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Abstract
Most malaria diagnosed outside endemic zones occurs in patients experiencing the consequences of what was likely a single infectious bite by an anopheline mosquito. A single species of parasite is nearly always involved and expert opinion on malaria chemotherapy uniformly prescribes species- and stage-specific treatments. However the vast majority of people experiencing malaria, those resident in endemic zones, do so repeatedly and very often with the involvement of two or more species and stages of parasite. Silent forms of these infections-asymptomatic and beyond the reach of diagnostics-may accumulate to form substantial and unchallenged reservoirs of infection. In such settings treating only the species and stage of malaria revealed by diagnosis and not others may not be sensible or appropriate. Developing therapeutic strategies that address all species and stages independently of diagnostic evidence may substantially improve the effectiveness of the control and elimination of endemic malaria.
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Affiliation(s)
- J Kevin Baird
- Eijkman-Oxford Clinical Research Unit, Jalan Diponegoro No.69, Jakarta, 10430, Indonesia,
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Cook J, Speybroeck N, Sochanta T, Somony H, Sokny M, Claes F, Lemmens K, Theisen M, Soares IS, D'Alessandro U, Coosemans M, Erhart A. Sero-epidemiological evaluation of changes in Plasmodium falciparum and Plasmodium vivax transmission patterns over the rainy season in Cambodia. Malar J 2012; 11:86. [PMID: 22443375 PMCID: PMC3364147 DOI: 10.1186/1475-2875-11-86] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2012] [Accepted: 03/25/2012] [Indexed: 11/17/2022] Open
Abstract
Background In Cambodia, malaria transmission is low and most cases occur in forested areas. Sero-epidemiological techniques can be used to identify both areas of ongoing transmission and high-risk groups to be targeted by control interventions. This study utilizes repeated cross-sectional data to assess the risk of being malaria sero-positive at two consecutive time points during the rainy season and investigates who is most likely to sero-convert over the transmission season. Methods In 2005, two cross-sectional surveys, one in the middle and the other at the end of the malaria transmission season, were carried out in two ecologically distinct regions in Cambodia. Parasitological and serological data were collected in four districts. Antibodies to Plasmodium falciparum Glutamate Rich Protein (GLURP) and Plasmodium vivax Merozoite Surface Protein-119 (MSP-119) were detected using Enzyme Linked Immunosorbent Assay (ELISA). The force of infection was estimated using a simple catalytic model fitted using maximum likelihood methods. Risks for sero-converting during the rainy season were analysed using the Classification and Regression Tree (CART) method. Results A total of 804 individuals participating in both surveys were analysed. The overall parasite prevalence was low (4.6% and 2.0% for P. falciparum and 7.9% and 6.0% for P. vivax in August and November respectively). P. falciparum force of infection was higher in the eastern region and increased between August and November, whilst P. vivax force of infection was higher in the western region and remained similar in both surveys. In the western region, malaria transmission changed very little across the season (for both species). CART analysis for P. falciparum in the east highlighted age, ethnicity, village of residence and forest work as important predictors for malaria exposure during the rainy season. Adults were more likely to increase their antibody responses to P. falciparum during the transmission season than children, whilst members of the Charay ethnic group demonstrated the largest increases. Discussion In areas of low transmission intensity, such as in Cambodia, the analysis of longitudinal serological data enables a sensitive evaluation of transmission dynamics. Consecutive serological surveys allow an insight into spatio-temporal patterns of malaria transmission. The use of CART enabled multiple interactions to be accounted for simultaneously and permitted risk factors for exposure to be clearly identified.
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Affiliation(s)
- Jackie Cook
- Institute of Tropical Medicine, Nationalestraat 155, Antwerp 2000, Belgium.
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Khim N, Siv S, Kim S, Mueller T, Fleischmann E, Singh B, Divis PCS, Steenkeste N, Duval L, Bouchier C, Duong S, Ariey F, Menard D. Plasmodium knowlesi infection in humans, Cambodia, 2007-2010. Emerg Infect Dis 2012; 17:1900-2. [PMID: 22000366 PMCID: PMC3310675 DOI: 10.3201/eid1710.110355] [Citation(s) in RCA: 72] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Two cases of Plasmodium knowlesi infection in humans were identified in Cambodia by 3 molecular detection assays and sequencing. This finding confirms the widespread distribution of P. knowlesi malaria in humans in Southeast Asia. Further wide-scale studies are required to assess the public health relevance of this zoonotic malaria parasite.
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Affiliation(s)
- Nimol Khim
- Pasteur Institute of Cambodia, Phnom Penh, Cambodia
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Reduced impact of pyrimethamine drug pressure on Plasmodium malariae dihydrofolate reductase gene. Antimicrob Agents Chemother 2011; 56:863-8. [PMID: 22123682 DOI: 10.1128/aac.05284-11] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Molecular investigations performed following the emergence of sulfadoxine-pyrimethamine (SP) resistance in Plasmodium falciparum have allowed the identification of the dihydrofolate reductase (DHFR) enzyme as the target of pyrimethamine. Although clinical cases of Plasmodium malariae are not usually treated with antifolate therapy, incorrect diagnosis and the high frequency of undetected mixed infections has probably exposed non-P. falciparum parasites to antifolate therapy in many areas. In this context, we aimed to assess the worldwide genetic diversity of the P. malariae dhfr gene in 123 samples collected in Africa and Asia, areas with different histories of SP use. Among the 10 polymorphic sites found, we have observed 7 new mutations (K55E, S58R, S59A, F168S, N194S, D207G, and T221A), which led us to describe 6 new DHFR proteins. All isolates from African countries were classified as wild type, while new mutations and haplotypes were recognized as exclusive to Madagascar (except for the double mutations at nucleotides 341 and 342 [S114N] found in one Cambodian isolate). Among these nonsynonymous mutations, two were likely related to pyrimethamine resistance: S58R (corresponding to C59R in P. falciparum and S58R in Plasmodium vivax; observed in one Malagasy sample) and S114N (corresponding to S108N in P. falciparum and S117N in P. vivax; observed in three Cambodian samples).
