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Achan J, Barry A, Leroy D, Kamara G, Duparc S, Kaszubska W, Gandhi P, Buffet B, Tshilab P, Ogutu B, Taylor T, Krishna S, Richardson N, Ramachandruni H, Rietveld H. Defining the next generation of severe malaria treatment: a target product profile. Malar J 2024; 23:174. [PMID: 38835069 DOI: 10.1186/s12936-024-04986-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2024] [Accepted: 05/14/2024] [Indexed: 06/06/2024] Open
Abstract
BACKGROUND Severe malaria is a life-threatening infection, particularly affecting children under the age of 5 years in Africa. Current treatment with parenteral artemisinin derivatives is highly efficacious. However, artemisinin partial resistance is widespread in Southeast Asia, resulting in delayed parasite clearance after therapy, and has emerged independently in South America, Oceania, and Africa. Hence, new treatments for severe malaria are needed, and it is prudent to define their characteristics now. This manuscript focuses on the target product profile (TPP) for new treatments for severe malaria. It also highlights preparedness when considering ways of protecting the utility of artemisinin-based therapies. TARGET PRODUCT PROFILE Severe malaria treatments must be highly potent, with rapid onset of antiparasitic activity to clear the infection as quickly as possible to prevent complications. They should also have a low potential for drug resistance selection, given the high parasite burden in patients with severe malaria. Combination therapies are needed to deter resistance selection and dissemination. Partner drugs which are approved for uncomplicated malaria treatment would provide the most rapid development pathway for combinations, though new candidate molecules should be considered. Artemisinin combination approaches to severe malaria would extend the lifespan of current therapy, but ideally, completely novel, non-artemisinin-based combination therapies for severe malaria should be developed. These should be advanced to at least phase 2 clinical trials, enabling rapid progression to patient use should current treatment fail clinically. New drug combinations for severe malaria should be available as injectable formulations for rapid and effective treatment, or as rectal formulations for pre-referral intervention in resource-limited settings. CONCLUSION Defining the TPP is a key step to align responses across the community to proactively address the potential for clinical failure of artesunate in severe malaria. In the shorter term, artemisinin-based combination therapies should be developed using approved or novel drugs. In the longer term, novel combination treatments should be pursued. Thus, this TPP aims to direct efforts to preserve the efficacy of existing treatments while improving care and outcomes for individuals affected by this life-threatening disease.
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Affiliation(s)
| | - Aïssata Barry
- Centre National de Recherche et de Formation sur le Paludisme, Ouagadougou, Burkina Faso
| | - Didier Leroy
- Medicines for Malaria Venture, Route de Pré-Bois 20, Post Box 1826, CH-1215, Geneva 15, Switzerland
| | - George Kamara
- Médecins Sans Frontières, Magburaka District Hospital, Freetown, Sierra Leone
| | - Stephan Duparc
- Medicines for Malaria Venture, Route de Pré-Bois 20, Post Box 1826, CH-1215, Geneva 15, Switzerland
| | - Wiweka Kaszubska
- Medicines for Malaria Venture, Route de Pré-Bois 20, Post Box 1826, CH-1215, Geneva 15, Switzerland
| | | | - Bénédicte Buffet
- Medicines for Malaria Venture, Route de Pré-Bois 20, Post Box 1826, CH-1215, Geneva 15, Switzerland
| | | | - Bernhards Ogutu
- Centre for Clinical Research, Kenya Medical Research Institute, Kisumu, Kenya
| | - Terrie Taylor
- Queen Elizabeth Central Hospital and Blantyre Malaria Project, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Sanjeev Krishna
- Institut Für Tropenmedizin, Eberhard Karls Universität Tübingen, and German Center for Infection Research (Dzif), Tübingen, Germany
- Centre de Recherches Médicales de Lambaréné (CERMEL), Lambaréné, Gabon
- Clinical Academic Group, Institute for Infection and Immunity, St. George's University of London, London, UK
- St George's University Hospitals NHS Foundation Trust, London, UK
| | | | - Hanu Ramachandruni
- Medicines for Malaria Venture, Route de Pré-Bois 20, Post Box 1826, CH-1215, Geneva 15, Switzerland.
| | - Hans Rietveld
- Medicines for Malaria Venture, Route de Pré-Bois 20, Post Box 1826, CH-1215, Geneva 15, Switzerland.
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Schmidt N, Van Den Ham K, Bower L, Li S, Lorenzi H, Doumbo S, Doumtabe D, Kayentao K, Ongoiba A, Traore B, Crompton P. Susceptibility to febrile malaria is associated with an inflammatory gut microbiome. RESEARCH SQUARE 2024:rs.3.rs-3974068. [PMID: 38645126 PMCID: PMC11030534 DOI: 10.21203/rs.3.rs-3974068/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/23/2024]
Abstract
Malaria is a major public health problem, but many of the factors underlying the pathogenesis of this disease are not well understood. Here, we demonstrate in Malian children that susceptibility to febrile malaria following infection with Plasmodium falciparum is associated with the composition of the gut microbiome prior to the malaria season. Gnotobiotic mice colonized with the fecal samples of malaria-susceptible children had a significantly higher parasite burden following Plasmodium infection compared to gnotobiotic mice colonized with the fecal samples of malaria-resistant children. The fecal microbiome of the susceptible children was enriched for bacteria associated with inflammation, mucin degradation, gut permeability and inflammatory bowel disorders (e.g., Ruminococcus gauvreauii, Ruminococcus torques, Dorea formicigenerans, Dorea longicatena, Lachnoclostridium phocaeense and Lachnoclostridium sp. YL32). However, the susceptible children also had a greater abundance of bacteria known to produce anti-inflammatory short-chain fatty acids and those associated with favorable prognosis and remission following dysbiotic intestinal events (e.g., Anaerobutyricum hallii, Blautia producta and Sellimonas intestinalis). Metabolomics analysis of the human fecal samples corroborated the existence of inflammatory and recovery-associated features within the gut microbiome of the susceptible children. There was an enrichment of nitric oxide-derived DNA adducts (deoxyinosine and deoxyuridine) and long-chain fatty acids, the absorption of which has been shown to be inhibited by inflamed intestinal epithelial cells, and a decrease in the abundance of mucus phospholipids. Nevertheless, there were also increased levels of pseudouridine and hypoxanthine, which have been shown to be regulated in response to cellular stress and to promote recovery following injury or hypoxia. Overall, these results indicate that the gut microbiome may contribute malaria pathogenesis and suggest that therapies targeting intestinal inflammation could decrease malaria susceptibility.
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Olagunju OJ, Ekwebene OC, Olagunju OE, Osanyinlusi O, Oyebanji OA, Egbo B. Malaria Parasitemia and Severe Health Complications in Children Under Five Years of Age in Nigeria: A Study Using the Demographic and Health Survey (DHS) Malaria Indicator Survey (MIS) 2021. Cureus 2024; 16:e58907. [PMID: 38800144 PMCID: PMC11118779 DOI: 10.7759/cureus.58907] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/23/2024] [Indexed: 05/29/2024] Open
Abstract
BACKGROUND In Nigeria, 97% of the population is at risk of contracting malaria. It is transmitted by female Anopheles mosquitoes carrying the Plasmodium parasite and can be lethal. An estimated 55 million illnesses and 80,000 deaths per year result from it. Children under five are more likely to contract malaria. Efforts to control malaria in Nigeria include indoor residual spraying, insecticide-treated bed nets, and quick detection and treatment of confirmed cases with effective antimalarial medications. These attempts have been impeded by limited healthcare access, poor financing, and drug-resistant parasites. Thus, the study of the relationship between malaria complications and housing for children under five is essential. METHODS The Demographic and Health Survey (DHS) Malaria Indicator Survey (MIS) 2021, a nationally representative data set from developing countries on population and health, was used for this study. A sample size of 13,727 was employed (n=13,727). Logistic regression analyses were conducted to test the association between the type of place of residence and malaria complications (outcome). RESULTS Overall, 4.2% (n=570, weight HV005) of participants in the sample reported malaria complications. The results of the logistic regression revealed that children residing in urban settlements (aOR 0.37, 95% CI 0.37-0.37, p-value <0.001), children from the poorest class families (aOR 11.63, 95% CI 1.62-1.63, p-value 0.004), children from poorer class families (aOR 7.56, 95% CI 7.55-7.57, p-value <0.001), children from middle-class families (aOR 4.05, 95% CI 4.03-9.06, p-value <0.001), children from richer class families (aOR 1.22, 95% CI 2.21-2.23, p-value <0.001), children of mothers with primary education (aOR 0.42, 95% CI 2.32-4.112, p-value 0.001), children of mothers with secondary education (aOR 0.24, 95% CI 3.21-3.22, p-value <0.001), children of mothers with higher education (aOR 0.08, 95% CI 0.72-0.80, p-value <0.001), and children of the female gender (aOR 0.65, 95% CI 0.65-0.66, p-value <0.001) are all associated with severe malaria complications. CONCLUSIONS In conclusion, the study examined malaria complications in Nigerian children under five by residency. The findings imply that rural children are more likely to have serious malaria complications than urban children. This emphasizes the necessity for targeted malaria therapies in rural areas with limited healthcare access.
