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Kumar A, Singh PP, Tyagi S, Hari Kishan Raju K, Sahu SS, Rahi M. Vivax malaria: a possible stumbling block for malaria elimination in India. Front Public Health 2024; 11:1228217. [PMID: 38259757 PMCID: PMC10801037 DOI: 10.3389/fpubh.2023.1228217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Accepted: 12/20/2023] [Indexed: 01/24/2024] Open
Abstract
Plasmodium vivax is geographically the most widely dispersed human malaria parasite species. It has shown resilience and a great deal of adaptability. Genomic studies suggest that P. vivax originated from Asia or Africa and moved to the rest of the world. Although P. vivax is evolutionarily an older species than Plasmodium falciparum, its biology, transmission, pathology, and control still require better elucidation. P. vivax poses problems for malaria elimination because of the ability of a single primary infection to produce multiple relapses over months and years. P. vivax malaria elimination program needs early diagnosis, and prompt and complete radical treatment, which is challenging, to simultaneously exterminate the circulating parasites and dormant hypnozoites lodged in the hepatocytes of the host liver. As prompt surveillance and effective treatments are rolled out, preventing primaquine toxicity in the patients having glucose-6-phosphate dehydrogenase (G6PD) deficiency should be a priority for the vivax elimination program. This review sheds light on the burden of P. vivax, changing epidemiological patterns, the hurdles in elimination efforts, and the essential tools needed not just in India but globally. These tools encompass innovative treatments for eliminating dormant parasites, coping with evolving drug resistance, and the development of potential vaccines against the parasite.
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Affiliation(s)
- Ashwani Kumar
- ICMR - Vector Control Research Centre, Puducherry, India
| | | | - Suchi Tyagi
- ICMR - Vector Control Research Centre, Puducherry, India
| | | | | | - Manju Rahi
- ICMR - Vector Control Research Centre, Puducherry, India
- Indian Council of Medical Research, Hqrs New Delhi, India
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2
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Orimadegun AE, Dada-Adegbola HO, Michael OS, Adepoju AA, Funwei RE, Olusola FI, Ajayi IO, Ogunkunle OO, Ademowo OG, Jegede AS, Baba E, Hamade P, Webster J, Chandroman D, Falade CO. Non-Malaria Causes of Fever among under-5 Children with Negative Results for Malaria Rapid Diagnostic Test in South-Western Nigeria. J Trop Pediatr 2022; 68:6650742. [PMID: 35895093 DOI: 10.1093/tropej/fmac061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
BACKGROUND Although the global malaria burden is decreasing, there are still concerns about overdiagnosis of malaria and the danger of misdiagnosis of non-malaria causes of fever. Clinicians continue to face the challenge of differentiating between these causes despite the introduction of malaria rapid diagnostic tests (mRDTs). AIM To determine the prevalence and causes of non-malaria-caused fever in children in South-Western Nigeria. METHODS Secondary analysis of data obtained to evaluate the effect of restricting antimalarial treatment to positive mRDT children in rural and urban areas of southwest Nigeria. Clinical examinations, laboratory tests for malaria parasites (including thick blood film and mRDT) and bacterial identification were performed on children aged 3-59 months (n = 511). The non-malaria group comprised febrile children who had both negative mRDT and microscopy results, while the malaria group included those who were positive for either mRDT or microscopy. We compared the causes of fever among children with non-malaria fever and those with malaria. RESULTS The prevalence of non-malaria fever and bacteria-malaria co-infection was 37.2% and 2.0%, respectively. Non-malarial pathogens identified were viral (54.7%) and bacterial (32.1%) infections. The bacterial infections included bacteriaemia (2.7%), urinary tract infections (21.6%), skin infections (11.6%) and otitis media (2.6%). The leading bacterial isolates were Staphylococcus aureus, Pseudomonas aeruginosa and Streptococcus pneumoniae. CONCLUSION The high prevalence and wide range of non-malarial infections reinforces the need for point-of-care tests to identify bacterial and viral infections to optimize the treatment of febrile illnesses in malaria-endemic areas.
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Affiliation(s)
- Adebola E Orimadegun
- Institute of Child Health, College of Medicine, University of Ibadan, Ibadan, Nigeria
| | - Hannah O Dada-Adegbola
- Department of Medical Microbiology, College of Medicine, University of Ibadan, Ibadan, Nigeria
| | - Obaro S Michael
- Department of Pharmacology and Therapeutics, College of Medicine, University of Ibadan, Ibadan, Nigeria
| | - Adedayo A Adepoju
- Department of Paediatrics, College of Medicine, University of Ibadan, Ibadan, Nigeria
| | - Roland E Funwei
- Department of Pharmacology and Therapeutics, College of Medicine, University of Ibadan, Ibadan, Nigeria
| | - Fiyinfoluwa I Olusola
- Department of Pharmacology and Therapeutics, College of Medicine, University of Ibadan, Ibadan, Nigeria
| | - IkeOluwapo O Ajayi
- Department of Epidemiology and Biostatistics, College of Medicine, University of Ibadan, Ibadan, Nigeria
| | | | - Olusegun G Ademowo
- Department of Pharmacology and Therapeutics, College of Medicine, University of Ibadan, Ibadan, Nigeria
- Institute for Advanced Medical Research and Training, College of Medicine, University of Ibadan, Ibadan, Nigeria
| | - Ayodele S Jegede
- Department of Sociology, Faculty of the Social Sciences, University of Ibadan, Ibadan, Nigeria
| | - Ebenezer Baba
- Malaria Consortium Regional Office for Africa, Kampala, Uganda
| | | | - Jayne Webster
- Department of Infectious and Tropical Diseases, London School of Tropical Medicine and Hygiene, London, UK
| | - Daniel Chandroman
- Department of Infectious and Tropical Diseases, London School of Tropical Medicine and Hygiene, London, UK
| | - Catherine O Falade
- Department of Pharmacology and Therapeutics, College of Medicine, University of Ibadan, Ibadan, Nigeria
- Institute for Advanced Medical Research and Training, College of Medicine, University of Ibadan, Ibadan, Nigeria
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3
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Oyegoke OO, Maharaj L, Akoniyon OP, Kwoji I, Roux AT, Adewumi TS, Maharaj R, Oyebola BT, Adeleke MA, Okpeku M. Malaria diagnostic methods with the elimination goal in view. Parasitol Res 2022; 121:1867-1885. [PMID: 35460369 PMCID: PMC9033523 DOI: 10.1007/s00436-022-07512-9] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Accepted: 04/01/2022] [Indexed: 01/08/2023]
Abstract
Malaria control measures have been in use for years but have not completely curbed the spread of infection. Ultimately, global elimination is the goal. A major playmaker in the various approaches to reaching the goal is the issue of proper diagnosis. Various diagnostic techniques were adopted in different regions and geographical locations over the decades, and these have invariably produced diverse outcomes. In this review, we looked at the various approaches used in malaria diagnostics with a focus on methods favorably used during pre-elimination and elimination phases as well as in endemic regions. Microscopy, rapid diagnostic testing (RDT), loop-mediated isothermal amplification (LAMP), and polymerase chain reaction (PCR) are common methods applied depending on prevailing factors, each with its strengths and limitations. As the drive toward the elimination goal intensifies, the search for ideal, simple, fast, and reliable point-of-care diagnostic tools is needed more than ever before to be used in conjunction with a functional surveillance system supported by the ideal vaccine.
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Affiliation(s)
- Olukunle O Oyegoke
- Discipline of Genetics School of Life Sciences, University of KwaZulu-Natal, Westville, Durban, South Africa
| | - Leah Maharaj
- Discipline of Genetics School of Life Sciences, University of KwaZulu-Natal, Westville, Durban, South Africa
| | - Oluwasegun P Akoniyon
- Discipline of Genetics School of Life Sciences, University of KwaZulu-Natal, Westville, Durban, South Africa
| | - Illiya Kwoji
- Discipline of Genetics School of Life Sciences, University of KwaZulu-Natal, Westville, Durban, South Africa
| | - Alexandra T Roux
- Discipline of Genetics School of Life Sciences, University of KwaZulu-Natal, Westville, Durban, South Africa
| | - Taiye S Adewumi
- Discipline of Genetics School of Life Sciences, University of KwaZulu-Natal, Westville, Durban, South Africa
| | - Rajendra Maharaj
- Office of Malaria Research, Medical Research Council, Durban, South Africa
| | | | - Matthew A Adeleke
- Discipline of Genetics School of Life Sciences, University of KwaZulu-Natal, Westville, Durban, South Africa
| | - Moses Okpeku
- Discipline of Genetics School of Life Sciences, University of KwaZulu-Natal, Westville, Durban, South Africa.
