Malaria and dengue are the most prevalent vector-borne diseases worldwide and represent major public health problems. Both are endemic in tropical regions, propitiating co-infection. Only few co-infection cases have been reported around the world, with insufficient data so far to enhance the understanding of the effects of co-infection in the clinical presentation and severity.Plasmodium sp. detection, ELISA, PCR and NS1 tests for dengue, viral hepatitis, HIV and leptospirosis. In total, 1,578 patients were recruited. Among them, 176 (11.1%) presented P. vivax malaria mono-infection, 584 (37%) dengue fever mono-infection, and 44 (2.8%) were co-infected. Co-infected patients had a higher chance of presenting severe disease (vs. dengue mono-infected), deep bleeding (vs. P. vivax mono-infected), hepatomegaly, and jaundice (vs. dengue mono-infected).A cross-sectional study was conducted (2009 to 2011) in hospitalized patients with acute febrile syndrome in the Brazilian Amazon. All patients were submitted to thick blood smear and PCR for In endemic areas for dengue and malaria, jaundice (in dengue patients) and spontaneous bleeding  should raise the suspicion of co-infection. Besides, whenever co-infection is confirmed, we recommend careful monitoring for bleeding and hepatic complications, which may result in a higher chance of severity, despite of the fact that no increased fatality rate was seen in this group. Malaria and dengue fever are typical diseases in tropical regions of developing countries; such as the Brazilian Amazon. They become serious problems in public health as they mostly affect vulnerable populations. Both diseases are mosquito-borne. These diseases present similar signs and symptoms. Brazil registers most of the malaria cases in the Amazon. The four dengue serotypes also circulate in this region. Similar to malaria, there are records of dengue outbreaks during the first months of the year, and isolated cases in the remaining months. Official records of malaria and dengue co-infection are infrequent in Brazil; however, we believe that this event is more frequent than usually reported. Our study detected high prevalence of the co-infection in the hospitalized patients infected with malaria or dengue in a tertiary health care unit, reference in the treatment of tropical and infectious diseases in Manaus, Amazonas, Brazil. We highlight the high likelihood of co-infected patients to present clinical complications. Besides, we observed that the presence of jaundice in dengue patients, and bleeding in malaria patients, are possible indications of co-infection. Therefore, this paper is useful to physicians working in the tropics, enabling the clinical suspicion of a not so rare condition. Malaria and dengue fever are the most prevalent vector-borne diseases worldwide and represent major public health problems. Dengue epidemics have been reported in several countries; 500,000 people with severe dengue require hospitalization each year, and 2.5% of those affected die. Similarly, malaria is a life-threatening disease which was responsible for 627,000 deaths in 2012 P. vivaxThe dengue virus (DENV) is the major arbovirus responsible for human disease in Brazil. The four serotypes cause a variety of clinical presentation in humans, ranging from acute self-limited febrile illness to severe and fatal forms Malaria and dengue are endemic in similar tropical regions, and therefore, may result in the possibility of co-infection. Urban demographic expansion, deforestation and agricultural settlements in peri-urban areas, are known causes of the increase in the probability of concurrent infection of these two diseases Considering the endemicity of dengue and malaria in the Amazon Fundação de Medicina Tropical Dr. Heitor Vieira Dourado , Manaus, Brazil. All participants signed an informed consent.The study was approved by the Ethics Review Board of P. vivax infection. FMT-HVD is a tertiary health care facility and a teaching and research center, which is the reference for infectious diseases in the region. Around 30% of all malaria cases reported in Manaus are assisted in this institution. During the study period, 14,884 cases of malaria and 6,302 cases of dengue fever were diagnosed in the hospital, from which 505 and 1,127, respectively, were hospitalized. In 2011, a dengue outbreak resulted in 5,400 cases reported at the FMT-HVD .The study design was a cross-sectional study of patients hospitalized with acute febrile syndrome (history of fever in the past 10 days) from 2009 to 2011. The study was carried out in FMT-HVD, Manaus, capital of Amazonas State, Northern Brazil, where all four dengue serotypes co-circulate since 2008 and 95% of malaria cases result from During the study period, all hospitalized patients with acute febrile syndrome were considered eligible. If they signed the informed consent, they were included and submitted to malaria and dengue investigation. They were also searched for hepatitis A, B and C, HIV and leptospirosis. Abdominal ultrasound and chest X-rays were also performed when indicated. Other tests were requested at physicians' discretion.P. vivax infection with primaquine-induced hemolysis (hemoglobin <10 g/dL and reticulocytes >1.5% or increased indirect bilirubin after starting primaquine) were also excluded from the analysis.Patients with P. vivax. They were compared to two different groups: malaria mono-infection (Group A), and dengue mono-infection (Group B). Severity was classified and managed according to the World Health Organization (WHO) guidelines for dengue and malaria The diagnosis of vivax malaria was confirmed by real-time PCR. The diagnosis of dengue was made either by a positive serology (IgM) or a positive NS1 protein or a positive molecular test (RT-PCR), considering that every patient was tested by all the three methods. The Group C was defined as patients co-infected with both dengue and 3. Real time polymerase chain reaction (qPCR) was performed to confirm P. vivax mono-infection. In brief, the extraction of total DNA from whole blood was performed using the QIAamp DNA Blood Mini Kit , according to the manufacturer's protocol. The DNA was amplified in an Applied Biosystems 7500 Fast System  using primers and TaqMan fluorescence labeled probes for RT-PCR Automatized blood biochemistry and whole blood count were performed systematically in all patients. The continuous variables used for analysis were the most altered throughout hospitalization. Walker's technique was used for thick blood smear The DENV diagnosis was based on three methods: a) IgM antibodies (MAC-ELISA) detection Serological tests for leptospirosis (IgM) Demographics, clinical and laboratorial characteristics from the group of patients co-infected with dengue and malaria vivax were compared to the group of patients mono-infected with dengue and the group of patients mono-infected with malaria vivax. The association between categorical variables and the risk of co-infection (as the outcome variable) was performed by means of univariable logistic regression with the presentation of the odds ratios and 95% confidence intervals. The 95% confidence intervals (95% CI) are presented. Means and standard deviation (SD) of continuous variables with normal distributions were compared using the Student's T test; those variables with non-normal distribution (as assessed by the Kolmogorov-Smirnov test) were described using median and interquartile range (IQR) and compared using the Kruskal-Wallis test. All the analyses were performed using Stata v.11  From 2009 to 2011, 1,578 patients with acute febrile syndrome were hospitalized at the FMT-HVD. Among them, 176  had vivax malaria mono-infection (Group A), 584  had dengue fever mono-infection (Group B) and 44  were co-infected with malaria and dengue (Group C). The prevalence of co-infected patients was 20% among patients with malaria and 7% among those with dengue .As shown in P. vivax mono-infected patients, the increased odds of deep bleeding in co-infected patients  was statistically significant (p<0.001), although platelet count was not different . These serotypes were the most common among the dengue mono-infection group, 127 (49.6%) and 80 (31.2%), respectively.No patient required hospitalization in the intensive care unit, and fatality rate was zero in our casuistic.In an endemic area of dengue fever and vivax malaria, we found a high prevalence of the co-infection, mainly among those with malaria. In Brazil, a prospective study performed in 2009 on 132 patients with vivax malaria found 11 co-infected and the prevalence was 8.3% In our study, being co-infected resulted in a much higher chance of presenting deep bleeding as compared to both groups of mono-infected patients, suggesting a possible synergistic pathogenic mechanism, which could be related to both capillary fragility and coagulation disorders, but not the low platelet count. Bleeding is reported as an infrequent finding in malaria, despite common platelet depletion Hepatic injury was also a concern in the co-infected group, which, together with bleeding, resulted in a higher chance of dengue severity according to WHO criteria. Jaundice in malaria is mostly a result of cholestasis or intravascular hemolysis A warning sign commonly used to describe severe dengue is hemoconcentration  Dengue warning signs, such as vomiting, abdominal pain and hepatomegaly, were very frequent in the co-infection cases. The cautious detection of these signs is of extreme importance as they characterize potential dengue severity In addition to classical warning signs and symptoms, dyspnea was also frequent in all groups, particularly in co-infected patients. Dyspnea is an early clinical feature of plasma leakage and, in dengue, may be the evidence of fluid accumulation of in the pleural cavity P. vivax on pregnancy are scarce The pregnant women had a more complicated presentation, although we could not follow up them until the end of their pregnancy. In a case series of co-infected patients from the Amazon region, pregnant women (2 of 11) presented severe acute lung edema and anemia Co-infected patients presented similar days of fever as compared to malaria patients. That means that a patient with the diagnosis of dengue presenting with prolonged evolution should raise the suspicion of malaria co-infection. Our findings corroborate the results of a long case series in Pakistan, which presented longer disease duration on patients co-infected with vivax malaria and dengue No specific dengue serotype was associated to the co-infected patients, however the number of cases was not big enough to test that hypothesis.Our study has some limitations. It was not possible to confirm dengue infection by PCR in all patients due to the time of the disease presentation and possible non-viremic periods. On the other hand, a positive IgM in patients with malaria could also reflect recent dengue infection or recent yellow fever vaccination. In addition, our results are not extendable to other healthcare settings or to community basis, since we only included hospitalized patients.On the other hand, this study has also some strengths. This is one of few studies addressing malaria and dengue co-infection, with a considerable amount of cases diagnosed by molecular tests. Besides, this work has been conducted by the same health care team, who applied consistent selection and severity criteria throughout the duration of the study. Furthermore, the majority of the existing works are case series reports and retrospective studies, which may produce low evidence level.Plasmodium sp. on cases with acute febrile syndrome. At last, the patients with parasitological malaria diagnosis which present spontaneous bleeding must be systematically investigated for dengue, and likewise, in suspected and confirmed dengue patients presenting jaundice, Plasmodium sp. investigation must be performed. Besides, whenever co-infection is confirmed, we recommend a carefully monitoring for bleeding and hepatic complications, which may result in a higher chance of severity, regardless of WHO criteria.Malaria and dengue co-infection is a relatively common event. Being malaria the disease with easier and faster diagnosis, in areas with known endemicity, it is recommended the systematic testing for Checklist S1STROBE checklist.(DOCX)Click here for additional data file.