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Affiliation(s)
- Olajide J Olagunju
- Infectious Disease, Case Western Reserve University School of Medicine, Cleveland, USA
| | - Onyeka C Ekwebene
- Biostatistics and Epidemiology, East Tennessee State University, Johnson City, USA
| | | | - Olagoke Osanyinlusi
- Pulmonology, Washington University School of Medicine in St. Louis, St. Louis, USA
| | - Oladayo A Oyebanji
- Infectious Disease, Case Western Reserve University School of Medicine, Cleveland, USA
| | - Ben Egbo
- Radiology, Potiskum Medical Centre, Potiskum, NGA
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Long B, MacDonald A, Liang SY, Brady WJ, Koyfman A, Gottlieb M, Chavez S. Malaria: A focused review for the emergency medicine clinician. Am J Emerg Med 2024; 77:7-16. [PMID: 38096639 DOI: 10.1016/j.ajem.2023.11.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Revised: 11/18/2023] [Accepted: 11/23/2023] [Indexed: 02/16/2024] Open
Abstract
INTRODUCTION Malaria is a potentially fatal parasitic disease transmitted by the Anopheles mosquito. A resurgence in locally acquired infections has been reported in the U.S. OBJECTIVE This narrative review provides a focused overview of malaria for the emergency clinician, including the epidemiology, presentation, diagnosis, and management of the disease. DISCUSSION Malaria is caused by Plasmodium and is transmitted by the Anopheles mosquito. Disease severity can range from mild to severe. Malaria should be considered in any returning traveler from an endemic region, as well as those with unexplained cyclical, paroxysms of symptoms or unexplained fever. Patients most commonly present with fever and rigors but may also experience cough, myalgias, abdominal pain, fatigue, vomiting, and diarrhea. Hepatomegaly, splenomegaly, pallor, and jaundice are findings associated with malaria. Although less common, severe malaria is precipitated by microvascular obstruction with complications of anemia, acidosis, hypoglycemia, multiorgan failure, and cerebral malaria. Peripheral blood smears remain the gold standard for diagnosis, but rapid diagnostic tests are available. Treatment includes specialist consultation and antimalarial drugs tailored depending on chloroquine resistance, geographic region of travel, and patient comorbidities. Supportive care may be required, and patients with severe malaria will require resuscitation. Most patients will require admission for treatment and further monitoring. CONCLUSION Emergency medicine clinicians should be aware of the presentation, diagnosis, evaluation, and management of malaria to ensure optimal outcomes.
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Affiliation(s)
- Brit Long
- Department of Emergency Medicine, Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, TX, USA.
| | - Austin MacDonald
- Department of Emergency Medicine, Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, TX, USA
| | - Stephen Y Liang
- Divisions of Emergency Medicine and Infectious Diseases, Washington University School of Medicine, 660 S. Euclid Ave, St. Louis, MO, USA.
| | - William J Brady
- Department of Emergency Medicine, University of Virginia School of Medicine, Charlottesville, VA, USA.
| | - Alex Koyfman
- Department of Emergency Medicine, The University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX, USA
| | - Michael Gottlieb
- Department of Emergency Medicine, Rush University Medical Center, Chicago, IL, USA
| | - Summer Chavez
- Department of Health Systems and Population Health Sciences, Tilman J. Fertitta Family College of Medicine, USA.
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Zhang YH, Xie LH, Li J, Qi YW, Shi JJ. Classification and clinical significance of immunogenic cell death-related genes in Plasmodium falciparum infection determined by integrated bioinformatics analysis and machine learning. Malar J 2024; 23:48. [PMID: 38360586 PMCID: PMC10868002 DOI: 10.1186/s12936-024-04877-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Accepted: 02/10/2024] [Indexed: 02/17/2024] Open
Abstract
BACKGROUND Immunogenic cell death (ICD) is a type of regulated cell death that plays a crucial role in activating the immune system in response to various stressors, including cancer cells and pathogens. However, the involvement of ICD in the human immune response against malaria remains to be defined. METHODS In this study, data from Plasmodium falciparum infection cohorts, derived from cross-sectional studies, were analysed to identify ICD subtypes and their correlation with parasitaemia and immune responses. Using consensus clustering, ICD subtypes were identified, and their association with the immune landscape was assessed by employing ssGSEA. Differentially expressed genes (DEGs) analysis, functional enrichment, protein-protein interaction networks, and machine learning (least absolute shrinkage and selection operator (LASSO) regression and random forest) were used to identify ICD-associated hub genes linked with high parasitaemia. A nomogram visualizing these genes' correlation with parasitaemia levels was developed, and its performance was evaluated using receiver operating characteristic (ROC) curves. RESULTS In the P. falciparum infection cohort, two ICD-associated subtypes were identified, with subtype 1 showing better adaptive immune responses and lower parasitaemia compared to subtype 2. DEGs analysis revealed upregulation of proliferative signalling pathways, T-cell receptor signalling pathways and T-cell activation and differentiation in subtype 1, while subtype 2 exhibited elevated cytokine signalling and inflammatory responses. PPI network construction and machine learning identified CD3E and FCGR1A as candidate hub genes. A constructed nomogram integrating these genes demonstrated significant classification performance of high parasitaemia, which was evidenced by AUC values ranging from 0.695 to 0.737 in the training set and 0.911 to 0.933 and 0.759 to 0.849 in two validation sets, respectively. Additionally, significant correlations between the expressions of these genes and the clinical manifestation of P. falciparum infection were observed. CONCLUSION This study reveals the existence of two ICD subtypes in the human immune response against P. falciparum infection. Two ICD-associated candidate hub genes were identified, and a nomogram was constructed for the classification of high parasitaemia. This study can deepen the understanding of the human immune response to P. falciparum infection and provide new targets for the prevention and control of malaria.
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Affiliation(s)
- Yan-Hui Zhang
- Key Laboratory of Gastrointestinal Cancer (Fujian Medical University), Ministry of Education, Fuzhou, China.
| | - Li-Hua Xie
- Key Laboratory of Gastrointestinal Cancer (Fujian Medical University), Ministry of Education, Fuzhou, China
| | - Jian Li
- State Key Laboratory of Cellular Stress Biology, Innovation Center for Cell Signaling Network, School of Life Sciences, Xiamen University, Xiamen, Fujian, China
| | - Yan-Wei Qi
- Department of Pathogenic Biology and Immunology, School of Basic Medical Sciences, Guangzhou Medical University, Guangzhou, China
| | - Jia-Jian Shi
- Key Laboratory of Gastrointestinal Cancer (Fujian Medical University), Ministry of Education, Fuzhou, China
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Batte A, Luyckx VA, Taylor TE, Conroy AL. Malaria guidelines fall short in diagnosing acute kidney injury. Lancet Glob Health 2024; 12:e194-e196. [PMID: 38245108 DOI: 10.1016/s2214-109x(23)00546-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Accepted: 11/15/2023] [Indexed: 01/22/2024]
Affiliation(s)
- Anthony Batte
- Child Health and Development Centre, Makerere University College of Health Sciences, Kampala, Uganda; Child Health and Development Centre, Makerere University College of Health Sciences, Kampala, Uganda
| | - Valerie A Luyckx
- Department of Public and Global Health, Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland; Renal Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Department of Paediatrics and Child Health, University of Cape Town, Cape Town, South Africa
| | - Terrie E Taylor
- Department of Osteopathic Medical Specialties, College of Osteopathic Medicine, Michigan State University, East Lansing, MI, USA; Queen Elizabeth Central Hospital and Blantyre Malaria Project, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Andrea L Conroy
- Global Health Uganda, Kampala, Uganda; Ryan White Center for Pediatric Infectious Disease and Global Health, Indiana University School of Medicine, Indianapolis, IN 46202, USA.
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Poespoprodjo JR, Douglas NM, Ansong D, Kho S, Anstey NM. Malaria. Lancet 2023; 402:2328-2345. [PMID: 37924827 DOI: 10.1016/s0140-6736(23)01249-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Revised: 05/22/2023] [Accepted: 06/16/2023] [Indexed: 11/06/2023]
Abstract
Malaria is resurging in many African and South American countries, exacerbated by COVID-19-related health service disruption. In 2021, there were an estimated 247 million malaria cases and 619 000 deaths in 84 endemic countries. Plasmodium falciparum strains partly resistant to artemisinins are entrenched in the Greater Mekong region and have emerged in Africa, while Anopheles mosquito vectors continue to evolve physiological and behavioural resistance to insecticides. Elimination of Plasmodium vivax malaria is hindered by impractical and potentially toxic antirelapse regimens. Parasitological diagnosis and treatment with oral or parenteral artemisinin-based therapy is the mainstay of patient management. Timely blood transfusion, renal replacement therapy, and restrictive fluid therapy can improve survival in severe malaria. Rigorous use of intermittent preventive treatment in pregnancy and infancy and seasonal chemoprevention, potentially combined with pre-erythrocytic vaccines endorsed by WHO in 2021 and 2023, can substantially reduce malaria morbidity. Improved surveillance, better access to effective treatment, more labour-efficient vector control, continued drug development, targeted mass drug administration, and sustained political commitment are required to achieve targets for malaria reduction by the end of this decade.
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Affiliation(s)
- Jeanne Rini Poespoprodjo
- Centre for Child Health and Department of Child Health, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Yogyakarta, Indonesia; Timika Malaria Research Facility, Papuan Health and Community Development Foundation, Timika, Indonesia; Mimika District Hospital and District Health Authority, Timika, Indonesia; Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, NT, Australia.
