Malaria Control & Elimination

Malaria elimination in Indonesia was launched officially as a national program in 2008 following a commitment during the 60th World Health Assembly in 2007. Indonesia’s three major malaria elimination goals include: 1) An annual parasite incidence (API) below 1 per 1000 population 2) Absence of indigenous cases 3) Active surveillance. Another key component of Indonesia’s elimination strategy includes the use of artesunate combination therapy (ACT) in place of chloroquine, because of evidence for widespread resistance. Objective: The objective of this study is to assess the impact of a new policy in malaria treatment using ACT in place of chloroquine together with long-lasting insecticidal net (LLINs) in order to achieve malaria elimination in two low malaria endemic areas (where the API are ranging from 1 - 5 per 1000 population): in Sabang city in Aceh Province, located in the western part of Indonesia and in the Jembrana district, in Bali province located in the eastern part of Indonesia. Method: Epidemiological data were collected from health centers and district health offices from 2008 to 2011 using a standardized reporting form. Both qualitative and quantitative data were collected. In-depth interviews with the authorities, health workers and other key informants such as village malaria volunteers, combined with direct observations were conducted in the two study areas. Result: In combination with LLINs and ACT beginning in 2008 there was decrease in the incidence of malaria in Sabang city from 3.7/1000 population in 2008 to 0.08/1000 population in the 2011, a decrease of almost 50 fold. No indigenous cases were found and a program of active surveillance is in place including surveillance immigrants to and from villages by local volunteers. Similarly in Jembrana district, since the widespread use of ACT and LLINs distribution there was a sharp fall in the incidence from 0.94/1000 population in 2008 to 0.05/1000 population in 2011, decrease of almost 20 fold over 3 years. An absence of indigenous cases reported and an active surveillance is in place by local volunteers. Conclusion: The combination of treatment activity used ACT and prevention used LLINs can reduce malaria even in low endemic. Active surveillance activity was required to ensure the absence of indigenous cases from the area. The model of malaria activities in Sabang city and Jembrana district can be implemented in all low malaria endemic areas in Indonesia in order to obtain the national goal of malaria elimination.

Inequalities in maternal and child health (MCH) are still critical in Tanzania where the government strives for attaining the millennium development goals (MDGs). With the hope for succeeding, she continues formulating or modifying and implementing her own policies while adopting and implementing policy initiatives recommended globally and establishing mechanisms for monitoring and evaluating programs. Several initiatives have demonstrated gains in reducing maternal and child morbidities and mortalities, increased health budgets, training and recruitment of health workforce, health buildings, procurement and supply of essential medicines, equipment, and other materials, fostering private-public-partnership, enrolling girls in schools, safe motherhood among other reproductive health issues, devolution of decision making powers to lower governance structures, coupled with launching short-term and long term programs for tackling MCH problems. However, evidence is still scanty on country’s successes in reducing MCH inequalities. With reference to literature, we synthesize evidence and arguments on whether Tanzania is on track toward attainment of MDG 4 and 5 and give suggestions for policy.

The transmission of Plasmodium falciparum , known as being responsible for the lethal and severe form of Malaria, has been importantly reduced in the last few years [1]. However, the effective fight against the disease is still facing some difficulties due to the high capacity of adaptation to the treatment of parasite, increasing its resistance to available medicaments [2]. Indeed, the appearance of P. falciparum chloroquine-resistant happened initially in the Magdalena’s Valley, Colombia, but soon it was discovered in other Latin America’s endemics areas, including Brazil, and Asia. More recently, resistance emerged as well in the African Continent, where it constitutes a stunning problem for disease control. Another relevant fact is the reporting of cases of severe malaria caused by the P. vivax , parasite traditionally responsible for the benign form of the disease [3-6].