Recent reductions in malaria in sub-Saharan Africa have been associated with increased coverage with long-lasting insecticidal nets (LLINs). Pyrethroids are currently the only insecticide class used for treating nets, and the rapid increase in resistance to pyrethroids in vector mosquitoes may jeopardise future vector control. Nets containing a novel combination of permethrin, a pyrethroid, and pyriproxyfen, an insect juvenile hormone mimic, (PPF-LLIN) may enhance malaria control, as well as reducing the spread of pyrethroid-resistant mosquitoes. This trial will determine whether PPF-LLINs provide incremental protection against malaria over current best practice of LLINs and prompt treatment in an area with pyrethroid-resistant vectors.A 2 armed cluster-randomised controlled trial will be conducted in Burkina Faso to assess whether PPF-LLIN (containing 2% permethrin and 1% pyriproxyfen w/w) provide better protection against clinical malaria in children than 2% permethrin-treated LLINs. Study subjects will be recruited and provided with LLINs at the start of the study. The LLINs will be exchanged for PPF-LLIN by cluster in a step-wedge fashion so 3 months before the end of the 2 year trial all participants will have a PPF-LLIN. The primary endpoint will be clinical malaria incidence measured by passive case detection in a cohort of children, aged 6 months to 5 years. Anaemia and parasite prevalence will also be measured in children during cross-sectional surveys. Exposure to malaria parasites will be assessed using light traps followed by identification of common vector species and their sporozoite infection rates. Safety evaluation will include recording of adverse events and pregnancy outcomes. The main endpoint analysis will include adjusting for distance between village clusters with different types of nets, as the impact of PPF-LLIN is likely to increase as larger areas are dominated by PPF-LLIN, reducing the spill over of mosquitoes from villages with LLINs.The step-wedge design is to measure the impact of an incrementally delivered environmental intervention where we expect the degree of control to be improved as more people use PPF-LLIN over a larger area. Trial findings will help inform policy makers on the effectiveness of PPF-LLIN nets for malaria control in areas of pyrethroid resistance.ISRCTN21853394 – AvecNet, registered on 3 April 2013.The online version of this article (doi:10.1186/s13063-015-0606-4) contains supplementary material, which is available to authorized users. Enormous progress has been made in the control of malaria in sub-Saharan Africa over the past decade ,2. A sigIn order to increase the effectiveness of LLINs, net treatments are being developed where nets are treated with a pyrethroid in combination with another active ingredient, such as pyriproxyfen ,11. PyriAnopheles gambiae s.s. than permethrin-only LLINs (Olyset) in experimental hut trials [Polyethylene nets treated with a combination of permethrin and pyriproxyfen ,) have been shown to induce higher mortality and reduce blood feeding of pyrethroid-resistant t trials . Howevert trials . MosquitHere we describe the proposed trial design and the methodology used. Although some of the outcome measurements and methods in this protocol are based on a previous vector control trial conducted in West Africa , the natTo assess whether PPF-LLIN provide added protection against clinical malaria in children compared with pyrethroid-only LLINs over 2 malaria transmission seasons of follow-up.To assess whether PPF-LLIN provide added protection compared to LLINs against anaemia and/or parasite prevalence in children.To assess and compare the prevalence of microscopy-confirmed gametocyte carriers in the LLIN group versus the PPF-LLIN group.To assess whether PPF-LLIN have a safety profile comparable with conventional LLINs in the trial population.To assess whether PPF-LLIN reduce the entomological inoculation rate (EIR) of mosquitoes collected inside houses compared to LLINs.To assess whether PPF-LLIN reduce pyrethroid resistance in the vector population.Anopheles gambiae and Anopheles funestus on egg production and the survival of the larvae that emerge from these eggs.To assess the impact of PPF-LLIN on 2, bisected by a river in a north-south axis. It is an area of West Sudanian savannah and the climate consists of a rainy season from May to October with little rain in other months. This defines the seasonal malaria transmission with most malaria episodes experienced during or immediately following the rainy season. The study area has 6 health centres and every village is affiliated to only 1 health centre. A baseline demographic survey conducted in July 2013 enumerated 63,903 individuals living in 93 villages, with most people living in small rural villages in houses made with mud or cement walls and thatched or metal roofs. The study’s field station is based at Banfora town which is the main town in the district. This study is in an area of cotton growing since 1968 with both the S and M forms of An. gambiae s.s. [The study site is situated south of the road from Banfora and Sideradougou  and is approximately 1,250 kmEach village or groups of neighbouring villages with more than 50 children aged 6 months to 5 years old will be invited to join the study, and will constitute a single cluster. Following local custom, sensitisation will start by discussions with community elders and then with representatives of the whole study community in order to explain the nature and requirements of the study. Village level permission will then be sought after sensitization meetings attended by village community leaders and health staff at the health centres; attendees’ names and village of residence will be documented. Witnessed written consent will also be sought from each net recipient, before net donation and exchange , depending on cluster size, will be randomly selected, stratified by age and invited to participate in the clinical and travel/residence surveys and passive case detection (PCD). The random sample will be stratified by age so that approximately equal numbers of children below and above 36 months will be invited into the study. This was done in case there were marked differences in clinical malaria associated with the different age groups and to ensure balance between the 2 study arms. No distinctions in the sampling scheme will be made regarding gender, ethnic group, medical condition or physical health. Children will only be included on the condition that their carers/parents give witnessed informed written consent. Assurance will also be sought from carers/parents that they expect that the child will remain resident in their village during the transmission season and will not be sent away. If informed consent is not provided for a randomly selected child then replacement children will be randomly selected from those remaining in the village.The impact of the intervention on the density of malaria vectors and their infection rate with malaria sporozoites will be measured in each village cluster. In each cluster 6 compounds will be selected randomly, from those that have consented to join the study and have at least 4 houses. In each household a room with a single adult male sleeper will be selected if the room owner/sleeper provides witnessed, verbal consent.A cluster-randomised controlled trial design will be used since: i) LLINs are a community-level intervention; and ii) the village cluster is a suitable unit for randomization since they represent a discrete spatial cluster. At the outset of the study, all households will be provided with new LLINs at the rate of 1.1 nets for every 2 people in their household; this will approximate 1 for every sleeping place. Each month for the next 4 months after LLIN donation, residents in 5 randomly selected village clusters will be asked to exchange their LLINs for PPF-LLIN. Stratified, random sampling will be used to ensure that by the end of year 1 (September 2014) there will be a similar number of residents with and without PPF-LLINs affiliated to each health centre. Every month from June to September in 2015, an additional 5 village clusters will be provided with PPF-LLIN, thus by the end of September 2015 all clusters will have PPF-LLIN  and thick smears will be stained for confirmation and parasite counting by study staff. Treatment will follow government guidelines.Plasmodium falciparum parasite rate in the population than children in the PCD cohort. Baseline data from the cohort will be used to compare the village clusters before the interventions, and the cohort from each village cluster provides its own baseline data before net exchange to PPF-LLIN. In addition, we will request anonymized medical records from the 6 health facilities located in the valley and use these to document clinical malaria in children aged 6 months to 5 years living in villages outside the study area. These children represent a further control group which can be used to track temporal changes in malaria incidence during the study period. If malaria declines in the study area in year 2, but not outside, we can be confident that the decline is due to the intervention, rather than confounding factors such as low rainfall. The end-of-season survey data will also be used to attempt to define a P. falciparum parasitaemia cut-off giving optimum sensitivity and specificity for malaria cases in this setting [The study cohort will be surveyed for malaria indices  at the beginning and end of both transmission seasons to generate data for the secondary endpoints. Where possible, at each malaria survey except the first, an average of 50 children from each village cluster who have not been enrolled in the cohort but are of a similar age will also be surveyed for these malaria indices. This additional group of children may better reflect the  setting .A schematic representation of the trial is shown in Figure In cluster-randomised controlled trials it is particularly important to minimize imbalance for factors known to be highly correlated with the disease outcome - in this case age and location. In each cluster, children will be enrolled with equal numbers of children aged 6 to 35 months and 36 to 60 months, and children who drop out of the study in year 2 will be replaced, as far as possible, by children of a similar age. At each step of the wedge, clusters will be selected, as far as possible, to maintain an even balance of children in the 2 age groups. Balanced randomization will be used to ensure that, within each health centre catchment area, half of village clusters will have PPF-LLIN and half LLINs by the end of July 2014.Stratified randomisation of village-cluster to the trial arms, as outlined above, will reduce some imbalances between these but, as only a relatively small number of units can be randomized in such a cluster design, it is important to assess baseline levels of malaria and known confounders. Baseline data parasite rates and anaemia collected from enrolled children in each cluster in May 2014 will be used to assess imbalances in malaria at the village-cluster level.Observer bias will be reduced where feasible. Both types of nets will