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Yeung S, Patouillard E, Allen H, Socheat D. Socially-marketed rapid diagnostic tests and ACT in the private sector: ten years of experience in Cambodia. Malar J 2011; 10:243. [PMID: 21851625 PMCID: PMC3173399 DOI: 10.1186/1475-2875-10-243] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2010] [Accepted: 08/18/2011] [Indexed: 11/10/2022] Open
Abstract
Whilst some populations have recently experienced dramatic declines in malaria, the majority of those most at risk of Plasmodium falciparum malaria still lack access to effective treatment with artemisinin combination therapy (ACT) and others are already facing parasites resistant to artemisinins.In this context, there is a crucial need to improve both access to and targeting of ACT through greater availability of good quality ACT and parasitological diagnosis. This is an issue of increasing urgency notably in the private commercial sector, which, in many countries, plays an important role in the provision of malaria treatment. The Affordable Medicines Facility for malaria (AMFm) is a recent initiative that aims to increase the provision of affordable ACT in public, private and NGO sectors through a manufacturer-level subsidy. However, to date, there is little documented experience in the programmatic implementation of subsidized ACT in the private sector. Cambodia is in the unique position of having more than 10 years of experience not only in implementing subsidized ACT, but also rapid diagnostic tests (RDT) as part of a nationwide social marketing programme. The programme includes behaviour change communication and the training of private providers as well as the sale and distribution of Malarine, the recommended ACT, and Malacheck, the RDT. This paper describes and evaluates this experience by drawing on the results of household and provider surveys conducted since the start of the programme. The available evidence suggests that providers' and consumers' awareness of Malarine increased rapidly, but that of Malacheck much less so. In addition, improvements in ACT and RDT availability and uptake were relatively slow, particularly in more remote areas.The lack of standardization in the survey methods and the gaps in the data highlight the importance of establishing a clear system for monitoring and evaluation for similar initiatives. Despite these limitations, a number of important lessons can still be learnt. These include the importance of a comprehensive communications strategy and of a sustained and reliable supply of products, with attention to the geographical reach of both. Other important challenges relate to the difficulty in incentivising providers and consumers not only to choose the recommended drug, but to precede this with a confirmatory blood test and ensure that providers adhere to the test results and patients to the treatment regime. In Cambodia, this is particularly complicated due to problems inherent to the drug itself and the emergence of artemisinin resistance.
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Affiliation(s)
- Shunmay Yeung
- Department of Global Health & Development, Faculty of Public Health & Policy, London School of Hygiene & Tropical Medicine, 15-17 Tavistock Place, London WC1H 9SH, UK.
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Al-Mekhlafi AM, Al-Mekhlafi HM, Mahdy MAK, Azazy AA, Fong MY. Human malaria in the highlands of Yemen. ANNALS OF TROPICAL MEDICINE AND PARASITOLOGY 2011; 105:187-95. [PMID: 21801497 PMCID: PMC4090792 DOI: 10.1179/136485911x12987676649421] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/29/2010] [Revised: 02/08/2011] [Accepted: 02/10/2011] [Indexed: 12/28/2022]
Abstract
Between June 2008 and March 2009, a cross-sectional study of human malaria was carried out in four governorates of Yemen, two (Taiz and Hodiedah) representing the country's highlands and the others (Dhamar and Raymah) the country's coastal plains/foothills. The main aims were to determine the prevalences of Plasmodium infection among 455 febrile patients presenting for care at participating health facilities and to investigate the potential risk factors for such infection. Malarial infection was detected in 78 (17·1%) of the investigated patients and was more likely to be detected among the febrile patients from the highlands than among those presenting in the coastal plains/foothills (22·6% v.13·9%; χ(2)=10·102; P=0·018). Binary logistic-regression models identified low household income [odds ratio (OR)=13·52; 95% confidence interval (CI)=2·62-69·67; P=0·002], living in a household with access to a water pump (OR=4·18; CI=1·60-10·96; P=0·004) and living in a household near a stream (OR=4·43; CI=1·35-14·56; P=0·014) as significant risk factors for malarial infection in the highlands. Low household income was the only significant risk factor identified for such infection in the coastal plains and foothills (OR = 8·20; CI=1·80-37·45; P=0·007). It is unclear why febrile patients in the highlands of Yemen are much more likely to be found to have malarial infection than their counterparts from the coastal plains and foothills. Although it is possible that malarial transmission is relatively intense in the highlands, it seems more likely that, compared with those who live at lower altitudes, those who live in the highlands are less immune to malaria, and therefore more likely to develop febrile illness following malarial infection. Whatever the cause of the symptomatic malarial infection commonly found in the highlands of Yemen, it is a matter of serious concern that should be addressed in the national strategy to control malaria.