A decline in malaria transmission is evident in malaria endemic areas of sub-Saharan Africa and is likely to reduce the proportion of fevers due to malaria. Fever has been used as a predictor of malaria, however, the proportion of fevers due to malaria vary with prevalence such that low malaria infection prevalence might alter the accuracy of fever as a marker of malaria. This study examined the diagnostic accuracy and proportion of fevers attributable to malaria among under-fives in a cross-sectional survey carried out in Bagamoyo district, Tanzania from April–May 2012 during peak malaria transmission. Consecutive under-fives with and without history of fever were recruited; for each, fever was measured by digital thermometer, and two Giemsa stained thick and thin blood films taken for parasite count and species identification. Accuracy of fever for prediction of malaria was assessed by performance indices, microscopy as gold standard. Proportion of fevers attributable to malaria was computed by the odds ratio technique at 0.05 significance level.{Formatting Citation} Only 98 out of 925 (10.6%) under-fives had parasitaemia. Among under-fives with a history of fever, the fraction attributable to malaria was 71.4% [95%CI: 54.8–81.9]; in those with measured fever ≥ 37.5˚C, the fraction was 74.3% [95%CI: 61.8–82.7]. In bivariate and multivariate analyses, at 1001-10000 parasites/μl the attributable fraction was 66%, and 93% for parasitaemia>10000/μl. Fever was more likely to be due to malaria among infants<12 months than subsequent months. Despite the recorded decline in malaria infection prevalence, fever is highly likely to be due to malaria among under-fives with fever and malaria infection in peripheral blood. This observation highlights the need to scale up and maintain parasitological confirmation of malaria; and to look for other causes of fever.

Vernonia amygdalina Delile (VA), family Asteraceae or Compositae is plants that is consumed locally as food and serve important ethnomedicinal uses. It grows throughout tropical Africa to a height of about 1 – 5 metres and it is indigenous to many West African Countries. Many parts of the plants are useful, they are used locally for the treatment of fever, Stomach disorder, jaundice, worm infestation, constipation, malaria, hiccups, kidney problems, amoebic dysentery, schistosomiasis, cough, wounds, diabetes, laxative, veneral diseases and other bacterial and protozoal infection. This review examines, discusses and summarizes the current evidence of ethnomedicinal uses, phytochemistry and biological activities as well as toxicity of this species with a view to identifying its therapeutic relations and possible contradictions, inconsistencies and gaps that may have arisen in the research literature. This review is based on literature study on journals and books of scientific origin from library, both manual and electronic sources such as PubMed, Science Direct, Elsevier, ACS, google Scholar etc using various combinations of search words. V. amagdalina is a tropical plant with a lot of interesting biological and medicinal uses. The plants are relatively not toxic, safe for consumption and possess a great potential as pharmaceutical leads for the treatment of diseases and beyond. This review will stimulate further research in the pharmacology and phytochemistry of V. amagdalina.

Malaria is the most important parasitic disease of humans. Cochrane Review support the World Health Organization (WHO) guidelines for malaria treatment which recommend that in all settings clinical suspicion of malaria should be confirmed by parasitological diagnosis using microscopy or Malarial Rapid Diagnostic Test (MRDT). Microscopic diagnosis sensitivity requires expertise and may not be feasible in developing countries in endemic areas and hence MRDT may complement this test. As declared in the World Malaria report 2013 there has been increased use of MRDT which reflect that this test is being taken seriously for diagnostic and management. With every diagnosis test there are lacunae which must be reviewed before interpretation of result. A rapid diagnosis test may be used in endemic areas because it is cost effective, so that rational treatment would be given and hence prevent drug resistance as well as reduce the economic burden.