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Angrisano F, Robinson LJ. Plasmodium vivax - How hidden reservoirs hinder global malaria elimination. Parasitol Int 2021; 87:102526. [PMID: 34896312 DOI: 10.1016/j.parint.2021.102526] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Revised: 12/03/2021] [Accepted: 12/04/2021] [Indexed: 01/23/2023]
Abstract
Plasmodium vivax is the most geographically widespread human malaria parasite. Global malaria efforts have been less successful at reducing the burden of P. vivax compared to P. falciparum, owing to the unique biology and related treatment complexity of P. vivax. As a result, P. vivax is now the dominant malaria parasite throughout the Asia-Pacific and South America causing up to 14 million clinical cases every year and is considered a major obstacle to malaria elimination. Key features circumventing existing malaria control tools are the transmissibility of asymptomatic, low-density circulating infections and reservoirs of persistent dormant liver stages (hypnozoites) that are undetectable but reactivate to cause relapsing infections and sustain transmission. In this review we summarise the new knowledge shaping our understanding of the global epidemiology of P. vivax infections, highlighting the challenges for elimination and the tools that will be required achieve this.
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Alvar J, Alves F, Bucheton B, Burrows L, Büscher P, Carrillo E, Felger I, Hübner MP, Moreno J, Pinazo MJ, Ribeiro I, Sosa-Estani S, Specht S, Tarral A, Wourgaft NS, Bilbe G. Implications of asymptomatic infection for the natural history of selected parasitic tropical diseases. Semin Immunopathol 2020; 42:231-246. [PMID: 32189034 PMCID: PMC7299918 DOI: 10.1007/s00281-020-00796-y] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Accepted: 03/03/2020] [Indexed: 12/18/2022]
Abstract
Progress has been made in the control or elimination of tropical diseases, with a significant reduction of incidence. However, there is a risk of re-emergence if the factors fueling transmission are not dealt with. Although it is essential to understand these underlying factors for each disease, asymptomatic carriers are a common element that may promote resurgence; their impact in terms of proportion in the population and role in transmission needs to be determined. In this paper, we review the current evidence on whether or not to treat asymptomatic carriers given the relevance of their role in the transmission of a specific disease, the efficacy and toxicity of existing drugs, the Public Health interest, and the benefit at an individual level, for example, in Chagas disease, to prevent irreversible organ damage. In the absence of other control tools such as vaccines, there is a need for safer drugs with good risk/benefit profiles in order to change the paradigm so that it addresses the complete infectious process beyond manifest disease to include treatment of non-symptomatic infected persons.
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Affiliation(s)
- Jorge Alvar
- Drugs for Neglected Diseases initiative, Geneva, Switzerland.
| | - Fabiana Alves
- Drugs for Neglected Diseases initiative, Geneva, Switzerland
| | - Bruno Bucheton
- Institut de Recherche pour le Développement, Université de Montpellier, Montpellier, France
| | - Louise Burrows
- Drugs for Neglected Diseases initiative, Geneva, Switzerland
| | | | - Eugenia Carrillo
- WHO Collaborating Cenre for Leishmaniasis, Instituto de Sakud Carlos III, Madrid, Spain
| | - Ingrid Felger
- Swiss Tropical and Public Health Institute, Basel, Switzerland
| | - Marc P Hübner
- Institute for Medical Microbiology, Immunology and Parasitology, University Hospital Bonn, Bonn, Germany
| | - Javier Moreno
- WHO Collaborating Cenre for Leishmaniasis, Instituto de Sakud Carlos III, Madrid, Spain
| | | | - Isabela Ribeiro
- Drugs for Neglected Diseases initiative, Geneva, Switzerland
| | - Sergio Sosa-Estani
- Drugs for Neglected Diseases initiative, Centro de Investigación de Epidemiología y Salud Pública (CIESP-IECS), CONICET, Buenos Aires, Argentina
| | - Sabine Specht
- Drugs for Neglected Diseases initiative, Geneva, Switzerland
| | - Antoine Tarral
- Drugs for Neglected Diseases initiative, Geneva, Switzerland
| | | | - Graeme Bilbe
- Drugs for Neglected Diseases initiative, Geneva, Switzerland
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Willie N, Zimmerman PA, Mehlotra RK. Plasmodium falciparum Histidine-Rich Protein 2 Gene Variation in a Malaria-Endemic Area of Papua New Guinea. Am J Trop Med Hyg 2018; 99:697-703. [PMID: 29968556 DOI: 10.4269/ajtmh.18-0137] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
Histidine-rich protein 2 of Plasmodium falciparum (PfHRP2) forms the basis of many current malaria rapid diagnostic tests (RDTs). It is concerning that there are parasites that lack part or all of the pfhrp2 gene, and thus do not express the PfHRP2 protein; such parasites are not identifiable by PfHRP2-detecting RDTs. Very limited information is available regarding pfhrp2 genetic variation in Papua New Guinea (PNG). In the present study, this gene variation was evaluated using 169 samples previously collected from the Wosera area in East Sepik Province of PNG. Molecular diagnosis of these samples showed that 81% were infected, and P. falciparum was present in 91% of those infected samples. One hundred and twenty samples were amplified for pfhrp2 exon-2, from which 12 randomly selected amplicons were sequenced, yielding 18 sequences, all of which were unique. Baker repeat type 2 × type 7 numbers ranged from 0 to 108. Epitope mapping analysis revealed that three major epitopes, DAHHAHHA, AHHAADAHHA, and AHHAADAHH, were present in high prevalence and frequencies. These major epitopes have been shown to be recognized by the monoclonal antibodies 3A4 and PTL-3 (DAHHAHHA), C1-13 (AHHAADAHHA), and S2-5 and C2-3 (AHHAADAHH). This study provides further information on the high genetic variation of pfhrp2 and its unclear relationship with prediction of RDT detection sensitivity, and identifies major epitopes in this gene from PNG. These results could be relevant and useful to understand the genetic diversity of this gene and the performance of current and future RDTs in this malarious region of the world.
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Affiliation(s)
- Nigani Willie
- Center for Global Health and Diseases, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Peter A Zimmerman
- Center for Global Health and Diseases, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Rajeev K Mehlotra
- Center for Global Health and Diseases, Case Western Reserve University School of Medicine, Cleveland, Ohio
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Pulford J, Kurumop S, Mueller I, Siba PM, Hetzel MW. The impact of the scale-up of malaria rapid diagnostic tests on the routine clinical diagnosis procedures for febrile illness: a series of repeated cross-sectional studies in Papua New Guinea. Malar J 2018; 17:202. [PMID: 29769128 PMCID: PMC5956836 DOI: 10.1186/s12936-018-2351-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2018] [Accepted: 05/07/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND This paper examines the impact of the scale-up of malaria rapid diagnostic tests (RDT) on routine clinical diagnosis procedures for febrile illness in primary healthcare settings in Papua New Guinea. METHODS Repeat, cross-sectional surveys in randomly selected primary healthcare services were conducted. Surveys included passive observation of consecutive febrile case management cases and were completed immediately prior to RDT scale-up (2011) and at 12- (2012) and 60-months (2016) post scale-up. The frequency with which specified diagnostic questions and procedures were observed to occur, with corresponding 95% CIs, was calculated for febrile patients prescribed anti-malarials pre- and post-RDT scale-up and between febrile patients who tested either negative or positive for malaria infection by RDT (post scale-up only). RESULTS A total of 1809 observations from 120 health facilities were completed across the three survey periods of which 915 (51%) were prescribed an anti-malarial. The mean number of diagnostic questions and procedures asked or performed, leading to anti-malarial prescription, remained consistent pre- and post-RDT scale-up (range 7.4-7.7). However, alterations in diagnostic content were evident with the RDT replacing body temperature as the primary diagnostic procedure performed (observed in 5.3 and 84.4% of cases, respectively, in 2011 vs. 77.9 and 58.2% of cases in 2016). Verbal questioning, especially experience of fever, cough and duration of symptoms, remained the most common feature of a diagnostic examination leading to anti-malarial prescription irrespective of RDT use (observed in 96.1, 86.8 and 84.8% of cases, respectively, in 2011 vs. 97.5, 76.6 and 85.7% of cases in 2016). Diagnostic content did not vary substantially by RDT result. CONCLUSIONS Rapid diagnostic tests scale-up has led to a reduction in body temperature measurement. Investigations are very limited when malaria infection is ruled out as a cause of febrile illness by RDT.