| | - Nicholas M Douglas
- Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, NT, Australia; Department of Infectious Diseases, Christchurch Hospital, Te Whatu Ora Waitaha, Christchurch, New Zealand; Department of Medicine, University of Otago, Christchurch, New Zealand
| | - Daniel Ansong
- School of Medicine and Dentistry, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Steven Kho
- Timika Malaria Research Facility, Papuan Health and Community Development Foundation, Timika, Indonesia; Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, NT, Australia
| | - Nicholas M Anstey
- Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, NT, Australia; Department of Infectious Diseases, Royal Darwin Hospital, Darwin, NT, Australia
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Ocen E, Opito R, Tegu C, Oula A, Olupot-Olupot P. Severe malaria burden, clinical spectrum and outcomes at Apac district hospital, Uganda: a retrospective study of routine health facility-based data. Malar J 2023; 22:325. [PMID: 37880694 PMCID: PMC10601152 DOI: 10.1186/s12936-023-04761-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Accepted: 10/19/2023] [Indexed: 10/27/2023] Open
Abstract
BACKGROUND Most data describing severe malaria (SM) in sub-Saharan Africa (SSA) are from research settings outside disease endemic areas. Using routinely collected data from Apac District Hospital, this study aimed at determining the burden and clinical spectrum of severe malaria. METHODS This was a retrospective study that reviewed all paediatric admission records for malaria in the 24 months period from Jan 2019 to Dec 2020 at Apac District Hospital. Data on children aged 60 days to 12 years who at admission tested positive for malaria and fulfilled the World Health Organization clinical criteria for surveillance of severe malaria were abstracted using a customized proforma designed to capture variables on social demographic, clinical presentation, treatment, and outcomes. In addition, the tool included laboratory variables for complete blood counts, haemoglobin, and glucose levels. Data were analysed using STATA V15.0. The study had ethical approval from Mbale Regional Referral Hospital REC, Approval No. MRRH-REC 053/2019. RESULTS A total of 5631 admission records were retrieved for this study period. Of these, 3649 (64.8%) were malaria admissions and 3422/3649 were children below 12years, with only 1864 (54.5%) of children having complete data. Of the 1864 children, 745 (40.0%) fulfilled the severe malaria inclusion criteria. Of the 745 children, 51.4% (n = 381) were males. The median age at admission was 31 months (IQR = 17-60). The most common clinical presentations among children with severe malaria were fever 722 (97.3%), cough 478 (64.2%), and difficulty in breathing 122 (17.9%). The median length of hospital stay was 2 (IQR; 2-4) days and 133 (17.9%) had prolonged hospital stay (> 4 days). Factors independently associated with prolonged hospital stay were, presenting with difficulty in breathing, aOR 1.83 (95% CI 1.02-3.27, P = 0.042) and prostration aOR 8.47 (95% CI 1.94-36.99, P = 0.004). A majority of admitted children, 735 (98.7%) survived, while 10 (1.3%) died of SM. CONCLUSION A high proportion (40.0%) of malaria admissions were due to SM. Prolonged Hospital stay was associated with prostration and difficulty in breathing. Overall mortality was low, 1.3% compared to mortality in the previously reported series. This study was able to use routinely collected data to describe the burden and clinical spectrum of SM. Improvement in the quality of data from such settings would improve disease descriptions for policy, monitoring of epidemics, response to interventions and to inform research.
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Affiliation(s)
- Emmanuel Ocen
- Department of Public Health, Faculty of Health Sciences, Busitema University, Mbale, Uganda
- Department of Health, Apac District Local Government, Apac, Uganda
| | - Ronald Opito
- Departmemnt of Public Health, School of Health Sciences, Soroti University, Soroti, Uganda
| | - Crispus Tegu
- Department of Paediatric and Child Health, Faculty of Health Sciences, Busitema University, Mbale, Uganda
| | - Alex Oula
- Department of Health, Apac District Local Government, Apac, Uganda
| | - Peter Olupot-Olupot
- Department of Public Health, Faculty of Health Sciences, Busitema University, Mbale, Uganda.
- Mbale Clinical Research Institute, Mbale, Uganda.
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Lintner Rivera M, Prager R, Gushu MB, June S, Phiri T, Salameh JP, Johnson HC, Taylor T, O'Brien NF. Point-of-care Ultrasound to Assess Hemodynamic Contributors to Acute Kidney Injury in Pediatric Patients With Cerebral Malaria: A Pilot Study. Pediatr Infect Dis J 2023; 42:844-850. [PMID: 37409812 DOI: 10.1097/inf.0000000000004021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/07/2023]
Abstract
BACKGROUND Acute kidney injury is common in severe malaria and is independently associated with mortality. The pathogenesis of acute kidney injury (AKI) in severe malaria remains incompletely understood. Ultrasound-based tools such as point-of-care ultrasound (POCUS), ultrasound cardiac output monitors (USCOMs) and renal arterial resistive index (RRI) can be used to detect hemodynamic and renal blood flow abnormalities contributing to AKI in malaria. METHODS We conducted a prospective study of Malawian children with cerebral malaria to determine the feasibility of using POCUS and USCOM to characterize hemodynamic contributors to severe AKI (Kidney Disease: Improving Global Outcomes stage 2 or 3). The primary outcome was feasibility (completion rate of study procedures). We also assessed for differences in POCUS and hemodynamic variables for patients with or without severe AKI. RESULTS We enrolled 27 patients who had admission cardiac and renal ultrasounds and USCOM. Completion rates were high for cardiac (96%), renal (100%) and USCOM studies (96%). Severe AKI occurred in 13 of 27 patients (48%). No patients had ventricular dysfunction. Only 1 patient in the severe AKI group was determined to be hypovolemic ( P = 0.64). No significant differences in USCOM, RRI or venous congestion parameters were detected among patients with and without severe AKI. Mortality was 11% (3/27) with the 3 deaths occurring in the severe AKI group ( P = 0.056). CONCLUSIONS Ultrasound-based cardiac, hemodynamic and renal blood flow measurements appear to be feasible in pediatric patients with cerebral malaria. We were unable to detect hemodynamic or renal blood flow abnormalities contributing to severe AKI in cerebral malaria. Larger studies are needed to corroborate these findings.
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Affiliation(s)
- Michael Lintner Rivera
- From the Department of Pediatrics, Division of Critical Care Medicine, University of Maryland Children's Hospital, Baltimore, MD
| | - Ross Prager
- Critical Care Medicine, Schulich Medicine and Dentistry, Western University, London Health Sciences Center, London, Ontario, Canada
| | | | - Sylvester June
- Queen Elizabeth Central Hospital, The Blantyre Malaria Project, Blantyre, Malawi
| | - Tusekile Phiri
- Queen Elizabeth Central Hospital, The Blantyre Malaria Project, Blantyre, Malawi
| | - Jean-Paul Salameh
- Faculty of Health Sciences, Queen's University, Kingston, Ontario, Canada
| | - Hunter C Johnson
- Department of Pediatrics, Division of Critical Care Medicine, Nationwide Children's Hospital, The Ohio State University, Columbus, Ohio
| | - Terrie Taylor
- Department of Osteopathic Medical Specialties, College of Osteopathic Medicine, Michigan State University, E. Lansing, MI
| | - Nicole F O'Brien
- Department of Pediatrics, Division of Critical Care Medicine, Nationwide Children's Hospital, The Ohio State University, Columbus, Ohio
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Clark DJ, Bond C, Andrews A, Muller DJ, Sarkisian A, Opoka RO, Idro R, Bangirana P, Witten A, Sausen NJ, Birbeck GL, John CC, Postels DG. Admission Clinical and EEG Features Associated With Mortality and Long-term Neurologic and Cognitive Outcomes in Pediatric Cerebral Malaria. Neurology 2023; 101:e1307-e1318. [PMID: 37541845 PMCID: PMC10558167 DOI: 10.1212/wnl.0000000000207657] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Accepted: 06/02/2023] [Indexed: 08/06/2023] Open
Abstract
BACKGROUND AND OBJECTIVES For children with cerebral malaria, mortality is high, and in survivors, long-term neurologic and cognitive dysfunctions are common. While specific clinical factors are associated with death or long-term neurocognitive morbidity in cerebral malaria, the association of EEG features with these outcomes, particularly neurocognitive outcomes, is less well characterized. METHODS In this prospective cohort study of 149 children age 6 months to 12 years who survived cerebral malaria in Kampala, Uganda, we evaluated whether depth of coma, number of clinical seizures, or EEG features during hospitalization were associated with mortality during hospitalization, short-term and long-term neurologic deficits, or long-term cognitive outcomes (overall cognition, attention, memory) over the 2-year follow-up. RESULTS Higher Blantyre or Glasgow Coma Scores (BCS and GCS, respectively), higher background voltage, and presence of normal reactivity on EEG were each associated with lower mortality. Among clinical and EEG features, the presence of >4 seizures on admission had the best combination of negative and positive predictive values for neurologic deficits in follow-up. In multivariable modeling of cognitive outcomes, the number of seizures and specific EEG features showed independent association with better outcomes. In children younger than 5 years throughout the study, seizure number and presence of vertex sharp waves were independently associated with better posthospitalization cognitive performance, faster dominant frequency with better attention, and higher average background voltage and faster dominant background frequency with better associative memory. In children younger than 5 years at CM episode but 5 years or older at cognitive testing, seizure number, background dominant frequency, and the presence of vertex sharp waves were each associated with changes in cognition, seizure number and variability with attention, and seizure number with working memory. DISCUSSION In children with cerebral malaria, seizure number is strongly associated with the risk of long-term neurologic deficits, while seizure number and specific EEG features (average background voltage, dominant rhythm frequency, presence of vertex sharp waves, presence of variability) are independently associated with cognitive outcomes. Future studies should evaluate the predictive value of these findings.
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Affiliation(s)
- Daniel J Clark
- From the Division of Neurology (D.J.C.), Nationwide Children's Hospital, Columbus, OH; Ryan White Center for Pediatric Infectious Diseases & Global Health (C.B., C.C.J.), Indiana University School of Medicine, Indianapolis; Department of Pediatrics (A.A.), MedStar Georgetown University Hospital; The George Washington University School of Medicine and Health Sciences (D.J.M., A.S., D.G.P.), Washington, DC; Department of Paediatrics and Child Health (R.O.O., R.I.), Makerere University College of Health Sciences; Department of Psychiatry (P.B.), Makerere University College of Health Sciences, Kampala, Uganda; Department of Neurosurgery (A.W.), Indiana University School of Medicine, Indianapolis; Department of Pediatrics (N.J.S.), Division of Emergency Medicine, University of Minnesota, Minneapolis; Department of Neurology (G.L.B.), University of Rochester, NY; University of Zambia (G.L.B.), School of Medicine, Lusaka; University Teaching Hospitals Children's Hospital (G.L.B.), Lusaka, Zambia; Children's National Medical Center (D.G.P.), Washington, DC; and Blantyre Malaria Project (D.G.P.), Kamuzu University of Health Sciences, Blantyre, Malawi.