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Barros FC, Victora CG, Scherpbier R, Gwatkin D. Socioeconomic inequities in the health and nutrition of children in low/middle income countries. Rev Saude Publica 2010; 44:1-16. [PMID: 20140324 DOI: 10.1590/s0034-89102010000100001] [Citation(s) in RCA: 85] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2009] [Accepted: 11/15/2009] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE To describe the effects of social inequities on the health and nutrition of children in low and middle income countries. METHODS We reviewed existing data on socioeconomic disparities within-countries relative to the use of services, nutritional status, morbidity, and mortality. A conceptual framework including five major hierarchical categories affecting inequities was adopted: socioeconomic context and position, differential exposure, differential vulnerability, differential health outcomes, and differential consequences. The search of the PubMed database since 1990 identified 244 articles related to the theme. Results were also analyzed from almost 100 recent national surveys, including Demographic Health Surveys and the UNICEF Multiple Indicator Cluster Surveys. RESULTS Children from poor families are more likely, relative to those from better-off families, to be exposed to pathogenic agents; once they are exposed, they are more likely to become ill because of their lower resistance and lower coverage with preventive interventions. Once they become ill, they are less likely to have access to health services and the quality of these services is likely to be lower, with less access to life-saving treatments. As a consequence, children from poor family have higher mortality rates and are more likely to be undernourished. CONCLUSIONS Except for child obesity and inadequate breastfeeding practices, all the other adverse conditions analyzed were more prevalent in children from less well-off families. Careful documentation of the multiple levels of determination of socioeconomic inequities in child health is essential for understanding the nature of this problem and for establishing interventions that can reduce these differences.
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Jombo GTA, Mbaawuaga EM, Denen AP, Dauda AM, Eyong KI, Akosu JT, Etukumana EA. Utilization of traditional healers for treatment of malaria among female residents in Makurdi city and its environs. ASIAN PAC J TROP MED 2010. [DOI: 10.1016/s1995-7645(10)60136-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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Hay SI, Okiro EA, Gething PW, Patil AP, Tatem AJ, Guerra CA, Snow RW. Estimating the global clinical burden of Plasmodium falciparum malaria in 2007. PLoS Med 2010; 7:e1000290. [PMID: 20563310 PMCID: PMC2885984 DOI: 10.1371/journal.pmed.1000290] [Citation(s) in RCA: 242] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2010] [Accepted: 05/05/2010] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND The epidemiology of malaria makes surveillance-based methods of estimating its disease burden problematic. Cartographic approaches have provided alternative malaria burden estimates, but there remains widespread misunderstanding about their derivation and fidelity. The aims of this study are to present a new cartographic technique and its application for deriving global clinical burden estimates of Plasmodium falciparum malaria for 2007, and to compare these estimates and their likely precision with those derived under existing surveillance-based approaches. METHODS AND FINDINGS In seven of the 87 countries endemic for P. falciparum malaria, the health reporting infrastructure was deemed sufficiently rigorous for case reports to be used verbatim. In the remaining countries, the mapped extent of unstable and stable P. falciparum malaria transmission was first determined. Estimates of the plausible incidence range of clinical cases were then calculated within the spatial limits of unstable transmission. A modelled relationship between clinical incidence and prevalence was used, together with new maps of P. falciparum malaria endemicity, to estimate incidence in areas of stable transmission, and geostatistical joint simulation was used to quantify uncertainty in these estimates at national, regional, and global scales. Combining these estimates for all areas of transmission risk resulted in 451 million (95% credible interval 349-552 million) clinical cases of P. falciparum malaria in 2007. Almost all of this burden of morbidity occurred in areas of stable transmission. More than half of all estimated P. falciparum clinical cases and associated uncertainty occurred in India, Nigeria, the Democratic Republic of the Congo (DRC), and Myanmar (Burma), where 1.405 billion people are at risk. Recent surveillance-based methods of burden estimation were then reviewed and discrepancies in national estimates explored. When these cartographically derived national estimates were ranked according to their relative uncertainty and replaced by surveillance-based estimates in the least certain half, 98% of the global clinical burden continued to be estimated by cartographic techniques. CONCLUSIONS AND SIGNIFICANCE Cartographic approaches to burden estimation provide a globally consistent measure of malaria morbidity of known fidelity, and they represent the only plausible method in those malaria-endemic countries with nonfunctional national surveillance. Unacceptable uncertainty in the clinical burden of malaria in only four countries confounds our ability to evaluate needs and monitor progress toward international targets for malaria control at the global scale. National prevalence surveys in each nation would reduce this uncertainty profoundly. Opportunities for further reducing uncertainty in clinical burden estimates by hybridizing alternative burden estimation procedures are also evaluated.