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Affiliation(s)
- Justin Pulford
- Papua New Guinea Institute of Medical Research, Goroka, Papua New Guinea. .,Liverpool School of Tropical Medicine, Liverpool, UK.
| | - Serah Kurumop
- Papua New Guinea Institute of Medical Research, Goroka, Papua New Guinea
| | - Ivo Mueller
- Walter and Eliza Hall Institute of Medical Research, Melbourne, Australia.,Barcelona Centre for International Health Research, Barcelona, Spain
| | - Peter M Siba
- Papua New Guinea Institute of Medical Research, Goroka, Papua New Guinea
| | - Manuel W Hetzel
- Swiss Tropical and Public Health Institute, Basel, Switzerland.,University of Basel, Basel, Switzerland
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8
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Hetzel MW, Pulford J, Ura Y, Jamea-Maiasa S, Tandrapah A, Tarongka N, Lorry L, Robinson LJ, Lilley K, Makita L, Siba PM, Mueller I. Insecticide-treated nets and malaria prevalence, Papua New Guinea, 2008-2014. Bull World Health Organ 2017; 95:695-705B. [PMID: 29147042 PMCID: PMC5689189 DOI: 10.2471/blt.16.189902] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2016] [Revised: 08/08/2017] [Accepted: 08/09/2017] [Indexed: 12/21/2022] Open
Abstract
Objective To investigate changes in malaria prevalence in Papua New Guinea after the distribution of long-lasting Insecticide-treated nets, starting in 2004, and the introduction of artemisinin-based combination therapy in 2011. Methods Two malaria surveys were conducted in 2010–2011 and 2013–2014. They included 77 and 92 randomly selected villages, respectively. In each village, all members of 30 randomly selected households gave blood samples and were assessed for malaria infection by light microscopy. In addition, data were obtained from a malaria survey performed in 2008–2009. Results The prevalence of malaria below 1600 m in altitude decreased from 11.1% (95% confidence interval, CI: 8.5–14.3) in 2008–2009 to 5.1% (95% CI 3.6–7.4) in 2010–2011 and 0.9% (95% CI 0.6–1.5) in 2013–2014. Prevalence decreased with altitude. Plasmodium falciparum was more common than P. vivax overall, but not everywhere, and initially the prevalence of P. vivax infection decreased more slowly than P. falciparum infection. Malaria infections were clustered in households. In contrast to findings in 2008–2009, no significant association between net use and prevalence was found in the later two surveys. The prevalence of both fever and splenomegaly also decreased but their association with malaria infection became stronger. Conclusion Large-scale insecticide-treated net distribution was associated with an unprecedented decline in malaria prevalence throughout Papua New Guinea, including epidemic-prone highland areas. The decline was accompanied by broader health benefits, such as decreased morbidity. Better clinical management of nonmalarial fever and research into residual malaria transmission are required.
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Affiliation(s)
- Manuel W Hetzel
- Swiss Tropical and Public Health Institute, Socinstrasse 57, Basel, 4002, Switzerland
| | - Justin Pulford
- International Public Health, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Yangta Ura
- Papua New Guinea Institute of Medical Research, Goroka and Madang, Papua New Guinea
| | - Sharon Jamea-Maiasa
- Papua New Guinea Institute of Medical Research, Goroka and Madang, Papua New Guinea
| | - Anthony Tandrapah
- Papua New Guinea Institute of Medical Research, Goroka and Madang, Papua New Guinea
| | - Nandao Tarongka
- Deceased, formerly, Papua New Guinea Institute of Medical Research, Madang, Papua New Guinea
| | - Lina Lorry
- Papua New Guinea Institute of Medical Research, Goroka and Madang, Papua New Guinea
| | - Leanne J Robinson
- Papua New Guinea Institute of Medical Research, Goroka and Madang, Papua New Guinea
| | - Ken Lilley
- Australian Army Malaria Institute, Enoggera, Australia
| | - Leo Makita
- National Department of Health, Waigani, Papua New Guinea
| | - Peter M Siba
- Papua New Guinea Institute of Medical Research, Goroka and Madang, Papua New Guinea
| | - Ivo Mueller
- Division of Population Health and Immunity, Walter and Eliza Hall Institute of Medical Research, Parkville, Australia
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Bell D, Fleurent AE, Hegg MC, Boomgard JD, McConnico CC. Development of new malaria diagnostics: matching performance and need. Malar J 2016; 15:406. [PMID: 27515426 PMCID: PMC4981959 DOI: 10.1186/s12936-016-1454-8] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2016] [Accepted: 07/28/2016] [Indexed: 12/02/2022] Open
Abstract
Despite advances in diagnostic technology, significant gaps remain in access to malaria diagnosis. Accurate diagnosis and misdiagnosis leads to unnecessary waste of resources, poor disease management, and contributes to a cycle of poverty in low-resourced communities. Despite much effort and investment, few new technologies have reached the field in the last 30 years aside from lateral flow assays. This suggests that much diagnostic development effort has been misdirected, and/or that there are fundamental blocks to introduction of new technologies. Malaria diagnosis is a difficult market; resources are broadly donor-dependent, health systems in endemic countries are frequently weak, and the epidemiology of malaria and priorities of malaria programmes and donors are evolving. Success in diagnostic development will require a good understanding of programme gaps, and the sustainability of markets to address them. Targeting assay development to such clearly defined market requirements will improve the outcomes of product development funding. Six market segments are identified: (1) case management in low-resourced countries, (2) parasite screening for low density infections in elimination programmes, (3) surveillance for evidence of continued transmission, (4) clinical research and therapeutic efficacy monitoring, (5) cross-checking for microscopy quality control, and (6) returned traveller markets distinguished primarily by resource availability. While each of these markets is potentially compelling from a public health standpoint, size and scale are highly variable and continue to evolve. Consequently, return on investment in research and development may be limited, highlighting the need for potentially significant donor involvement or the introduction of novel business models to overcome prohibitive economics. Given the rather specific applications, a well-defined set of stakeholders will need to be on board for the successful introduction and scaling of any new technology to these markets.
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Affiliation(s)
- David Bell
- Global Good Fund/Intellectual Ventures Laboratory, 3150 139th Ave SE, Bellevue, WA, 98005, USA.
| | | | | | | | - Caitlin C McConnico
- International Training and Education Center for Health (I-TECH), Gaborone, Botswana
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10
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Pulford J, Smith I, Mueller I, Siba PM, Hetzel MW. Health Worker Compliance with a 'Test And Treat' Malaria Case Management Protocol in Papua New Guinea. PLoS One 2016; 11:e0158780. [PMID: 27391594 PMCID: PMC4938505 DOI: 10.1371/journal.pone.0158780] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2016] [Accepted: 06/21/2016] [Indexed: 12/05/2022] Open
Abstract
The Papua New Guinea (PNG) Department of Health introduced a ‘test and treat’ malaria case management protocol in 2011. This study assesses health worker compliance with the test and treat protocol on a wide range of measures, examines self-reported barriers to health worker compliance as well as health worker attitudes towards the test and treat protocol. Data were collected by cross-sectional survey conducted in randomly selected primary health care facilities in 2012 and repeated in 2014. The combined survey data included passive observation of current or recently febrile patients (N = 771) and interviewer administered questionnaires completed with health workers (N = 265). Across the two surveys, 77.6% of patients were tested for malaria infection by rapid diagnostic test (RDT) or microscopy, 65.6% of confirmed malaria cases were prescribed the correct antimalarials and 15.3% of febrile patients who tested negative for malaria infection were incorrectly prescribed an antimalarial. Overall compliance with a strictly defined test and treat protocol was 62.8%. A reluctance to test current/recently febrile patients for malaria infection by RDT or microscopy in the absence of acute malaria symptoms, reserving recommended antimalarials for confirmed malaria cases only and choosing to clinically diagnose a malaria infection, despite a negative RDT result were the most frequently reported barriers to protocol compliance. Attitudinal support for the test and treat protocol, as assessed by a nine-item measure, improved across time. In conclusion, health worker compliance with the full test and treat malaria protocol requires improvement in PNG and additional health worker support will likely be required to achieve this. The broader evidence base would suggest any such support should be delivered over a longer period of time, be multi-dimensional and multi-modal.
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Affiliation(s)
- Justin Pulford
- Papua New Guinea Institute of Medical Research, Goroka, Papua New Guinea
- Liverpool School of Tropical Medicine, Liverpool, United Kingdom
- * E-mail:
| | - Iso Smith
- Papua New Guinea Institute of Medical Research, Goroka, Papua New Guinea
| | - Ivo Mueller
- Walter and Eliza Hall Institute of Medical Research, Melbourne, Australia
- Barcelona Centre for International Health Research, Barcelona, Spain
| | - Peter M. Siba
- Papua New Guinea Institute of Medical Research, Goroka, Papua New Guinea
| | - Manuel W. Hetzel
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
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11
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Bell D, Wilson BK. New Malaria Tests: Square Pegs for Round Holes? Trends Parasitol 2015; 31:612-613. [PMID: 26597021 DOI: 10.1016/j.pt.2015.10.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2015] [Accepted: 10/22/2015] [Indexed: 10/22/2022]
Abstract
To eradicate malaria new technologies are needed, not least in the detection of parasites. However, malaria program implementation is complex, and solutions that appear obvious fit less well on close inspection. Understanding the gaps in current programs is essential to selecting approaches likely to transition successfully to the field.