| | - Caitlin Bond
- From the Division of Neurology (D.J.C.), Nationwide Children's Hospital, Columbus, OH; Ryan White Center for Pediatric Infectious Diseases & Global Health (C.B., C.C.J.), Indiana University School of Medicine, Indianapolis; Department of Pediatrics (A.A.), MedStar Georgetown University Hospital; The George Washington University School of Medicine and Health Sciences (D.J.M., A.S., D.G.P.), Washington, DC; Department of Paediatrics and Child Health (R.O.O., R.I.), Makerere University College of Health Sciences; Department of Psychiatry (P.B.), Makerere University College of Health Sciences, Kampala, Uganda; Department of Neurosurgery (A.W.), Indiana University School of Medicine, Indianapolis; Department of Pediatrics (N.J.S.), Division of Emergency Medicine, University of Minnesota, Minneapolis; Department of Neurology (G.L.B.), University of Rochester, NY; University of Zambia (G.L.B.), School of Medicine, Lusaka; University Teaching Hospitals Children's Hospital (G.L.B.), Lusaka, Zambia; Children's National Medical Center (D.G.P.), Washington, DC; and Blantyre Malaria Project (D.G.P.), Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Alexander Andrews
- From the Division of Neurology (D.J.C.), Nationwide Children's Hospital, Columbus, OH; Ryan White Center for Pediatric Infectious Diseases & Global Health (C.B., C.C.J.), Indiana University School of Medicine, Indianapolis; Department of Pediatrics (A.A.), MedStar Georgetown University Hospital; The George Washington University School of Medicine and Health Sciences (D.J.M., A.S., D.G.P.), Washington, DC; Department of Paediatrics and Child Health (R.O.O., R.I.), Makerere University College of Health Sciences; Department of Psychiatry (P.B.), Makerere University College of Health Sciences, Kampala, Uganda; Department of Neurosurgery (A.W.), Indiana University School of Medicine, Indianapolis; Department of Pediatrics (N.J.S.), Division of Emergency Medicine, University of Minnesota, Minneapolis; Department of Neurology (G.L.B.), University of Rochester, NY; University of Zambia (G.L.B.), School of Medicine, Lusaka; University Teaching Hospitals Children's Hospital (G.L.B.), Lusaka, Zambia; Children's National Medical Center (D.G.P.), Washington, DC; and Blantyre Malaria Project (D.G.P.), Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Daniel J Muller
- From the Division of Neurology (D.J.C.), Nationwide Children's Hospital, Columbus, OH; Ryan White Center for Pediatric Infectious Diseases & Global Health (C.B., C.C.J.), Indiana University School of Medicine, Indianapolis; Department of Pediatrics (A.A.), MedStar Georgetown University Hospital; The George Washington University School of Medicine and Health Sciences (D.J.M., A.S., D.G.P.), Washington, DC; Department of Paediatrics and Child Health (R.O.O., R.I.), Makerere University College of Health Sciences; Department of Psychiatry (P.B.), Makerere University College of Health Sciences, Kampala, Uganda; Department of Neurosurgery (A.W.), Indiana University School of Medicine, Indianapolis; Department of Pediatrics (N.J.S.), Division of Emergency Medicine, University of Minnesota, Minneapolis; Department of Neurology (G.L.B.), University of Rochester, NY; University of Zambia (G.L.B.), School of Medicine, Lusaka; University Teaching Hospitals Children's Hospital (G.L.B.), Lusaka, Zambia; Children's National Medical Center (D.G.P.), Washington, DC; and Blantyre Malaria Project (D.G.P.), Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Angela Sarkisian
- From the Division of Neurology (D.J.C.), Nationwide Children's Hospital, Columbus, OH; Ryan White Center for Pediatric Infectious Diseases & Global Health (C.B., C.C.J.), Indiana University School of Medicine, Indianapolis; Department of Pediatrics (A.A.), MedStar Georgetown University Hospital; The George Washington University School of Medicine and Health Sciences (D.J.M., A.S., D.G.P.), Washington, DC; Department of Paediatrics and Child Health (R.O.O., R.I.), Makerere University College of Health Sciences; Department of Psychiatry (P.B.), Makerere University College of Health Sciences, Kampala, Uganda; Department of Neurosurgery (A.W.), Indiana University School of Medicine, Indianapolis; Department of Pediatrics (N.J.S.), Division of Emergency Medicine, University of Minnesota, Minneapolis; Department of Neurology (G.L.B.), University of Rochester, NY; University of Zambia (G.L.B.), School of Medicine, Lusaka; University Teaching Hospitals Children's Hospital (G.L.B.), Lusaka, Zambia; Children's National Medical Center (D.G.P.), Washington, DC; and Blantyre Malaria Project (D.G.P.), Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Robert O Opoka
- From the Division of Neurology (D.J.C.), Nationwide Children's Hospital, Columbus, OH; Ryan White Center for Pediatric Infectious Diseases & Global Health (C.B., C.C.J.), Indiana University School of Medicine, Indianapolis; Department of Pediatrics (A.A.), MedStar Georgetown University Hospital; The George Washington University School of Medicine and Health Sciences (D.J.M., A.S., D.G.P.), Washington, DC; Department of Paediatrics and Child Health (R.O.O., R.I.), Makerere University College of Health Sciences; Department of Psychiatry (P.B.), Makerere University College of Health Sciences, Kampala, Uganda; Department of Neurosurgery (A.W.), Indiana University School of Medicine, Indianapolis; Department of Pediatrics (N.J.S.), Division of Emergency Medicine, University of Minnesota, Minneapolis; Department of Neurology (G.L.B.), University of Rochester, NY; University of Zambia (G.L.B.), School of Medicine, Lusaka; University Teaching Hospitals Children's Hospital (G.L.B.), Lusaka, Zambia; Children's National Medical Center (D.G.P.), Washington, DC; and Blantyre Malaria Project (D.G.P.), Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Richard Idro
- From the Division of Neurology (D.J.C.), Nationwide Children's Hospital, Columbus, OH; Ryan White Center for Pediatric Infectious Diseases & Global Health (C.B., C.C.J.), Indiana University School of Medicine, Indianapolis; Department of Pediatrics (A.A.), MedStar Georgetown University Hospital; The George Washington University School of Medicine and Health Sciences (D.J.M., A.S., D.G.P.), Washington, DC; Department of Paediatrics and Child Health (R.O.O., R.I.), Makerere University College of Health Sciences; Department of Psychiatry (P.B.), Makerere University College of Health Sciences, Kampala, Uganda; Department of Neurosurgery (A.W.), Indiana University School of Medicine, Indianapolis; Department of Pediatrics (N.J.S.), Division of Emergency Medicine, University of Minnesota, Minneapolis; Department of Neurology (G.L.B.), University of Rochester, NY; University of Zambia (G.L.B.), School of Medicine, Lusaka; University Teaching Hospitals Children's Hospital (G.L.B.), Lusaka, Zambia; Children's National Medical Center (D.G.P.), Washington, DC; and Blantyre Malaria Project (D.G.P.), Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Paul Bangirana
- From the Division of Neurology (D.J.C.), Nationwide Children's Hospital, Columbus, OH; Ryan White Center for Pediatric Infectious Diseases & Global Health (C.B., C.C.J.), Indiana University School of Medicine, Indianapolis; Department of Pediatrics (A.A.), MedStar Georgetown University Hospital; The George Washington University School of Medicine and Health Sciences (D.J.M., A.S., D.G.P.), Washington, DC; Department of Paediatrics and Child Health (R.O.O., R.I.), Makerere University College of Health Sciences; Department of Psychiatry (P.B.), Makerere University College of Health Sciences, Kampala, Uganda; Department of Neurosurgery (A.W.), Indiana University School of Medicine, Indianapolis; Department of Pediatrics (N.J.S.), Division of Emergency Medicine, University of Minnesota, Minneapolis; Department of Neurology (G.L.B.), University of Rochester, NY; University of Zambia (G.L.B.), School of Medicine, Lusaka; University Teaching Hospitals Children's Hospital (G.L.B.), Lusaka, Zambia; Children's National Medical Center (D.G.P.), Washington, DC; and Blantyre Malaria Project (D.G.P.), Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Andy Witten
- From the Division of Neurology (D.J.C.), Nationwide Children's Hospital, Columbus, OH; Ryan White Center for Pediatric Infectious Diseases & Global Health (C.B., C.C.J.), Indiana University School of Medicine, Indianapolis; Department of Pediatrics (A.A.), MedStar Georgetown University Hospital; The George Washington University School of Medicine and Health Sciences (D.J.M., A.S., D.G.P.), Washington, DC; Department of Paediatrics and Child Health (R.O.O., R.I.), Makerere University College of Health Sciences; Department of Psychiatry (P.B.), Makerere University College of Health Sciences, Kampala, Uganda; Department of Neurosurgery (A.W.), Indiana University School of Medicine, Indianapolis; Department of Pediatrics (N.J.S.), Division of Emergency Medicine, University of Minnesota, Minneapolis; Department of Neurology (G.L.B.), University of Rochester, NY; University of Zambia (G.L.B.), School of Medicine, Lusaka; University Teaching Hospitals Children's Hospital (G.L.B.), Lusaka, Zambia; Children's National Medical Center (D.G.P.), Washington, DC; and Blantyre Malaria Project (D.G.P.), Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Nicholas J Sausen
- From the Division of Neurology (D.J.C.), Nationwide Children's Hospital, Columbus, OH; Ryan White Center for Pediatric Infectious Diseases & Global Health (C.B., C.C.J.), Indiana University School of Medicine, Indianapolis; Department of Pediatrics (A.A.), MedStar Georgetown University Hospital; The George Washington University School of Medicine and Health Sciences (D.J.M., A.S., D.G.P.), Washington, DC; Department of Paediatrics and Child Health (R.O.O., R.I.), Makerere University College of Health Sciences; Department of Psychiatry (P.B.), Makerere University College of Health Sciences, Kampala, Uganda; Department of Neurosurgery (A.W.), Indiana University School of Medicine, Indianapolis; Department of Pediatrics (N.J.S.), Division of Emergency Medicine, University of Minnesota, Minneapolis; Department of Neurology (G.L.B.), University of Rochester, NY; University of Zambia (G.L.B.), School of Medicine, Lusaka; University Teaching Hospitals Children's Hospital (G.L.B.), Lusaka, Zambia; Children's National Medical Center (D.G.P.), Washington, DC; and Blantyre Malaria Project (D.G.P.), Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Gretchen L Birbeck
- From the Division of Neurology (D.J.C.), Nationwide Children's Hospital, Columbus, OH; Ryan White Center for Pediatric Infectious Diseases & Global Health (C.B., C.C.J.), Indiana University School of Medicine, Indianapolis; Department of Pediatrics (A.A.), MedStar Georgetown University Hospital; The George Washington University School of Medicine and Health Sciences (D.J.M., A.S., D.G.P.), Washington, DC; Department of Paediatrics and Child Health (R.O.O., R.I.), Makerere University College of Health Sciences; Department of Psychiatry (P.B.), Makerere University College of Health Sciences, Kampala, Uganda; Department of Neurosurgery (A.W.), Indiana University School of Medicine, Indianapolis; Department of Pediatrics (N.J.S.), Division of Emergency Medicine, University of Minnesota, Minneapolis; Department of Neurology (G.L.B.), University of Rochester, NY; University of Zambia (G.L.B.), School of Medicine, Lusaka; University Teaching Hospitals Children's Hospital (G.L.B.), Lusaka, Zambia; Children's National Medical Center (D.G.P.), Washington, DC; and Blantyre Malaria Project (D.G.P.), Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Chandy C John