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Affiliation(s)
- Simon I. Hay
- Spatial Ecology and Epidemiology Group, Department of Zoology, University of Oxford, Oxford, United Kingdom
- Malaria Public Health and Epidemiology Group, Centre for Geographic Medicine, KEMRI–University of Oxford–Wellcome Trust Research Programme, Nairobi, Kenya
| | - Emelda A. Okiro
- Malaria Public Health and Epidemiology Group, Centre for Geographic Medicine, KEMRI–University of Oxford–Wellcome Trust Research Programme, Nairobi, Kenya
- Centre for Tropical Medicine, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, United Kingdom
| | - Peter W. Gething
- Spatial Ecology and Epidemiology Group, Department of Zoology, University of Oxford, Oxford, United Kingdom
| | - Anand P. Patil
- Spatial Ecology and Epidemiology Group, Department of Zoology, University of Oxford, Oxford, United Kingdom
| | - Andrew J. Tatem
- Department of Geography, University of Florida, Gainesville, Florida, United States of America
- Emerging Pathogens Institute, University of Florida, Gainesville, Florida, United States of America
| | - Carlos A. Guerra
- Spatial Ecology and Epidemiology Group, Department of Zoology, University of Oxford, Oxford, United Kingdom
| | - Robert W. Snow
- Malaria Public Health and Epidemiology Group, Centre for Geographic Medicine, KEMRI–University of Oxford–Wellcome Trust Research Programme, Nairobi, Kenya
- Centre for Tropical Medicine, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, United Kingdom
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Lawpoolsri S, Chavez IF, Yimsamran S, Puangsa-Art S, Thanyavanich N, Maneeboonyang W, Chaimungkun W, Singhasivanon P, Maguire JH, Hungerford LL. The impact of human reservoir of malaria at a community-level on individual malaria occurrence in a low malaria transmission setting along the Thai-Myanmar border. Malar J 2010; 9:143. [PMID: 20504308 PMCID: PMC2887882 DOI: 10.1186/1475-2875-9-143] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2010] [Accepted: 05/26/2010] [Indexed: 11/15/2022] Open
Abstract
Background The probability of contracting malaria in a given individual is determined not only by the individual's characteristics, but also the ecological factors that characterize the level of human-vector contact in the population. Examination of the relationship between "individual" and "supra-individual" variables over time is important for understanding the local malaria epidemiology. This is essential for planning effective intervention strategies specifically for each location. Methods A retrospective cohort study was conducted, which followed a community-cohort of about 3,500 residents in seven hamlets along the Thai-Myanmar border between 1999 and 2006. Potential malaria determinants measured at different levels (temporal variables, individual variables, and hamlet variables) were incorporated into multilevel models to estimate their effects on an individual's risk of malaria attack. Results The monthly minimum temperature was significantly associated with the seasonal variation of malaria risk. An individual risk of malaria attack decreased by about 50% during the period that active surveillance was conducted; an additional 15% and 25% reduction of Plasmodium falciparum and Plasmodium vivax incidence, respectively, was observed after the use of artesunate-mefloquine combination therapy (ACT) for treatment of P. falciparum. Male children (age < 16 years old) were at highest risk of both P. falciparum and P. vivax attack. An increase in the hamlet's incidence of P. falciparum and P. vivax by 1 per 100 persons in a previous month resulted in 1.14 and 1.34 times increase in the risk of P. falciparum and P. vivax, respectively, among individuals in a particular hamlet. Conclusion In a small area with low malaria transmission intensity, the variation in mosquito abundance is relatively similar across the residential areas; incidence of malaria between hamlets, which reflects the community level of human infectious reservoirs, is an important predictor for the malaria risk among individuals within these hamlets. Therefore, local malaria control strategies should focus on interventions that aim to reduce the gametocyte carriage in the population, such as early detection and treatment programmes and the use of ACT for P. falciparum.
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Affiliation(s)
- Saranath Lawpoolsri
- Department of Tropical Hygiene, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.
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Assessing the quality of service of village malaria workers to strengthen community-based malaria control in Cambodia. Malar J 2010; 9:109. [PMID: 20412600 PMCID: PMC2873522 DOI: 10.1186/1475-2875-9-109] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2009] [Accepted: 04/23/2010] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Malaria continues to be a major public health problem in remote forested areas in Cambodia. As a national strategy to strengthen community-based malaria control, the Cambodian government has been running the Village Malaria Worker (VMW) project since 2001. This study sought to examine the nature and quality of the VMWs' services. METHODS Data collection was carried out in February and March 2008 through interviews with one of the two VMWs who takes the lead in malaria control activities in each of the 315 VMW villages (n = 251). The questionnaire addressed 1) the sociodemographic characteristics of VMWs, 2) service quality, 3) actions for malaria prevention and vector control, and 4) knowledge of malaria epidemiology and vector ecology. RESULTS VMWs were effective in conducting diagnosis with Rapid Diagnostic Tests (RDTs) and prescribing anti-malarials to those who had positive RDT results, skills that they had acquired through their training programmes. However, most other services, such as active detection, explanations about compliance, and follow-up of patients, were carried out by only a small proportion of VMWs. The variety of actions that VMWs took for malaria prevention and vector control was small (average action index score 12.8/23), and their knowledge was very limited with less than 20% of the VMWs giving correct answers to six out of seven questions on malaria epidemiology and vector ecology. Knowledge of vector breeding places and malaria transmission were significant determinants of both the quality of VMWs' services and the variety of their actions for malaria prevention and vector control. CONCLUSIONS VMWs' services focused primarily on diagnosis and treatment. Their focus needs to be broadened to cover other aspects of malaria control in order to further strengthen community-based malaria control. VMWs' actions and knowledge also need substantial improvement. Strengthening training programmes can help achieve better performance by VMWs.