be of a similar shape and colour. As well as using RDTs, blood films will be read by microscopists blinded to the identity and intervention status of the subjects. Mosquito collector bias will be reduced by using standard Centers for Disease Control and Prevention (CDC) miniature light traps, which do not rely on the ability of the fieldworker to collect specimens. Trap catches will be examined by a different person to the trap collector and they will be blinded to the trap location and intervention status. The processes of the intervention, both for PPF-LLIN and LLINs, will be monitored closely not only for quality but also to document any bias between the clusters.The LLINs are manufactured by Sumitomo Chemical (Japan). These are WHO recommended and meet WHO specifications with 2% w/w permethrin incorporated into polyethylene fibres giving adequate release of permethrin for about 5 years. These nets will be distributed at the beginning of the main transmission season, at no cost to the recipients. We will use white ‘extra family’ size rectangular nets (180 cm wide × 190 cm long × 150 cm high) of a white colour throughout. Government Roll Back Malaria information, education and communication procedures will be followed to encourage correct net use and maintenance, including supplying the nets in individual pre-opened bags.LLINs will be stored locked at ambient temperature in Banfora, under the control of a delegated individual, ready to be moved to the Health Facilities in batches by lorries and held by the officers in charge before being transported to the villages for distribution by the study team. In advance of distribution, the number of beds/sleeping places and the number with LLINs will be counted. New nets will be exchanged for old nets at the household level to achieve one LLIN per bed/sleeping place. Net use by study children will be monitored during the monthly travel/residence surveys during the 2014 and 2015 transmission seasons.PPF-LLIN will be provided by Sumitomo Chemical (Japan) and are currently undergoing evaluation by the WHO Pesticide Evaluation Scheme. The nets contain 2% w/w permethrin and 1% w/w pyriproxyfen incorporated into polyethylene fibres giving adequate release of permethrin and pyriproxyfen for an estimated 3 years . The PPF-LLIN will be the same size and colour as the LLINs and will be distributed the same way, but this distribution will be to the first 5 village clusters 1 month after the LLIN distribution and will be rolled out in a wedge-shaped design at monthly intervals during the main transmission season in 2014 and 2015. PPF-LLIN will be stored and distributed in a similar manner to the control LLINs.PCD for malaria will be maintained during the transmission seasons in 2014 and 2015 . Parents/guardians will be encouraged to take their child to the health facility their village is affiliated with at any time their child becomes unwell. The cost of travel and treatment for sick children will be met from the study funds. Study nurses will work in close collaboration with the government health workers to monitor malaria cases as indicated above. Project fieldworkers will visit each nurse regularly, at least once a week, to record children with malaria episodes.The end of transmission season survey in December 2015 will be the final study visit for the enrolled children in the cohort and will be similar to the end transmission season survey in 2014.During the course of the study participants are free to receive medication from health personnel outside the study team but they are encouraged to use their allocated health facility. During the clinical surveys, sick children, those with anaemia (haemoglobin (Hb) <9 g/dL), diagnosed malaria or any other mild illness will be referred to their health facility. Children with severe malaria, or other serious conditions, will be referred to Banfora or Sideradougou Health Centres for treatment.For safety considerations (see section below) we will identify asthmatic residents in study villages by name, household and village. During distribution and follow-up of PPF-LLIN in 2014 and 2015 these residents will be checked weekly by trial nurses for any aggravation of their symptoms for the first month after net donation and at the end of this month they will ask these residents to contact the study team if they have cause for concern. We will also identify pregnant women in study villages from antenatal clinic records, from June 2014 onwards, and outcomes of pregnancies will be recorded onto data forms, including miscarriages, live/still birth, weight and any recorded malformations. The regular monthly demographic surveillance system (DSS) in trial villages will also include reports of miscarriages. Data on asthmatics and pregnancy outcomes will then be linked to the date of reception of PPF-LLIN to examine if the events are associated with PPF-LLIN.The main morbidity outcome will be incidence of clinical disease assessed by PCD; data from this will provide the primary endpoint of the study. Mild malaria and parasitaemia is common in all children in this area of highly seasonal malaria -23. StudDuring the surveys all children enrolled in the cohort who are present and the randomly selected children for the cross-sectional surveys will be clinically examined for obvious symptoms and signs of illness, temperature will be measured with calibrated digital thermometers and spleen enlargement will be measured by experienced nurses using Hackett’s scoring system. All children will be finger pricked for immediate measurement of anaemia using a spectrophotometer  and preparation of thick smears. If a child reports with fever in the last 48 hours and/or with a temperature ≥37.5 °C they will also be checked for presence of parasites by RDT.The primary endpoint selected is the definition of malaria used commonly in West Africa in research studies and in National Treatment Guidelines -26. ThisAn. gambiae s.l., An. funestus and other anophelines recorded. The presence of sporozoites in An. gambiae s.l. will be identified using an enzyme-linked immunosorbent assay [An. gambiae s.l. females will be typed to species by PCR [An. gambiae s.s., S and M forms will be identified by PCR [Exposure to mosquitoes will be measured by surveillance with light traps to obtain the primary entomological endpoint . A CDC mnt assay  and An. s by PCR . In the d by PCR . Publishd by PCR ,32.6 sentinel clusters will be selected for measurement of the secondary entomological endpoints. Larvae will be collected from a range of breeding sites within each of these sites at the beginning and end of the transmission season in each year of the study. The prevalence of resistance to pyrethroids will be measured using standard diagnostic dose assays with papers impregnated with permethrin, obtained from WHO . To quanAnopheles gambiae egg production and the survival of the larvae that emerge from these eggs, blood-fed mosquitoes will be collected from inside houses via manual aspiration or when exiting houses using exit traps. The female mosquitoes will be transported to the local insectary at Banfora and the number of females that lay eggs, number of eggs hatching and survival to L2 larval stages will be recorded. This will be performed in all 6 sentinel clusters at the beginning and end of the transmission season in each year. In the first round of monitoring, all houses will have standard LLINs and at the final round of monitoring all will have PPF-LLIN.To assess the impact of PPF-LLIN on LLIN distribution will be completed in mid-2014. Study nurses and field assistants will be provided with refresher training on diagnosis of malaria, the use of RDT and study procedures in 2014 and 2015 before the transmission season.The compound of each study child will be geo-referenced using a hand-held global positioning system, as the primary data analysis has a spatial component. Travel/residence of cohort children will be assessed at monthly intervals on brief questionnaires to estimate their time at risk, and their bed net usage will be assessed at the same time.Thick blood films will be stained with Giemsa and examined under 1000-fold magnification by trained, experienced microscopists. Parasite counts will be recorded per high power field and 100 fields will be counted before a slide is declared negative. Parasite density will be estimated assuming that one parasite per high power field equals 500 parasites/μL . 2 slideAlthough adverse events (AEs) arising from either net are highly unlikely, we will document their safety in a community setting, by recording AEs and serious adverse events (SAEs) in the study cohort and population for the duration of the study. The trial will follow standard definitions for AE and SAE agreed by consensus of the Collaborating Centres of the WHO International Drug Monitoring Centre . The occurrence of AEs will be sought by non-directive questioning of the study children at monthly visits during the trial. AEs will also be recorded if volunteered by study children or their parent/carer or are noted by nurses through physical examination, laboratory test, or other assessments at any contact with the participant; these will be recorded on the child’s CRF for that visit. All AEs such as skin rashes, respiratory problems, streaming eyes, and so forth, will be recorded with the grade of severity .In addition, we will record pregnancy outcomes for all resident pregnant women, and asthma signs/symptoms in pre-identified asthmatic residents, as indicated in the clinical data collection and patient treatments above.During the course of the study, SAEs will be captured using a specific SAE report form and within 2 days of the start of the SAE, field staff will deliver a completed SAE report to the study physician. The study physician will log these in a query book noting the child’s study identification number or the residents demographic surveillance system number and village of residence and report these to the Principle Investigator who will inform the responsible member of the trial Data and Safety Monitoring Committee. Excessive grouping of SAEs by clusters will be reported to the study’s Data Monitoring and Ethics Committee and Trial Steering Committee.If an individual wants to terminate his/her participation, no further follow-up will be performed. There will be no replacement during the surveillance period in either year but in May 2015 children who have withdrawn, or are no longer in the study for whatever reason, will be replaced by children resident in the same cluster and of the same age group if informed consent is provided. If a household withdraws consent, no further follow-up will be made in that household. A child who was participating from that household will be replaced from within the same cluster and age group and, if the house was participating in the entomology collections, it will be replaced by a neighbouring house of the same type if possible. If a village opts out of the study before July in either year replacement by a neighbouring village will be considered.P. falciparum parasites of any density detected by RDT in the absence of other detectable cause of fever.Primary: incidence of