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Affiliation(s)
- David Bell
- The Global Good Fund, Intellectual Ventures Laboratory, 3150 139th Ave SE, Bellevue, WA 98005, USA.
| | - Benjamin K Wilson
- The Global Good Fund, Intellectual Ventures Laboratory, 3150 139th Ave SE, Bellevue, WA 98005, USA
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12
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Umbers AJ, Unger HW, Rosanas-Urgell A, Wangnapi RA, Kattenberg JH, Jally S, Silim S, Lufele E, Karl S, Ome-Kaius M, Robinson LJ, Rogerson SJ, Mueller I. Accuracy of an HRP-2/panLDH rapid diagnostic test to detect peripheral and placental Plasmodium falciparum infection in Papua New Guinean women with anaemia or suspected malaria. Malar J 2015; 14:412. [PMID: 26480941 PMCID: PMC4617889 DOI: 10.1186/s12936-015-0927-5] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2015] [Accepted: 09/25/2015] [Indexed: 12/30/2022] Open
Abstract
Background The diagnosis of malaria during pregnancy is complicated by placental sequestration, asymptomatic infection, and low-density peripheral parasitaemia. Where intermittent preventive treatment (IPT) with sulfadoxine-pyrimethamine is threatened by drug resistance, or is inappropriate due to low transmission, intermittent screening and treatment (ISTp) with rapid diagnostic tests for malaria (RDT) could be a valuable alternative. Therefore, the accuracy of RDTs to detect peripheral and placental infection was assessed in a declining transmission setting in Papua New Guinea (PNG). Methods The performance of a combination RDT detecting histidine-rich protein-2 (HRP-2) and Plasmodium lactate dehydrogenase (pLDH), and light microscopy (LM), to diagnose peripheral Plasmodium falciparum and Plasmodium vivax infections during pregnancy, were assessed using quantitative real-time PCR (qPCR) as the reference standard. Participants in a malaria prevention trial in PNG with a haemoglobin ≤90 g/L, or symptoms suggestive of malaria, were tested. Ability of RDT and LM to detect active placental infection on histology was evaluated in some participants. Results Among 876 women, 1162 RDTs were undertaken (anaemia: 854 [73.5 %], suspected malaria: 308 [26.5 %]). qPCR detected peripheral infection during 190 RDT episodes (165 P. falciparum, 19 P. vivax, 6 mixed infections). Overall, RDT detected peripheral P. falciparum infection with 45.6 % sensitivity (95 % CI 38.0–53.4), a specificity of 96.4 % (95.0–97.4), a positive predictive value of 68.4 % (59.1–76.8), and a negative predictive value of 91.1 % (89.2–92.8). RDT performance to detect P. falciparum was inferior to LM, more so amongst anaemic women (18.6 vs 45.3 % sensitivity, Liddell’s exact test, P < 0.001) compared to symptomatic women (72.9 vs 82.4 % sensitivity, P = 0.077). RDT and LM missed 88.0 % (22/25) and 76.0 % (19/25) of P. vivax infections, respectively. In a subset of women tested at delivery and who had placental histology (n = 158) active placental infection was present in 19.6 %: all three peripheral blood infection detection methods (RDT, LM, qPCR) missed >50 % of these infections. Conclusions In PNG, HRP-2/pLDH RDTs may be useful to diagnose peripheral P. falciparum infections in symptomatic pregnant women. However, they are not sufficiently sensitive for use in intermittent screening amongst asymptomatic (anaemic) women. These findings have implications for the management of malaria in pregnancy. The adverse impact of infections undetected by RDT or LM on pregnancy outcomes needs further evaluation. Electronic supplementary material The online version of this article (doi:10.1186/s12936-015-0927-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Alexandra J Umbers
- Department of Medicine at the Doherty Institute, The University of Melbourne, Melbourne, Australia. .,Papua New Guinea Institute of Medical Research (PNG IMR), Goroka, Papua New Guinea.
| | - Holger W Unger
- Department of Medicine at the Doherty Institute, The University of Melbourne, Melbourne, Australia. .,Papua New Guinea Institute of Medical Research (PNG IMR), Goroka, Papua New Guinea.
| | - Anna Rosanas-Urgell
- Papua New Guinea Institute of Medical Research (PNG IMR), Goroka, Papua New Guinea. .,Institute of Tropical Medicine, Antwerp, Belgium.
| | - Regina A Wangnapi
- Papua New Guinea Institute of Medical Research (PNG IMR), Goroka, Papua New Guinea.
| | - Johanna H Kattenberg
- Papua New Guinea Institute of Medical Research (PNG IMR), Goroka, Papua New Guinea. .,Walter and Eliza Hall Institute of Medical Research (WEHI), Melbourne, Australia.
| | - Shadrach Jally
- Papua New Guinea Institute of Medical Research (PNG IMR), Goroka, Papua New Guinea.
| | - Selina Silim
- Papua New Guinea Institute of Medical Research (PNG IMR), Goroka, Papua New Guinea.
| | - Elvin Lufele
- Papua New Guinea Institute of Medical Research (PNG IMR), Goroka, Papua New Guinea.
| | - Stephan Karl
- Walter and Eliza Hall Institute of Medical Research (WEHI), Melbourne, Australia.
| | - Maria Ome-Kaius
- Papua New Guinea Institute of Medical Research (PNG IMR), Goroka, Papua New Guinea.
| | - Leanne J Robinson
- Papua New Guinea Institute of Medical Research (PNG IMR), Goroka, Papua New Guinea. .,Walter and Eliza Hall Institute of Medical Research (WEHI), Melbourne, Australia.
| | - Stephen J Rogerson
- Department of Medicine at the Doherty Institute, The University of Melbourne, Melbourne, Australia.
| | - Ivo Mueller
- Walter and Eliza Hall Institute of Medical Research (WEHI), Melbourne, Australia. .,Barcelona Institute for Global Health (ISGLOBAL), Barcelona, Spain.
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Sserwanga A, Sears D, Kapella BK, Kigozi R, Rubahika D, Staedke SG, Kamya M, Yoon SS, Chang MA, Dorsey G, Mpimbaza A. Anti-malarial prescription practices among children admitted to six public hospitals in Uganda from 2011 to 2013. Malar J 2015; 14:331. [PMID: 26306395 PMCID: PMC4549911 DOI: 10.1186/s12936-015-0851-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2015] [Accepted: 08/16/2015] [Indexed: 11/21/2022] Open
Abstract
Background In 2011, Uganda’s Ministry of Health switched policy from presumptive treatment of malaria to recommending parasitological diagnosis prior to treatment, resulting in an expansion of diagnostic services at all levels of public health facilities including hospitals. Despite this change, anti-malarial drugs are often prescribed even when test results are negative. Presented is data on anti-malarial prescription practices among hospitalized children who underwent diagnostic testing after adoption of new treatment guidelines. Methods Anti-malarial prescription practices were collected as part of an inpatient malaria surveillance program generating high quality data among children admitted for any reason at government hospitals in six districts. A standardized medical record form was used to collect detailed patient information including presenting symptoms and signs, laboratory test results, admission and final diagnoses, treatments administered, and final outcome upon discharge. Results Between July 2011 and December 2013, 58,095 children were admitted to the six hospitals (hospital range 3294–20,426).A total of 56,282 (96.9 %) patients were tested for malaria, of which 26,072 (46.3 %) tested positive (hospital range 5.9–57.3 %). Among those testing positive, only 84 (0.3 %) were first tested after admission and 295 of 30,389 (1.0 %) patients who tested negative at admission later tested positive. Of 30,210 children with only negative test results, 11,977 (39.6 %) were prescribed an anti-malarial (hospital range 14.5–53.6 %). The proportion of children with a negative test result who were prescribed an anti-malarial fluctuated over time and did not show a significant trend at any site with the exception of one hospital where a steady decline was observed. Among those with only negative test results, children 6–12 months of age (aOR 3.78; p < 0.001) and those greater than 12 months of age (aOR 4.89; p < 0.001) were more likely to be prescribed an anti-malarial compared to children less than 6 months of age. Children with findings suggestive of severe malaria were also more likely to be prescribed an anti-malarial after a negative test result (aOR 1.98; p < 0.001). Conclusions Despite high testing rates for malaria at all sites, prescription of anti-malarials to patients with negative test results remained high, with the exception of one site where a steady decline occurred.
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Affiliation(s)
- Asadu Sserwanga
- Infectious Diseases Research Collaboration, Kampala, Uganda.
| | - David Sears
- Department of Medicine, San Francisco General Hospital, University of California, San Francisco, USA.
| | - Bryan K Kapella
- Malaria Branch, Division of Parasitic Diseases and Malaria, US Centers for Disease Control and Prevention, Atlanta, USA.
| | - Ruth Kigozi
- Infectious Diseases Research Collaboration, Kampala, Uganda.
| | - Denis Rubahika
- National Malaria Control Programme, Ministry of Health Uganda, Kampala, Uganda.
| | - Sarah G Staedke
- Infectious Diseases Research Collaboration, Kampala, Uganda. .,London School of Hygiene and Tropical Medicine, London, UK.
| | - Moses Kamya
- Infectious Diseases Research Collaboration, Kampala, Uganda. .,Child Health and Development Centre, Makerere University College of Health Sciences, Kampala, Uganda.
| | - Steven S Yoon
- Malaria Branch, Division of Parasitic Diseases and Malaria, US Centers for Disease Control and Prevention, Atlanta, USA.
| | - Michelle A Chang
- Malaria Branch, Division of Parasitic Diseases and Malaria, US Centers for Disease Control and Prevention, Atlanta, USA.
| | - Grant Dorsey
- Department of Medicine, San Francisco General Hospital, University of California, San Francisco, USA.
| | - Arthur Mpimbaza
- Infectious Diseases Research Collaboration, Kampala, Uganda. .,Child Health and Development Centre, Makerere University College of Health Sciences, Kampala, Uganda.