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Africa's 9th malaria day celebration in 2009 and its bearing on most vulnerable groups. ASIAN PAC J TROP MED 2010. [DOI: 10.1016/s1995-7645(10)60072-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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Jorgensen P, Nambanya S, Gopinath D, Hongvanthong B, Luangphengsouk K, Bell D, Phompida S, Phetsouvanh R. High heterogeneity in Plasmodium falciparum risk illustrates the need for detailed mapping to guide resource allocation: a new malaria risk map of the Lao People's Democratic Republic. Malar J 2010; 9:59. [PMID: 20181273 PMCID: PMC2841197 DOI: 10.1186/1475-2875-9-59] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2009] [Accepted: 02/24/2010] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Accurate information on the geographical distribution of malaria is important for efficient resource allocation. The Lao People's Democratic Republic has experienced a major decline in malaria morbidity and mortality in the past decade. However, efforts to respond effectively to these changes have been impeded by lack of detailed data on malaria distribution. In 2008, a countrywide survey on Plasmodium falciparum diagnosed in health centres and villages was initiated to develop a detailed P. falciparum risk map with the aim to identify priority areas for malaria control, estimate population at risk, and guide resource allocation in the Lao People's Democratic Republic. METHODS P. falciparum incidence data were collected from point-referenced villages and health centres for the period 2006-2008 during a country-wide survey between December 2008 and January 2009. Using the highest recorded annual rate, continuous surfaces of P. falciparum incidence were produced by the inverse distance weighted interpolation technique. RESULTS Incidence rates were obtained from 3,876 villages and 685 health centres. The risk map shows that P. falciparum is highly heterogeneous in the northern and central regions of the country with large areas of no transmission. In the southern part, transmission is pervasive and the risk of P. falciparum is high. It was estimated that 3.4 million people (60% of the population) live at risk of malaria. CONCLUSIONS This paper presents the first comprehensive malaria risk map of the Lao People's Democratic Republic based entirely on empirical data. The estimated population at risk is substantially lower than previous estimates, reflecting the presence of vast areas with focal or no malaria transmission as identified in this study. These findings provide important guidance for malaria control interventions in the Lao People's Democratic Republic, and underline the need for detailed data on malaria to accurately predict risk in countries with heterogeneous transmission.
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Richards AK, Banek K, Mullany LC, Lee CI, Smith L, Oo EKS, Lee TJ. Cross-border malaria control for internally displaced persons: observational results from a pilot programme in eastern Burma/Myanmar. Trop Med Int Health 2009; 14:512-21. [DOI: 10.1111/j.1365-3156.2009.02258.x] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Mueller I, Widmer S, Michel D, Maraga S, McNamara DT, Kiniboro B, Sie A, Smith TA, Zimmerman PA. High sensitivity detection of Plasmodium species reveals positive correlations between infections of different species, shifts in age distribution and reduced local variation in Papua New Guinea. Malar J 2009; 8:41. [PMID: 19284594 PMCID: PMC2657150 DOI: 10.1186/1475-2875-8-41] [Citation(s) in RCA: 76] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2008] [Accepted: 03/11/2009] [Indexed: 11/29/2022] Open
Abstract
Background When diagnosed by standard light microscopy (LM), malaria prevalence can vary significantly between sites, even at local scale, and mixed species infections are consistently less common than expect in areas co-endemic for Plasmodium falciparum, Plasmodium vivax and Plasmodium malariae. The development of a high-throughput molecular species diagnostic assay now enables routine PCR-based surveillance of malaria infections in large field and intervention studies, and improves resolution of species distribution within and between communities. Methods This study reports differences in the prevalence of infections with all four human malarial species and of mixed infections as diagnosed by LM and post-PCR ligase detection reaction – fluorescent microsphere (LDR-FMA) assay in 15 villages in the central Sepik area of Papua New Guinea. Results Significantly higher rates of infection by P. falciparum, P. vivax, P. malariae and Plasmodium ovale were observed in LDR-FMA compared to LM diagnosis (p < 0.001). Increases were particularly pronounced for P. malariae (3.9% vs 13.4%) and P. ovale (0.0% vs 4.8%). In contrast to LM diagnosis, which suggested a significant deficit of mixed species infections, a significant excess of mixed infections over expectation was detected by LDR-FMA (p < 0.001). Age of peak prevalence shifted to older age groups in LDR-FMA diagnosed infections for P. falciparum (LM: 7–9 yrs 47.5%, LDR-FMA: 10–19 yrs 74.2%) and P. vivax (LM: 4–6 yrs 24.2%, LDR-FMA: 7–9 yrs 50.9%) but not P. malariae infections (10–19 yrs, LM: 7.7% LDR-FMA: 21.6%). Significant geographical variation in prevalence was found for all species (except for LM-diagnosed P. falciparum), with the extent of this variation greater in LDR-FMA than LM diagnosed infections (overall, 84.4% vs. 37.6%). Insecticide-treated bednet (ITN) coverage was also the dominant factor linked to geographical differences in Plasmodium species infection prevalence explaining between 60.6% – 74.5% of this variation for LDR-FMA and 81.8% – 90.0% for LM (except P. falciparum), respectively. Conclusion The present study demonstrates that application of molecular diagnosis reveals patterns of malaria risk that are significantly different from those obtained by standard LM. Results provide insight relevant to design of malaria control and eradication strategies.
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Affiliation(s)
- Ivo Mueller
- Papua New Guinea Institute of Medical Research, Goroka, Papua New Guinea.
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Maude RJ, Pontavornpinyo W, Saralamba S, Aguas R, Yeung S, Dondorp AM, Day NPJ, White NJ, White LJ. The last man standing is the most resistant: eliminating artemisinin-resistant malaria in Cambodia. Malar J 2009; 8:31. [PMID: 19228438 PMCID: PMC2660356 DOI: 10.1186/1475-2875-8-31] [Citation(s) in RCA: 143] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2009] [Accepted: 02/20/2009] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Artemisinin combination therapy (ACT) is now the recommended first-line treatment for falciparum malaria throughout the world. Initiatives to eliminate malaria are critically dependent on its efficacy. There is recent worrying evidence that artemisinin resistance has arisen on the Thai-Cambodian border. Urgent containment interventions are planned and about to be executed. Mathematical modeling approaches to intervention design are now integrated into the field of malaria epidemiology and control. The use of such an approach to investigate the likely effectiveness of different containment measures with the ultimate aim of eliminating artemisinin-resistant malaria is described. METHODS A population dynamic mathematical modeling framework was developed to explore the relative effectiveness of a variety of containment interventions in eliminating artemisinin-resistant malaria in western Cambodia. RESULTS The most effective intervention to eliminate artemisinin-resistant malaria was a switch of treatment from artemisinin monotherapy to ACT (mean time to elimination 3.42 years (95% CI 3.32-3.60 years). However, with this approach it is predicted that elimination of artemisinin-resistant malaria using ACT can be achieved only by elimination of all malaria. This is because the various forms of ACT are more effective against infections with artemisinin-sensitive parasites, leaving the more resistant infections as an increasing proportion of the dwindling parasite population. CONCLUSION Containment of artemisinin-resistant malaria can be achieved by elimination of malaria from western Cambodia using ACT. The "last man standing" is the most resistant and thus this strategy must be sustained until elimination is truly achieved.