clinical episodes of malaria presenting at health facilities defined as a child with an axillary temperature ≥37.5°C or a history of fever in the past 48 hours, together with the presence of P. falciparum parasite rates in children in the 2 study arms measured at the end of the transmission season.Secondary: (i) mean Hb concentration in children in the 2 study arms measured at the end of the transmission season survey; (ii) P. falciparum parasitaemia cut-off to give optimum sensitivity and specificity in this settingthe incidence of malaria defined by history of fever or temperature ≥37.5 °C and a the number of children with enlarged spleens at the end of each transmission season.In addition we will also reportTransmission parameters in the 2 arms of the study will be estimated from measurements made throughout the 2 transmission seasons.An. gambiae s.l. and An. funestus/light trap/night inside sleeping rooms.Primary: the EIR for An. gambiae s.l. collected inside houses in both study arms.Secondary: (i) change in the prevalence  and strength  of resistance to permethrin in each study arm throughout the study; (ii) the fertility and fecundity of adult female An. gambiae to measure mean population longevity.Tertiary: (i) the relative abundance of different anopheline species and forms in light traps collected in each arm of the trial; (ii) the parity of LLINs reduce malaria morbidity by approximately 50% . The comP. falciparum around 30% [Assuming prevalence of ound 30% , 20 clusAn. gambiae s.l. per trap/village will be 45 during the rainy season (with a CV = 0.35). In order to demonstrate a 33% reduction in blood-questing indoor mosquitoes  associated with PPF-LLIN, with 80% power and at the 5% level of significance, would require 6 houses in each cluster and 14 clusters in each arm of the trial over 2 years [Based on a study using light traps in an adjacent study area in Burkina Faso in 2010, we expect that the mean number of female The demographic data will be recorded by fieldworkers and the clinical data by study nurses on standardised data forms. Each child in the cohort will be identified by a unique identification number and non-cohort children participating in the cross-sectional surveys will be identified by their demographic surveillance number. All forms and datasets will identify participants by these numbers, and names will not be entered.After the collection and verification, data will be moved to the data management unit in Banfora for data entry. Data forms will be double entered (firstly by field staff and then by data entry staff) and the entries combined and errors corrected to produce a single dataset. This will be checked for consistency by generic and study-specific algorithms designed to identify sources of error. Inconsistencies will be checked against the original forms and errors will be corrected where possible, for example by checking in the field, or put to missing, to produce final datasets.All forms with subject names and/or clinical data will be kept in a cabinet and locked when not in use; the key will be kept by the study coordinator or delegate. The electronic datasets will be password protected. Hard copies of the data will be stored for 10 years. Clinical forms will be kept separately from that containing personal identification . The datasets will be password protected and only accessed by authorized study staff and the study data manager until after publication. Data will be stored for at least 10 years.A per protocol and an intention to treat analysis will be conducted.The primary endpoint is a comparison of the incidence of clinical episodes of malaria in children in the 2 intervention groups, measured by PCD. After a case of malaria is treated, time of observation will be censored for 3 weeks and further attacks of malaria during this period are not considered. History of travel away from the village for periods of over a week will be captured by the monthly surveys and time at risk will be censored for such periods. In addition, malaria cases in children who resided outside their study village for more than half the elapsed study period at the time of illness will be censored. An initial analysis will compare the incidence rates between the 2 intervention groups, adjusted for duration of sleeping under a PPF-LLIN. However, the main endpoint analysis will also adjust for distance between village clusters with different types of nets . This adEach of the outcome measures collected in this study will be analysed using multi-level statistical modelling methods, with appropriate distributional assumptions . Within each model, effect size  will, as appropriate, be adjusted for clustering within the groups of villages, the shortest distance between each PPF-LLIN cluster of villages and its nearest control, LLIN, village-cluster, the time of use of current nets (to account for different times in PPF-LLIN and LLIN conditions for each group of villages), village-cluster size, sex distribution, house design, bed net use, and other relevant potential confounding factors. Effect sizes will be presented as mean differences or rate differences/ratios as appropriate, with 95% confidence intervals.Differences in malaria transmission experienced in the 2 arms of the study will be estimated by comparing the EIR in village clusters between the 2 arms, adjusted for length of time under PPF-LLIN and distance between village clusters with the 2 different types of nets. Generalised estimating equations will be used to estimate differences in numbers of indoor mosquitoes, adjusting for repeated measures within clusters and possible covariates.P. falciparum parasitaemia cut-off defined to give optimum sensitivity and specificity in this setting; (iii) parasite rates  in children at the end of the transmission seasons; (iv) number of children with enlarged spleens at the end of the transmission seasons; and (v) prevalence of anaemia . Anaemic statuses will be defined as: severe anaemia = Hb <5 g/dL, moderate anaemia = Hb range from 5 to <8 g/dL and mild anaemia = Hb range from 8 to <11 g/dL.For the secondary clinical endpoints we will compare: (i) mean Hb concentration in children at the end of the transmission seasons; (ii) incidence of malaria defined by history of fever or temperature ≥37.5 °C and a t test, adjusting for possible co-variates. If the data do not satisfy normality and constant variance assumptions, an appropriate non-parametric test will be applied. Both linear regression (for continuous variables such as Hb levels) and logistic regression (for dichotomous variables such as presence or absence of parasitaemia) will be used to quantify the group differences allowing for individual level covariates  using covariance structures that represent the appropriate level of clustering.In general, all quantitative outcomes will be compared using appropriate summary statistics, such as mean differences or risk ratios. Hypothesis testing will be based on a 2-sample unpaired This study is conducted in accordance with the principles set forth in the International Conference on Harmonisation Harmonised Tripartite Guideline for Good Clinical Practice and the Declaration of Helsinki in its current version, whichever affords the greater protection to the participants. It was approved by the Comité d’Ethique pour la Recherche en Santé on 8 October 2013 (ref: 2013-10-101), the Institutional review board from Centre National de Recherche et de Formation sur le Paludisme and by Durham University Biological and Biomedical Sciences Devolved Ethics Sub-Committee on 17 January 2014.The future of malaria vector control in sub-Saharan Africa is threatened by the rapid rise of malaria vectors resistant to pyrethroids , currentThis is the first clinical trial where a combination of insecticides will be used on one bed net. Unusually the net includes pyriproxyfen which is an insect growth regulator. Unlike conventional insecticides such as permethrin, its main mode of action is not to kill mosquitoes, but to reduce their fertility and fecundity, once they have blood-fed. We hypothesise that the impact of this intervention will be greatest when a large number of people/communities use this net over a wide area. In essence we anticipate that the intervention will have a community-wide impact, reducing the number of mosquitoes within a PPF-LLIN treated area. It is largely for this reason that we have selected a novel study design where this new net is rolled out in a step-wedge fashion to the populations over a 2-year period. We expect that as coverage increases those living in clusters with PPF-LLIN surrounded by other clusters with PPF-LLIN will be better protected against malaria vectors than those on the fringes, where mosquitoes may spill-over from areas without PPF-LLIN. Thus, in the analysis we will consider both where and when people get malaria in order to estimate the efficacy of PPF-LLIN.The main outcome measure will be clinical malaria incidence as measured by PCD which is considered to generate information of more direct relevance to public health than active case detection and is thus more suitable for evaluating population-level malaria interventions . It is pThis apparent protection has been linked to passive transfer of anti-malaria antibodies by earlier experimental studies -46. In aThere are no apparent risks to the safety of individuals or communities in the use of the conventional nets. Permethrin-treated long-lasting nets have been fully evaluated by the WHO Pesticide Evaluation Scheme and approved for vector control . HoweverStudy children will benefit from a health check at the surveys and all participants will benefit from the health facility clinical services which will be supported by training and the presence of study nurses in addition to government staff. It is also important that the correct normal practice of parents/carers in the case of their child becoming sick is not altered in a detrimental fashion by their child being enrolled in the study. For example a parent/carer may delay taking a child to the nearest health facility/post if they think that a study nurse is visiting their village the next day. Both the provision of fares when a children reports sick at a health facility and emphasis of the vital role of parent/carers during enrolment and the conduct of the study will help to mitigate against this.The rapid spread of pyrethroid resistance in African vectors is a cause of concern. Although we are currently lacking direct evidence that this is interfering with malaria control, it is likely that this will become an issue in future. There is therefore an urgent need to find alternative strategies for dealing with insecticide resistance. A net like PPF-LLIN that uses a combination of 2 different classes of active ingredients represents a possible solution to the problem since it is less likely that vectors will be resistant to both classes, especially since no cross resistance has been reported for these 2 active ingredients. The results of this trial will therefore be of interest to those involved in malaria control in Burkina Faso and other countries as an insecticide resistance management strategy.Recruiting.


