to chronic renal disease, including nephrotic syndrome, often non-responsive to steroid treatment [The pathophysiology of severe falciparum malaria is complex and multifactorial with parasitized red blood cell destruction resulting in the release of haemoglobin and other toxic metabolites, up-regulation of cytokines, acute phase reactants all playing important pathogenic roles which may cause inflammation, tubulo-interstitial damage, glomerulonephritis and pigment nephropathy, all of which may lead to acute kidney injury (AKI) . Moreovereatment -12.et al. [Though the occurrence of haemoglobinuria and AKI is a significant complication in children with malaria, only a few studies have reported the magnitude. A recent study reported that as many as 19.1% of children with acute falciparum malaria developed haemoglobinuria . AKI haset al.  in The Get al. .Recent studies have shown that cases of severe malaria and its complications are on the increase probably because of the emergence of drug resistant parasites ,19. EarlThe study was case–control in design. Cases were recruited from the Children’s Clinics and Emergency Unit of the University College Hospital (UCH), Ibadan, Nigeria, while controls were selected among children living in the same neighbourhood of the respective cases. The UCH is a foremost tertiary referral hospital located in Ibadan, South-West of Nigeria. The yearly admissions in the Department of Paediatrics, UCH are approximately 2,500 with about 11% of them being cases of complicated malaria. Based on the 2006 National Census, Ibadan has an estimated population of 2,550,393. Children less than 15 years constitute about 19% of the population of Ibadan.Cases were children who presented with symptoms, signs and positive blood smear for malaria parasite and control were children of similar socioeconomic status who had no symptoms and negative blood smear for malaria parasite as control. Cases were grouped into uncomplicated and complicated malaria as defined by the World Health Organization . Only ei3 in renal volume  between cases and control. Therefore, studying unmatched 170 cases and 131 controls gave a statistical power (1-β) of over 90% at 95% confidence interval (CI).At the design stage of the study, it was assumed that utilizing ultrasound, there would be a mean difference of 13.0 cmTrained research Nurses and assistants administered a pre-tested structured record form to parents and their children at the time of recruitment. Each child was examined by the paediatrician with socio-demographic data, weight and height recorded. Laboratory investigations carried out included blood smear for malaria parasite counts, plasma urea and creatinine. The malaria parasites were counted against 200 white blood cells (WBC) and parasite density was calculated for each patient based on an assumed total WBC of 8,000/μL of blood . All chiAll subjects had both kidneys scanned within 24 hours of presenting in the hospital using a portable Micromax Sonosite Inc. Bothell, WA, USA, with 5–8 MHz curved array transducer. All participants were scanned in the supine and decubitus positions in the longitudinal and transverse planes for length, width, anterio-posterior diameter and cortical thickness measured in centimeters. The liver and spleen were used as acoustic windows for the kidneys on the right and left respectively. The acquired measurements were recorded in a data form. Two certified sonologists performed the scan independently at each visit. These sonologists were blinded to the laboratory test results. The degree of agreement between findings reported by the sonologists was evaluated with the initial ten patients scanned (k = 0.9) in the pilot study.Data on kidney length, width, anterio-posterior size and cortical thickness were analysed using SPSS 16.0 statistical software . Kidney volume was estimated using the ellipsoid formula ,28. RenaParticipation in the study was completely voluntary and based on written informed consent from child caregivers and assent of the children. Parents were made to understand that they were free to withdraw their consent at any time, and that they will continue to receive standard level of care even in such situation. Privacy of participants was maintained by using serial numbers on the case record forms. The study protocol was approved by the University of Ibadan/University College Hospital Ethical Review Committee.P. falciparum malaria comprising 85 uncomplicated and 85 complicated malaria cases and 131 healthy children with negative blood smear for malaria parasite participated in this study. There were more male than female children with malaria illness (M: F = 1.4: 1); (Table 2/hour) which resolved within the first 24 – 36 hours of admission following administration of intravenous fluid in addition to other treatments. All the 42 children who had severe anaemia (haemoglobin <5 g/dl) were transfused with packed red blood cells at 12 to 15 ml per body weight (kg). However, no study participants had clinical signs of dehydration at the time of ultrasonographic scanning. All the four deaths recoded in this study had complicated  malaria giving case fatality rate of 4.7% (4/85).One hundred and seventy children with confirmed 3 for right kidney and of 18.2 cm3 for the left. All the study participants had haemoglobin AA type.Mean values of malaria parasite counts for UM and CM were as shown in Table The mean renal length, cortical thickness and estimated volume were compared between the right and left kidneys Table . The ageThe estimated and adjusted mean values of kidney size, cortical thickness and renal volume are shown in Table 3 for the right kidney (p <0.001) and 5.79 cm3 for left kidney (p = 0.026). Similarly, adjusted mean renal volume of the CM group was significantly higher than UM with mean differences of 9.31 cm3 for the right kidney (p = 0.001) and 8.87 cm3 for left kidney (p = 0.003).The adjusted mean renal volume of control and UM were not significantly different. The adjusted mean renal volume of the CM group was significantly higher than control with mean differences of 7.82 cmIn all increased parenchymal echogenicity of the kidneys were found in 12 children with complicated (14.1% of 85), eight (9.4%) had it in both kidney while four (4.7%) had it in the right kidney only. Increased parenchymal echogenicity of the kidneys was found in none of the control as well as those with uncomplicated malaria. There was no significant association between parasite counts and any of the kidney sizes. The mean renal length, cortical thickness and estimated volume of the three children who had dark coloured urine (haemoglobinuria) were not significantly different from others. Similarly, the mean values of renal sizes among four deaths were not significantly different from other children.Many studies have reported the effects of malaria on the kidneys , with moet al. [et al. [Moreover, the present study showed that UM group had increased length, width and cortical thickness in both right and left kidneys but not in the volume compared with healthy children. On the other hand, children with complicated malaria had increased renal lengths, width, and volume when compared with uncomplicated and control groups. These increased renal length, width, and volume were more in the CM group than UM. This finding suggests that the change in renal dimensions may have worsened with increasing severity of malaria illness. However, the relationship between renal length and volume has been controversially reported in previous studies. While Thakur et al.  in theiret al. ,33. WidjP. falciparum infection in the patients. Previous studies have shown that wide spread sequestration of parasitized red blood cells, excessive release of inflammatory cytokines and “sludging” effects of the parasite cause widespread swelling in many end-organs including the kidneys [Though the observed increased renal sizes in complicated malaria compared with mild malaria and healthy children were not surprising, the exact mechanism is not clear from our study. It is plausible that this observed difference in renal size may be due to the direct and indirect effects of severe manifestations of  kidneys . In the  kidneys , who shoOne issue that restricts the generalization of findings from this study is the fact that cases and control were not effectively matched in terms of age and height. These two factors are important correlates of renal sizes. However, children who participated in the study had relatively comparable renal function as determined by the plasma creatinine and urea levels. Although both creatinine and urea levels are not reliable measures of renal function because they do not pick up subtle changes and there is also a significant time lag between onset of injury and elevation of plasma creatinine.Magnetic Resonance Imaging and Computed Tomography have been shown to give better measures of renal length and volume using the disc-summation method , but in The authors declare that they have no competing interests.AEO, OMA and OOA designed the research, AEO supervised the care of all children with malaria illness, OMA and AA performed the ultrasound scanning, and AEO, OMA, AA and OOA wrote the manuscript. All authors read and approve the final manuscript.