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Affiliation(s)
- Richard J Maude
- Faculty of Tropical Medicine, Mahidol University, Rajthevee, Bangkok 10400, Thailand.
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67
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Abstract
The Asia-Pacific region has at least 50% of its population at risk for malaria. In Malaysia, indigenous malaria is largely concentrated among the Orang Asli in Peninsular Malaysia. A cross-sectional study was conducted in an Orang Asli community in the district of Raub, Pahang, to determine the predictors of malaria. Age, seldom/never wearing protective clothing while in the jungle, going out at night, ever staying in another village, and living in bamboo-walled homes were found to be associated with malaria (crude odds ratio = 1.8-4.5; 95% confidence interval [CI] = 1.1-9.1) After adjusting for confounding, major predictors of malaria were age ≤12 years (adjusted odds ratio [aOR] = 4.3;95% CI = 2.2-8.4),), never/seldom wearing protective clothing while in the jungle (aOR = 3.8; 95% CI = 1.8-8.0), and going out at night (aOR = 2.5; 95% CI = 1.4-4.8). The findings lend support for intensifying behaviour modification in this population.
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Affiliation(s)
- Gurpreet Kaur
- Institute for Public Health, Ministry of Health, Jalan
Bangsar, Kuala Lumpur, Malaysia,
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68
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Myers WP, Myers AP, Cox-Singh J, Lau HC, Mokuai B, Malley R. Micro-geographic risk factors for malarial infection. Malar J 2009; 8:27. [PMID: 19216781 PMCID: PMC2649150 DOI: 10.1186/1475-2875-8-27] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2008] [Accepted: 02/13/2009] [Indexed: 11/17/2022] Open
Abstract
Background Knowledge of geography is integral to the study of insect-borne infectious disease such as malaria. This study was designed to evaluate whether geographic parameters are associated with malarial infection in the East Sepik province of Papua New Guinea (PNG), a remote area where malaria is a major cause of morbidity and mortality. Methods A global positioning system (GPS) unit was used at each village to collect elevation, latitude and longitude data. Concurrently, a sketch map of each village was generated and the villages were sub-divided into regions of roughly equal populations. Blood samples were taken from subjects in each region using filter paper collection. The samples were later processed using nested PCR for qualitative determination of malarial infection. The area was mapped using the GPS-information and overlaid with prevalence data. Data tables were examined using traditional chi square statistical techniques. A logistic regression analysis was then used to determine the significance of geographic risk factors including, elevation, distance from administrative centre and village of residence. Results Three hundred and thirty-two samples were included (24% of the total estimated population). Ninety-six were positive, yielding a prevalence of 29%. Chi square testing within each village found a non-random distribution of cases across sub-regions (p < 0.05). Multivariate logistic regression techniques suggested malarial infection changed with elevation (OR = 0.64 per 10 m, p < 0.05) and distance from administrative centre (OR = 1.3 per 100 m, p < 0.05). Conclusion These results suggest that malarial infection is significantly and independently associated with lower elevation and greater distance from administrative centre in a rural area in PNG. This type of analysis can provide information that may be used to target specific areas in developing countries for malaria prevention and treatment.
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Affiliation(s)
- Ward P Myers
- Infectious Disease, Children's Hospital Boston, Boston, USA.
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69
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Rapid decrease of malaria morbidity following the introduction of community-based monitoring in a rural area of central Vietnam. Malar J 2009; 8:3. [PMID: 19123932 PMCID: PMC2657912 DOI: 10.1186/1475-2875-8-3] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2008] [Accepted: 01/05/2009] [Indexed: 11/02/2022] Open
Abstract
BACKGROUND Despite a successful control programme, malaria has not completely disappeared in Vietnam; it remains endemic in remote areas of central Vietnam, where standard control activities seem to be less effective. The evolution of malaria prevalence and incidence over two and half years in a rural area of central Vietnam, after the introduction of community-based monitoring of malaria cases, is presented. METHODS After a complete census, six cross-sectional surveys and passive detection of malaria cases (by village and commune health workers using rapid diagnostic tests) were carried out between March 2004 and December 2006 in Ninh-Thuan province, in a population of about 10,000 individuals. The prevalence of malaria infection and the incidence of clinical cases were estimated. RESULTS Malaria prevalence significantly decreased from 13.6% (281/2,068) in December 2004 to 4.0% (80/2,019) in December 2006. Plasmodium falciparum and Plasmodium vivax were the most common infections with few Plasmodium malariae mono-infections and some mixed infections. During the study period, malaria incidence decreased by more than 50%, from 25.7/1,000 population at risk in the second half of 2004 to 12.3/1,000 in the second half of 2006. The incidence showed seasonal variations, with a yearly peak between June and December, except in 2006 when the peak observed in the previous years did not occur. CONCLUSION Over a 2.5-year follow-up period, malaria prevalence and incidence decreased by more than 70% and 50%, respectively. Possibly, this could be attributed to the setting up of a passive case detection system based on village health workers, indicating that a major impact on the malaria burden can be obtained whenever prompt diagnosis and adequate treatment are available.