Plasmodium falciparum antigens glutamate-rich protein R0 (GLURP-R0) and apical membrane antigen 1 (AMA-1) were measured by enzyme-linked immunosorbent assay in Senegalese children under the age of 10 years in 2010 living in Saraya and Velingara districts (with SMC using SP+AQ [SMC+] since 2007) and Tambacounda district (without SMC (SMC−)). For both P. falciparum antigens, total IgG response were significantly higher in the SMC− compared with the SMC+ group . There was as well a nonsignificant tendency for higher percentage of positive responders in the SMC− compared with the SMC+ group . Results suggest that long-term malaria chemoprevention by SMC/SP+AQ have limited impact on the development of acquired immunity, as tested using the P. falciparum antigens GLURP-R0 and AMA-1. However, other factors, not measured in this study, may interfere as well.Seasonal malaria chemoprevention (SMC) is defined as the intermittent administration of full treatment courses of an antimalarial drug to children during the peak of malaria transmission season with the aim of preventing malaria-associated mortality and morbidity. SMC using sulfadoxine–pyrimethamine (SP) combined with amodiaquine (AQ) is a promising strategy to control malaria morbidity in areas of highly seasonal malaria transmission. However, a concern is whether SMC can delay the natural acquisition of immunity toward malaria parasites in areas with intense SMC delivery. To investigate this, total IgG antibody (Ab) responses to  Although the incidence of malaria is declining in many parts of sub-Saharan Africa, it remains an important public health problem, especially in risk groups such as infants, children, and pregnant women. This heavy burden raises the need to optimize control tools and devise appropriate intervention schemes. Several studies have shown a sharp decline of the risk of malaria infections in these risk groups through the use of intermittent preventive treatment (IPT) with sulfadoxine–pyrimethamine (SP) in infants (IPTi),12Plasmodium falciparum antigens were significantly lower in children treated once with SP than in controls.In Mozambique, chemoprophylaxis with SP did not significantly modify the development of natural immunity in infancy.P. falciparum histidine-rich protein II rapid diagnostic test , they were offered standard arthemisin combinaison therapy (ACT) first-line treatment (artesunate–amodiaquine) while children with severe malaria were referred to the nearest health district hospital. Finger-prick blood samples were collected from each study participants and blotted onto pre-labeled chromatographic filter paper , and stored with silica gel at 4°C until the serological analyses. Thick and thin blood films were also done for microscopic identification of Plasmodium species.Samples were collected during a cross-sectional survey in 2010 involving children under 10 years of age living in three health districts located in southern Senegal where malaria transmission is highly seasonal (see ber) see  since 20Blood thick smears were stained with 5% Giemsa, and parasite density was determined by counting the number of asexual parasites per 200 white blood cells, and calculated per microliter using the following formula: number of parasites × 8,000/200, assuming a white blood cell count of 8,000 cells/μL. Absence of malaria parasites in 200 high-power ocular fields of the thick films by two microscopists were considered as negative.P = 0.012).A total of 1,578 children under 10 years were enrolled in districts with SMC (Saraya and Velingara) and similar number of children under 10 years were enrolled in the district without SMC (Tambacounda). Malaria prevalence by microscopy was 7.3%  and 10.1%  in SMC+ and SMC− districts, respectively  and P. falciparum apical membrane antigen 1 (AMA-1) recombinant proteins.From the 1,578 collected filter paper samples in each district, a randomization list was generated and a subsample of 372  was selected for serological analysis. The 372 filter paper samples were extracted as described (16). Antibody titers were measured by indirect enzyme-linked immunosorbent assay as described in reference,P = 0.06; for AMA-1: 45.6% versus 40.0%, respectively, P = 0.24). Similarly, regarding the crude IgG response (measured as arbitrary units), they were significantly higher in the SMC− compared with the SMC+ group . When subdividing the groups into those that were positive or negative for P. falciparum, respectively, among the P. falciparum negative samples, the mean level of antibody response against GLURP-R0 was significantly higher in the SMC− as compared with SMC+ group ; however, this was not significant regarding AMA-1 . Similarly, for the P. falciparum positives samples, the IgG response was significantly higher in SMC− group  compared with SMC+ group , P < 0.001 and P = 0.001 for GLURP-R0 and AMA-1, respectively  were not available during our study period, which is a limitation of our study. Our observations show that long-term malaria chemoprevention by SMC/SP+AQ may have limited impact on the development of antibody response against P. falciparum antigens such as GLURP-R0 and AMA-1; however, other factors may interfere such as heterogeneity of exposure and higher previous exposure that are significant predictors of higher antibody responses.By comparing antibody responses to


Malaria is the most important parasitic disease worldwide, accounting for 1 million deaths each year. Severe malaria is a systemic illness characterized by dysfunction of brain tissue and of one or more peripheral organs as lungs and kidney. The most severe and most studied form of malaria is associated with cerebral complications due to capillary congestion and the adhesion of infected erythrocytes, platelets, and leukocytes to brain vasculature. Thus, leukocyte rolling and adhesion in the brain vascular bed during severe malaria is singular and distinct from other models of inflammation. The leukocyte/endothelium interaction and neutrophil accumulation are also observed in the lungs. However, lung interactions differ from brain interactions, likely due to differences in the blood-brain barrier and blood-air barrier tight junction composition of the brain and lung endothelium. Here, we review the importance of endothelial dysfunction and the mechanism of leukocyte/endothelium interaction during severe malaria. Furthermore, we hypothesize a possible use of adjunctive therapies to antimalarial drugs that target the interaction between the leukocytes and the endothelium. P. falciparum in peripheral blood, convulsions, and coma, after ruling out any other cause of coma such as meningitis [Malaria is the most important parasitic disease worldwide. It is present in more than 100 countries, putting 1.2 billion people at risk and accounting for more than 800 thousand deaths each year . Clinicaningitis , 5. Pathningitis . In someningitis  and acutningitis  and can ningitis , 12. DesA main characteristic of brain physiology is the immune privilege conferred by the BBB to brain tissue . However P. falciparum erythrocyte membrane proteins (PfEMP1) [During human cerebral malaria, the importance of infected red blood cells adhesion to brain microvasculature is well established . Necrops(PfEMP1) . However(PfEMP1) , 19, 20.(PfEMP1)  and leuk(PfEMP1) , 23 are Endothelium activation markers have been used in clinical studies to predict malaria severity , 25. Durα which activate endothelial cells [α accounts for many factors involved in development of CM [The interaction between leukocytes and endothelial cells during human CM could not depend on cell-cell contact. Instead, leukocytes and lymphocytes produce inflammatory mediators as TNF-al cells , 30. Endnt of CM  as incrent of CM  and, cos+ and CD8+ T cells to the CNS vasculature [ P. berghei-infected mice, showing that leukocytes do not accumulate in brains tissue but induce endothelium dysfunction, leading to vascular leakage, neurological signs, and coma [β2-integrin complex abolishes the development of cerebral dysfunction associated with P. berghei infection [On the other hand, the adhesion of leukocytes to brain vasculature is often observed during experimental cerebral malaria , 34. A rculature . Howeverculature . Observaand coma , 36. Thenfection . Howevernfection . The autnfection .+ T lymphocytes. Recent studies regarding experimental CM show that the membranes of endothelial cells and iRBC fuse by trogocytosis, resulting in the expression of Plasmodium antigens [+ T lymphocytes, thus contributing to the adaptive immune response to P. berghei infection [ P. falciparum phagocytosis by human endothelial cells [ P. falciparum phagocytosis by endothelial cells in vivo and its clinical relevance remain to be elucidated.A new approach of leukocyte and endothelium interaction in brain during CM has been proposed through interaction between MHC class I molecules and CD8antigens . Endothenfection . It is nal cells . HoweverOverall, microvascular congestion observed in both human and experimental CM leads to severe cerebral endothelial damage, resulting in the breakdown of the BBB mainly at the level of postcapillary venules , 31, 42. Plasmodium in different organs [The brain is not the only organ affected during severe malaria. Twenty percent of patients diagnosed with severe malaria develop acute lung injury (ALI) and acute respiratory distress syndrome (ARDS) , 9. ALI/t organs . Plasmodium cycle within the host. When merozoites leave the liver, they are located inside host-derived buds named merosomes, whose membranes are disrupted within the pulmonary capillary beds to allow merozoites to reach the erythrocytes [ Plasmodium-infected mice reveled edema formation and the migration of monocytes and neutrophils to lung tissue [β2-integrins and consequent leukocyte arrest in the vasculature [ P. berghei-infected mice; however, it is not essential for development of experimental cerebral malaria signals [ P. berghei-infected mice depends on the expression of ICAM-1 [The lung vasculature in malaria infection is essential to initiate thehrocytes , 51. Thehrocytes –47. The hrocytes . Chemokihrocytes , 53, 54.g tissue . Howeverg tissue , until ng tissue . Indeed,culature , 57. P-s signals . On the f ICAM-1 , 59, whif ICAM-1 . It is if ICAM-1 . Indeed,α [ P. falciparum infected erythrocytes, resulting in the reorganization of their junctional proteins [The morphological and biochemical differences between lung and brain endothelial cells account for the distinct inflammatory responses in both organs. Despite both endothelial cell types containing nonfenestrated endothelium, brain endothelial cells present fewer caveolae and are richer in tight junctions than lung endothelium , 62. Theα , LPS [64proteins . In addiproteins . Of noteproteins . P. berghei-infected mice [ P. berghei-infected mice [1 but not P2Y12 on platelets induces the downstream activation of the RhoA pathway, resulting in platelet/leukocyte aggregation and migration to the lung [αM integrin and adhered to pulmonary endothelial cells via ICAM-1 [In addition to the direct interaction between leukocytes and the endothelium described earlier, leukocytes can bind platelets and then adhere to the endothelium. Piguet and colleagues showed that platelet and mononuclear cell trapping occurs in the lungs ofted mice . In addited mice . The stithe lung . In addia ICAM-1 .The study of leukocyte/endothelium interactions within the lung during malaria is limited but extremely important. Mice depleted of neutrophils showed reduced malaria associated ALI and delayed mortality , suggestIn accordance with the findings presented above both in human and animals, the leukocyte/endothelium interaction plays a role in the development of pathogenesis of severe malaria particularly in malaria-induced ALI , 45, 47.