HIV and malaria are among the leading causes of morbidity and mortality during pregnancy in Africa. However, data from Congolese pregnant women are lacking. The aim of the study was to determine the magnitude, predictive factors, clinical, biologic and anthropometric consequences of malaria infection, HIV infection, and interactions between malaria and HIV infections in pregnant women.t-test or a non-parametric test, if appropriate. Categorical variables were compared using the Chi-square or Fisher’s exact test, if appropriate. Backward multivariable analysis was used to evaluate the potential risk factors of malaria and HIV infections. The odds ratios with their 95% confidence interval (95% CI) were estimated to measure the strengths of the associations. Analyses resulting in values of P < 0.05 were considered significant.A cross-sectional study was conducted among pregnant women admitted and followed up at Camp Kokolo Military Hospital from 2009 to 2012 in Kinshasa, the Democratic Republic of Congo. Differences in means between malaria-positive and malaria-negative cases or between HIV-positive and HIV-negative cases were compared using the Student’s A malaria infection was detected in 246/332 (74.1%) pregnant women, and 31.9% were anaemic. Overall, 7.5% (25/332) of mothers were infected by HIV, with a median CD4 count of 375  cells/μL. The mean (±SD) birth weight was 2,613 ± 227 g, with 35.7% of newborns weighing less than 2,500 g (low birth weight). Low birth weight, parity and occupation were significantly different between malaria-infected and uninfected women in adjusted models. However, fever, anemia, placenta previa, marital status and district of residence were significantly associated to HIV infection.The prevalence of malaria infection was high in pregnant women attending the antenatal facilities or hospitalized and increased when associated with HIV infection. Malaria is well established as a major global health problem worldwide ,2. MalarIn the DRC, malaria is reported to be the principal cause of morbidity and mortality, especially among vulnerable population like pregnant women and children less than five years of age. Close to 70% of all outpatient health care visits and an average of 30% of hospital admissions are malaria-related . A recenUnderstanding the epidemiology of malaria and HIV during pregnancy is important for deciding the best control strategies. Unfortunately, vital registration systems in sub-Saharan African countries have low coverage and do not produce accurate estimation of this co-infection. Health workers in the Congolese Army are unable to identify high or risk factors for both malaria and HIV infections so as to tailor interventions and do effective health monitoring. Moreover, pregnant women married to soldiers and single soldiers are habitually facing war-related poverty and human movements. Therefore, the study aims were to determine the magnitude, predictive factors, clinical, biologic and anthropometric consequences of malaria infection, HIV infection, and interactions between malaria and HIV infections in pregnant women.A prospective study for the prevalence of malaria, HIV infection, HIV co-infection, and low birth weight from pregnancy to delivery as well as a comparative study of health consequences at the delivery was conducted from 2009 to 2012.2 with an estimated total population of 7,411,989 of whom more than 50% are female [The Camp Kokolo Military Hospital (HMRK) was the study setting and is the largest public hospital in the country, situated at the western part of Kinshasa, the capital city of DRC. The town covers an area of 9,965.21 kme female . The HMRAll pregnant women who were suspected of malaria and followed up in routine antenatal care service at HMRK or hospitalized in the same hospital with at least one antenatal visit between 2009 and 2012 were included to this study , which was conducted in compliance with the principles of the Helsinki Declaration II. Patients were informed about the research purposes and gave written informed consent. The Ethics Committee of the Université Protestante du Congo (UPC) approved the consent procedure. The guidance of this study was in the context of the routine diagnosis and of normal medical care. Limited epidemiological, clinical and biological information were collected anonymized. Blood samples collection were also performed in the context of the routine diagnosis and of normal medical care for which the department of Tropical Medicine was granted the agreement N/Réf: 007/UPC/SGAC/MM/AB/2009 from the Medical faculty of UPC and the Faculty of Medicine of the University of Kinshasa.Plasmodium, responsible for malaria cases. Study participants who were positive for malaria were treated. All mothers were provided a standard counseling and were systematically screened for the presence of HIV antibody by using Determine HIV 1/2 rapid test kits . At the delivery, birth weights of newborns were recorded using standard methods.Mothers were interviewed to obtain socio-demographic, biographic, and clinical variables. These pregnant women were tested using both blood films (thin and thick blood smear) and polymerase chain reaction (PCR) for the presence of vs. single women as parents of soldiers), occupation (housewives without income vs. others with income), and the district of residence . The laboratory variables were: haemoglobin concentration (g/dL) and parasitaemia (parasites/μL). Clinical variables were: history of fever, body aches defines as the combination of asthenia and muscle pain, headaches, nausea and vomiting, bleeding, respiratory tract infection (rhinorrhoea and cough), placenta previa, digestive disorders with gastritis, constipation, diarrhoea and Salmonella infection.The demographic details recorded were: age on admission classified as follows: < 20 years, 20–24 and ≥ 25 years, marital status  were estimated to measure the strengths of the associations. Analyses resulting in values of P < 0.05 were considered significant. All reported p-values were two-tailed using Stata, version 12 .The variables were summarized as frequencies, means (standard deviation = SD), medians (interquartile range = IQR). Differences in means between malaria-positive and malaria-negative cases or between HIV-positive and HIV-negative cases were compared using the Student’s Over the study period, a total of 1,200 pregnant women attended the routine antenatal care services or hospitalized at MRHCK were screened, out of whom 348 were eligible for the study. Out of these, 332 agreed to participate (95.4%) and were tested for malaria and HIV infections  were anaemic (Hb  <  11.0 g/dL). Out of the 332 pregnant women who were interviewed, 37.9% (126/332) had fever, 14.9% (49/332) had headache and 3.5% (38/332) complained of general body weakness whereas 39.8% (132/332) had respiratory tract infection. Other symptoms included nausea 7.5% (25/332), digestive disorder 10.5 (35/332) and bleeding 6.9% (23/332). The geometric parasite density and the 95% confidence interval (CI) in patients with positive slide were 3383 (IQR = 2038-5618) parasites/μL.The overall malaria parasite proportion was 74.1% (246/332) and Table Figure Except of malaria infection, the rest variables were not associated (P > 0.05) with Table .Table 3Table P. falciparum malaria is highly endemic [Pregnancy is associated with increased susceptibility to malaria in areas where malaria is endemic ,15. The  endemic . This paThe proportion of malaria infection in pregnancy in this study was 74.1% in Kinshasa where malaria transmission is perennial and represents a substantial burden for the local population . This prFalciparum infections are frequent in adults [By contrast with several study, fever was not significantly associated with malaria infection in the following study during pregnancy despite the fact that in endemic areas asymptomatic n adults -23. Feven adults . This reThe prevalence of HIV infection was 7.5% in the present study. This result is higher than the previous 4.2% reported in DRC by UNAIDS in 2003 . A numbeThe prevalence of HIV infection was associated to malaria in 5.7% Figure . MalariaP. falciparum, particularly in their first two pregnancies [Every year, approximately 25 million women become pregnant in sub-Saharan Africa, where malaria is endemic, and are at increased risk of infection with gnancies . Interacgnancies -9,17,23.P. falciparum malaria and HIV infection in pregnant women. It has been shown that many studies in Africa shows that co-infection with HIV influences the burden of malaria in pregnancy. HIV increases the degree to which malaria is associated with severe anemia and low birth weight beyond the effect of HIV itself on these outcomes. HIV also puts women of all gravidities at risk for placental infection with malaria, not only women in their first or second pregnancy [On multivariate analysis, HIV-infection was significantly associated with fever, anaemia, placenta previa, marital status, and district of residence. This finding characterized the impact of anaemia and fever related to regnancy -9,15,23.regnancy . UnfortuLBW was highly associated to malaria infection in pregnant women. It is estimated that in areas where malaria is endemic, around 19% of infant LBWs are due to malaria and 6% of infant deaths are due to LBW caused by malaria ,26.Although the present study has yielded some important preliminary findings in regard of malaria and HIV infections in pregnant women in DRC, its design is not without flaws. A number of caveats need to be noted regarding the present study. First, as a cross-sectional design, it does not allow us to make any causal inferences from these findings. Second limitation concerns the restriction of the inclusion criteria and the absence of real follow-up due to the difficulty to enroll patients. Third, there were a relatively small number of HIV-infected pregnant women. While 332 patients were initially enrolled, only 5.7% were infected. In that case, it was relevant to examine the association between HIV-infected women and uninfected women in depth. Furthermore, the lack of unmeasured factors may bias these results. Another limitation was the challenge to collected data. Most women in this study were uneducated and were embarrassed to answer questions. In other cases, data in registers were absent or poorly reported.The present findings will impact on clinical practice and public health related to malaria in pregnant women. In obtaining as much relevant socioeconomic information  as possible, present results will help to understand the pathophysiology and to apply the epidemiology evidence in clinical practice and public health. The consequences of socioeconomic deprivation on pregnancy outcomes are anaemia and low birth weight . Policy Prevention of malaria in Congolese pregnant women might rely on intermittent preventive treatment with sulphadoxine-pyrimethamine, which reduces higher probability of placental parasitaemia, anaemia, and low birth weight ,32. ThusThere is evidence of high prevalence of malaria and HIV infections in Congolese pregnant women. Prevention and surveillance of infectious diseases progression are needed to reduce the incidence of malaria and HIV infections in pregnant women in DRC by improving better management and public health panel control. Qualitative research should be encouraged to obtain more in depth, locally-relevant, and descriptive data examining the impact of infectious diseases in DRC.