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Rambaud-Althaus C, Shao AF, Kahama-Maro J, Genton B, d’Acremont V. Managing the Sick Child in the Era of Declining Malaria Transmission: Development of ALMANACH, an Electronic Algorithm for Appropriate Use of Antimicrobials. PLoS One 2015; 10:e0127674. [PMID: 26161753 PMCID: PMC4498609 DOI: 10.1371/journal.pone.0127674] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2014] [Accepted: 04/17/2015] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE To review the available knowledge on epidemiology and diagnoses of acute infections in children aged 2 to 59 months in primary care setting and develop an electronic algorithm for the Integrated Management of Childhood Illness to reach optimal clinical outcome and rational use of medicines. METHODS A structured literature review in Medline, Embase and the Cochrane Database of Systematic Review (CDRS) looked for available estimations of diseases prevalence in outpatients aged 2-59 months, and for available evidence on i) accuracy of clinical predictors, and ii) performance of point-of-care tests for targeted diseases. A new algorithm for the management of childhood illness (ALMANACH) was designed based on evidence retrieved and results of a study on etiologies of fever in Tanzanian children outpatients. FINDINGS The major changes in ALMANACH compared to IMCI (2008 version) are the following: i) assessment of 10 danger signs, ii) classification of non-severe children into febrile and non-febrile illness, the latter receiving no antibiotics, iii) classification of pneumonia based on a respiratory rate threshold of 50 assessed twice for febrile children 12-59 months; iv) malaria rapid diagnostic test performed for all febrile children. In the absence of identified source of fever at the end of the assessment, v) urine dipstick performed for febrile children <2 years to consider urinary tract infection, vi) classification of 'possible typhoid' for febrile children >2 years with abdominal tenderness; and lastly vii) classification of 'likely viral infection' in case of negative results. CONCLUSION This smartphone-run algorithm based on new evidence and two point-of-care tests should improve the quality of care of <5 year children and lead to more rational use of antimicrobials.
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Affiliation(s)
- Clotilde Rambaud-Althaus
- Epidemiology and Public Health department, Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | - Amani Flexson Shao
- Epidemiology and Public Health department, Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
- National Institute for Medical Research, Tukuyu Medical Research Center, Tukuyu, Tanzania
| | - Judith Kahama-Maro
- City Medical Office of Health, Dar es Salaam City Council, Dar es Salaam, Tanzania
| | - Blaise Genton
- Epidemiology and Public Health department, Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
- Infectious Disease Service, University Hospital, Lausanne, Switzerland
- Department of Ambulatory Care and Community Medicine, University Hospital, Lausanne, Switzerland
| | - Valérie d’Acremont
- Epidemiology and Public Health department, Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
- Infectious Disease Service, University Hospital, Lausanne, Switzerland
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15
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Sears D, Mpimbaza A, Kigozi R, Sserwanga A, Chang MA, Kapella BK, Yoon S, Kamya MR, Dorsey G, Ruel T. Quality of inpatient pediatric case management for four leading causes of child mortality at six government-run Ugandan hospitals. PLoS One 2015; 10:e0127192. [PMID: 25992620 PMCID: PMC4437786 DOI: 10.1371/journal.pone.0127192] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2014] [Accepted: 04/12/2015] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND A better understanding of case management practices is required to improve inpatient pediatric care in resource-limited settings. Here we utilize data from a unique health facility-based surveillance system at six Ugandan hospitals to evaluate the quality of pediatric case management and the factors associated with appropriate care. METHODS All children up to the age of 14 years admitted to six district or regional hospitals over 15 months were included in the study. Four case management categories were defined for analysis: suspected malaria, selected illnesses requiring antibiotics, suspected anemia, and diarrhea. The quality of case management for each category was determined by comparing recorded treatments with evidence-based best practices as defined in national guidelines. Associations between variables of interest and the receipt of appropriate case management were estimated using multivariable logistic regression. RESULTS A total of 30,351 admissions were screened for inclusion in the analysis. Ninety-two percent of children met criteria for suspected malaria and 81% received appropriate case management. Thirty-two percent of children had selected illnesses requiring antibiotics and 89% received appropriate antibiotics. Thirty percent of children met criteria for suspected anemia and 38% received appropriate case management. Twelve percent of children had diarrhea and 18% received appropriate case management. Multivariable logistic regression revealed large differences in the quality of care between health facilities. There was also a strong association between a positive malaria diagnostic test result and the odds of receiving appropriate case management for comorbid non-malarial illnesses - children with a positive malaria test were more likely to receive appropriate care for anemia and less likely for illnesses requiring antibiotics and diarrhea. CONCLUSIONS Appropriate management of suspected anemia and diarrhea occurred infrequently. Pediatric quality improvement initiatives should target deficiencies in care unique to each health facility, and interventions should focus on the simultaneous management of multiple diagnoses.
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Affiliation(s)
- David Sears
- Department of Medicine, San Francisco General Hospital, University of California San Francisco, San Francisco, CA, United States of America
| | - Arthur Mpimbaza
- Uganda Malaria Surveillance Project, Kampala, Uganda
- Child Health & Development Centre, Makerere University, Kampala, Uganda
| | - Ruth Kigozi
- Uganda Malaria Surveillance Project, Kampala, Uganda
| | | | - Michelle A. Chang
- Malaria Branch, Centers for Disease Control and Prevention, Atlanta, GA, United States of America
| | - Bryan K. Kapella
- Malaria Branch, Centers for Disease Control and Prevention, Atlanta, GA, United States of America
| | - Steven Yoon
- Malaria Branch, Centers for Disease Control and Prevention, Atlanta, GA, United States of America
- United States President’s Malaria Initiative, Centers for Disease Control and Prevention, Atlanta, GA, United States of America
| | - Moses R. Kamya
- Department of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - Grant Dorsey
- Department of Medicine, San Francisco General Hospital, University of California San Francisco, San Francisco, CA, United States of America
| | - Theodore Ruel
- Department of Pediatrics, University of California San Francisco, San Francisco, CA, United States of America
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16
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Abba K, Kirkham AJ, Olliaro PL, Deeks JJ, Donegan S, Garner P, Takwoingi Y. Rapid diagnostic tests for diagnosing uncomplicated non-falciparum or Plasmodium vivax malaria in endemic countries. Cochrane Database Syst Rev 2014; 2014:CD011431. [PMID: 25519857 PMCID: PMC4453861 DOI: 10.1002/14651858.cd011431] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
BACKGROUND In settings where both Plasmodium vivax and Plasmodium falciparum infection cause malaria, rapid diagnostic tests (RDTs) need to distinguish which species is causing the patients' symptoms, as different treatments are required. Older RDTs incorporated two test lines to distinguish malaria due to P. falciparum, from malaria due to any other Plasmodium species (non-falciparum). These RDTs can be classified according to which antibodies they use: Type 2 RDTs use HRP-2 (for P. falciparum) and aldolase (all species); Type 3 RDTs use HRP-2 (for P. falciparum) and pLDH (all species); Type 4 use pLDH (fromP. falciparum) and pLDH (all species).More recently, RDTs have been developed to distinguish P. vivax parasitaemia by utilizing a pLDH antibody specific to P. vivax. OBJECTIVES To assess the diagnostic accuracy of RDTs for detecting non-falciparum or P. vivax parasitaemia in people living in malaria-endemic areas who present to ambulatory healthcare facilities with symptoms suggestive of malaria, and to identify which types and brands of commercial test best detect non-falciparum and P. vivax malaria. SEARCH METHODS We undertook a comprehensive search of the following databases up to 31 December 2013: Cochrane Infectious Diseases Group Specialized Register; MEDLINE; EMBASE; MEDION; Science Citation Index; Web of Knowledge; African Index Medicus; LILACS; and IndMED. SELECTION CRITERIA Studies comparing RDTs with a reference standard (microscopy or polymerase chain reaction) in blood samples from a random or consecutive series of patients attending ambulatory health facilities with symptoms suggestive of malaria in non-falciparum endemic areas. DATA COLLECTION AND ANALYSIS For each study, two review authors independently extracted a standard set of data using a tailored data extraction form. We grouped comparisons by type of RDT (defined by the combinations of antibodies used), and combined in meta-analysis where appropriate. Average sensitivities and specificities are presented alongside 95% confidence intervals (95% CI). MAIN RESULTS We included 47 studies enrolling 22,862 participants. Patient characteristics, sampling methods and reference standard methods were poorly reported in most studies. RDTs detecting 'non-falciparum' parasitaemiaEleven studies evaluated Type 2 tests compared with microscopy, 25 evaluated Type 3 tests, and 11 evaluated Type 4 tests. In meta-analyses, average sensitivities and specificities were 78% (95% CI 73% to 82%) and 99% (95% CI 97% to 99%) for Type 2 tests, 78% (95% CI 69% to 84%) and 99% (95% CI 98% to 99%) for Type 3 tests, and 89% (95% CI 79% to 95%) and 98% (95% CI 97% to 99%) for Type 4 tests, respectively. Type 4 tests were more sensitive than both Type 2 (P = 0.01) and Type 3 tests (P = 0.03).Five studies compared Type 3 tests with PCR; in meta-analysis, the average sensitivity and specificity were 81% (95% CI 72% to 88%) and 99% (95% CI 97% to 99%) respectively. RDTs detecting P.vivax parasitaemiaEight studies compared pLDH tests to microscopy; the average sensitivity and specificity were 95% (95% CI 86% to 99%) and 99% (95% CI 99% to 100%), respectively. AUTHORS' CONCLUSIONS RDTs designed to detect P. vivax specifically, whether alone or as part of a mixed infection, appear to be more accurate than older tests designed to distinguish P. falciparum malaria from non-falciparum malaria. Compared to microscopy, these tests fail to detect around 5% ofP. vivax cases. This Cochrane Review, in combination with other published information about in vitro test performance and stability in the field, can assist policy-makers to choose between the available RDTs.