α production [κB nuclear translocation, and the subsequent expression of ICAM-1 [Recently, Frosch and John suggested that an adjunctive therapy that impaired the inflammatory response induced during malaria should be combined with antimalarial drugs . Severaloduction , CD36 exoduction , 75, NO oduction , 76, or oduction  and presoduction , which aoduction –82. Our f ICAM-1 .κB p65 phosphorylation and induced AKT signaling, which decreased the expression of adhesion molecules on the endothelial cell surface [ P. berghei-infected mice were treated with statins, a class of drugs that inhibit the rate-limiting step in cholesterol synthesis and that show pleiotropic effects, demonstrated that statins decreased the production of chemokines [ in vitro treatment of human endothelial cells with statins followed by stimulation with P. falciparum-infected erythrocytes decreased the expression of adhesion molecules, suggesting that statins could exert an antiadhesive role in the treatment of severe malaria [Srinivas and colleagues studied the effect of treatment with activated protein C on a patient with severe malaria coinfected with leptospirosis and observed a rapid outcome . The bin surface , 85. Thu surface . Other memokines  and decremokines  probablyemokines . Accordi malaria . Statins malaria .+, CD4+, and CD45+ cells in the brain vasculature of P. berghei-infected mice, likely decreasing ICAM-1 expression and stabilizing the tight junction protein ZO-1 in brains [α, and downregulating ICAM-1 and VCAM-1. These Ang-1 actions result in decreased leukocyte/endothelial interaction and, consequently, host outcome [The endothelial barrier stabilizer sphingosine-1-phosphate (S1P) also rescued mice from severe malaria by decreasing the numbers of CD8n brains , 92. Tra outcome –97.4 and its receptor ALX has anti-inflammatory and proresolving activity in inflammatory models such as allergic airway inflammation [4 improved survival in P. berghei-infected mice by decreasing the production of proinflammatory cytokines but not the accumulation of CD8+/IFN-γ+ cells in brain tissue [4 impairment of leukocyte activation, the mechanism of action of LXA4 on endothelium during severe malaria was recently disclosed by intravital studies of the microvasculature of P. berghei-infected mice. The authors showed that treatment with LXA4 did not modulate leukocyte adhesion to the brain vasculature or decrease the expression of β2-integrin in leukocytes (unpublished data). On the other hand, treatment with LXA4 impaired endothelial activation during severe malaria and restored the blood flow in brains of P. berghei-infected mice [4 exerted its effects by stimulating the activity of heme oxygenase 1 (HO-1), an isoenzyme that catabolizes free heme released under pathological conditions, especially in pathologies such as malaria which are associated with intravascular hemolysis [ Plasmodium life cycle [Another family of lipids has been studied for its anti-inflammatory activity during severe malaria. Lipoxins (LX) are products of arachidonic acid metabolism and are produced through sequential lipoxygenase activity following cell-cell interactions in the inflammatory milieu (reviewed by ). The inammation  and autoammation  by reducammation . The admn tissue . In addited mice . The autemolysis . HO-1 upemolysis . During emolysis , 105. Dufe cycle , 107. Fufe cycle .α production; (d) inhibiting the procoagulant activity of endothelial cells; and (e) decreasing intravascular platelet aggregation [In hemolytic disorders such as malaria, low bioavailability of NO is observed, as free hemoglobin is a potent scavenger of this gaseous molecule . Thereforegation , 111.Indeed, pathophysiological phenomena experienced during experimental severe malaria are not fully translated to human severe malaria –118. The


The World Health Organization (WHO) recommends for sub-Saharan Africa a package of prompt and effective case-management combined with the delivery of insecticide-treated nets (ITN) and intermittent preventive treatment during pregnancy (IPTp) with sulphadoxine-pyrimethamine (SP) through the national antenatal care (ANC) programs. Implemented in Côte d’Ivoire around 2005, few Data on IPTp coverage and efficacy in the country are available.A multicentre, cross-sectional survey was conducted in Côte d’Ivoire from September 2009 to May 2010 at six urban and rural antenatal clinics. IPTp-sp coverage, Socio-economic and obstetrical data of mothers and neonate birth weights were documented. Peripheral blood as well as placental and cord blood were used to prepare thick and thin blood films. In addition, pieces of placental tissues were used to prepare impression smears and maternal haemoglobin concentration was measured. Regression logistics were used to study factors associated with placental malaria and LBW (<2.500 grams).≥2). Variability in the results was observed depending on the type of area . Plasmodium falciparum was detected in the peripheral blood of 97 women (7.3%) and in the placenta of 119 women (9%). LBW infants were born to 18.8% (22/107) of women with placental malaria and 8.5% (103/1097) of women without placental malaria. LBW was associated with placental malaria.A total of 1317 delivered women were enrolled with a median age of 26 years. A proportion of 43.28% of the women had received at least two doses of IPTsp during the current pregnancy although a high proportion (90.4%) of women received antenatal care and made enough visits (This study found relative low coverage of IPTp in the study areas which supported findings that high ANC attendance does not guarantee high IPTp coverage. Urgent efforts are required to improve service delivery of this important intervention. Plasmodium falciparum infections every year [Malaria is one of the most important preventable causes of poor maternal health and adverse birth outcomes . In sub-ery year .To prevent malaria during pregnancy and its adverse outcomes, the World Health Organization (WHO) recommends the use of intermittent preventive treatment with sulfadoxine-pyrimethamine (IPTp-SP), sleeping under an insecticide treated bed net (ITN) and prompt management of malaria cases and anaemia .ITPp consists of administering, to all pregnant women, at least two doses of intermittent preventive treatment with sulfadoxine-pyrimethamine (IPTp/SP) during the second and third trimesters of pregnancy during routinely scheduled antenatal clinic visits irrespective of the presence of signs for a malaria infection ,5.Clinical trials and program evaluations in stable transmission areas have shown that this intervention is safe, efficacious, and effective in preventing maternal anemia, placental parasitemia, and LBW -8.Côte d’Ivoire has implemented the WHO recommendations for preventing malaria since 2005. Few data regarding IPTp-SP coverage and its efficacy are available since its implementation in the country ,10.It therefore seems important to assess the ITP situation in the country fives years after the adoption of this policy by the National Malaria Control Program.The objective of this study was to evaluate the coverage of IPT-SP and its efficacy five years after its implementation in Côte d’Ivoire.P. falciparum.The study was carried out in urban  and rural areas . In the study sites, perennial malaria transmission with seasonal peaks is mostly attributable to Pregnant women who gave birth at any of the six study clinics during the study period, gave their written informed consent, and donated placentas for blood collection were enrolled.The sample size calculation was based on the estimate of a proportion of placental malaria. The prevalence of placental malaria after IPT-SP implementation was approximatively 10% . With a During labor, venous blood samples were collected for determination of Hb concentration and malaria diagnosis. Immediately after delivery, babies were weighed using a hanging weighing scale . Data regarding newborn characteristics  were collected. Blood smears were made with blood collected from the maternal side of the delivered placenta and the umbilical vein cord. In addition, pieces of placental tissues were used to prepare impression smears after swabbing it on blotting paper.Thick films and placental impression smears were stained with 10% Giemsa for 15 minutes. To determine the percentage of malaria parasitemia from placental impression smears, malaria parasite-infected red cells were counted against 2000 erythrocytes.Placental infection status was categorized as infected  and noninfected (parasite negative smear). Smears with malaria pigment but with no asexual parasite stages were declared as unknown and were not included in the analysis. Malaria pigment is a sign of malaria infection during pregnancy. We would consider these samples as positive.Microscopic examination of blood smears was done under oil immersion for parasite detection and 200 high-power fields were examined before the smear was considered negative.Parasites were enumerated using thick film, as previously described . The parThe thin film was used to speciate the parasites. Each blood film was independently examined by two microscopists. In cases of discrepancy, a third microscopist counted the number of parasites in the films. The average of two counts that agreed was used as the final level of parasitemia. Venous blood (5 mL) was collected using butterfly needles into ethylenediaminetetraacetic acid Vacutainer® tubes  for measurement of Hb levels using an automated hematology analyzer .The study was approved by the Comité National d’Ethique et de Recherche (CNER) of Côte d’Ivoire. All study participants were informed in their local language about the study objectives and procedures. For each study participant, written informed consent was obtained and the participant was free to withdraw consent at any time of the study without influencing their access to health services.≥3 doses. Bed net usage was coded as whether or not the woman usually slept under a bed net. We defined anemia as hemoglobin concentration, 11 g/dl and low birth weight (LBW) as infant’s birth weight <2500 g.We classified participants as primigravidae (first pregnancy), secondigravidea (second pregnancy) and multigravidae (third and subsequent pregnancy). Doses of SP IPTp were classified as no SP treatment, 1 dose, 2 doses, or ≥3 doses) and bed net use. Outcome variables were peripheral parasitemia , placental parasitemia , maternal hemoglobin concentration at delivery and anemia, infant’s birth weight and LBW.The exposure variables of interest were SP IPTp  based on univariable analysis were included. Statistical analysis was performed using Stata® version 10.0 .Differences in frequencies were compared by either chi-squared or Fisher’s exact tests as appropriate, and continuous variables by Student’s A total of 1317  delivered women were enrolled. Characteristics of the mothers are summarized in Table A total of 1300 women attended antenatal clinics at least once during pregnancy but only 75.3% completed the recommended three or more ANC visits.