Intermittent preventive treatment (IPT) is a proven malaria control strategy in infants and pregnancy. School-aged children represent 26 % of the African population, and an increasing percentage of them are scholarized. Malaria is causing 50 % of deaths in this age group and malaria control efforts may shift the malaria burden to older age groups. Schools have been suggested as a platform for health interventions delivery immunization) and as a possible delivery system for IPT in schoolchildren (IPTsc). However, the current evidence on the efficacy and safety of IPTsc is limited and the optimal therapeutic regimen remains controversial.Plasmodium falciparum AND schoolchildren NOT infant NOT pregnancy.A systematic search for studies reporting efficacy and safety of IPT in schoolchildren was conducted using PubMed, Web of Science, Clinicaltrials and WHO/ICTRP database, and abstracts from congresses with the following key words: intermittent, preventive treatment AND malaria OR Five studies were identified. Most IPTsc regimes demonstrated substantial protection against malaria parasitaemia, with dihydroartemisinin-piperaquine (DP) given monthly having the highest protective effect (PE) . Contrarily, SP did not provide any PE against parasitaemia. However, no IPT regimen provided a PE above 50 % in regard to anaemia, and highest protection was provided by SP+ amodiaquine (AQ) given four-monthly . The best protection against clinical malaria was observed in children monthly treated with DP . However, there was no protection when the drug was given three-monthly. No severe adverse events were associated with the drugs used for IPTsc.IPTsc may reduce the malaria-related burden in schoolchildren. However, more studies assessing efficacy of IPT in particular against malaria-related anaemia and clinical malaria in schoolchildren must be conducted. Malaria is a major public health problem in sub-Saharan Africa (SSA), with 90 % of the burden occurring in African children –3. To daPlasmodium falciparum AND schoolchildren NOT infant NOT pregnancy. Study eligibility was assessed in an unblinded manner. Studies had to be published articles written in English. Inclusion criteria were determined following the PICO format: (P) Participants: children of school age, resident in a malaria-endemic area; (I) Interventions: clinical trials evaluating the efficacy and safety of IPT; (C) Comparisons: the efficacy of available drug regimes compared to each other or with placebo; (O) Outcomes: the proportion of children with parasitaemia, anaemia and clinical malaria to provide the effect estimates , relative risk (RR), protective effect (PE), and their corresponding 95 % confidence interval (CI). If a selected study included more than one comparator or drug regimen, each comparison was regarded as a separate study. Studies which enrolled children younger than 5 years were included if data on children over 5 years were available for analysis. Studies evaluating chemoprophylaxis, screening and prompt treatment, as well as study protocol, were excluded.A single investigator (JMR) developed and conducted a systematic literature search for published IPTsc studies, on 28 April, 2014. Studies were identified using PubMed, Web of Science, Clinicaltrials [Clinicaltrials.gov and World Health Organization international clinical trials registry platform (WHO ICTRP) database] and abstracts from congresses. Combinations of the following search terms were used: intermittent, preventive treatment AND malaria OR All the titles and abstracts were collected through the electronic search and filtered for potentially eligible articles. For each study, the following information was extracted: first author, publication year, year of study start and end, study design, randomization procedures, inclusion criteria, insecticide-treated net or bed-net use, local malaria transmission details of study groups, number of enrolled children, outcomes assessed and adverse events. Data from eligible studies were extracted based on the intention to-treat principle into a purpose-built database . This review follows the PRISMA guidelines .A total of five trials assessing the efficacy of IPT for preventing asymptomatic and clinical malaria and anaemia in school-aged children were identified and included for analysis Fig.  23–27].–27.23–27® photometer in all trials. Data on anaemia were reported in three of them [IPT schedules differed between trials and were given every 5 months, four-monthly, three-monthly, bimonthly, monthly, or only at baseline Table . All fiv of them , 25, 27. of them , 25 and  of them  and mont of them , 6 weeks of them , every 3 of them  and actiIPT with SP combined with AS and AQ + AS reduced significantly the risk of malaria parasitaemia. The prevalence of parasitaemia by treatment group was 6.6, 6.2 and 34.4 % for SP + AS, AQ + AS and vitamin C, respectively (P < 0.001) . The risvs placebo: 12.6 %; p = 0.041). The PE effect of IPTsc on anaemia was generally lower in all trials that assessed this endpoint, and ranged from 14 to 50 %. SP + AQ (given three-monthly), SP + AS, AQ + AS and DP (administered monthly) demonstrated similar PE of IPTsc against anaemia in schoolchildren. The PE effect of DP given three monthly was the lowest   in Kollé, Mali. In Tororo, Uganda (2014), the prevalence of anaemia was significantly lower in the DP given monthly arm (12 %) but not the DP given three-monthly arm (17 %), compared with the placebo arm (20 %). SP + AQ (given four-monthly) reduced significantly the risk of anaemia (6.3 %), in Bondo, Kenya  in Kambila, Mali. The PE of SP + AS in Mali was 67 % (95 % CI: 42–98). In the trial conducted in Kollé, Mali, AQ + AS had a PE of 47 % (95 % CI 32–67). In 2014 DP given monthly in Tororo had the highest PE , however, this same drug regimen administered three- to five-monthly in Tororo in 2014 had a no PE  and four in the placebo group. The most commonly severe adverse events were: problems of balance, dizziness, feeling faint, nausea, or vomiting. One severe skin reaction was reported in the placebo group. In the study conducted in Tororo, Uganda, 2014, one death occurred in the IPT intervention group (DP three-monthly) due to acute lymphoblastic leukaemia. Fourteen severe adverse events were observed, but were judged unlikely to be associated with treatment. In almost all trials, mild or moderate adverse events were frequent in IPT group compared to placebo group. However, in the study conducted in Tororo (2014), mild or moderate adverse events including: fever, headache, nausea and vomiting were commonly associated with malaria, and were more frequent in placebo group than in the intervention arms. SP + AQ was significantly associated with vomiting in Tororo, 2010, and AQ + AS had the highest rate of headache in Kollé Table .Table 5SThe aim of this review was to provide an overview of the effectiveness of IPT to prevent parasitaemia, clinical malaria and malaria-related anaemia in older children and to find out the most promising drug regimen for IPT in this specific population. The most appropriate drug regimen for IPTsc should provide protection against malaria-related anaemia and asymptomatic malaria parasitaemia, as these are the main features of malaria in this specific population. In this review, the studies used a wide variety of IPT regimes incorporating different drugs, dosages, timings, and numbers of IPT rounds.The PE of IPT against malaria parasitaemia ranged from 49 to 94 % in the trials that assessed this endpoint. The highest PE was observed using DP monthly. SP + AQ given four-monthly, also demonstrated a high PE. SP monotherapy provided the lowest PE against malaria parasitaemia. This low efficacy of SP is not surprising and highlights the wide spread of resistance to this drug across Africa. The prevalence of 540E, one of the key SP resistance mediators, was found to be less than 50 % in Mali, whereas high prevalence of this marker (above 50 %) was observed in Uganda and Kenya . This isThe protective effect of IPTsc against malaria-related anaemia was relatively low in most trials that assessed this endpoint. DP given three- to five-monthly had the lowest PE against anaemia while DP given three- to five-monthly, or SP + AS and AQ + AS did not demonstrate any superiority in terms of mean change in haemoglobin levels compared to placebo. However, the combination of two drugs with long half-life (SP + AQ) in two studies , 26 incrNo deaths could be attributed to administration of drugs for IPTsc and observed severe adverse events occurred in both interventions and control groups. However, some adverse events judged mild or moderate were more frequent in intervention groups in one study.Based on these findings, SP monotherapy should be considered the worst therapeutic regimen for IPTsc in area of high resistance to SP. However, SP has several benefits, including its low cost and proven safety. Moreover, studies have shown that SP could still be effective even in the presence of a high level of resistance in adults . The undThis review suggests a need for harmonization in regard to the timing and frequency of drug administration as well as the time frame for drug evaluation in the context of IPT. IPT describes the administration of a drug at specified time intervals, allowing a very low concentration of drug (below the inhibitory level) between two treatments, with the aim of preventing mortality or morbidity. This should differ from chemoprophylaxis where the drug concentration is maintained above the level that inhibits parasitic growth . A greatBeside the choice of the appropriate drug regimen, one would anticipate the feasibility of this strategy. Schools have been suggested as a platform for health intervention delivery . These interventions have been shown to improve not only children’s health and nutrition, but also their learning ability , 40. Thevs placebo or controls against clinical or asymptomatic malaria and anaemia were assessed without combined estimates.The present study has a number of limitations. Since the search focused on the Pubmed database and articles published in English, there is a risk some other studies are missing. However, this is unlikely given the very limited number of trials conducted on IPTsc. Individual patient data were unavailable, therefore, the effect of baseline parasitaemia, age, ITN usage, or nutritional status on the efficacy of IPT could not be assessed. The high variability  across studies precludes a meta-analysis. Moreover, the small number of available studies could not allow a pooled analysis in sub-group regimes. Therefore, protective effect of regimes This systematic review found only five studies assessing the efficacy of IPTsc. Today, SP may not be a promising regimen for IPTsc in areas where resistance to this drug is high. Arteminisinin combination therapies (ACTs)  provided acceptable protective efficacy against clinical malaria, parasitaemia and anaemia. DP administered monthly demonstrated the highest PE. However, acceptability, feasibility and thus, effectiveness of a monthly administration of IPTsc is not known. Further, ACT is used for curative purposes. Combining at least two long half-life drugs, such as piperaquine plus SP may be, at present, the most promising option. More studies assessing efficacy of IPTsc in particular against malaria-related anaemia and clinical malaria must be conducted.