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Affiliation(s)
- Katharine Abba
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, UK.
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17
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Plasmodium falciparum parasites lacking histidine-rich protein 2 and 3: a review and recommendations for accurate reporting. Malar J 2014; 13:283. [PMID: 25052298 PMCID: PMC4115471 DOI: 10.1186/1475-2875-13-283] [Citation(s) in RCA: 154] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2014] [Accepted: 06/27/2014] [Indexed: 11/21/2022] Open
Abstract
Malaria rapid diagnostic tests (RDTs) play a critical role in malaria case management, surveillance and case investigations. Test performance is largely determined by design and quality characteristics, such as detection sensitivity, specificity, and thermal stability. However, parasite characteristics such as variable or absent expression of antigens targeted by RDTs can also affect RDT performance. Plasmodium falciparum parasites lacking the PfHRP2 protein, the most common target antigen for detection of P. falciparum, have been reported in some regions. Therefore, accurately mapping the presence and prevalence of P. falciparum parasites lacking pfhrp2 would be an important step so that RDTs targeting alternative antigens, or microscopy, can be preferentially selected for use in such regions. Herein the available evidence and molecular basis for identifying malaria parasites lacking PfHRP2 is reviewed, and a set of recommended procedures to apply for future investigations for parasites lacking PfHRP2, is proposed.
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19
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Manyando C, Njunju EM, Chileshe J, Siziya S, Shiff C. Rapid diagnostic tests for malaria and health workers' adherence to test results at health facilities in Zambia. Malar J 2014; 13:166. [PMID: 24885996 PMCID: PMC4026818 DOI: 10.1186/1475-2875-13-166] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2014] [Accepted: 04/27/2014] [Indexed: 11/10/2022] Open
Abstract
Background In Zambia, there has been a large scaling up of interventions to control malaria in recent years including the deployment of rapid diagnostic tests (RDTs) to improve malaria surveillance data as well as guide malaria treatment in health facilities. The practical challenge is the impact of RDT results on subsequent management of patients. This study explored the role of RDTs in malaria diagnosis and the health workers’ adherence to test results. Methods An observational prospective study was carried out at health centres in four districts, namely Chibombo, Chingola, Chipata, and Choma. Children under the age of five years with history of fever were recruited and the clinicians’ use of RDT results was observed to establish whether prescriptions were issued prior to the availability of parasitological results or after, and whether RDT results influenced their prescriptions. Results Of the 2, 393 recruited children, 2, 264 had both RDT and microscopic results. Two in three (68.6%) children were treated with anti-malarials despite negative RDT results and almost half (46.2%) of these were prescribed Coartem®. Only 465 (19.4%) of the 2,393 children were prescribed drugs before receiving laboratory results. A total of 76.5% children were prescribed drugs after laboratory results. Children with RDT positive results were 2.66 (95% CI (2.00, 3.55)) times more likely to be prescribed anti-malarial drugs. Children who presented with fever at admission (although history of fever or presence of fever at admission was an entry criterion) were 42% less likely to be prescribed an anti-malarial drug compared to children who had no fever (AOR = 0.58; 95% CI (0.52, 0.65)). It was noted that proportions of children who were RDT- and microscopy-positive significantly declined over the years from 2005 to 2008. Conclusions RDTs may contribute to treatment of febrile illness by confirming malaria cases from non-malaria cases in children under the age of five. However, the adherence of the health workers to prescribing anti-malarials to only RDT-positive cases at health facility level will still require to be explored further as their role is crucial in more precise reporting of malaria cases in this era towards malaria elimination as the target.
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Senn N, Rarau P, Salib M, Manong D, Siba P, Rogerson S, Mueller I, Genton B. Use of antibiotics within the IMCI guidelines in outpatient settings in Papua New Guinean children: an observational and effectiveness study. PLoS One 2014; 9:e90990. [PMID: 24626194 PMCID: PMC3953204 DOI: 10.1371/journal.pone.0090990] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2013] [Accepted: 02/06/2014] [Indexed: 12/24/2022] Open
Abstract
Introduction There is a need to investigate the effectiveness and appropriateness of antibiotics prescription within the Integrated Management of Childhood Illness (IMCI) strategy in the context of routine outpatient clinics. Methods Making use of a passive case detection system established for a malaria prevention trial in outpatient clinics in Papua New Guinea, the appropriateness and effectiveness of the use of antibiotics within the IMCI was assessed in 1605 young children. Main outcomes were prescription of antibiotics and re-attendances within 14 days for mild pneumonia, mild diarrhoea and uncomplicated malaria whether they were managed with or without antibiotics (proxy of effectiveness). Appropriateness was assessed for both mild and severe cases, while effectiveness was assessed only for mild diseases. Results A total of 6975 illness episodes out of 8944 fulfilled inclusion criteria (no previous attendance <14 days+full medical records). Clinical incidence rates (episodes/child/year; 95% CI) were 0.85 (0.81–0.90) for pneumonia, 0.62 (0.58–0.66) for malaria and 0.72 (0.65–0.93) for diarrhoea. Fifty three percent of 6975 sick children were treated with antibiotics, 11% were not treated with antibiotics when they should have been and in 29% antibiotics were prescribed when they should not have been. Re-attendance rates within 14 days following clinical diagnosis of mild pneumonia were 9% (126/1401) when managed with antibiotics compared to 8% (56/701) when managed without (adjusted Hazard Ratio (aHR) = 1.00 (0.57–1.76), p = 0.98). Rates for mild diarrhoea were 8% (73/874) and 9% (79/866) respectively (aHR = 0.8 (0.42–1.57), p = 0.53). Conclusion Non-adherence to IMCI recommendations for prescription of antibiotics is common in routine settings in Papua New Guinea. Although recommended, the use of antibiotics in young children with mild pneumonia as defined by IMCI criteria did not impact on their outcome. Better tools and new strategies for the identification of bacterial infections that require antibiotics are urgently needed.
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Affiliation(s)
- Nicolas Senn
- Vector Born Unit, PNG Institute of Medical Research, Madang (MAD), Papua New Guinea; Health Intervention Unit, Swiss Tropical and Public Health Institute, Basel (BS), Switzerland; University of Basel, Basel (BS), Switzerland; Department of Medicine, University of Melbourne, Melbourne, Australia
| | - Patricia Rarau
- Vector Born Unit, PNG Institute of Medical Research, Madang (MAD), Papua New Guinea
| | - Mary Salib
- Vector Born Unit, PNG Institute of Medical Research, Madang (MAD), Papua New Guinea
| | - Doris Manong
- Vector Born Unit, PNG Institute of Medical Research, Madang (MAD), Papua New Guinea
| | - Peter Siba
- Vector Born Unit, PNG Institute of Medical Research, Madang (MAD), Papua New Guinea
| | - Stephen Rogerson
- Department of Medicine, University of Melbourne, Melbourne, Australia
| | - Ivo Mueller
- Vector Born Unit, PNG Institute of Medical Research, Madang (MAD), Papua New Guinea; Dept. of Infections & Immunity, Walter & Eliza Hall Institute of Medical Research, Melbourne, Australia; Centre de Recerca en Salut Internacional de Barcelona (CRESIB), Barcelona, Spain
| | - Blaise Genton
- Health Intervention Unit, Swiss Tropical and Public Health Institute, Basel (BS), Switzerland; University of Basel, Basel (BS), Switzerland
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D'Acremont V, Kilowoko M, Kyungu E, Philipina S, Sangu W, Kahama-Maro J, Lengeler C, Cherpillod P, Kaiser L, Genton B. Beyond malaria--causes of fever in outpatient Tanzanian children. N Engl J Med 2014; 370:809-17. [PMID: 24571753 DOI: 10.1056/nejmoa1214482] [Citation(s) in RCA: 311] [Impact Index Per Article: 31.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND As the incidence of malaria diminishes, a better understanding of nonmalarial fever is important for effective management of illness in children. In this study, we explored the spectrum of causes of fever in African children. METHODS We recruited children younger than 10 years of age with a temperature of 38°C or higher at two outpatient clinics--one rural and one urban--in Tanzania. Medical histories were obtained and clinical examinations conducted by means of systematic procedures. Blood and nasopharyngeal specimens were collected to perform rapid diagnostic tests, serologic tests, culture, and molecular tests for potential pathogens causing acute fever. Final diagnoses were determined with the use of algorithms and a set of prespecified criteria. RESULTS Analyses of data derived from clinical presentation and from 25,743 laboratory investigations yielded 1232 diagnoses. Of 1005 children (22.6% of whom had multiple diagnoses), 62.2% had an acute respiratory infection; 5.0% of these infections were radiologically confirmed pneumonia. A systemic bacterial, viral, or parasitic infection other than malaria or typhoid fever was found in 13.3% of children, nasopharyngeal viral infection (without respiratory symptoms or signs) in 11.9%, malaria in 10.5%, gastroenteritis in 10.3%, urinary tract infection in 5.9%, typhoid fever in 3.7%, skin or mucosal infection in 1.5%, and meningitis in 0.2%. The cause of fever was undetermined in 3.2% of the children. A total of 70.5% of the children had viral disease, 22.0% had bacterial disease, and 10.9% had parasitic disease. CONCLUSIONS These results provide a description of the numerous causes of fever in African children in two representative settings. Evidence of a viral process was found more commonly than evidence of a bacterial or parasitic process. (Funded by the Swiss National Science Foundation and others.).