≥2).A high proportion (90.4%) of women received antenatal care and made enough visits  received ≥1 dose of IPT-SP. The IPT-SP coverage (≥2 doses) was 43.3% (570/1317) and varied according to the study site, the number of ANC visits and age of mother (Table IPTp coverage rate (≥2 doses) was higher in rural areas (47.8%) than in urban areas (29.8%) (p <0.0001). However, the highest rate was recorded at Cocody site (55.9%), followed by Yaou (51.8%), and Bonoua (48.2) and the lowest rate was observed in Abobo PK18 (14.3) and Yopougon (18.5%).Although 98.7% (1300/1317) of recently pregnant women visited ANC at least once in an eligible trimester, only 67.7% received the first dose of SP, and of the 91.5% (1190/1300) of women who returned for a second ANC visit, only 48.0% (571/1190) received a second dose.LBW infants were born to 19.7% (23/117) of women with placental malaria and 8.6% (103/1200) of women without placental malaria (p < 0.0001).The factors associated with LBW in the multivariable analysis were placental malaria  and in the placenta of 119 women (9.0%). Among the 97 mothers with peripheral malaria parasitaemia, 29 (6.6%) did not receive IPT-SP and 45 (7.9%) received at least two doses of SP (p = 0.45). Placental impression smears were positive for 56 (9.8%) women who had received at least two doses of SP and for 36 (8.2%) women who had not received IPT-SP (p = 0.39).vs 7.1%; p =0.004). The prevalence of women with peripheral parasitemia was 10.8% (33/303), 6.9% (29/420), and 5.8% (35/594) respectively in primigravidae, secondigravidae, and multigravidae (p = 0.04). Slightly higher prevalence of placental malaria was recorded with 11.8% (35/303), 9.7% (41/420), and 7.2% (43/594) respectively in primigravidae, secondigravidae and multigravidae women (p = 0.08). The factors associated with placental malaria in multivariable analysis, were malaria during pregnancy , should be implemented in our country to increase the access to antenatal care and IPT-SP use as well as other prophylactic methods such as ITNs.The overall low coverage occurs despite the finding that among 1317, 1190 (90.4%) women received antenatal care and attended enough visits (≥2) during pregnancy. Higher IPTp coverage has been reported even in settings with lower ANC attendance rates ,19. HighThe high proportion of women who attended ANC in an eligible gestation of pregnancy and received their first dose of SP who then made a second ANC visit (90%) demonstrates that women’s ANC attendance was not the primary cause for the ineffectiveness of the IPTp strategy observed. Consistent with other studies, our findings suggest that health provider practices rather than women’s ANC attendance are primarily responsible for the ineffectiveness of the IPTp strategy in this setting ,21-24.Stock outs of SP, absence of cups and clean drinking water for taking SP by DOT , unclearDuring the study, SP was not always available at pharmacy sites and clean cups and water were also not available to administer the drugs in most of study sites . Women should purchase SP from an external pharmacy and take the drugs at home. Regular availability of SP in the health facility is an important factor in improving the use of IPTp and implementation of the DOT scheme. SP for IPTp in public hospitals in Côte d’Ivoire was supplied by the Ministry of Health. However, periodic supply shortages were frequently reported.In contrast to IPTp, ITN use during pregnancy was very low (3.6%). This is because these women were not offered an ITN at ANC. ANC is a more effective delivery channel for ITNs and IPTp.Many studies have reported the prevalence of placental malaria in areas of stable endemic malaria transmission in Africa ,2. In a et al. in a study conducted at the time of delivery in an area where IPTsp coverage rate (≥2 doses) was 49.8% [However, the prevalence of placental malaria observed in our study is almost double that reported by Vanga-Bosson as 49.8% .This difference between the two studies may due to different study sites, ITNs use (3.6% 47.9%) and effective use of IPTp-sp during pregnancy.A low prevalence of peripheral and placental Plasmodium infection at delivery was also observed in Bangui, Central African Republic  and in TPlasmodium infection at delivery between participants having taken SP versus those who had not for IPTp. Resistance to SP and/or IPTp-sp compliance could be the reasons of this similarity. Compliance with the recommendation that IPTp drug should be given under supervision was very low in this study. Only about a third of women who received IPTp took SP in the clinic. Reporting receiving SP or having a record of receiving SP also does not mean the drug was taken. We had no method to verify that SP was taken as reported. Allowing pregnant women to take the IPTp drug unsupervised at the clinic or at home makes compliance uncertain and undermines the essence of IPTp.In our study there was no difference in regards to prevalence of peripheral and placental Many studies have shown SP to be highly effective at reducing peripheral and placental malaria parasite infection in pregnant women as well as improving pregnancy outcomes . The incP. falciparum malaria had a higher risk of delivering a LBW baby than those without detectable placental P. falciparum corresponding to a relative risk of 2.9, supporting the strong association between P. falciparum infection during pregnancy and LBW.LBW infants were born to 18.8% (22/107) of women with placental malaria and 8.5% (103/1097) of women without placental malaria. Women with microscopically detectable placental Our data indicate that IPTp-sp is not associated with a reduction in LBW. Some studies have however, highlighted an association ,33.HIV infection is known to be associated with an increased risk of malaria and LBW, and it may have affected the occurrence of LBW and maternal anemia. HIV may have acted as a confounder in the present study. In the clinical trial sites, HIV screening was routinely undertaken by the National HIV Control Program during the trial, but the HIV status was only determined for 60% of the women. However, the overall prevalence of HIV infection in the present study area was 4% . WHO IPTThe study has several limitations. First, the study findings are limited in terms of overall generalization and impact since the study might have been faced with recall bias. Furthermore, the study was conducted at the health facilities, and this may lead to selection bias as the situation of pregnant women who do not attend the health facility is not known.Another limitation in this study is the non assessment of the reliability of IPTp use by evaluating the presence of measurable sulfa in maternal plasma during pregnancy.Despite these limitations, our data provides useful information for the assessment and implementation of IPTp in Côte d’Ivoire and will also inform policy decision.IPTp presents greater challenges to deliver through ANC. Urgent efforts are required to improve service delivery of this important intervention.The plausible interventions to address the gaps and deficiencies include developing a health promotion package to explain the benefits of SP as IPTp agent. In addition health workers should be provided continuing education and training to improve their knowledge of IPTp strategy and DOT scheme. Activities of health workers manning the antenatal clinics should also be supervised. Efficacy of IPTp-sp needs to be evaluated in a controlled trial.


Glucose-6-phosphate dehydrogenase (G6PD) deficiency exhibits considerable allelic heterogeneity which manifests with variable biochemical and clinical penetrance. It has long been thought that G6PD deficiency confers partial protection against severe malaria, however prior genetic association studies have disagreed with regard to the strength and specificity of a protective effect, which might reflect differences in the host genetic background, environmental influences, or in the specific clinical phenotypes considered.A case-control association study of severe malaria was conducted in The Gambia, a region in West Africa where there is considerable allelic heterogeneity underlying expression of G6PD deficiency trait, evaluating the three major nonsynonymous polymorphisms known to be associated with enzyme deficiency  in a cohort of 3836 controls and 2379 severe malaria cases.Each deficiency allele exhibited a similar trend toward protection against severe malaria overall (15–26 % reduced risk); however, in stratifying severe malaria to two of its constituent clinical subphenotypes, severe malarial anaemia (SMA) and cerebral malaria (CM), the three deficiency alleles exhibited trends of opposing effect, with risk conferred to SMA and protection with respect to CM. To assess the overall effect of G6PD deficiency trait, deficiency alleles found across all three loci were pooled. G6PD deficiency trait was found to be significantly associated with protection from severe malaria overall (OR 0.83 [0.75–0.92], In a part of Africa where multiple alleles contribute to expression of G6PD deficiency trait, these findings clarify and extend previous work done in populations where a single variant predominates, and taken together suggest a causal role for G6PD deficiency trait itself with respect to severe malaria, with opposing effects seen on two major clinical subphenotypes. Glucose-6-phosphate dehydrogenase (G6PD) deficiency is an X-linked enzyme disorder with a global distribution, affecting hundreds of millions of people worldwide . It is aGenetic epidemiological evidence examining this hypothesis has been lacking in clarity, however, with past case-control association studies differing with respect to the strength and specificity of a protective effect –18, and The most common G6PD deficiency allele in sub-Saharan Africa is the C202T (A-) variant, and studies of this mutation have driven most association studies in this region. However, while the C202T allele is predominant in east Africa , in WestEthics approval was granted by The Gambia Government/Medical Research Council Joint Ethics Committee and by the Oxford Tropical Research Ethics Committee, and written informed consent was obtained from a parent or guardian prior to enrolment.The case-control cohort studied is comprised of 3836 controls and 2379 severe malaria cases, recruited at the Royal Victoria Hospital in Banjul. Malaria cases were confirmed by thin blood smear, and designated as ‘severe’ following WHO criteria, with two partially overlapping clinical syndromes identified in the majority of cases: severe malarial anaemia and cerebral malaria. Severe malarial anaemia (SMA) is defined here as packed cell volume mentclass2pt{minimGenotyping was performed on genomic DNA that was whole genome amplified via either primer extension pre-amplification or multiple displacement amplification reaction. Single nucleotide polymorphisms (SNPs) were then assayed via multiplexed genotyping on the Sequenom MASSarray platform. Automated genotype calls were manually curated via visual examination of cluster plots and mass spectra, with ambiguous genotypes re-coded as missing.Data curation was performed using custom Perl scripts and the PLINK software package . Gender Association testing was conducted using custom scripts written in R . A logisComposite G6PD deficiency trait genotype was defined as the sum of deficiency alleles present at all deficiency loci (968G + 542A + 202T) for an individual. Thus, a male was coded as 0 or 2, based on the absence or presence of a single deficiency allele across the three loci, while a female with a total of one deficiency allele present was coded as 1, and two deficiency alleles as 2 . It should be noted that this composite genotype was never greater than two because this scenario would require two deficiency alleles to co-occur on the same chromosome. Full expression of the G6PD deficiency trait, i.e. complete enzyme deficiency, was a binary genotype (0 or 1) inferred according to the absence or presence of one  or two  deficiency alleles in total across the three loci. Thus, a 202T male hemizgygote, 968G/202T female compound heterozygote, and a 542AA female homozygote would all be scored as 1 for full G6PD deficiency trait expression.Estimated odds ratios (OR) were adjusted by including the following covariates: HbS (sickle locus) genotype, self-reported ethnicity, and sex (omitted in sex-stratified tests). All odds ratios are presented here as ‘OR [95 % CI]’.G6PD known to be associated with enzyme deficiency, including A968G, T542A, C680A, and C202T  and cerebral malaria (CM). Although these subphenotype tests were not equally powered to detect signals of association due to sample size differences  was compiled, where