Plasmodium falciparum and intestinal helminths co-infection among school children in rural communities of Kwara State, Nigeria.Malaria and intestinal helminths co-infection are major public health problems particularly among school age children in Nigeria. However the magnitude and possible interactions of these infections remain poorly understood. This study determined the prevalence, impact and possible interaction of Schistosoma haematobium. Plasmodium falciparum was confirmed by microscopy using thick and thin blood films methods and packed cell volume (PCV) was determined using hematocrit reader. Univariate analysis and chi-square statistical tests were used to analyze the data.Blood, urine and stool samples were collected from 1017 primary school pupils of ages 4–15 years. Stool samples were processed using both Kato-Katz and formol-ether concentration techniques and microscopically examined for intestinal helminths infection. Urine samples were analyzed using sedimentation method for P. falciparum, S. haematobium, or intestinal helminth. S. haematobium accounted for the largest proportion (44.4%) of a single infection followed by P. falciparum (20.6%). The prevalence of malaria and helminth co-infection in the study was 14.4%. Four species of intestinal helminths were recovered from the stool samples and these were hookworm (22.5%), Hymenolepis species (9.8%), Schistosoma mansoni (2.9%) and Enterobius vermicularis (0.6%). The mean densities of P. falciparum in children co-infected with S. haematobium and hookworm were higher compared to those infected with P. falciparum only though not statistically significant (p = 0.062). The age distribution of both S. haematobium (p = 0.049) and hookworm (p = 0.034) infected children were statistically significant with the older age group (10–15 years) recording the highest prevalence of 47.2% and 25% respectively. Children who were infected with S. haematobium (RR = 1.3) and hookworm (RR = 1.4) have equal chances of being infected with P. falciparum as children with no worm infection. On the other hand children infected with Hymenolepis spp. (p<0.0001) are more likely to be infected with P. falciparum than Hymenolepis spp. uninfected children (RR = 2.0)Overall, 61.2% of all school children had at least an infection of either Hymenolepis spp. induced increase susceptibility to P. falciparum could have important consequences on how concurrent infections affect the expression or pathogenesis of these infections.These findings suggest that multiple parasitic infections are common in school age children in rural communities of Kwara State Nigeria. The  P. falciparum, S. haematobium, or intestinal helminths with S. haematobium and P. falciparum accounting for the largest proportion of a single infection with 44.4% and 20.6% respectively. Children who were infected with S. haematobium (RR = 1.3) and hookworm (RR = 1.4) have equal chances of being infected with P. falciparum as children when compared with children with no infection. On the other hand children infected with Hymenolepis spp. (p<0.0001) have a higher chance of being infected with P. falciparum when compared to uninfected children (RR = 2.0). These findings suggest that Hymenolepis spp. may be associated with increase susceptibility to P. falciparum in this population of Nigeria children.Malaria, schistosomiasis and intestinal helminths are parasitic diseases responsible for high morbidity and mortality in most tropical areas of the world. These parasitic diseases are common in Nigeria where people are co-infected with more than one parasite. This study investigate the prevalence and impact of these parasite co-infections in school age children in rural communities of Kwara State Nigeria. The result shows that over 61.0% of the school children had at least an infection of either  Plasmodium [Plasmodium falciparum is responsible for a high burden of disease and a loss of growth in endemic countries estimated to be as high as 1.3% of gross domestic product per year [falciparum malaria infection are associated with high morbidity and mortality occurring in sub-Saharan Africa [Malaria and helminth infection are the most important public-health problems affecting children in Sub-Saharan Africa . It is easmodium . Malarian Africa . Differen Africa ,6. Thesen Africa  and immun Africa .Ascaris lumbricoides, hookworm and Trichuris trichiura), coupled with schistosomiasis are responsible for more than 40% of the worldwide morbidity from all tropical infections, excluding malaria [Malaria and helminths infections are widespread and they both have similar geographical and overlapping distribution in developing countries with the major consequence of the co-infection being anaemia ,3. The m malaria . Childre malaria ,12. Conc malaria . Studies malaria ,15 or wo malaria ,17 malarfalciparum malaria and helminths infections are reportedly endemic and pose a significant health problem among children [P. falciparum malaria parasitaemia and helminth co-infection in school children living in a setting where malaria is endemic. The results of this study could provide valuable information to local health authorities for improving existing control strategies.In Nigeria, children ,19. Theychildren ,21. Studchildren ,23. Despchildren ,17. ConsThe study was approved by the Kwara State ministry of Health Ethical Committee (MOH/KS/777/41). Before sample collection meetings were held with community leaders, teachers and community members. The objectives of the study including the study procedures, samples to be taken, study benefits, potential risks and discomforts were explained. Informed consent for all children who participated in the study was sought from parents and legal guardians after they have been clearly informed about the study. Parental consent given from parents/guardians were verbal. The ethical committee approved the use of oral consent as most parents were illiterates. Children were also requested to give consent and were informed of their right to refuse to participate in the study and to withdraw at any time during the study without jeopardizing their right of access to other health services. Consent was recorded as ‘yes’ or ‘no’ on an individual form designed for sample collection. The pains and the precautions of procedures such as collection of blood samples were fully explained to parents and children. Newly opened needle and syringe were used for each child. Before samples were collected, demographic data such as sex, age, weight, height and name of subject were recorded. Subjects diagnosed with malaria or helminths were treated appropriately free of charge according to national guidelines. Identification numbers were used instead of children names and information collected were kept confidential.This cross-sectional study was conducted among primary and secondary schools in Pategi and Lafiagi communities in Nigeria. Pategi and Lafiagi are located in Pategi and Edu Local Government Areas (LGAs) in Kwara State, Nigeria. Population of Pategi is 110,852 people while that of Lafiagi is 102,780 people . Both coP. falciparum parasitemia. Thick blood films were prepared, air dried, Giemsa-stained, and observed under the microscope for identification and quantification of malaria parasites. Malaria parasites were counted against 200 leukocytes, and counts were expressed as the number of parasites per microliter of blood, assuming an average leukocyte count of 8,000 cells/μl of blood [About 2 ml of blood samples were collected by venous blood for the determination of of blood .For Packed Cell Volume (PCV), micro hematocrit tubes filled with blood were centrifuged in a micro-hematocrit rotor for 5 minutes at 10,000g. The tubes were placed in the micro-hematocrit reader and children with PCV values ≤ 31% were considered as anaemic, which was further classified as mild (21–30%), moderate (15–20%), or severe (≤15%) .Clean plastic containers were distributed for both stool and urine collection, and instructions were given for proper collection. Instructions were given to collect only terminal drops of urine The formol-ether concentration technique and Kato-Katz thick smear technique were used for quantitative determination of helminths ova . Stool sUrine samples were analyzed using sedimentation method. Samples were left to stand on the bench for about 30 minutes. Afterwards the topmost part of the urine was discarded leaving about 10 ml in the bottle. The contents of each bottle was mixed thoroughly with the sediment and was transferred into a 20 ml centrifuge tube. The tubes were then centrifuged at 1000 r/min for 2 min. The supernatant was discarded and the residue was put on a clean glass slide and examined under 10X objective lens of the microscope. Intensity of infection was estimated as number eggs per 10ml of urine.2 tests. Relative Risk (RR) were calculated for risk estimation between P. falciparum and helminths. Logistic regression was carried out to investigate the relationship between anemia and occurrence of parasitic infection in the study population. P-value ≤ 0.05 was considered significant during the analysisData were double-entered and cross-checked in Microsoft Excel version 2013. Statistical analysis was done using SPSS version 16 for windows. For univariate analysis, frequencies were compared using the Fisher's exact tests. Prevalence of malaria, helminth and co-infection and gender were compared using χS. haematobium, intestinal helminths and malaria co-infection. The mean age of the study population was 9.52 ± 1.904 years while the mean height was 124.19 ± 2.54 cm and the mean weight was 25.34 ± 4.26 kg.A total of 1017 blood, urine and stool samples collected from primary school children aged 4 to 15 years were microscopically investigated in other to determine the prevalence and impact of P. falciparum, Schistosoma haematobium, hookworm, Hymenolepis specie or Enterobious vamicularis. S. haematobium accounted for the largest proportion (44.4%) of a single infection followed by P. falciparum parasitaemia (20.6%). Hookworm and Hymenolepis spp. had a prevalence of 22.5% and 9.8% respectively while E. vermicularis had the lowest prevalence of 0.6%. The intensities of infection expressed as geometric mean parasite count of positive samples is shown in The prevalence and intensities of all the parasites seen in the blood, stool and urine samples of the study subjects are shown in P. falciparum parasitaemia, the youngest age group (4–9 years) had the highest prevalence of 22.7% but the difference was not statistically significant (p = 0.14). The distribution of S. haematobium by age was slightly significant (p = 0.049) with the older age group (10–15 years) recording the highest prevalence (47.2%). Distribution of hookworm by age also showed a significant difference (p = 0.034) with the older age group recording the highest prevalence (25%) of infection. No significant difference was observed in the age distribution of Hymenolepis spp. and E. vermicularis in the study populationThe mean age of the study population is 9.5 ± 1.9 years. P. falciparum parasitaemia, female (21.1%) were slightly more infected than males (20.0%) but the difference was not statistically significant (p = 0.69).The distribution of parasitic infection according to gender among the school children is presented in The prevalence of polyparasitism based on age and sex in the study population is shown in P, falciparum and S. haematobium (p = 0.04), P. falciparum and hookworm (p = 0.01) with a Relative Risk of 1.3 and 1.4 respectively. Children who were infected with S. haematobium (RR = 1.3) and hookworm (RR = 1.4) have equal chances of likely being infected with P. falciparum as children with no worm infection. On the other hand, children exposed to Hymenolepis spp. (p<0.0001) are more likely to be infected with P. falciparum than Hymenolepis spp. uninfected children (RR = 2.0)The association between the presence of malaria parasitaemia and intestinal helminths among the study subjects is shown in Plasmodium falciparum (P = <0.001), S. haematobium (p < 0.001) and hookworm (p < 0.001) infections showed strong significant association with anemia. Also the occurrence of P. falciparum + S. haematobium (P = <0.001), P. falciparum + hookworm (p = 0.004), S. haematobium + hookworm (P = <0.001) and P. falciparum + Hymenolepis spp. (P = <0.001) co- infections were strong predictors of the occurrence of anemia in the study populationA logistic regression analysis was carried out to determine the occurrence of anemia among the school children using the single and double parasitic infection as predictors . PlasmodP. falciparum alone had the lowest geometric mean parasite density (GMPD) per microliter of blood in the study population. Significantly high GMPD was observed among children co-infected with P. falciparum + Hymenolepis spp. as compared to those with P. falciparum alone. Also P. falciparum + hookworms and P. falciparum + S. haematobium co-infections also recorded a significantly higher GMPD in comparison to P. falciparum alone (p < 0.001) (Children infected exclusively with < 0.001) .S. haematobium alone, co-infection of P. falciparum and S. haematobium, co-infection of S. haematobium and hookworm had significantly higher proportion of children with low PCV when compared to children without infection. None of the children in the study population presented with severe anemia while the prevalence of moderate and mild anemia was 1.2% and 30.0% respectively.Hymenolepis spp. may increase the chance of being infected with P. falciparum and also increase the geometric mean parasite count of P. falciparum. The implication of this is that Hymenolepis spp. modestly increases the degree of susceptibility against P. falciparum malaria among school children in rural communities of Ilorin, Nigeria. To the best of our knowledge, this work provides the first report of the prevalence of Hymenolepis spp. and its association to P. falciparum infection. Hymenolepis spp. is not a frequently encountered helminth infection in Nigeria. Previous authors have reported a higher prevalence of 18.3% in the 80s in the Niger Delta area of the country [Hymenolepis spp. often remain asymptomatic and severe infections can occur in individuals with more than 20,000 eggs per gram of feces. Symptoms of severe diseases include enteritis with or without diarrhea, abdominal pain, and loss of appetite. Children may experience more severe intestinal symptoms, which can include epilepsy, probably due to the toxic action that the products of the inflammation cause [This study suggests that underlying infection with  country  while lo country . Hymenolon cause . FurtherP. falciparum infection and S. haematobium infection and P. falciparum infection and hookworm infection. In many previous studies, observation for the interaction between P. falciparum infection and S. haematobium infection had yielded contrasting reports. While some studies reported increased susceptibility to P. falciparum infection in the presence of S. haematobium [S. haematobium on P. falciparum [P. falciparum and helminths. Explanations for these contrasting results have been given in terms of immunonological interactions and microgeographical variation [P. falciparum, schistosomiasis and helminth co-infection observed in this study are supported by other previous studies in Sub-Saharan Africa [A near to equal association was observed between matobium  others hlciparum . These cariation . The ratariation ,34. Alson Africa ,22.S. haematobioum. P. falciparum, hookworm and Hymenolepis spp. The prevalence of urinary schistosomiasis (44.4%) reported in this study suggests that Pategi and Lafiagi LGAs of Kwara State are endemic for urinary schistosomiasis. Earlier study in Bida Niger State, Nigeria a community that shares both socio-cultural and geographical attributes with Pategi and Lafiagi showed high prevalence of urinary schistosomiasis [P. falciparum with S. haematobium was the highest, followed by P. falciparum and hookworm. Both falciparum malaria and helminths have similar geographical distribution and it is estimated that over a third of the world's population, mainly those living in the tropics and subtropics are infected [The most prevalent parasites in this study were somiasis . The preinfected . FactorsS. haematobium and hookworm are significant with respect to age, with the older age group (10–15 years) being more infected. This reflects the fact that older age groups are involved in more water activity contact and also have higher duration of exposure to infection of other soil transmitted helminths. For P. falciparum parasitaemia, the prevalence was higher among the younger age group. It was previously observed that the majority of malaria infections in individuals living in endemic regions are asymptomatic with the young children bearing the highest burden of disease and carrying asymptomatic infections for most of the time [P. falciparum parasite prevalence with age, observed in this study is in agreement with our previous study [Ascaris lumbricoides which was one of the commonest intestinal parasite in Nigeria was not detected in the current study. This observation has been previously made by some authors who have reported this specie to be rare in some areas in Sub-Saharan Africa [The observed prevalence of both the time ,18. The us study ,38. Ascan Africa ,4.S. haematobium [P. falciparum schistosomiasis co-infected school children. Also the logistic regression analysis predicts that the occurrence of anemia among the school children is strongly influenced by the presence of single or co-infection of P. falciparum, hookworm and S. haematobium. These observations further confirms previous reports of a positive relationship that exist between parasitic infections and anemia and also the possible synergistic interaction of these parasites as a strong etiology of anemia [About 39% of the children in the study were classified as anemic with majority being moderately anemic. Many studies have reported anemia as one of the major health problems resulting from malaria , hookwormatobium ,4 infectf anemia ,41,42.P. falciparum was observed in co-infection with helminths when compared to P. falciparum alone. This observation has been previously reported by other authors [P. falciparum and S. haematobium, P. falciparum and hookworms or P. falciparum and Hymenolepis spp. It thus appears that S. haematobium, hookworm or Hymenolepis spp. are associated with higher prevalence of P. falciparum in this population of Nigeria children.Higher mean geometric parasite density of  authors ,44. HighThere is an urgent call by WHO and its collaborating partners to scale up interventions to control and eliminate Neglected Tropical Diseases (NTDs) in the WHO African region. Schistosomiasis and soil transmitted helminths are among the NTDs targeted for elimination. In other for this to materialize, the affected areas must be identified and its burden must be assessed. This remains a crucial and urgent roadmap in other to achieve complete control and elimination of the NTDs in Africa. This study is therefore important for policy makers and stakeholders in the control of NTDs in Africa.P. falciparum, S. haematobium and intestinal helminths was observed among school children in Pategi and Lafiagi communities of Kwara State Nigeria. This is the first study to document the prevalence of these co-infections and also highlighting the impact of Hymenolepis spp. and P. falciparum co-infection among children in the middle belt of Nigeria. The effort of Kwara State Government in reducing the morbidity caused by S. haematobium and intestinal helminths through yearly mass deworming with Albendazole and praziquantel treatment should be complimented with adequate health education. Toilets should be provided in the schools with water for hand washing and personal hygiene enforced in other to create attitudes that will break the cycle of this infections.Conclusively, high prevalence of co-infection of S1 Checklist(DOC)Click here for additional data file.