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Affiliation(s)
- Valérie D'Acremont
- From the Swiss Tropical and Public Health Institute and University of Basel, Basel (V.D., J.K.-M., C.L., B.G.), the Department of Ambulatory Care and Community Medicine, University of Lausanne (V.D., B.G.), and the Infectious Diseases Service, University Hospital (B.G.), Lausanne, and the Laboratory of Virology, Division of Infectious Diseases and Division of Laboratory Medicine, University Hospital of Geneva, and Faculty of Medicine, University of Geneva, Geneva (P.C., L.K.) - all in Switzerland; the City Medical Office of Health, Dar es Salaam City Council (V.D., J.K.M.), and Amana Hospital (M.K., W.S.), Dar es Salaam, Ifakara Health Institute, Dar es Salaam and Ifakara (B.G.), and St. Francis Hospital, Ifakara (E.K., S.P.) - all in Tanzania
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Pulford J, Kurumop SF, Ura Y, Siba PM, Mueller I, Hetzel MW. Malaria case management in Papua New Guinea following the introduction of a revised treatment protocol. Malar J 2013; 12:433. [PMID: 24279720 PMCID: PMC4222867 DOI: 10.1186/1475-2875-12-433] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2013] [Accepted: 11/25/2013] [Indexed: 11/10/2022] Open
Abstract
Background This paper reports on the availability of diagnostic tools and recommended anti-malarials in the 12-month period immediately following the implementation of a new national malaria treatment protocol (NMTP) in Papua New Guinea (PNG). Health worker adherence to the new NMTP is also examined and comparisons made with previously reported pre-implementation findings. Methods A countrywide cross-sectional survey in randomly selected primary health care facilities (n = 88). Data were collected via passive observation of the clinical case management of fever or suspected malaria patients and via an interviewer administered questionnaire completed with the officer in charge of each participating health care facility. Results Malaria rapid diagnostic tests (RDTs) and the new first-line anti-malarial medication, artemether-lumefantrine (AL), were available in 53.4% and 51.1% of surveyed heath facilities, respectively. However, they were more widely available in the larger health centres as compared to the smaller aid-posts (90.2% vs. 21.3% and 87.8% vs. 19.2%, respectively). Overall, 68.3% of observed fever cases (n = 445) were tested for malaria by RDT and 39% prescribed an anti-malarial, inclusive of 98.2% of RDT positive patients and 19.8% of RDT negative cases. The availability and use of malaria RDTs was greater in the current survey as compared to pre-implementation of the new NMTP (8.9% vs. 53.4% & 16.2% vs. 68.3%, respectively) as was the availability of AL (0% vs. 51.1%). The percentage of fever patients prescribed anti-malarials decreased substantially post implementation of the new NMTP (96.4% vs. 39.0%). Conclusions PNG has achieved high coverage of malaria RDTs and AL at the health centre level, but these resources have yet to reach the majority of aid-posts. Malaria case management practice has substantially changed in the 12-month period immediately following the new NMTP, although full protocol adherence was rarely observed.
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Affiliation(s)
- Justin Pulford
- Papua New Guinea Institute of Medical Research (PNGIMR), Goroka, EHP 441, Papua New Guinea.
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23
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Manning L, Davis TME. The mechanistic, diagnostic and prognostic utility of biomarkers in severe malaria. Biomark Med 2013; 7:363-80. [DOI: 10.2217/bmm.13.50] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
Malaria remains an important global cause of severe illness and mortality. This literature review summarizes available data on how biomarkers might be applied to diagnose, prognosticate and provide mechanistic insights in patients with severe malaria. Of the large number of candidate biomarkers, only PfHRP2 has consistently demonstrated clinical utility and, when incorporated into rapid antigen detection tests, has shown diagnostic sensitivity above 95%, which is at least as good as light microscopy. As a quantitative test, PfHRP2 also shows some promise in differentiating severe malarial from non-malarial disease in areas where asymptomatic carriage of malaria parasites is common, and possibly as a tool to estimate sequestered parasite burden and subsequent mortality. Biomarkers such as pLDH and panmalarial antigen have lower sensitivity for non-falciparum malaria in rapid antigen detection tests. There is an urgent need to discover and validate better biomarkers for incorporation into rapid antigen detection tests in countries where Plasmodium vivax is a common cause of severe disease. A large number of host-derived acute-phase reactants, markers of endothelial dysfunction and immune mediators have been proposed as biomarkers. Although they have provided mechanistic insights into the immunopathology of severe malaria, their roles as clinical tools remain uncertain.
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Affiliation(s)
- Laurens Manning
- School of Medicine & Pharmacology, Fremantle Hospital & Health Service, The University of Western Australia, 35 Stirling Highway, Crawley, WA 6009, Australia
| | - Timothy Mark Earls Davis
- School of Medicine & Pharmacology, Fremantle Hospital & Health Service, The University of Western Australia, 35 Stirling Highway, Crawley, WA 6009, Australia
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Senn N, Rarau P, Manong D, Salib M, Siba P, Reeder JC, Rogerson SJ, Genton B, Mueller I. Effectiveness of Artemether/Lumefantrine for the Treatment of Uncomplicated Plasmodium vivax and P. falciparum Malaria in Young Children in Papua New Guinea. Clin Infect Dis 2013; 56:1413-20. [DOI: 10.1093/cid/cit068] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Abstract
PURPOSE OF REVIEW The emergence of Plasmodium knowlesi, a parasite of Southeast Asian macaques, into the human population is ongoing and widespread across Southeast Asia. Humans entering P. knowlesi transmission areas are at risk. Patients present with uncomplicated, complicated and fatal disease, therefore prompt accurate diagnosis and treatment are essential. This review focuses on recent descriptions of asymptomatic and symptomatic infections in children, pathophysiology in adults, treatment and diagnosis, and highlights the importance of monitoring transmission and host-switch events. RECENT FINDINGS New reports on P. knowlesi infections identify regional differences in aetiology and vector species. Parasitaemia is associated with disease severity and specific diagnostic tools are required. Treatment failures have not been reported. The severe form of P. knowlesi malaria can be compared with severe falciparum malaria to inform the pathophysiology of both infections. SUMMARY P. knowlesi presents new challenges to malaria-control efforts in Southeast Asia. Sensitive and specific diagnostic tools are required for communities and travellers at risk. Currently P. knowlesi transmission appears to occur away from human settlements. However, ongoing host-switch events from macaques to humans cannot be excluded. Changes in P. knowlesi transmission across the region should be monitored to preempt outbreaks of this virulent pathogen.
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Rossi IA, D'Acremont V, Prod'Hom G, Genton B. Safety of falciparum malaria diagnostic strategy based on rapid diagnostic tests in returning travellers and migrants: a retrospective study. Malar J 2012; 11:377. [PMID: 23158019 PMCID: PMC3528469 DOI: 10.1186/1475-2875-11-377] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2012] [Accepted: 10/30/2012] [Indexed: 11/25/2022] Open
Abstract
Background Rapid diagnostic tests for malaria (RDTs) allow accurate diagnosis and prompt treatment. Validation of their usefulness in travellers with fever was needed. The safety of a strategy to diagnose falciparum malaria based on RDT followed by immediate or delayed microscopy reading at first attendance was evaluated in one referral hospital in Switzerland. Methods A retrospective study was conducted in the outpatient clinic and emergency ward of University Hospital, covering a period of eight years (1999–2007). The study was conducted in the outpatient clinic and emergency ward of University Hospital. All adults suspected of malaria with a diagnostic test performed were included. RDT and microscopy as immediate tests were performed during working hours, and RDT as immediate test and delayed microscopy reading out of laboratory working hours. The main outcome measure was occurrence of specific complications in RDT negative and RDT positive adults. Results 2,139 patients were recruited. 1987 had both initial RDT and blood smear (BS) result negative. Among those, 2/1987 (0.1%) developed uncomplicated malaria with both RDT and BS positive on day 1 and day 6 respectively. Among the 152 patients initially malaria positive, 137 had both RDT and BS positive, four only BS positive and five only RDT positive (PCR confirmed) (six had only one test performed). None of the four initially RDT negative/BS positive and none of the five initially BS negative/RDT positive developed severe malaria while 6/137 of both RDT and BS positive did so. The use of RDT allowed a reduction of a median of 2.1 hours to get a first malaria test result. Conclusions A malaria diagnostic strategy based on RDTs and a delayed BS is safe in non-immune populations, and shortens the time to first malaria test result.