presence of the trait required either one  or two  deficiency alleles in total across the three loci. In these association tests Table ; Fig. 1,nsortium . ImportaAs G6PD deficiency is an X-linked trait, and the subject of gender-specificity has been conflicting in previous association studies of severe malaria –15, sex-In examining multiple G6PD deficiency alleles in The Gambia, it was found that such alleles were associated with protection from severe malaria overall, but exhibited differential effects with respect to two important clinical presentations of severe malaria, conferring protection from cerebral malaria (CM) and increasing risk for severe malarial anaemia (SMA). Taken together with prior work from populations where a single variant, C202T (A-), predominates, there is compelling evidence for a direct, causal role for G6PD deficiency trait in modification of clinical malaria subphenotypes, confirming past results demonstrating protection from CM , 22, as As this study was limited to just one country, with its own distinct genetic background and environmental exposure history, including its own unique pattern of exposure to malaria, it will be important that further investigation be conducted in as many study populations in as diverse a range of geographic areas as possible, and there is ongoing work toward this end being conducted by the MalariaGEN consortium (manuscript in preparation). As there is substantial variation in the biochemical penetrance of G6PD deficiency alleles, it will also be useful for future work to include enzyme activity assays when feasible.G6PD should distinguish between the different presentations of severe malaria.The present study provides the somewhat paradoxical result that a single gene can be associated with protection from and susceptibility to disease from the same infectious agent. This highlights the fact that severe malaria comprises distinct clinical presentations, and the extent to which these syndromes differ from one another. These findings are not unexpected, then, given that G6PD deficiency is known to predispose individuals to haemolytic anaemia in the presence of oxidant stresses from infection, drugs, and diet . As the The differential association patterns seen here also suggest possible mechanistic differences between sickle cell trait (HbS) and G6PD deficiency in the modulation of malaria clinical phenotypes.in vitro [Sickle cell homozygous and heterozygous states have been variously reported to affect invasion and growth in vitro , 40, or in vitro –43 and ein vitro , 44 settin vitro , impairein vitro  or reducin vitro  may alsoin vitro growth phenotypes [in vivo is mixed for both Plasmodium vivax [Plasmodium falciparum [Studies of parasite phenotypes inside the G6PD-deficient erythrocyte have been more equivocal. While some have found evidence of invasion preferences  or aberrenotypes , others enotypes , 51. Simum vivax , 21 and lciparum , 14, 20.lciparum , 53), orlciparum ), might in vitro experiments relevant to severe manifestations of malaria. Ultimately, if knowledge gained from investigations surrounding the malaria protection hypothesis is to inform clinical treatment, a better understanding of the molecular mechanisms as they relate to severe disease will be crucial.Importantly, differences in the protection afforded by HbS and G6PD deficiency highlight the need to study clinical biomarkers and conduct In a region of West Africa with significant functional allelic heterogeneity, these data confirm that G6PD deficiency state is protective against severe malaria, but in contrast to sickle cell trait, this protection is limited to the CM subphenotype, with possible increased risk conferred to SMA. These results support the malaria protection hypothesis, but also suggest important mechanistic differences between the malaria-protective mechanisms of G6PD deficiency versus sickle cell trait.


Central diabetes insipidus is an uncommon feature of malaria. A previously healthy 72-year-old man presented with fever, rigors, and altered mental status after a recent trip to Liberia, a country known for endemic falciparum malaria. Investigations confirmed plasmodium falciparum parasitemia. Within one week after admission, the serum sodium rose to 166 mEq/L and the urine output increased to 7 liters/day. Other labs were notable for a high serum osmolality, low urine osmolality, and low urine specific gravity. The hypernatremia did not respond to hypotonic fluids. Diabetes insipidus was suspected and parenteral desmopressin was started with a prompt decrease in urinary output and improvement in mental status. Additional testing showed normal anterior pituitary hormones. The desmopressin was eventually tapered off with complete resolution of symptoms. Central diabetes insipidus occurred likely as a result of obstruction of the neurohypophyseal microvasculature. Other endocrinopathies that have been reported with malaria include hyponatremia, adrenal insufficiency, hypothyroidism, hypocalcemia, hypophosphatemia, hyper-, and hypoglycemia, but none manifested in our patient. Though diabetes insipidus is a rare complication of malaria, clinicians need to be aware of this manifestation, as failure to do so may lead to fatality particularly if the patient is dehydrated. Malaria remains a major public health challenge. As per WHO, there were about 198 million cases of malaria in 2013 with an estimated 584,000 deaths. Cerebral malaria is defined as an unexplained coma in a patient with malarial parasitemia. This is a life-threatening complication of malaria. Cytoadherence and sequestration of red blood cells in the microvasculature are thought to be the key pathophysiology. Here we present the case report of a 72-year-old patient who developed an unusual complication of cerebral malaria and central diabetes insipidus followed by a review on endocrine complications associated with malaria.A previously healthy 72-year-old man presented with a four-day history of fever, rigors, back pain, and altered mental status. He had returned from a trip to Liberia, a country with endemic chloroquine-resistant falciparum malaria, two weeks prior to presentation. He took doxycycline chemoprophylaxis during the trip however discontinued it prematurely upon return.Investigations confirmed plasmodium falciparum parasitemia (greater than 10%) with acute kidney injury. He was started on parenteral quinidine followed by artesunate and exchange transfusion. The serum sodium was 132 mEq/L at admission. A head CT scan at admission did not reveal any acute findings. A brain MRI done 2 months prior as work up of an unexplained syncope was within normal limits.Within a week after admission, there was rise in serum sodium and urine output as shown in The hypernatremia did not respond to fluid therapy. Diabetes insipidus was suspected based on the above findings and parenteral desmopressin was started with a prompt decrease in serum sodium and urine output . This waWe have described a patient who presented with cerebral malaria developing a very rare complication, central diabetes insipidus. The classic presentation of malaria with relapsing and remitting fevers occurs in only 50–70% of persons infected with plasmodium species  and the Endocrine and metabolic abnormalities that have been reported in the literature with malaria include hyponatremia, diabetes insipidus, hypercortisolemia, adrenal insufficiency, primary and secondary hypothyroidism, hyper- and hypoglycemia, hyper- and hypokalemia, hypophosphatemia, hypocalcemia, and hypomagnesemia. Hyponatremia could result due to SIADH (syndrome of inappropriate antidiuretic hormone), cerebral salt wasting, or gastrointestinal and renal losses. Holst and his group  estimateDiabetes insipidus as occurred in our patient could have resulted due to obstruction of neurohypophyseal microvasculature by the malarial parasites. Mature forms of the parasite, including trophozoites and the meronts, sequester in the microvasculature; nonparasitized RBCs adhere to the parasitized RBCs (rosetting) and parasitized RBCs adhere among each other (agglutination). As the parasites grow within the RBCs, they become less deformable causing mechanical obstruction and impaired microvascular circulation. A variety of proinflammatory cytokines, including TNF-alpha increases the cytoadherence . Only a r = 0.332, P = 0.02) [Both cortisol excess and adrenal insufficiencies have been reported as a complication of malaria. In a study conducted by Wilson et al.  it was s = 0.02) . In our Thyroid abnormalities previously published include primary and secondary hypothyroidism . These cThien and coworkers studied gluconeogenesis in different populations of individuals affected with falciparum malaria to various degrees of severity and found an increased rate of gluconeogenesis in both complicated and uncomplicated cases. This finding was additionally supported by the presence of low levels of the gluconeogenic amino acid precursor, glutamine. The authors commented that prolonged fasting is an important risk factor for hypoglycemia and full recognition of this complication is especially critical in the most susceptible population, children and pregnant women . AnotherHyperkalemia associated with severe malaria is thought to be due to a combination of acute renal failure and lactic acidosis. Increased extra cellular release of potassium could also occur in the context of hemolysis and rhabdomyolysis. Our patient, although presented with acute kidney injury, did not develop hyperkalemia and there was a prompt decrease in creatinine with hydration. Hypokalemia had been described in up to 40% of children  with sevIn summary, central diabetes insipidus is a rare and atypical complication of malaria. Although uncommon, clinicians need to be aware of this manifestation since early diagnosis prevents serious outcomes. Particularly in hot, humid, and arid climates of sub-Saharan Africa and Indian subcontinent where parasitic infection and dehydration are common, dehydration compounded by diabetes insipidus can even lead to death if left unrecognized. Our patient did not have other metabolic or hormonal abnormalities that have been reported in the literature including hyponatremia, adrenal insufficiency, cortisol excess, thyroid dysfunction, hyper/hypoglycemia, or other electrolyte imbalances.In our patient the diabetes insipidus symptoms lasted for around four weeks and desmopressin was eventually tapered off. It is important to carefully monitor other anterior pituitary hormone status along with electrolytes while caring for a patient with acute onset of central diabetes insipidus.


Plasmodium falciparum infection  occur among infants, children and prima–gravida women living in sub-Saharan Africa  and 627,000 malaria deaths  were estimated in 2013 . The majn Africa .Plasmodium vivax, the second malaria species in terms of epidemiological importance but less deadly than P. falciparum, causes ~ 70–80 million clinical malaria cases annually with 2.85 billion people living at risk of infection  protein, has gone through extensive testing in Africa where a recent phase 3 trial showed a 27 and 46% protection against clinical malaria in African infant and children respectively but unfortunately its efficacy wanes down in a relatively short time , or antigens acting in the ADCI and/or opsonization as fragments from MSP2, MSP3, GLURP and PFF0165. Even though single antigens might be only weakly effective, their combination together with RTS,S is expected to be more effective in controlling the disease and, as a result, reducing transmission by mosquitoes  and the development of an effective and affordable malaria vaccine will bring an unprecedented rate of life saving and consequent improvement of life quality for the populations living in malaria-endemic countries.The authors do not have any conflicts.