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70
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Moore SJ, Min X, Hill N, Jones C, Zaixing Z, Cameron MM. Border malaria in China: knowledge and use of personal protection by minority populations and implications for malaria control: a questionnaire-based survey. BMC Public Health 2008; 8:344. [PMID: 18828901 PMCID: PMC2576233 DOI: 10.1186/1471-2458-8-344] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2008] [Accepted: 10/01/2008] [Indexed: 11/10/2022] Open
Abstract
Background Malaria control in remote, forested areas of the Mekong region relies on personal protection from mosquito bites. Uptake of these methods may be limited by knowledge of the link between mosquitoes and malaria as well as social and economic aspects. Understanding barriers to uptake will inform malaria control programmes on targets for improvement of delivery. Methods A total 748 key respondents: health providers and village heads, from 187 villages and 25 different ethnic groups, were interviewed using structured questionnaires. Differences in use of personal protection, and knowledge of malaria between groups were analysed using chi-square; and binary logistic regression used for multivariate analysis. Results Malaria knowledge was poor with 19.4% of women and 37.5% of men linking mosquitoes with malaria, although 95.6% knew one or more methods of mosquito control. Virtually all respondents used personal protection at some time during the year; and understanding of malaria transmission was strongly associated with bednet use. Those working in forest agriculture were significantly more likely to know that mosquitoes transmit malaria but this did not translate into a significantly greater likelihood of using bednets. Furthermore, use of personal protection while woing outdoors was rare, and less than 3% of respondents knew about the insecticide impregnation of bednets. The use of bednets, synthetic repellents and mosquito coils varied between ethnic groups, but was significantly more frequent among those with higher income, more years of education and permanent housing. The reported use of repellents and coils was also more common among women despite their low knowledge of malaria transmission, and low likelihood of having heard information on malaria within the last year. Conclusion The use of personal protection must be increased, particularly among outdoor workers that have higher malaria risk. However, personal protection is widely used and widely accepted to prevent nuisance biting mosquitoes, with the major barrier to use being affordability. Therefore, social marketing campaigns aimed at women and those that work outdoors that provide highly subsidised products, especially insecticide impregnation kits for bednets and hammock nets are most likely to succeed in lowering malaria morbidity among non Han-Chinese groups in rural China.
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Affiliation(s)
- Sarah J Moore
- DCVBU, London School of Hygiene and Tropical Medicine, London, UK.
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Dysoley L, Kaneko A, Eto H, Mita T, Socheat D, Börkman A, Kobayakawa T. Changing patterns of forest malaria among the mobile adult male population in Chumkiri District, Cambodia. Acta Trop 2008; 106:207-12. [PMID: 18471797 DOI: 10.1016/j.actatropica.2007.01.007] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2006] [Revised: 01/13/2007] [Accepted: 01/19/2007] [Indexed: 11/29/2022]
Abstract
Forest malaria remains a major problem in many parts of Southeast Asia and South America. In Cambodia, where a significant reduction of malaria morbidity and mortality has been observed in the last 20 years, the forest malaria situation was studied in Chumkiri District by analysing the available passive case detection data and conducting malariometric (n=1018) and questionnaire surveys (n=374) in four forest-fringe villages. There has been a decreasing trend of malaria incidence from 2001. Plasmodium falciparum was highly predominant and P. vivax was rare. The nearby-forest villages showed significantly higher parasite rates than the far-from-forest villages (9.0% vs. 1.2%, p<0.01). Malaria was highly restricted to the male adults but was nearly non-existent in other accompanying family members, including small children and females. Low income and working in forests were strongly associated with the malaria risk. Our results suggest that transmission has greatly reduced in forest-fringe villages, but remains active in forests, which is primarily maintained between the forest vector Anopheles dirus and ethnic minority inhabitants. Specific interventions directed to these previously neglected in-forest inhabitants to protect themselves and male adult villagers during their forest activities are necessary to achieve an ultimate goal of malaria elimination from Cambodia.
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Affiliation(s)
- Lek Dysoley
- Department of International Affairs and Tropical Medicine, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjku-ku, Tokyo, Japan.