P. falciparum malaria outbreak was reported in the Shan Special Region II of Myanmar in June of 2014.From 2007 to 2013, intensive control measures reduced malaria burden by 90 % along the China-Myanmar border. However, despite these measures a Epidemiological, parasitological and entomological investigations were performed. Dihydroartemisinin piperaquine (DAPQ) was immediately administered to treat parasite positive individuals. Long lasting insecticidal nets (LLIN), indoor residual spraying (IRS) with insecticides and behavior change communication (BCC) were also provided for outbreak control. An embedded efficacy study was conducted evaluating DP. Molecular genotyping via polymerase chain reaction (PCR) was performed on the Kelch gene on chromosome 13.Plasmodium falciparum by RDT and microscopy. Two fatalities resulted from the outbreak. The attack rate was 72.8 % (67/92) and the incidence density rate was 14.2 per 100 person-weeks. The positive rate of rapid diagnostic test (RDT) was 72.2 % (65/90) and microscopically-determine parasite rate 42.2 % (38/90). Adjusted odds ratio (OR) of multivariate logistic regression analysis for aged <15 years, 15–45 years, inappropriate treatment from a private healer and lack of bed nets were 13.51 , 7.75 (1.48–44.97), 3.78 (1.30–46.18) and 3.21(1.21–15.19) respectively. In the six surrounding communities of the outbreak site, positive RDT rate was 1.2 % (4/328) and microscopically-determine parasite rate 0.6 % (2/328). Two light traps collected a total of 110 anopheline mosquitoes including local vectors, An. minimus, An. sinensis and An. maculates. After intensive control, the detection of malaria attacks, parasites and antigen were reduced to zero between July 1 and December 1, 2014. The cure rate of P. falciparum patients at day 42 was 94.3 % . The PCR did not detect K13-propeller mutations.All infections were identified as P. falciparum caused the outbreak. Age, seeking inappropriate treatment and lack of bed nets were risk factors for infection during the outbreak. P. falciparum was sensitive to treatment with DAPQ. The integrated measures controlled the outbreak and prevented the spread of P. falciparum effectively. The results of this study indicate that malaria control on the China-Myanmar border, especially among special populations, needs further collaboration between China, Myanmar and international societies.Imported The online version of this article (doi:10.1186/s40249-016-0127-8) contains supplementary material, which is available to authorized users. Please see Additional file P. falciparum partial resistance to artemisinin has been one of the most concerning issues [Remarkable progress has been achieved in reducing malaria cases and deaths over the last decade. The malaria target under the Millennium Development Goal 6 has been met, and 55 countries are on track to reduce their malaria burden by 75 %, in line with the World Health Assembly’s target for 2015 . Countrig issues –13.th, 2014, a P. falciparum malaria outbreak was reported in the Aidao Rubber Plantation, located close to the border. Officials from China, Myanmar and Health Poverty Action (HPA) jointly conducted the outbreak investigation and led the control efforts. Here is reported the outbreak investigation, the public health response and the efficacy results from an integrated efficacy study along with a discussion on the implications of our findings.With the nascent goal for regional malaria elimination in the GMS, arises the need to develop regional and local initiatives. Malaria control along the international border and attempts to contain drug resistance have received much attention, but effective interventions remain challenging , 5, 9. CThe outbreak was reported in a private rubber plantation, Aido Rubber Plantation (ARP), about 10 km away from the China-Myanmar border. The plantation was established in 2004. At the time when the outbreak was reported, there were 122 inhabitants, in 24 households of which 14 families were of the Lahu ethnic minority who emigrated from Lancang County, China in 2004. There were 10 families of the Wa ethnic minority who emigrated from other villages of the Shan Special region of Myanmar in 2005. All houses have wood and bamboo walls and grass or asbestos roofs that enable easy entry for mosquitoes. There were only three bed nets in the whole community. The Health Center of Tenglong Rubber Company (HCTRC) is approximately 8 kilometers away from ARP and is the nearest public health facility. Additionally, there is a private healer at Rubber Plantation 18 about 2 kilometers away from ARP  on the morning of June 19. The results were reported to Wa State Department of Health in Myanmar; Kunming office of HPA, Yunnan Institute of Parasitic Diseases (YIPD) and Menglian Center for Disease Control and Prevention (CDC) in China  and axillary temperatures were measured. Additionally, thick and thin blood smears were prepared for all subjects including the 50 individuals previously tested by the HPA with RDT. A standardized questionnaire to assess risk factors was completed during a face-to-face interview with each patient or caretaker. The data were collected from each individual consisting of age, gender, number and date of malaria attacks, gravity of attacks, locations from which treatment was sought, results of RDTs and microscopy, ownership of bed nets and type of house, and travel excursions between May 1 and June 19 Fig. .st to 26th, 2014 in all six surrounding communities ranging between 1 and 5 km from the ARP. The six communities were Bangbai village, Rubber Plantation 20, Rubber Plantation 18, Laodaoban village, Waizhai village and Rubber Plantation 17 & 23  was administered to every malaria case, once a day for 3 days . Patient2 to all houses of the ARP, and houses of malaria patients and their neighbors in the six surrounding communities on June 27th. Two community health workers (CHW) were trained and equipped with RDT and DP to carry out diagnosis and treatment of malaria. At least one CHW visited the ARP and its surrounding villages each day from June 21st to August 31st, to actively detect and treat malaria patients. Behavior change communication (BCC) was conducted from June 20 to 27, 2014. Investigators communicated with every patient or caretaker while they administered a face-to-face interview, and the CHWs also conducted BCC during their household visits. The core information of communication included the cause of malaria, vectors, high risk areas, seeking appropriate diagnosis and treatment, and instruction on the use of bed nets  were distributed to each household in the outbreak site to isolate malaria patients from uninfected inhabitants. On the next day, an extra 59 LLINs were distributed to the six other communities to replace torn nets. Indoor residual spraying (IRS) with lambda-cyhalothrin  was carried out at a dose of 25 mg per mAt the outbreak site, two light traps  were used to collect both indoor and outdoor mosquitoes overnight. The genus was identified in the field, and anophelines were sent to laboratory of Menglian CDC for identification of species .P. falciparum, older than 1 year, with a body weight ≥ 5 kg, and presenting with a parasite density of 500–100 000 parasites per μL, were recruited to this study, after obtaining full informed consent. Exclusion criteria were defined as previously described [Based on the results of microscopy, patients with mono-infections of escribed .The study design was based on the standard 42 day follow up survey as defined by the WHO , 22. TheDAPQ was sourced from Zhejiang Holley Nanhu Pharmaceutical Co. Ltd, and provided at 65 mg/kg body weight.A general physical exam was conducted at enrollment. Axillary temperature was measured and blood was collected for blood smears and filter paper spots (about 100uL blood per patient) at enrollment, every 8–12 h in the first 3 days and then on day 7, 14, 21, 28, 35 and 42.Plasmodium species or, if needed, to detect mixed infections. DNA extraction and genotype analysis were conducted based on investigation of the three polymorphic genetic markers msp1, msp2, and glurp, according to WHO recommended procedures [Malaria blood films were stained with Giemsa, and slides were examined by two independent microscopists in YIPD and considered negative if no parasites were seen after examination of 200 oil-immersion fields in a thick blood film. Parasite clearance was defined as no detection of asexual parasites per 500 white blood cells in two sequential microscopic examinations within an 8–12 h interval . PCR wasocedures , 23, 24.ocedures , 26.Treatment outcome was categorized based on the WHO definitions for early treatment failure (ETF), late clinical failure (LCF), late parasitological failure (LPF), and adequate clinical and parasitological response (ACPR) .Data were double entered and cleaned in EpiData 3.1 , and analyzed in Epi Info 7 . Attack rate (AR) and incidence density (ID) was calculated using the following formula :\documenP < 0.05. A multivariate logistic model was used to identify risk factors of malaria infections during the outbreak. In the model, the outcome (dependent) variable was the RDT result, and independent variables were demographic characteristics, staying overnight in other places, seeking treatment, ownership of bed net and type of roof [A Chi-squared test was used to compare the proportions and significance was  of roof , 28. The of roof , 21, 22.The outbreak investigation and control protocol was approved by Wa State Department of Health (WDH). Oral agreements for the outbreak surveys and control interventions were obtained from all individuals. Ethical approval for in vivo efficacy study was granted by the Ethics Committee of Yunnan Institute of Parasitic Diseases (YIPD), China. Informed written consent was obtained from all adult subjects or caretakers of children who participated in DP therapeutic efficacy study, and the participants had the right to withdraw from the study at any time. All results were kept confidential and were unlinked to any identifying information.P. falciparum by microscopy. In order to better understand the focus of the outbreak further 50 inhabitants were tested by RDT and 32  were found positive. This result prompted a formal outbreak investigation.The outbreak was reported when three out of four patients were found to be positive for Of the 122 inhabitants of ARP, 92 were investigated. Two deaths were reported by the private healer and interviewees during the face-to-face interview. 