- From the Division of Neurology (D.J.C.), Nationwide Children's Hospital, Columbus, OH; Ryan White Center for Pediatric Infectious Diseases & Global Health (C.B., C.C.J.), Indiana University School of Medicine, Indianapolis; Department of Pediatrics (A.A.), MedStar Georgetown University Hospital; The George Washington University School of Medicine and Health Sciences (D.J.M., A.S., D.G.P.), Washington, DC; Department of Paediatrics and Child Health (R.O.O., R.I.), Makerere University College of Health Sciences; Department of Psychiatry (P.B.), Makerere University College of Health Sciences, Kampala, Uganda; Department of Neurosurgery (A.W.), Indiana University School of Medicine, Indianapolis; Department of Pediatrics (N.J.S.), Division of Emergency Medicine, University of Minnesota, Minneapolis; Department of Neurology (G.L.B.), University of Rochester, NY; University of Zambia (G.L.B.), School of Medicine, Lusaka; University Teaching Hospitals Children's Hospital (G.L.B.), Lusaka, Zambia; Children's National Medical Center (D.G.P.), Washington, DC; and Blantyre Malaria Project (D.G.P.), Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Douglas G Postels
- From the Division of Neurology (D.J.C.), Nationwide Children's Hospital, Columbus, OH; Ryan White Center for Pediatric Infectious Diseases & Global Health (C.B., C.C.J.), Indiana University School of Medicine, Indianapolis; Department of Pediatrics (A.A.), MedStar Georgetown University Hospital; The George Washington University School of Medicine and Health Sciences (D.J.M., A.S., D.G.P.), Washington, DC; Department of Paediatrics and Child Health (R.O.O., R.I.), Makerere University College of Health Sciences; Department of Psychiatry (P.B.), Makerere University College of Health Sciences, Kampala, Uganda; Department of Neurosurgery (A.W.), Indiana University School of Medicine, Indianapolis; Department of Pediatrics (N.J.S.), Division of Emergency Medicine, University of Minnesota, Minneapolis; Department of Neurology (G.L.B.), University of Rochester, NY; University of Zambia (G.L.B.), School of Medicine, Lusaka; University Teaching Hospitals Children's Hospital (G.L.B.), Lusaka, Zambia; Children's National Medical Center (D.G.P.), Washington, DC; and Blantyre Malaria Project (D.G.P.), Kamuzu University of Health Sciences, Blantyre, Malawi
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Agnandji ST, Recker M, Mordmüller B, Glöckner S, Adegnika AA, Lell B, Otieno L, Otieno W, Owusu-Agyei S, Asante KP, Agbenyega T, Ansong D, Macete E, Aide P, Sorgho H, Tinto H, Mturi N, Lusingu JPA, Gesase S, Hoffman I, Masoud NS, Newton CR, Bojang K, Krause G, Kremsner PG. Prostration and the prognosis of death in African children with severe malaria. Int J Infect Dis 2023; 134:240-247. [PMID: 37414210 DOI: 10.1016/j.ijid.2023.06.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Revised: 06/19/2023] [Accepted: 06/29/2023] [Indexed: 07/08/2023] Open
Abstract
OBJECTIVES Malaria is still one of the main reasons for hospitalization in children living in sub-Saharan Africa. Rapid risk stratification at admission is essential for optimal medical care and improved prognosis. Whereas coma, deep breathing, and, to a lesser degree, severe anemia are established predictors of malaria-related death, the value of assessing prostration for risk stratification is less certain. METHODS Here we used a retrospective multi-center analysis comprising over 33,000 hospitalized children from four large studies, including two observational studies from the Severe Malaria in African Children network, a randomized controlled treatment study, and the phase-3-clinical RTS,S-malaria vaccine trial, to evaluate known risk factors of mortality and with a specific emphasis on the role of prostration. RESULTS Despite comparable age profiles of the participants, we found significant inter- and intra-study variation in the incidence of fatal malaria as well as in the derived risk ratios associated with the four risk factors: coma, deep breathing, anemia, and prostration. Despite pronounced variations, prostration was significantly associated with an increased risk of mortality (P <0.001) and its consideration resulted in improved predictive performance, both in a multivariate model and a univariate model based on the Lambaréné Organ Dysfunction Score. CONCLUSION Prostration is an important clinical criterion to determine severe pediatric malaria with possible fatal outcomes.
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Affiliation(s)
- Selidji T Agnandji
- Institute for Tropical Medicine, University Hospital Tübingen, Tübingen, Germany; Centre de Recherches Médicales de Lambaréné (CERMEL), Lambaréné, Gabon; Translational Thematic Unit Malaria, German Center for Infection Research (DZIF), Tübingen, Germany
| | - Mario Recker
- Institute for Tropical Medicine, University Hospital Tübingen, Tübingen, Germany; Department of Ecology and Conservation, University of Exeter, Exeter, UK.
| | - Benjamin Mordmüller
- Institute for Tropical Medicine, University Hospital Tübingen, Tübingen, Germany; Centre de Recherches Médicales de Lambaréné (CERMEL), Lambaréné, Gabon; Translational Thematic Unit Malaria, German Center for Infection Research (DZIF), Tübingen, Germany; Radboud University Medical Centre, Department of Medical Microbiology, Nijmegen, The Netherlands
| | - Stephan Glöckner
- Department of Epidemiology, Helmholtz Centre for Infection Research, Braunschweig, Germany; Translational Infrastructure Epidemiology, German Center for Infection Research (DZIF), Braunschweig, Germany
| | - Akim A Adegnika
- Institute for Tropical Medicine, University Hospital Tübingen, Tübingen, Germany; Centre de Recherches Médicales de Lambaréné (CERMEL), Lambaréné, Gabon; Translational Thematic Unit Malaria, German Center for Infection Research (DZIF), Tübingen, Germany
| | - Bertrand Lell
- Centre de Recherches Médicales de Lambaréné (CERMEL), Lambaréné, Gabon; Department of Medicine I, Division of Infectious Diseases and Tropical Medicine, Medical University of Vienna, Vienna, Austria
| | - Lucas Otieno
- Kenya Medical Research Institute, KEMRI-Walter Reed Project, Kombewa, Kenya
| | - Walter Otieno
- Kenya Medical Research Institute, KEMRI-Walter Reed Project, Kombewa, Kenya
| | | | | | - Tsiri Agbenyega
- Kwame Nkrumah University of Science and Technology, Agogo, Ghana
| | - Daniel Ansong
- Kwame Nkrumah University of Science and Technology, Agogo, Ghana
| | - Eusebio Macete
- Centro de Investigação em Saúde de Manhiça, Manhiça, Mozambique
| | - Pedro Aide
- Centro de Investigação em Saúde de Manhiça, Manhiça, Mozambique
| | - Hermann Sorgho
- Institut de Recherche en Science de la Santé, Nanoro, Burkina Faso
| | - Halidou Tinto
- Institut de Recherche en Science de la Santé, Nanoro, Burkina Faso
| | - Neema Mturi
- Kenya Medical Research Institute, KEMRI-Wellcome Trust Research Programme, Centre Medicine Research, Kilifi, Kenya
| | | | - Samwel Gesase
- NjugNational Institute for Medical Research, Korogwe, Tanzania
| | - Irving Hoffman
- University of North Carolina (UNC), Division of Infectious Diseases, North Carolina, USA; University of North Carolina (UNC) Project, Lilongwe, Malawi
| | - Nahya Salim Masoud
- Muhimbili University of Health and Allied Sciences (MUHAS), Dar es Salaam and Ifakara Health Institute, Bagamoyo, Tanzania
| | - Charles R Newton
- Kenya Medical Research Institute, KEMRI-Wellcome Trust Programme, Kilifi, Kenya; Department of Psychiatry, University of Oxford, Oxford, UK
| | - Kalifa Bojang
- Medical Research Council (MRC) Unit at London School of Hygiene and Tropical Medicine, Banjul, The Gambia
| | - Gérard Krause
- Department of Epidemiology, Helmholtz Centre for Infection Research, Braunschweig, Germany; Translational Infrastructure Epidemiology, German Center for Infection Research (DZIF), Braunschweig, Germany
| | - Peter Gottfried Kremsner
- Institute for Tropical Medicine, University Hospital Tübingen, Tübingen, Germany; Centre de Recherches Médicales de Lambaréné (CERMEL), Lambaréné, Gabon; Translational Thematic Unit Malaria, German Center for Infection Research (DZIF), Tübingen, Germany
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12
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Paasi G, Okalebo CB, Ongodia P, Namayanja C, Eregu EEI, Abongo G, Olupot M, Amorut D, Muhindo R, Okiror W, Ndila C, Olupot-Olupot P. PARIST study protocol: a phase I/II randomised, controlled clinical trial to assess the feasibility, safety and effectiveness of paracetamol in resolving acute kidney injury in children with severe malaria. BMJ Open 2023; 13:e068260. [PMID: 37524553 PMCID: PMC10391814 DOI: 10.1136/bmjopen-2022-068260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/02/2023] Open
Abstract
BACKGROUND Acute kidney injury (AKI) has in the past been considered a rare complication of malaria in children living in high-transmission settings. More recently, however, a growing number of paediatric case series of AKI in severe malaria studies in African children have been published (Artesunate vs Quinine in the Treatment of Severe P. falciparum Malaria in African children and Fluids Expansion as Supportive Therapy trials). The Paracetamol for Acute Renal Injury in Severe Malaria Trial (PARIST) therefore, aims to assess feasibility, safety and determine the effective dose of paracetamol, which attenuates nephrotoxicity of haemoproteins, red-cell free haemoglobin and myoglobin in children with haemoglobinuric severe malaria. METHODS PARIST is a phase I/II unblinded randomised controlled trial of 40 children aged >6 months and <12 years admitted with confirmed haemoglobinuric severe malaria (blackwater fever), a positive blood smear for P. falciparum malaria and either serum creatinine (Cr) increase by ≥0.3 mg/dL within 48 hours or to ≥1.5 times baseline and elevated blood urea nitrogen (BUN) >20 mg/dL. Children will be randomly allocated on a 1:1 basis to paracetamol intervention dose arm (20 mg/kg orally 6-hourly for 48 hours) or to a control arm to receive standard of care for temperature control (ie, tepid sponging for 30 min if fever persists give rescue treatment). Primary outcome is renal recovery at 48 hours as indicated by stoppage of progression and decrease of Cr level below baseline, BUN (<20 mg/dL). Data analysis will be on the intention-to-treat principle and a per-protocol basis.Results from this phase I/II clinical trial will provide preliminary effectiveness data of this highly potential treatment for AKI in paediatric malaria (in particular for haemoglobinuric severe malaria) for a larger phase III trial. ETHICS AND DISSEMINATION Ethical and regulatory approvals have been granted by the Mbale Hospital Institutional Ethics Review Committee (MRRH-REC OUT 002/2019), Uganda National Council of Science and Technology (UNCST-HS965ES) and the National drug Authority (NDA-CTC 0166/2021). We will be disseminating results through journals, conferences and policy briefs to policy makers and primary care providers. TRIAL REGISTRATION NUMBER ISRCTN84974248.