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Yeung S, Van Damme W, Socheat D, White NJ, Mills A. Access to artemisinin combination therapy for malaria in remote areas of Cambodia. Malar J 2008; 7:96. [PMID: 18510724 PMCID: PMC2430580 DOI: 10.1186/1475-2875-7-96] [Citation(s) in RCA: 91] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2007] [Accepted: 05/29/2008] [Indexed: 12/01/2022] Open
Abstract
Background Malaria-endemic countries are switching antimalarial drug policy to artemisinin combination therapies (ACTs) and the global community are considering the setting up of a global subsidy mechanism in order to make them accessible and affordable. However, specific interventions may be needed to reach remote at-risk communities and to ensure that they are used appropriately. This analysis documents the coverage with ACTs versus artemisinin monotherapies, and the effectiveness of malaria outreach teams (MOTs) and Village Malaria Workers (VMWs) in increasing access to appropriate diagnosis and treatment with ACTs in Cambodia, the first country to switch national antimalarial drug policy to an ACT of artesunate and mefloquine (A+M) in 2000. Methods A cross-sectional survey was carried out in three different types of intervention area: with VMWs, MOTs and no specific interventions. Individuals with a history of fever in the last three weeks were included in the study and completed a questionnaire on their treatment seeking and drug usage behaviour. Blood was taken for a rapid diagnostic test (RDT) and data on the household socio-economic status were also obtained. Results In areas without specific interventions, only 17% (42/251) of respondents received a biological diagnosis, 8% (17/206) of respondents who received modern drug did so from a public health facility, and only 8% of them (17/210) received A+M. Worryingly, 78% (102/131) of all artemisinin use in these areas was as a monotherapy. However, both the VMW scheme and MOT scheme significantly increased the likelihood of being seen by a trained provider (Adjusted Odds Ratios (AOR) of 148 and 4 respectively) and of receiving A+M (AORs of 2.7 and 7.7 respectively). Conclusion The coverage rates of appropriate diagnosis and treatment of malaria were disappointingly low and the use of artemisinin monotherapy alarmingly high. This reflects the fragmented nature of Cambodia's health system in remote areas and the reliance placed by these communities on informal vendors from whom artemisinin monotherapies are widely available. However VMWs in particular are an effective means of improving access to malaria diagnosis and treatment. The VMW scheme and the social marketing of RDTS and blister-packaged artesunate and mefloquine have both been scaled up nationally. Case management in the public sector has also reportedly improved. Given recent concerns regarding the development of artemisinin drug resistance on the Thai-Cambodia border, the effectiveness of these measures in reducing the use of artemisinin monotherapy needs to be urgently re-evaluated.
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Affiliation(s)
- Shunmay Yeung
- Health Policy Unit, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK.
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73
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Richards AK, Smith L, Mullany LC, Lee CI, Whichard E, Banek K, Mahn M, Shwe Oo EK, Lee TJ. Prevalence of Plasmodium falciparum in active conflict areas of eastern Burma: a summary of cross-sectional data. Confl Health 2007; 1:9. [PMID: 17803819 PMCID: PMC2034373 DOI: 10.1186/1752-1505-1-9] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2007] [Accepted: 09/05/2007] [Indexed: 11/29/2022] Open
Abstract
Background Burma records the highest number of malaria deaths in southeast Asia and may represent a reservoir of infection for its neighbors, but the burden of disease and magnitude of transmission among border populations of Burma remains unknown. Methods Plasmodium falciparum (Pf) parasitemia was detected using a HRP-II antigen based rapid test (Paracheck-Pf®). Pf prevalence was estimated from screenings conducted in 49 villages participating in a malaria control program, and four retrospective mortality cluster surveys encompassing a sampling frame of more than 220,000. Crude odds ratios were calculated to evaluate Pf prevalence by age, sex, and dry vs. rainy season. Results 9,796 rapid tests were performed among 28,410 villagers in malaria program areas through four years (2003: 8.4%, 95% CI: 8.3 – 8.6; 2004: 7.1%, 95% CI: 6.9 – 7.3; 2005:10.5%, 95% CI: 9.3 – 11.8 and 2006: 9.3%, 95% CI: 8.2 – 10.6). Children under 5 (OR = 1.99; 95% CI: 1.93 – 2.06) and those 5 to 14 years (OR = 2.24, 95% CI: 2.18 – 2.29) were more likely to be positive than adults. Prevalence was slightly higher among females (OR = 1.04, 95% CI: 1.02 – 1.06) and in the rainy season (OR = 1.48, 95% CI: 1.16 – 1.88). Among 5,538 rapid tests conducted in four cluster surveys, 10.2% were positive (range 6.3%, 95% CI: 3.9 – 8.8; to 12.4%, 95% CI: 9.4 – 15.4). Conclusion Prevalence of plasmodium falciparum in conflict areas of eastern Burma is higher than rates reported among populations in neighboring Thailand, particularly among children. This population serves as a large reservoir of infection that contributes to a high disease burden within Burma and likely constitutes a source of infection for neighboring regions.
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Affiliation(s)
- Adam K Richards
- Department of Internal Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, 305 East 161Street, Bronx, USA 10451
- Global Health Access Program, Mae Sot, Thailand
| | - Linda Smith
- Global Health Access Program, Mae Sot, Thailand
- Planet Care/Global Health Access Program, 801 Cedar Street Suite 200, Berkeley, CA, USA 94710
| | - Luke C Mullany
- Global Health Access Program, Mae Sot, Thailand
- Center for Public Health and Human Rights, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, USA 21205
| | - Catherine I Lee
- Global Health Access Program, Mae Sot, Thailand
- Planet Care/Global Health Access Program, 801 Cedar Street Suite 200, Berkeley, CA, USA 94710
| | - Emily Whichard
- Global Health Access Program, Mae Sot, Thailand
- Planet Care/Global Health Access Program, 801 Cedar Street Suite 200, Berkeley, CA, USA 94710
| | - Kristin Banek
- Global Health Access Program, Mae Sot, Thailand
- The MENTOR Initiative-Liberia, Monrovia, Liberia
- 15806 East Saratoga Place Aurora, CO 80015 USA
| | - Mahn Mahn
- Backpack Health Worker Team, 659, Moo 1 – Thasailuad, Mae Sot, Tak, Thailand, 63110
| | - Eh Kalu Shwe Oo
- Karen Department of Health and Welfare, No. 663 Moo 1 – Thasailuad, Asia High Way, Mae Sot, Tak, Thailand 63110
| | - Thomas J Lee
- Global Health Access Program, Mae Sot, Thailand
- Department of Medicine, University of California at Los Angeles, 924 Westwood Blvd. Suite 300, Los Angeles, CA, USA 90024
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