90 (73.8 %) suspected cases were tested with both RDT and microscopy. Questionnaires were administered in all 90 subjects (Table The median age was 22.9 years (rang: 3 months-70 years). The male/female sex ratio was 0.96 Table .As a result of the retrospective data collection, the first malaria patient, a 52-year male, was diagnosed by the private healer on May 17 and died on May 27. He had been mining for gold in Salween River Valley and returned back to ARP on May 8; the second fatality, 23-year male, occurred on June 14, but he had never been out of ARP. The both fatalities were Lahu ethnic minority, and they presented the symptoms of complicated malaria including shivering, high fever, severe headache, hematuria, abnormal posturing, nystagmus and coma.P. falciparum by RDT and 38 (42.2 %) were found positive by microscopy . From the 65 RDT positive subjects, 30 (46.2 %) were male and 27 (41.6 %) children (<15 years)  were positive for P. falciparum by RDT, three of them were from Banbai village, which is approximately 1 kilometer away from the centre of the outbreak. The fourth case was from Laodaoban village, which is two kilometers away from ARP. All 328 subjects did not report being overnight in other places from May 1st to June 19th.To estimate the size of the outbreak, a total of 328 volunteer participants from the six surrounding communities were screened by both RDT and microscopy in a short cross–sectional survey. The median age of the subjects was 21.0 years (rang: 1 month - 80 years). The male/female sex ratio was 0.8. Four (1.2 %) individuals were found positive for OR 3.78, P < 0.01) and lack of bed nets  were associated with malaria infection during the outbreak. The most important risk factor was age <15 years with an OR of 13.5 (P < 0.01)  identified seeking treatment from the private healer  and rapidly, within 10 days. There were no malaria attacks found after July 1st. The trained CHWs were unable to find any individuals with parasites and/or that were RDT positivity in ARP and the six surrounding communities. Furthermore, malaria has not been found in those communities until December 31st 2014.During the outbreak, prior to the first intervention, the attack rate and incidence density were 60.7 % (56/92) and 15.9 per 100 person-weeks respectively. After the intervention this fell to 12.2 % (11/90) and 8.9 per 100 person-weeks Fig. . The resth to 7:00 am of June 21st (11 h), 110 of anopheline mosquitoes were collected. The light traps collected nine anopheline mosquitoes indoors including one (11.1 %) An. minimus and four (44.4 %) An. sinensis, and 101 anopheline mosquitoes outdoors including eight (7.9 %) An. minimus, 20 (19.8 %) An. maculates and 20 An. sinensis   was much higher than the microscopically-determined parasite rate (38.9 %). As all slides were reexamined by two expert microscopists in YIPD and the RDT  detects histidine-rich protein-2 (HRP2) of P. falciparum and specific lactate dehydrogenase (Pv-pLDH) of P. vivax [P. falciparum parasitemia to sub-microscopy levels, but did not clear parasites and interrupt transmission completely. In addition, HRP2 is detectable by RDT for about 2 weeks after parasite clearance [P. falciparum infections.According to the report from the private healer and the face-to-face interview, the gold miner was the first patient, and he died on May 27P. vivax , one explearance . As the An. minimus and An. sinensis indoors; and a certain proportion of An. maculates, An. sinensis and An. minimus outdoors. An. minimus is considered the local principle vector; An. sinensis is a secondary vector and An. maculates is an important vector in the GMS [P. falciparum to the existing vectors, and that the existing vectors were able to reestablish transmission.The PCR identified that all 35 parasite samples belonged to the same msp1, msp 2 and glurp genotype. The entomological survey found  the GMS . These rThe multivariate logistic regression analysis (MVLRA) identified that age, seeking inappropriate treatment and lack of bed nets were risk factors during the outbreak. Children less than 5 years accounted for 32.3 % of total 65 RDT positive subjects. This indicated that children, especially less than 5 years, were at the highest risk during the outbreak. While the sixth and tenth rounds of the GFATM’s China Malaria Program covered the Shan Special Region II of Myanmar, the malaria control programs neglected the ARP. As the ARP was a unique community consisting of the illegal, Chinese-immigrant Lahu people and the internal, Myanmar-immigrant Wa people, the inhabitants were too poor to seek appropriate diagnosis and effective treatment. Their first choice was to visit the private healer when they were ill. The private healer incorrectly administered a single artemether injection for malaria treatment and the ARP inhabitants did not return for the additional injections if they felt well. This led to artemether injection for less than 3 days. This sub-therapeutic dose of artemether relieved symptoms of malaria patients, but allowed residual parasites to maintain transmission and establish the outbreak. Additionally, the malaria control programs routinely distributed LLINs resulting in one net per two persons, however, the ARP had never received any LLINs prior to the outbreak, thus preventing protection from the mosquito vector.P. falciparum is assumed to last about 10 days [th to 20th would indicate the third generation of patients from the initial outbreak (Fig. P. falciparum was just detected in two individuals, and there were only four positive RDTs in the six surrounding communities after the interventions. The strategy, with the noted absence of out MDA, had controlled the outbreak and prevented P. falciparum from spreading in the six surrounding communities. This success is likely attributed to active collaboration and joint efforts of China, Myanmar and international NGOs as well as strong community involvement.The life cycle of  10 days . In thiseak Fig. . As one P. falciparum in this outbreak was still sensitive to DAPQ and that DAPQ was effective for the treatment of this outbreak, noting the absence of K13-propeller mutations in these parasite samples. Additional to this observation, the results of in vivo monitoring from 2007 to 2013 that indicate that P. falciparum was sensitive to DAPQ along China-Myanmar border [P. falciparum malaria [DAPQ was the most commonly used ACT in malaria programs on the China-Myanmar border. While artemisinin resistance has extended across much of Myanmar , the resr border , demonstr border . While t malaria , these ist, 2013, the outbreak occurred during the transition phase from China’s to Myanmar’s malaria program when surveillance and interventions were the weakest. Taken together, these lessons show that collaboration between China, Myanmar and international societies for malaria control should be strengthened and improved.Several lessons can be learned from the outbreak. First, particular attention should be given the transient and neglected groups. The lack of effective interventions and surveillance among neglected populations may lead to outbreaks or even a resurgence of malaria. Second, inappropriate diagnoses and treatments still exist in the private sector on the China-Myanmar border. Coverage and service of public health facilities should be increased and strengthened to allow access to easy alternative to private healers. Additionally, the ban of sale of fake and sub-standard antimalarial drugs, including artemisinin monotherapy should be more thoroughly enforced. Third, as the GFATM terminated the tenth round of its malaria program by December 31An. minimus, An. maculate and An. sinensis. This provided evidence for inclusion of LLINs and IRS as part of outbreak response.It is noted that the entomological survey is one limitation of his study as the collection of anopheline mosquitoes was only carried out by two light traps for one night, and human landing collection was not carried out. Entomological data of local malaria vectors are still lacking in Shan Special region II of Myanmar, and further research may be needed. However, the light traps were successful in collecting local malaria vectors including: P. falciparum malaria outbreak. Age, seeking inappropriate treatment and lack of bed nets were risk factors of malaria infection during the outbreak. K13-propeller mutations were not found in the P. falciparum parasites and DAPQ was demonstrably effective in treating infections. Treatment of malaria cases, combined with LLIN distribution, IRS and BCC, successfully controlled the outbreak and prevented the spread of P. falciparum. On the China-Myanmar border, malaria control, especially among special populations, needs further collaboration between China, Myanmar and international societies.This investigation confirmed, contained, and characterized


Insecticide-treated bed nets (ITNs) are the cornerstone of malaria control in sub-Saharan Africa but their effectiveness may be compromised by the spread of pyrethroid resistance among malaria vectors. The objective of this investigation was to assess the effectiveness of ITNs to prevent malaria in an area of Malawi with moderate pyrethroid resistance.One deltamethrin ITN was distributed in the study area for every two individuals in each household plus one extra ITN for households with an odd number of residents. A fixed cohort of 1,199 children aged six to 59 months was seen monthly for one year and at sick visits to measure malaria infection and use of ITNs. Insecticide resistance among malaria vectors was measured. The effect of ITN use on malaria incidence was assessed, adjusting for potential confounders using generalized estimating equations accounting for repeated measures.Plasmodium falciparum over 905 person-years at risk (PYAR), resulting in an observed incidence of 2.1 infections per person-year (iPPY). ITNs were used during 97% of the PYAR. The main vector was Anopheles funestus: mortality in WHO tube assays after exposure to 0.05% deltamethrin was 38%  29–47), and resistance was due to elevated oxidase enzymes. After adjusting for potential confounders, the incidence of malaria infection among ITN users was 1.7 iPPY (95% CI 1.5-2.1) and among non-bed net users was 2.6 iPPY (95% CI 2.0-3.3). Use of ITNs reduced the incidence of malaria infection by 30%  compared to no bed nets.There were 1,909 infections with An. funestus is the major malaria vector. Malaria control programmes should continue to distribute and promote ITNs in areas with low to moderate pyrethroid resistance; however, insecticide resistance may intensify further and it is not known whether ITNs will remain effective at higher levels of resistance. There is an urgent need to identify or develop new insecticides and technologies to limit the vulnerability of ITNs to insecticide resistance.ITNs significantly reduced the incidence of malaria infection in children in an area with moderate levels of pyrethroid resistance and considerable malaria transmission. This is the first study to show that ITNs provide protection in areas where pyrethroid-resistant  Bed nets have been used as a physical barrier to prevent nuisance mosquito biting since the Sixth Century BC, but were not used extensively for malaria control until after pyrethroid insecticides were applied to net material in the mid-1980s . The comPyrethroids are currently the only class of insecticide recommended for use on ITNs due to their low mammalian toxicity and long residual activity . ConcernAnopheles gambiae s.s. in West Africa in the early 1990s [Anopheles funestus and implicated in an epidemic of malaria in South Africa following the switch from DDT to pyrethroids for indoor residual spraying (IRS) [Pyrethroid resistance was first reported in ng (IRS) . Pyrethrng (IRS) , at leasng (IRS) . Pyrethrng (IRS) ,13. ResiWhile there