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Affiliation(s)
- George Paasi
- Clinical trials department, Mbale Clinical Research Institute, Mbale, Uganda
- Department of Community and Public Health, Busitema University Faculty of Health Sciences, Mbale, Uganda
| | - Charles Benard Okalebo
- Clinical trials department, Mbale Clinical Research Institute, Mbale, Uganda
- Department of Community and Public Health, Busitema University Faculty of Health Sciences, Mbale, Uganda
| | - Paul Ongodia
- Clinical trials department, Mbale Clinical Research Institute, Mbale, Uganda
| | - Cate Namayanja
- Clinical trials department, Mbale Clinical Research Institute, Mbale, Uganda
- Department of Paediatrics and Child Health, Busitema University Faculty of Health Sciences, Mbale, Uganda
| | - Egiru Emma Isaiah Eregu
- Department of Paediatrics and Child Health, Busitema University Faculty of Health Sciences, Mbale, Uganda
| | - Grace Abongo
- Clinical trials department, Mbale Clinical Research Institute, Mbale, Uganda
| | - Moses Olupot
- Clinical trials department, Mbale Clinical Research Institute, Mbale, Uganda
| | - Denis Amorut
- Clinical trials department, Mbale Clinical Research Institute, Mbale, Uganda
| | - Rita Muhindo
- Clinical trials department, Mbale Clinical Research Institute, Mbale, Uganda
| | - William Okiror
- Clinical trials department, Mbale Clinical Research Institute, Mbale, Uganda
- Department of Community and Public Health, Busitema University Faculty of Health Sciences, Mbale, Uganda
| | - Carolyne Ndila
- Clinical trials department, Mbale Clinical Research Institute, Mbale, Uganda
| | - Peter Olupot-Olupot
- Clinical trials department, Mbale Clinical Research Institute, Mbale, Uganda
- Faculty of Health Sciences, Department of Community and Public Health, Busitema University, Tororo, Uganda
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Conroy AL, Datta D, Opoka RO, Batte A, Bangirana P, Gopinadhan A, Mellencamp KA, Akcan-Arikan A, Idro R, John CC. Cerebrospinal fluid biomarkers provide evidence for kidney-brain axis involvement in cerebral malaria pathogenesis. Front Hum Neurosci 2023; 17:1177242. [PMID: 37200952 PMCID: PMC10185839 DOI: 10.3389/fnhum.2023.1177242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Accepted: 04/14/2023] [Indexed: 05/20/2023] Open
Abstract
Introduction Cerebral malaria is one of the most severe manifestations of malaria and is a leading cause of acquired neurodisability in African children. Recent studies suggest acute kidney injury (AKI) is a risk factor for brain injury in cerebral malaria. The present study evaluates potential mechanisms of brain injury in cerebral malaria by evaluating changes in cerebrospinal fluid measures of brain injury with respect to severe malaria complications. Specifically, we attempt to delineate mechanisms of injury focusing on blood-brain-barrier integrity and acute metabolic changes that may underlie kidney-brain crosstalk in severe malaria. Methods We evaluated 30 cerebrospinal fluid (CSF) markers of inflammation, oxidative stress, and brain injury in 168 Ugandan children aged 18 months to 12 years hospitalized with cerebral malaria. Eligible children were infected with Plasmodium falciparum and had unexplained coma. Acute kidney injury (AKI) on admission was defined using the Kidney Disease: Improving Global Outcomes criteria. We further evaluated blood-brain-barrier integrity and malaria retinopathy, and electrolyte and metabolic complications in serum. Results The mean age of children was 3.8 years (SD, 1.9) and 40.5% were female. The prevalence of AKI was 46.3% and multi-organ dysfunction was common with 76.2% of children having at least one organ system affected in addition to coma. AKI and elevated blood urea nitrogen, but not other measures of disease severity (severe coma, seizures, jaundice, acidosis), were associated with increases in CSF markers of impaired blood-brain-barrier function, neuronal injury (neuron-specific enolase, tau), excitatory neurotransmission (kynurenine), as well as altered nitric oxide bioavailability and oxidative stress (p < 0.05 after adjustment for multiple testing). Further evaluation of potential mechanisms suggested that AKI may mediate or be associated with CSF changes through blood-brain-barrier disruption (p = 0.0014), ischemic injury seen by indirect ophthalmoscopy (p < 0.05), altered osmolality (p = 0.0006) and through alterations in the amino acids transported into the brain. Conclusion In children with cerebral malaria, there is evidence of kidney-brain injury with multiple potential pathways identified. These changes were specific to the kidney and not observed in the context of other clinical complications.
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Affiliation(s)
- Andrea L. Conroy
- Ryan White Center for Pediatric Infectious Disease and Global Health, Indiana University School of Medicine, Indianapolis, IN, United States
| | - Dibyadyuti Datta
- Ryan White Center for Pediatric Infectious Disease and Global Health, Indiana University School of Medicine, Indianapolis, IN, United States
| | - Robert O. Opoka
- Department of Paediatrics and Child Health, Makerere University College of Health Sciences, Kampala, Uganda
- Global Health Uganda, Kampala, Uganda
- Undergraduate Medical Education, The Aga Khan University, Nairobi, Kenya
| | - Anthony Batte
- Global Health Uganda, Kampala, Uganda
- Child Health and Development Centre, Makerere University College of Health Sciences, Kampala, Uganda
| | - Paul Bangirana
- Global Health Uganda, Kampala, Uganda
- Department of Psychiatry, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Adnan Gopinadhan
- Ryan White Center for Pediatric Infectious Disease and Global Health, Indiana University School of Medicine, Indianapolis, IN, United States
| | - Kagan A. Mellencamp
- Ryan White Center for Pediatric Infectious Disease and Global Health, Indiana University School of Medicine, Indianapolis, IN, United States
| | - Ayse Akcan-Arikan
- Division of Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine, Texas Children’s Hospital, Houston, TX, United States
- Division of Nephrology, Department of Pediatrics, Baylor College of Medicine, Texas Children’s Hospital, Houston, TX, United States
| | - Richard Idro
- Department of Paediatrics and Child Health, Makerere University College of Health Sciences, Kampala, Uganda
- Global Health Uganda, Kampala, Uganda
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, United Kingdom
| | - Chandy C. John
- Ryan White Center for Pediatric Infectious Disease and Global Health, Indiana University School of Medicine, Indianapolis, IN, United States
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14
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Schuermans A, Van den Eynde J, Mekahli D, Vlasselaers D. Long-term outcomes of acute kidney injury in children. Curr Opin Pediatr 2023; 35:259-267. [PMID: 36377251 DOI: 10.1097/mop.0000000000001202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PURPOSE OF REVIEW Acute kidney injury (AKI) affects up to 35% of all critically ill children and is associated with substantial short-term morbidity and mortality. However, the link between paediatric AKI and long-term adverse outcomes remains incompletely understood. This review highlights the most recent clinical data supporting the role of paediatric AKI as a risk factor for long-term kidney and cardiovascular consequences. In addition, it stresses the need for long-term surveillance of paediatric AKI survivors. RECENT FINDINGS Recent large-scale studies have led to an increasing understanding that paediatric AKI is a significant risk factor for adverse outcomes such as hypertension, cardiovascular disease and chronic kidney disease (CKD) over time. These long-term sequelae of paediatric AKI are most often observed in vulnerable populations, such as critically ill children, paediatric cardiac surgery patients, children who suffer from severe infections and paediatric cancer patients. SUMMARY A growing body of research has shown that paediatric AKI is associated with long-term adverse outcomes such as CKD, hypertension and cardiovascular disease. Although therapeutic pathways tailored to individual paediatric AKI patients are yet to be validated, we provide a framework to guide monitoring and prevention in children at the highest risk for developing long-term kidney dysfunction.