Background: Uganda has some of the highest reported malaria transmission rates in the world. Methods: We reviewed published and un-published reports to provide a historical perspective and evolution of malaria case management strategies/policies in Uganda. Review findings: In the 1990s, uncomplicated malaria treatment was hampered by widespread parasite resistance to chloroquine (CQ) and sulphadoxine-pyrimethamine (SP). Paradoxically, faced with this challenge, the country changed the first-line regimen, in 2000, to CQ+SP and adopted home based management of fever (HBMF) for children < 5 years old. HBMF increased the proportion accessing CQ+SP within 24 hours from 7% in 2001 to 39% in 2003. However, after another policy shift, in 2004, to Artemether-Lumefantrine (AL), HBMF is to date implemented in only 34 of 112 districts. The private sector supports first treatment contact for 40-50% of fevers. However, engaging private sector providers remains challenging. Consequently, by 2011, only 30% of febrile children took AL on the same/next day after symptom onset. In 2011 there was a policy shift from presumptive treatment to parasite-based diagnosis. Following the policy change, the proportion of tests by rapid diagnostic tests (RDTs) increased to about 55% compared to 30% by microscopy. However a major challenge remains clinician’s adherence to test results. Reassuringly, AL remains efficacious. In 13 studies conducted between 2002 and 2010, the median PCR corrected day 28 efficacy was 98% (range: 71.9%–100%). However, counterfeit medicines remain a threat and the lack of an effective phamacovigilance system is concerning. A recent study demonstrated that 39% of sampled artemisinin combination therapies were counterfeits. Conclusion: Despite an increase in official development assistance over the last decade, by 2013 there remained gaps in national ambitions for universal access to prompt and effective treatment. A major challenge is the low profile of the national malaria control programme within the ministry of health structure which limits its capacity to coordinate multiple stakeholders. Secondly, there is a need for decentralized planning and implementation with greater involvement of the zonal, district, health facility and community levels. Finally, it will be critical to engage the challenging but very important private sector.

Cerebral Malaria (CM) is the most severe neurological presentation of acute falciparum malaria, the clinical hallmark of which is the presence of coma. It is a diffuse encephalopathy associated with seizures in at least 80%, and status epilepticus, in up to a third of cases. The case fatality rate of CM ranges between 5% and 50%. Although most survivors make a full recovery, neurological sequelae such as hemiplegia, speech problems, cortical blindness and epilepsy occur in 3-31%. Plasmodium falciparum is responsible for almost all the mortality from malaria and is the only species that appear to directly affect the central nervous system causing neurological deficits and cognitive sequelae. The World Health Organization estimated that more than 83% of P. falciparum malaria occurs in sub- Saharan Africa where children bear the brunt of the disease with over one million children dying annually. The aim of this review is to provide an update on cerebral malaria.

Plasmodium falciparum is the parasite that causes the most severe form of malaria responsible for nearly a million deaths a year. Currently, science has been established about its cellular structures, its metabolic processes, and even the molecular structures of its intrinsic membrane proteins responsible for transporting water, nutrient, and waste molecules across the Parasite Plasma Membrane (PPM). Based on the molecular structure of the parasite’s membrane and the quantitative mechanics of how erythritol interacts with the multi-functional channel protein expressed in the PPM, I hypothesize that Plasmodium falciparum has an Achilles’ heel that can be attacked with erythritol, the well-known sweetener that is classified as generally safe. Most organisms have in their cell membrane two types of water-channel proteins: aquaporins to maintain hydro-homeostasis across the membrane and aquaglyceroporins to uptake glycerols etc. In contrast, P. falciparum has only one type of such proteins---the multifunctional aquaglyceroporin (PfAQP) expressed in the PPM to do both jobs. Moreover, the parasite also uses PfAQP to excrete its metabolic wastes (ammonia included) produced at a very high rate in the blood stage. This extremely high efficiency of the bug using one protein for multiple essential tasks makes the parasite fatally vulnerable. Erythritol in the blood stream can kill the parasite by clogging up its PfAQP channel that needs to be open for maintaining hydro-homeostasis and for excreting toxic wastes across the bug’s PPM. In vitro tests are to measure the growth/death rate of P. falciparum in blood with various erythritol concentrations. In vivo experiments are to administer groups of infected mice with various doses of erythritol and monitor the parasite growth levels in each group. Moreover, clinic trials can be performed to observe the added effects of administering to patients erythritol along with the known drugs because erythritol was classified as a safe food ingredient.