has been some limited evidence linking the operational failure of pyrethroid-based IRS to resistant vectors -16, therPlasmodium falciparum prevalence in children aged two to ten years is 40-50% [Malaria remains a significant problem in Malawi, where the entire population is at risk and it was estimated that 48% of the population resides in areas where the age standardized s 40-50%  and mores 40-50% . The Mals 40-50% . Since 2s 40-50% .An. funestus and An. gambiae s.l.) to be susceptible to all insecticides, including pyrethroids. Within three years, however, anopheline resistance to pyrethroids could be found in eight of 11 sites examined down the length of the country [An. funestus than An. gambiae s.l.; biochemical assays demonstrated that the resistance mechanism was metabolically based for both species.WHO phenotypic resistance assays conducted in Malawi in 2007 found both major malaria vectors  28–49) . This area has never received indoor residual spraying for malaria control.The study was conducted in the Traditional Authority of Sitola in Machinga District, surrounding the town of Liwonde . The study area is bordered on the west by the Shire River and on the northeast by the Likwenu River and Liwonde National Park  and passive (sick visits) surveillance.The initial household census was used to determine the number of ITNs needed per house by allocating one ITN per two household residents plus one extra for households with odd numbers of residents. The long-lasting bed nets distributed were Permanet 2.0 , treated with deltamethrin, and a total of 5,146 ITNs were distributed to household heads during the month of May 2012. The allocation algorithm used in the area was the same as that used by the National Malaria Control Programme in the national ITN distribution that took place in July 2012 .The sample size was based on a generalized estimating equations modelling approach with a Poisson distribution and accounted for the correlated nature of repeated measurements on study children using an exchangeable correlation structure . The incChildren were eligible to participate if they were between six and 59 months as of 1 March, 2012, not taking daily cotrimoxazole for HIV infection or exposure, weighed 5 kg or more and planned to stay in the study area for at least one month.Plasmodium testing by nested polymerase chain reaction (PCR) at the Malawi College of Medicine in Blantyre [P. falciparum, Plasmodium malariae, Plasmodium ovale, and Plasmodium vivax. At monthly visits, malaria testing was conducted using a histidine-rich protein 2 (HRP-2) P. falciparum malaria rapid diagnostic test .At enrolment and all monthly visits, children and their caregivers were invited to a central location near their home; no reimbursement or incentive was provided to caregivers to attend the routine monthly visits. At enrolment and the tenth monthly visit, children had their height and weight measured. At each monthly visit, axillary temperature was measured and a finger stick was performed to collect a blood sample for thick and thin blood smears and haemoglobin (Hb) measurement using a Hemocue®  portable haemoglobinometer. At enrolment, a dried blood spot was also made for Blantyre . All samAt enrolment and all monthly visits, parents or caregivers were questioned regarding the child’s two-week illness history, household bed net ownership and bed net use. Bed net use by the child was referenced for the night before the survey, the two-week period before the survey and for typical use during the current season. Study ITNs were not distributed until after enrolment in May 2012, and many residents retained their older bed nets. Therefore, the age of the bed net used by the child was requested along with the caregiver’s assessment of the condition .At enrolment, all children were provided with a full, weight-appropriate treatment course of dispersible artemether-lumefantrine ; the first dose was observed by study staff, and parents or caregivers were instructed on how and when to give the remaining doses. At subsequent visits, only children with positive RDT results were treated with an appropriate anti-malarial.Study staff attempted to contact any child who did not attend the monthly visit to schedule a make-up visit. Any child who did not attend three consecutive visits for any reason was withdrawn from the study and censored as of their last visit date.During the study period, caregivers were encouraged to bring participants to the study clinic located at Machinga District Hospital, the only health care facility within 30 km of Liwonde Town, if they became sick. Artemisinin-based combination therapy is free at public health facilities, and 91% of children under five years of age with fever in the two weeks before the Malawi Malaria Indicator Survey in 2012 and treated with an anti-malarial received an artemisinin-based combination therapy, suggesting limited use of private physicians and drug shops . Sick ch, pers comm). Briefly, children attending monthly visits between December 2012 and January 2013 and September and October 2013 were randomly selected for follow-up home visits, which occurred between zero and eight days after the monthly visit. Caregiver responses to questions about ITN use at the monthly visits were compared to the same questions asked at the home visit plus visual inspection of the ITN reported to be used by the child. The proportion of positive and negative agreement of ITN use between caregiver report and home visit were calculated and 95% CI were constructed using bootstrapping.The reliability of caregiver-reported ITN use was evaluated twice during the study period  were conducted in ten houses per cluster using standard methods . Sexing ocedures . Phenotyr larvae .To determine whether the mechanism of resistance was an elevated oxidase or esterase enzyme, mosquitoes were pre-exposed to the synergist, piperonyl butoxide (PBO), for one hour before the WHO tube assay was conducted. Synergists are non-toxic to insects but improve the effect of an insecticide by inhibiting the metabolic enzymes (oxidases and esterases) that cause mosquitoes to be resistant. Mosquitoes were exposed to PBO in 250 ml Wheaton bottles. The bottles were coated by adding 1 ml of a stock solution of 400 mg/L of PBO (corresponding to a dose of 400 ml/bottle) in acetone, rotating the bottles to ensure all surfaces were covered and then allowing the acetone to evaporate. Two to five days old female mosquitoes were added to the bottle and exposed for one hour. The mosquitoes were then removed and exposed to 0.05% deltamethrin or 0.75% permethrin in WHO tube assays as described above .kdr) locus using either a leg or wing removed from the mosquito corpse of mosquitoes for which species identification was confirmed molecularly. Stratified samples of mosquitoes of both species determined by the WHO resistance assay to be resistant or susceptible to permethrin or deltamethrin were randomly selected for testing for commonly reported kdr mutations. Two different assays were utilized depending on the species being tested: Huynh et al. for An. gambiae s.l. and Morgan et al. for An. funestus [2 UV imager . Further sequencing was done on An. funestus samples to determine if single nucleotide polymorphisms associated with resistant populations were present within the amplified region. Samples were processed using BigDye® Terminator v3.1 , purified with BigDye® XTerminator and sequenced on an ABI 3500 sequencer . Sequences were aligned using Lasergene® SeqMan  and confirmed using the basic local alignment search tool feature.Assays were performed to detect mutations in the knockdown resistance  were selected from the mosquitoes alive or killed by the resistance bioassay and tested using PCR to determine the sibling species. Mosquitoes of the An. gambiae complex were identified using the methods described by Wilkins et al. [An. funestus group were identified using a modification of the protocol described by Koekemoer et al. with intentional mismatched primers [An. funestus, specimens were tested with primers for An. funestus s.s., Anopheles vaneedeni, Anopheles rivulorum, An. rivulorum-like, Anopheles parensis, and Anopheles leesoni. Anopheles gambiae s.l. were tested with primers for An. gambiae s.s., Anopheles arabiensis, Anopheles coluzzii, Anopheles quadriannulatus (species A) and Anopheles melas/merus. Mosquitoes that did not amplify against one of these primers were retested with universal primers for the internal transcribed spacer 2 region to determine whether the lack of amplification was due to poor specimen preservation.Mosquitoes of both species  or no bed net. Bed nets used between enrolment and the end of the ITN distribution were classified as a UTN if they were reported to be 36 months or older; however, as of 1 June, 2012, after ITNs were distributed by the project, no bed nets were considered to be untreated. Children were described as anaemic (Hb <11 g/dl) or not anaemic (Hb ≥11 g/dl).The main outcome was A number of potential confounders was measured and included in the analysis. Baseline parasitaemia was measured by PCR and used to indicate previous exposure to malaria infection. A proxy measure of individual exposure to malaria transmission was generated by using the inverse distance-weighted (IDW) malaria prevalence in children within 1 km, divided into terciles . HousehoData from monthly and sick visits were combined into one dataset and time between visits was calculated as person-time at risk. After every positive result treated with artemether-lumefantrine, including the baseline treatment dose, 10.5 days were subtracted from the person-time at risk to account for the half-life of lumefantrine .As febrile children who came for sick visits in between monthly visits would have been tested again for malaria with an RDT, there was the potential that the second of sequentially positive RDTs was a false positive due to persistent antigen from a recently treated infection. Follow-up of infected children after malaria treatment in Uganda found that the median duration of persistent antigenaemia using HRP2-based RDTs was 35 days (95% CI 33–37), although the possibility of re-infection could not be ruled out . A mathe1/R0) where R1 is the rate among ITN or UTN users and R0 is the rate among non-bed net users. The attributable rate difference was calculated as R1-R0 and interpreted as the number of malaria infections prevented by ITNs annually.SAS®  was used for all analyses. Data were analysed using Poisson regression with a generalized estimating equations approach (PROC GENMOD) to account for the extra correlation from repeated measures on the same child . Both thHousehold heads provided verbal consent to have their household mapped and residents enumerated. Parents or caregivers provided verbal consent to have their child screened for eligibility, and read and signed written informed consent forms if the child was found to be eligible. Households selected for PSCs provided verbal consent. The protocol was reviewed and approved by the Malawi College of Medicine Research Ethics Committee  and by the US Centers for Disease Control and Prevention institutional review board .There were 2,804 houses in the study area, and 2,178 (78%) agreed to be mapped and enumerated  0.92, 0.97) and 1,018 (85%) children completed one year of follow-up . The median Hb measurement was 10.0 g/dl  and 72% of children were anaemic. A third of children (32%) were stunted and 3% met the definition of wasted. Less than one-fifth (18%) of the caregivers had completed primary school.Slightly less than half (48%) of the enrolled children were female Table . At baseAt baseline, bed net use the night before the survey was reported for 78% of children, but only 44% were reported to have used an ITN. Use of an ITN the night before the survey was strongly associated with use of an ITN over the previous fortnight: 97% of those who used an ITN the night before the survey had used an ITN every night out of the previous 14 nights and the remainder had used an ITN at least once in the last two weeks. Among those reporting not using an ITN the night before the survey, 99% reported not using an ITN at all during the previous 14 nights. A large proportion (59%) of the ITNs were reported to have holes, with one-fifth (21%) reported to have at least one hole fist-sized or greater. The median number of ITNs within 300 m of participants at baseline was 8 .P. falciparum identified, most (65%) through active surveillance at monthly visits , and ITN use the night before the survey was reported for 864 (97%) PYAR, UTN use for 17 (2%) PYAR and no bed net for 15 (2%) PYAR. To measure the reliability of caregiver-reported ITN use at the routine monthly surveys, study staff visited 211 randomly selected children from December 2012-January 2013 and 325 children between September and October 2013 . The observed proportions of positive agreement between caregiver report and home visit on ITN use by the child in the first and second surveys were 98.8% (95% CI 97.6-99.8) and 93.3% (95% CI 91.2-95.3), respectively. The proportions of negative agreement in the first and second survey were 28.6% (95% CI 0–75) and 20.0% (95% CI 0.1-35.0).An. funestus Giles and 142 (16%) as An. gambiae s.l. Mean indoor resting density for both species was highest in April 2012 and again between December 2012 and March 2013  and two (2%) were positive, respectively.There were 885 female anophelines collected through PSC; 743 (84%) were identified as An. funestus after exposure to 0.05% deltamethrin and 0.75% permethrin was 38 and 25%, respectively. After exposure to the synergist (PBO), mortality rates with these insecticides rose to 89 and 98%, respectively. Mortality of An. gambiae s.l. to 0.05% deltamethrin and 0.75% permethrin was 53 and 65%, and exposure to PBO increased mortality from 0.75% permethrin to 100%. No testing of An. gambiae s.l. to 0.05% deltamethrin after PBO exposure was conducted due to low numbers of mosquitoes. Taken together, the results of increased pyrethroid susceptibility after exposure to PBO implicate elevated oxidase enzymes as the primary resistance mechanism.Results of the phenotypic resistance assays are shown in Table An. gambiae s.l. tested, none possessed either of the two kdr-like mutations L1014F (West African kdr) or L1014S (East African kdr) reported in An. gambiae s.s. Of the 20 An. funestus samples chosen for additional sequencing, seven resistant and eight susceptible samples yielded complete sequences. Based on alignments with the An. funestus FUMOZ laboratory colony, which originates from Mozambique and does not possess kdr, none had any single nucleotide polymorphisms that were unique to either the resistant or susceptible populations. In summary, neither vector species showed evidence for the presence of kdr genes.Of the 22 An. funestus s.l. identified to species out of 100 that survived exposure to pyrethroids, and 12 tested out of 39 that were killed by exposure to pyrethroid and all (100%) were found to be An. funestus s.s. There were 17 An. gambiae s.l. tested that survived the pyrethroid exposure and 22 that did not, and 16 and 22, respectively, were identified to species; 100% of the surviving mosquitoes and 95% (21/22) of the killed mosquitoes were found to be An. arabiensis. One (5%) of the killed mosquitoes was identified as An. gambiae s.s.There were 23 In univariate analysis, children between six and 11 months old experienced twice the malaria incidence than those older than 12 months; malaria infection at baseline was also associated with almost twice the malaria incidence of those without infection at baseline Table . Use of After controlling for all variables significantly associated with malaria incidence in univariate analyses, use of an ITN was associated with a protective effectiveness of 30%  and among UTN users was 2.0 iPPY (95% CI 1.6-2.6), whereas among children who did not use any bed net, the model-adjusted incidence was 2.6 iPPY (95% CI 2.0-3.3). The attributable rate difference for ITNs  was 0.9 malaria infections averted per person-year, or 815 malaria infections averted in the study population. Therefore, for every ten children protected by ITNs, nine malaria infections were prevented annually.An. funestus, the main malaria vector, and 53% of An. gambiae s.l., the secondary vector, in WHO tube assays. Prior to the continent-wide increase in pyrethroid resistance, randomized controlled trials of the efficacy of ITNs compared to no bed nets in areas with similar malaria incidence to Malawi showed ≥50% reductions in the incidence of malaria [vs randomized controlled trial) and analytical methods. Additionally, the high rate of ITN use in this population may have suppressed transmission, benefitting non-bed net users and reducing differences between users and non-users of ITNs.ITNs were found to reduce the incidence of malaria by 30% among children six to 59 months old in an area of Malawi where deltamethrin killed only 38% of  malaria -49. It iITNs prevent malaria through several modes of action: the insecticide deters mosquitoes from entering houses, irritates the mosquitoes that encounter the insecticide, causing them to leave the area prematurely, and kills the mosquitoes that acquire a lethal dose. In addition, ITNs provide a physical barrier to blood feeding. This latter mode of action is the only one that does not depend on the insecticide, and potentially could account for continued ITN effectiveness in areas with pyrethroid resistance if the barrier effect was an important component of the ITN mode of action. However, evidence of the effectiveness of UTNs to reduce malaria transmission is limited: several observational studies have found UTNs to be protective against malaria , but theThere are other data to suggest that ITNs provide more than just a physical barrier to malaria transmission in areas with resistant mosquitoes. A recent meta-analysis of the entomologic impacts of pyrethroid resistance found that ITNs were significantly more effective at reducing blood feeding, inducing exophily and killing mosquitoes than UTNs despite pyrethroid resistance . This reAn. funestus is the dominant vector. As the clearest example to date of operational failure of insecticide-based vector control was in South Africa after An. funestus became metabolically resistant to the pyrethroids used in the IRS programme in the late 1990s [This is the first study to show that ITNs continue to prevent malaria infections in an area where pyrethroid-resistant te 1990s , the reste 1990s , and thete 1990s . UnfortuA weakness in all studies of insecticide resistance and malaria transmission is the actual measurement of resistance. WHO recommends measurement of phenotypic resistance through standardized WHO tube assays or the CDC bottle assay . Both tekdr; although this somewhat arbitrary classification system was used in this analysis, it is not based on any epidemiologic or entomologic outcomes [Aside from the issue of whether existing assays accurately measure the resistance of the mosquitoes responsible for transmitting malaria, it is not clear whether there is a threshold at which resistance may begin to have an epidemiologic impact. Strode and colleagues classified resistance levels into low, medium and high based on phenotypic assays and prevalence of outcomes . It is cThis study had several important limitations. Resistance among mosquito vectors had already occurred in this area so no comparison with ITNs under conditions of full vector susceptibility in this population could be made. ITN use in this population was significantly higher than anticipated, decreasing the precision of the protective effectiveness estimate, and potentially limiting the generalizability of the study results to other areas. The ITNs used in this study were new at the start, and it is possible that effectiveness will decline as bed nets degrade physically. To examine this possibility, the study was extended by an additional nine months; results are being analysed and will be published soon. Use of RDTs for malaria diagnosis during the monthly and sick visits, rather than the gold standard of microscopy, was necessary given the extremely high number of encounters with study participants where malaria infection was measured; but RDTs may pick up treated infections that still have persistent antigen. This problem was assessed by varying the interval for determining whether consecutive positive RDT results were independent, and did not find any difference in interpretation of results.This study had several strengths, including that it was designed prospectively to answer the question of ITN effectiveness in an area with significant pyrethroid resistance, rather than conceived as a secondary data analysis. A fixed cohort with a high follow-up rate was observed, and ITN use was evaluated frequently over the course of the study with two surveys to examine the reliability of caregiver report of ITN use. Both active and passive surveillance were combined to try to capture all malaria infections, both symptomatic and asymptomatic, and all infections were parasitologically confirmed. Potential confounders were carefully measured and included in the final model, including estimates of malaria exposure and measures of ITN density that may cause a community effect. A recent review lamented the lack of concomitant measures of insecticide resistance in other studies of ITNs and pyrethroid resistance ; this ststatus quo. Periodic monitoring of the effectiveness of ITNs in areas of moderate to high pyrethroid resistance should continue, while research on new insecticides and new technologies should be pursued urgently to eliminate the pyrethroid Achilles’ heel of ITNs.ITNs continue to protect children from malaria in an area of Malawi with very high reported ITN use, moderate insecticide resistance and high rates of malaria transmission, annually preventing nine cases of malaria for every ten children protected. Based on these findings, national malaria control programmes should continue to procure and distribute ITNs for areas with moderate insecticide resistance. However, as the measures of insecticide resistance used in this investigation are imperfect, and distribution and intensity of insecticide resistance could still increase, these findings do not suggest complacency with the