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Affiliation(s)
- Art Schuermans
- PKD Research Group, Department of Cellular and Molecular Medicine, KU Leuven
| | - Jef Van den Eynde
- PKD Research Group, Department of Cellular and Molecular Medicine, KU Leuven
| | - Djalila Mekahli
- PKD Research Group, Department of Cellular and Molecular Medicine, KU Leuven
- Department of Pediatric Nephrology, University Hospitals Leuven
| | - Dirk Vlasselaers
- Department of Intensive Care Medicine, University Hospitals Leuven
- Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium
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15
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Blankson SO, Rietmeyer L, Tettey P, Dikroh L, Tornyigah B, Adamou R, Moussiliou A, Padounou C, Amoussou A, Mensah BA, Alao MJ, Awandare G, Ndam NT, Roussilhon C, Tahar R. High Plasma Levels of Neopterin Are Associated with Increased Mortality among Children with Severe Malaria in Benin. Diagnostics (Basel) 2023; 13:diagnostics13030528. [PMID: 36766633 PMCID: PMC9914932 DOI: 10.3390/diagnostics13030528] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 01/24/2023] [Accepted: 01/25/2023] [Indexed: 02/04/2023] Open
Abstract
Among the barriers to accessing adequate treatment and high-level monitoring for malaria febrile patients is the lack of effective prognostic markers. Neopterin, which is a marker of monocyte/macrophage activation, was found have increased during severe malaria. In this study, we used quantitative ELISA in order to assess the levels of plasma soluble neopterin in 151 patients from a cohort of Beninese children with severe malaria. We evaluated the prognostic accuracy of this molecule in order to predict the outcome of the disease. Our results show that neopterin levels were not significantly different between patients with different forms of severe malaria, including severe non-cerebral malaria (SNCM) and cerebral malaria (CM). However, the levels of this molecule were found to be higher in patients with severe malarial anemia (SMA) among both CM and SNCM cases (p-value = 0.02). Additionally, the levels of this molecule were found to be higher in patients who died from these pathologies compared to those who survived among the two clinical groups (p-value < 0.0001) and within the same group (p-value < 0.0001 for the CM group, p-value = 0.0046 for the SNCM group). The AUC-ROC for fatality among all the severe cases was 0.77 with a 95%CI of (0.69-0.85). These results suggest that plasma neopterin levels constitute a potential biomarker for predicting fatality among severe falciparum malaria patients.
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Affiliation(s)
- Samuel Odarkwei Blankson
- MERIT, IRD, Université de Paris Cité, 75006 Paris, France
- West African Centre for Cell Biology of Infectious Pathogens, Department of Biochemistry, Cell and Molecular Biology, College of Basic and Applied Sciences, University of Ghana, Accra LG 54, Ghana
| | | | - Patrick Tettey
- Department of Immunology, Noguchi Memorial Institute for Medical Research, University of Ghana, Accra LG 54, Ghana
| | - Liliane Dikroh
- Department of Immunology, Noguchi Memorial Institute for Medical Research, University of Ghana, Accra LG 54, Ghana
| | - Bernard Tornyigah
- MERIT, IRD, Université de Paris Cité, 75006 Paris, France
- Department of Immunology, Noguchi Memorial Institute for Medical Research, University of Ghana, Accra LG 54, Ghana
| | - Rafiou Adamou
- Institut de Recherche Clinique du Benin (IRCB), Calavi, Benin
| | | | | | - Annick Amoussou
- Service de Pédiatrie, Centre Hospitalo-Universitaire, Suruléré (CHU-Suruléré), Cotonou, Benin
| | - Benedicta Ayiedu Mensah
- Department of Immunology, Noguchi Memorial Institute for Medical Research, University of Ghana, Accra LG 54, Ghana
| | - Maroufou J. Alao
- Département de Pédiatrie, Hôpital Mère-Enfant la Lagune (CHUMEL), Cotonou, Benin
| | - Gordon Awandare
- West African Centre for Cell Biology of Infectious Pathogens, Department of Biochemistry, Cell and Molecular Biology, College of Basic and Applied Sciences, University of Ghana, Accra LG 54, Ghana
| | - Nicaise Tuikue Ndam
- MERIT, IRD, Université de Paris Cité, 75006 Paris, France
- Department of Parasitology, Noguchi Memorial Institute for Medical Research, University of Ghana, Accra LG 54, Ghana
| | | | - Rachida Tahar
- MERIT, IRD, Université de Paris Cité, 75006 Paris, France
- Department of Parasitology, Noguchi Memorial Institute for Medical Research, University of Ghana, Accra LG 54, Ghana
- Correspondence: ; Tel.: +331-70-64-94-33
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16
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Lin Y, Tebulo A, Small D, Seydel K, Taylor T, Zhang B. Using Malarial Retinopathy to Improve the Diagnosis of Pediatric Cerebral Malaria. Am J Trop Med Hyg 2023; 108:69-75. [PMID: 36509055 PMCID: PMC9833082 DOI: 10.4269/ajtmh.22-0547] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Accepted: 10/03/2022] [Indexed: 12/14/2022] Open
Abstract
In malaria endemic areas, a high proportion of children have detectable parasitemia but show no clinical symptoms. When comatose from a cause other than malaria, this group confounds the cerebral malaria (CM) definition, making accurate diagnosis challenging. One important biomarker of CM is malarial retinopathy, a set of specific features visible in the ocular fundus. In this study, we quantified the contribution of malarial retinopathy in discriminating malaria-caused coma from non-malaria-caused coma. We estimated that 10% of our study cohort of N = 1,192 patients who met the WHO clinical definition of CM in Malawi had non-malarial coma based on a Gaussian mixture model using the parasite protein Plasmodium falciparum histidine-rich protein-2. A classification based on platelets, white blood cells, and retinopathy significantly improved the discriminative power of a previously established model including only platelets plus white blood cells (area under the receiver operating characteristic curve: 0.89 versus 0.75, P value < 0.001). We conclude that malarial retinopathy is highly predictive of malaria-caused versus non-malaria-caused coma and recommend that an ocular funduscopic examination to determine malarial retinopathy status be included in the assessment of parasitemic comatose African children.
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Affiliation(s)
- Yuzhou Lin
- Department of Statistics, Harvard University, Cambridge, Massachusetts
| | - Andrew Tebulo
- Blantyre Malaria Project, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Dylan Small
- Department of Statistics and Data Science, The Wharton School, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Karl Seydel
- Blantyre Malaria Project, Kamuzu University of Health Sciences, Blantyre, Malawi
- Department of Osteopathic Medical Specialties, Michigan State University, East Lansing, Michigan
| | - Terrie Taylor
- Blantyre Malaria Project, Kamuzu University of Health Sciences, Blantyre, Malawi
- Department of Osteopathic Medical Specialties, Michigan State University, East Lansing, Michigan
| | - Bo Zhang
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Center, Seattle, Washington
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17
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Conroy AL, Tran TM, Bond C, Opoka RO, Datta D, Liechty EA, Bangirana P, Namazzi R, Idro R, Cusick S, Ssenkusu JM, John CC. Plasma Amino Acid Concentrations in Children With Severe Malaria Are Associated With Mortality and Worse Long-term Kidney and Cognitive Outcomes. J Infect Dis 2022; 226:2215-2225. [PMID: 36179241 PMCID: PMC10205609 DOI: 10.1093/infdis/jiac392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Revised: 09/14/2022] [Accepted: 09/20/2022] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Global changes in amino acid levels have been described in severe malaria (SM), but the relationship between amino acids and long-term outcomes in SM has not been evaluated. METHODS We measured enrollment plasma concentrations of 20 amino acids using high-performance liquid chromatography in 500 Ugandan children aged 18 months to 12 years, including 122 community children and 378 children with SM. The Kidney Disease: Improving Global Outcomes criteria were used to define acute kidney injury (AKI) at enrollment and chronic kidney disease (CKD) at 1-year follow-up. Cognition was assessed over 2 years of follow-up. RESULTS Compared to laboratory-defined, age-specific reference ranges, there were deficiencies in sulfur-containing amino acids (methionine, cysteine) in both community children and children with SM. Among children with SM, global changes in amino acid concentrations were observed in the context of metabolic complications including acidosis and AKI. Increases in threonine, leucine, and valine were associated with in-hospital mortality, while increases in methionine, tyrosine, lysine, and phenylalanine were associated with postdischarge mortality and CKD. Increases in glycine and asparagine were associated with worse attention in children <5 years of age. CONCLUSIONS Among children with SM, unique amino acid profiles are associated with mortality, CKD, and worse attention.
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Affiliation(s)
- Andrea L Conroy
- Ryan White Center for Pediatric Infectious Disease and Global Health, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Tuan M Tran
- Ryan White Center for Pediatric Infectious Disease and Global Health, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Caitlin Bond
- Ryan White Center for Pediatric Infectious Disease and Global Health, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Robert O Opoka
- Department of Paediatrics and Child Health, Makerere University College of Health Sciences, Global Health Uganda, Kampala, Uganda
| | - Dibyadyuti Datta
- Ryan White Center for Pediatric Infectious Disease and Global Health, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Edward A Liechty
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Paul Bangirana
- Department of Psychiatry, Makerere University College of Health Sciences, Global Health Uganda, Kampala, Uganda
| | - Ruth Namazzi
- Department of Paediatrics and Child Health, Makerere University College of Health Sciences, Global Health Uganda, Kampala, Uganda
| | - Richard Idro
- Department of Paediatrics and Child Health, Makerere University College of Health Sciences, Global Health Uganda, Kampala, Uganda
| | - Sarah Cusick
- Division of Pediatric Epidemiology and Clinical Research, Department of Pediatrics, University of Minnesota, Minneapolis, Minnesota, USA
| | - John M Ssenkusu
- Department of Epidemiology and Biostatistics, Makerere University School of Public Health, Kampala, Uganda
| | - Chandy C John
- Ryan White Center for Pediatric Infectious Disease and Global Health, Indiana University School of Medicine, Indianapolis, Indiana, USA
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18
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Ippolito MM, Kabuya JBB, Hauser M, Kamavu LK, Banda PM, Yanek LR, Malik R, Mulenga M, Bailey JA, Chongwe G, Louis TA, Shapiro TA, Moss WJ. Whole Blood Transfusion for Severe Malarial Anemia in a High Plasmodium falciparum Transmission Setting. Clin Infect Dis 2022; 75:1893-1902. [PMID: 35439307 PMCID: PMC10200327 DOI: 10.1093/cid/ciac304] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND Severe malaria resulting from Plasmodium falciparum infection is the leading parasitic cause of death in children worldwide, and severe malarial anemia (SMA) is the most common clinical presentation. The evidence in support of current blood transfusion guidelines for patients with SMA is limited. METHODS We conducted a retrospective cohort study of 911 hospitalized children with SMA in a holoendemic region of Zambia to examine the association of whole blood transfusion with in-hospital survival. Data were analyzed in adjusted logistic regression models using multiple imputation for missing data. RESULTS The median age of patients was 24 months (interquartile range, 16-30) and overall case fatality was 16%. Blood transfusion was associated with 35% reduced odds of death in children with SMA (odds ratio, 0.65; 95% confidence interval, .52-.81; P = .0002) corresponding to a number-needed-to-treat (NNT) of 14 patients. Children with SMA complicated by thrombocytopenia were more likely to benefit from transfusion than those without thrombocytopenia (NNT = 5). Longer storage time of whole blood was negatively associated with survival and with the posttransfusion rise in the platelet count but was not associated with the posttransfusion change in hemoglobin concentration. CONCLUSIONS Whole blood given to pediatric patients with SMA was associated with improved survival, mainly among those with thrombocytopenia who received whole blood stored for <4 weeks. These findings point to a potential use for incorporating thrombocytopenia into clinical decision making and management of severe malaria, which can be further assessed in prospective studies, and underline the importance of maintaining reliable blood donation networks in areas of high malaria transmission.