Background: Several of the intended P. falciparum vaccine candidate antigens are highly polymorphic and could render a vaccine ineffective if their antigenic sites were not represented in the vaccine. This study aimed to characterize genetic diversity of vaccine candidate antigens merozoite surface protein-3 (MSP-3), apical membrane antigen-1 (AMA-1) and erythrocyte binding antigen (EBA-175) in P. falciparum isolates from Senegal. Methods: DNA analysis was completed on 170 isolates of P. falciparum collected from Keur Soce in Senegal between 2006 and 2008. Genetic diversity was determined in the three P. falciparum genes by, PCR followed by restriction fragment length polymorphism (RFLP). Results: From 170 samples collected, successful, PCR products were obtained from 135 (79%), 140 (82%) and 128 (75%) for AMA-1, MSP-3 and EBA-175, respectively. The results showed that the EBA-175 gene presented 4 different alleles [EBA-175F_loop (62.3%), EBA-175C_loop (46.1%), EBA-175~400bp (17.6%), EBA-175~360bp (8.4%)]. Regarding the MSP-3 patterns, the analysis revealed the presence of three alleles MSP-3_K1 (49.2%), MSP-3_3D7 (54.2%) and MSP-3~350bp (15%). For AMA-1, the results showed three different alleles AMA-1_K1 (39%), AMA-1_HB3 (33%), AMA-1_3D7 (32%). Conclusion: Characterization of the genetic diversity in Plasmodium isolates from Keur Soce in Senegal in the three genes investigated showed a high degree of polymorphism. These findings are helpful in the formulation of a vaccine considering restricted repertoire populations.

Background: Most studies that assess efficacy of antimalarial drugs focus on the outcome of clinical treatment. However, community surveys of surrogate indicators are often more practical and can provide a wider view of possible changes in drug response, but it has not been clear whether assessment of parasite isolates from patients and asymptomatic individuals are directly comparable. In the present work, we have compared the prevalence of molecular markers associated with resistance to sulfadoxine-pyrimethamine in parasites isolated from asymptomatic and symptomatic individuals. Methods: The study was conducted during April and May 2008 in Anonkoua-Kouté (Abobo-Abidjan) in southern Côte d’Ivoire, an area where SP has been intensively used for more than 20 years. Plasmodium falciparum monospecific infection was detected by blood smears, followed by a genomic DNA extraction from blood spots on filter paper. Extracted DNA was amplified by nested-PCR, and pfdhfr and pfdhps sequences analyzed. Results: Ninety six of 107 asymptomatic schoolchildren sampled were positive for P. falciparum; 48 of these isolates were used for molecular analysis. A subset of 67 samples from malaria patients of school age was analyzed in parallel. For pfdhfr, the wild-type NCSI and the triple mutant IRNI alleles were both present in about 30 and 50% of the isolates from asymptomatic children and symptomatic malaria patients, respectively. For pfdhps, the symptomatic children mostly carried the single mutant genotype SGKAA although the double mutant AGKAA was the predominant allele in both populations. Conclusions: Direct comparison of molecular markers of SP resistance demonstrates that the prevalence of these alleles is comparable in isolates derived from asymptomatic and symptomatic individuals. The results from this study support the possibility of using cross sectional surveys of surrogate molecular markers of SP efficacy to inform decisions about choice of drugs for intermittent preventive treatment of pregnant women or seasonal malaria chemoprophylaxis.

Malaria caused by Plasmodium species is often observed in areas where malaria is endemic. Malaria prevalence in metropolitan Abeokuta of Ogun State, Nigeria was studied between October, 2012 and January 2013. Oral interviews were used to get personal data of participants. Blood samples were obtained from 384 consented participants from the seven primary health centers. Blood film examination using Giemsa staining techniques was used to detect malaria parasites in the blood. From the 384 participants examined 273 (71.1%) were positive with malaria parasites. Species detected included Plasmodium falciparum (95.6%), Plasmodium malariae (3.3%), P. ovale (0.7%) and P. vivax (0.4%). The age-group 1-11 years had the highest malaria prevalence 94 (81%) while 51-60 had the least 6(54.5%). The malaria prevalence in relation to age was significant (p=0.011, p<0.05). The males 110 (73.8%) were slightly more affected than the females 163 (69.4%), but not statistically significant (p=0.347, p>0.05). Malaria prevalence was significantly higher among those with no formal education 80 (81.6%) and least among post-secondary educational. Prevalence among occupational groups showed significant difference, where the unemployed group were more infected and the retiree group had the least infection (p=0.014, p<0.05). The singles (56.4%) were more infected than the married (43.6%). The prevalence in relation to age was significant (p=0.000, p<0.05). The study has revealed that malaria disease can affect all age groups and both males and females’ sexes irrespective of their educational and occupational cadre. Public enlightenment efforts need to be intensified towards the prevention of malaria.