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Affiliation(s)
- Isabelle Anne Rossi
- Travel Clinic, Department of Ambulatory Care and Community Medicine, University of Lausanne, Lausanne, CH-1011, Switzerland.
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Manning L, Laman M, Rosanas-Urgell A, Turlach B, Aipit S, Bona C, Warrell J, Siba P, Mueller I, Davis TME. Rapid antigen detection tests for malaria diagnosis in severely ill Papua New Guinean children: a comparative study using Bayesian latent class models. PLoS One 2012; 7:e48701. [PMID: 23144935 PMCID: PMC3489828 DOI: 10.1371/journal.pone.0048701] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2012] [Accepted: 09/28/2012] [Indexed: 11/18/2022] Open
Abstract
Background Although rapid diagnostic tests (RDTs) have practical advantages over light microscopy (LM) and good sensitivity in severe falciparum malaria in Africa, their utility where severe non-falciparum malaria occurs is unknown. LM, RDTs and polymerase chain reaction (PCR)-based methods have limitations, and thus conventional comparative malaria diagnostic studies employ imperfect gold standards. We assessed whether, using Bayesian latent class models (LCMs) which do not require a reference method, RDTs could safely direct initial anti-infective therapy in severe ill children from an area of hyperendemic transmission of both Plasmodium falciparum and P. vivax. Methods and Findings We studied 797 Papua New Guinean children hospitalized with well-characterized severe illness for whom LM, RDT and nested PCR (nPCR) results were available. For any severe malaria, the estimated prevalence was 47.5% with RDTs exhibiting similar sensitivity and negative predictive value (NPV) to nPCR (≥96.0%). LM was the least sensitive test (87.4%) and had the lowest NPV (89.7%), but had the highest specificity (99.1%) and positive predictive value (98.9%). For severe falciparum malaria (prevalence 42.9%), the findings were similar. For non-falciparum severe malaria (prevalence 6.9%), no test had the WHO-recommended sensitivity and specificity of >95% and >90%, respectively. RDTs were the least sensitive (69.6%) and had the lowest NPV (96.7%). Conclusions RDTs appear a valuable point-of-care test that is at least equivalent to LM in diagnosing severe falciparum malaria in this epidemiologic situation. None of the tests had the required sensitivity/specificity for severe non-falciparum malaria but the number of false-negative RDTs in this group was small.
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Affiliation(s)
- Laurens Manning
- School of Medicine and Pharmacology, University of Western Australia, Fremantle Hospital, Fremantle, Western Australia, Australia
| | - Moses Laman
- School of Medicine and Pharmacology, University of Western Australia, Fremantle Hospital, Fremantle, Western Australia, Australia
- Papua New Guinea Institute of Medical Research, Madang, Papua New Guinea
| | | | - Berwin Turlach
- Centre for Applied Statistics, University of Western Australia, Crawley, Western Australia, Australia
| | - Susan Aipit
- Papua New Guinea Institute of Medical Research, Madang, Papua New Guinea
| | - Cathy Bona
- Papua New Guinea Institute of Medical Research, Madang, Papua New Guinea
| | - Jonathan Warrell
- Papua New Guinea Institute of Medical Research, Madang, Papua New Guinea
| | - Peter Siba
- Papua New Guinea Institute of Medical Research, Madang, Papua New Guinea
| | - Ivo Mueller
- Papua New Guinea Institute of Medical Research, Madang, Papua New Guinea
- Barcelona Centre for International Health Research (CRESIB), Barcelona, Spain
- Walter and Eliza Hall Institute, Parkville, Melbourne, Australia
| | - Timothy M. E. Davis
- School of Medicine and Pharmacology, University of Western Australia, Fremantle Hospital, Fremantle, Western Australia, Australia
- * E-mail:
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Rosanas-Urgell A, Senn N, Rarau P, Aponte JJ, Reeder JC, Siba PM, Michon P, Mueller I. Lack of associations of α(+)-thalassemia with the risk of Plasmodium falciparum and Plasmodium vivax infection and disease in a cohort of children aged 3-21 months from Papua New Guinea. Int J Parasitol 2012; 42:1107-13. [PMID: 23085147 DOI: 10.1016/j.ijpara.2012.10.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2012] [Revised: 10/01/2012] [Accepted: 10/01/2012] [Indexed: 10/27/2022]
Abstract
Despite consistent evidence of a protective effect of α(+)-thalassemia against severe Plasmodium falciparum disease, the mechanisms underlying this protection remain unknown. An increase in risk of Plasmodium vivax malaria in early childhood resulting in a cross-species protection against severe P. falciparum malaria has been proposed as a possible mechanism in Melanesian children. The association of α(+)-thalassemia genotypes with a risk of P. falciparum and P. vivax infection and uncomplicated illness was reassessed in a cohort of 1,112 Papua New Guinean children, followed from 3 to 21 months of age. Three hundred and eighty-nine (35.0%) children were homozygous for α(+)-thalassemia (-α/-α), 506 (45.5%) heterozygous (αα/-α) and 217 (19.5%) homozygous for the wild-type allele. No significant differences in the incidence of P. falciparum (Pf) or P. vivax (Pv) malaria were observed between α(+)-thalassemia homozygote (Pf: incidence rate ratio (IRR)=1.13, CI(95) (0.82, 1.56), P=0.45, Pv: IRR=1.15, CI(95) (0.88, 1.50), P=0.31), heterozygote (Pf: IRR=0.98, CI(95) (0.71, 1.34), P=0.93, Pv: IRR=1.14, CI(95) (0.88, 1.48), P=0.33) and wild-type children. The prevalence of infection with either species did not differ between α(+)-thalassemia genotypes, although densities of P. vivax (but not of P. falciparum) infections were significantly higher in α(+)-thalassemia homozygote and heterozygote children. An excessive risk of moderate-to-severe anemia (Hb<8 g/dl) was observed in α(+)-thalassemia homozygote children (IRR=1.54, CI(95) (1.12, 2.11), P=0.008). This study therefore failed to confirm an increased risk of P. vivax or P. falciparum malaria in very young, α(+)-thalassemic children without significant levels of acquired immunity. This confirms the lack of protection by α(+)-thalassemia against uncomplicated P. falciparum and challenges the hypothesis of immunological cross-protection between P. falciparum and P. vivax as a mechanism underlying α(+)-thalassemia protection against severe P. falciparum disease in Melanesian children.
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Finding parasites and finding challenges: improved diagnostic access and trends in reported malaria and anti-malarial drug use in Livingstone district, Zambia. Malar J 2012; 11:341. [PMID: 23043557 PMCID: PMC3496597 DOI: 10.1186/1475-2875-11-341] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2012] [Accepted: 10/03/2012] [Indexed: 11/29/2022] Open
Abstract
Background Understanding the impact of malaria rapid diagnostic test (RDT) use on management of acute febrile disease at a community level, and on the consumption of anti-malarial medicines, is critical to the planning and success of scale-up to universal parasite-based diagnosis by health systems in malaria-endemic countries. Methods A retrospective study of district-wide community-level RDT introduction was conducted in Livingstone District, Zambia, to assess the impact of this programmed on malaria reporting, incidence of mortality and on district anti-malarial consumption. Results Reported malaria declined from 12,186 cases in the quarter prior to RDT introduction in 2007 to an average of 12.25 confirmed and 294 unconfirmed malaria cases per quarter over the year to September 2009. Reported malaria-like fever also declined, with only 4,381 RDTs being consumed per quarter over the same year. Reported malaria mortality declined to zero in the year to September 2009, and all-cause mortality declined. Consumption of artemisinin-based combination therapy (ACT) dropped dramatically, but remained above reported malaria, declining from 12,550 courses dispensed by the district office in the quarter prior to RDT implementation to an average of 822 per quarter over the last year. Quinine consumption in health centres also declined, with the district office ceasing to supply due to low usage, but requests for sulphadoxine-pyrimethamine (SP) rose to well above previous levels, suggesting substitution of ACT with this drug in RDT-negative cases. Conclusions RDT introduction led to a large decline in reported malaria cases and in ACT consumption in Livingstone district. Reported malaria mortality declined to zero, indicating safety of the new diagnostic regime, although adherence and/or use of RDTs was still incomplete. However, a deficiency is apparent in management of non-malarial fever, with inappropriate use of a low-cost single dose drug, SP, replacing ACT. While large gains have been achieved, the full potential of RDTs will only be realized when strategies can be put in place to better manage RDT-negative cases.
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