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Affiliation(s)
- Matthew M Ippolito
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- The Johns Hopkins Malaria Research Institute, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
- Department of Pharmacology and Molecular Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Jean-Bertin B Kabuya
- Department of Clinical Sciences, Tropical Diseases Research Centre, Ndola, Zambia
| | - Manuela Hauser
- Faculty of Medicine, University of Basel, Basel, Switzerland
- Children’s Research Center, University Children’s Hospital, Zurich, Switzerland
| | - Luc K Kamavu
- Saint Paul’s General Hospital, Nchelenge, Luapula Province, Zambia
| | | | - Lisa R Yanek
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Rubab Malik
- Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Modest Mulenga
- Directorate of Research and Postgraduate Studies, Lusaka Apex Medical University, Lusaka, Zambia
| | - Jeffrey A Bailey
- Department of Pathology and Laboratory Medicine, Brown University Warren Alpert Medical School, Providence, Rhode Island, USA
| | - Gershom Chongwe
- Department of Clinical Sciences, Tropical Diseases Research Centre, Ndola, Zambia
| | - Thomas A Louis
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Theresa A Shapiro
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- The Johns Hopkins Malaria Research Institute, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
- Department of Pharmacology and Molecular Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - William J Moss
- The Johns Hopkins Malaria Research Institute, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
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19
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Todd JL, Topazian HM, Zulu M, Mafunga P, Mapanje C, Kaphatika JG, Chagomerana MB, Hoffman I, Juliano JJ, Mvalo T. RTS,S vaccination is associated with reduced parasitemia and anemia among children diagnosed with malaria in the outpatient department of a district hospital in rural Malawi. FRONTIERS IN EPIDEMIOLOGY 2022; 2:1039414. [PMID: 38455317 PMCID: PMC10910957 DOI: 10.3389/fepid.2022.1039414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Accepted: 10/27/2022] [Indexed: 03/09/2024]
Abstract
The RTS,S/AS01 malaria vaccine was recently approved by the World Health Organization, but real-world effectiveness is still being evaluated. We measured hemoglobin concentration and parasite density in vaccinated and unvaccinated children who had been diagnosed with malaria by rapid diagnostic test (mRDT) in the outpatient department of a rural hospital in Malawi. Considering all mRDT positive participants, the mean hemoglobin concentration among unvaccinated participants was 9.58 g/dL. There was improvement to 9.82 g/dL and 10.36 g/dL in the 1 or 2 dose group (p = 0.6) and the 3 or 4 dose group (p = 0.0007), respectively. Among a microscopy positive subset of participants, mean hemoglobin concentration of unvaccinated participants was 9.55 g/dL with improvement to 9.82 g/dL in the 1 or 2 dose group (p = 0.6) and 10.41 g/dL in the 3 or 4 dose group (p = 0.003). Mean parasite density also decreased from 115,154 parasites/μL in unvaccinated children to 87,754 parasites/μL in children who had received at least one dose of RTS,S (p = 0.04). In this study population, vaccination was associated with significant improvements in both hemoglobin concentration and parasite density in the setting of real-world administration of the RTS,S/AS01 vaccine.
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Affiliation(s)
- Jacob L. Todd
- Institute for Global Health and Infectious Diseases, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Hillary M. Topazian
- MRC Centre for Global Infectious Disease Analysis, Imperial College London, London, United Kingdom
| | - Madalitso Zulu
- University of North Carolina Project Malawi, Lilongwe, Malawi
| | - Pilirani Mafunga
- Malaria Alert Centre, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Clement Mapanje
- University of North Carolina Project Malawi, Lilongwe, Malawi
| | | | - Maganizo B. Chagomerana
- Department of Medicine, Institute for Global Health and Infectious Diseases, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Irving Hoffman
- Department of Medicine, Institute for Global Health and Infectious Diseases, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Jonathan J. Juliano
- Division of Infectious Diseases, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, NC, United States
| | - Tisungane Mvalo
- Department of Pediatrics, Institute for Global Health and Infectious Diseases, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
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20
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Srinamon K, Watson JA, Silamut K, Intharabut B, Phu NH, Diep PT, Lyke KE, Fanello C, von Seidlein L, Chotivanich K, Dondorp AM, Day NPJ, White NJ. The prognostic and diagnostic value of intraleukocytic malaria pigment in patients with severe falciparum malaria. Nat Commun 2022; 13:6882. [PMID: 36371433 PMCID: PMC9653500 DOI: 10.1038/s41467-022-34678-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Accepted: 11/02/2022] [Indexed: 11/13/2022] Open
Abstract
Severe falciparum malaria is a major cause of death in tropical countries, particularly in African children. Rapid and accurate diagnosis and prognostic assessment are critical to clinical management. In 6027 prospectively studied patients diagnosed with severe malaria we assess the prognostic value of peripheral blood film counts of malaria pigment containing polymorphonuclear leukocytes (PMNs) and monocytes. We combine these results with previously published data and show, in an individual patient data meta-analysis (n = 32,035), that the proportion of pigment containing PMNs is predictive of in-hospital mortality. In African children the proportion of pigment containing PMNs helps distinguish severe malaria from other life-threatening febrile illnesses, and it adds to the prognostic assessment from simple bedside examination, and to the conventional malaria parasite count. Microscopy assessment of pigment containing PMNs is simple and rapid, and should be performed in all patients hospitalised with suspected severe malaria.
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Affiliation(s)
- Ketsanee Srinamon
- grid.10223.320000 0004 1937 0490Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, 10400 Thailand
| | - James A. Watson
- grid.412433.30000 0004 0429 6814Oxford University Clinical Research Unit, Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam ,grid.4991.50000 0004 1936 8948Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, New Richards Building, Old Road Campus, Roosevelt Drive, Oxford, OX3 7LG UK ,grid.499581.8WorldWide Antimalarial Resistance Network, Oxford, UK
| | - Kamolrat Silamut
- grid.10223.320000 0004 1937 0490Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, 10400 Thailand
| | - Benjamas Intharabut
- grid.10223.320000 0004 1937 0490Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, 10400 Thailand
| | - Nguyen Hoan Phu
- grid.412433.30000 0004 0429 6814Oxford University Clinical Research Unit, Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam
| | - Pham Thi Diep
- grid.412433.30000 0004 0429 6814Oxford University Clinical Research Unit, Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam
| | - Kirsten E. Lyke
- grid.411024.20000 0001 2175 4264Center for Vaccine Development and Global Health, University of Maryland School of Medicine, Baltimore, MD USA
| | - Caterina Fanello
- grid.10223.320000 0004 1937 0490Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, 10400 Thailand ,grid.4991.50000 0004 1936 8948Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, New Richards Building, Old Road Campus, Roosevelt Drive, Oxford, OX3 7LG UK
| | - Lorenz von Seidlein
- grid.10223.320000 0004 1937 0490Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, 10400 Thailand ,grid.4991.50000 0004 1936 8948Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, New Richards Building, Old Road Campus, Roosevelt Drive, Oxford, OX3 7LG UK
| | - Kesinee Chotivanich
- grid.10223.320000 0004 1937 0490Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, 10400 Thailand
| | - Arjen M. Dondorp
- grid.10223.320000 0004 1937 0490Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, 10400 Thailand ,grid.4991.50000 0004 1936 8948Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, New Richards Building, Old Road Campus, Roosevelt Drive, Oxford, OX3 7LG UK
| | - Nicholas P. J. Day
- grid.10223.320000 0004 1937 0490Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, 10400 Thailand ,grid.4991.50000 0004 1936 8948Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, New Richards Building, Old Road Campus, Roosevelt Drive, Oxford, OX3 7LG UK
| | - Nicholas J. White
- grid.10223.320000 0004 1937 0490Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, 10400 Thailand ,grid.4991.50000 0004 1936 8948Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, New Richards Building, Old Road Campus, Roosevelt Drive, Oxford, OX3 7LG UK
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21
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Abstract
Severe malaria is a medical emergency. It is a major cause of preventable childhood death in tropical countries. Severe malaria justifies considerable global investment in malaria control and elimination yet, increasingly, international agencies, funders and policy makers are unfamiliar with it, and so it is overlooked. In sub-Saharan Africa, severe malaria is overdiagnosed in clinical practice. Approximately one third of children diagnosed with severe malaria have another condition, usually sepsis, as the cause of their severe illness. But these children have a high mortality, contributing substantially to the number of deaths attributed to ‘severe malaria’. Simple well-established tests, such as examination of the thin blood smear and the full blood count, improve the specificity of diagnosis and provide prognostic information in severe malaria. They should be performed more widely. Early administration of artesunate and broad-spectrum antibiotics to all children with suspected severe malaria would reduce global malaria mortality.
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Affiliation(s)
- Nicholas J White
- Mahidol Oxford Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand. .,Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK.
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22
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Watson JA, Uyoga S, Wanjiku P, Makale J, Nyutu GM, Mturi N, George EC, Woodrow CJ, Day NPJ, Bejon P, Opoka RO, Dondorp AM, John CC, Maitland K, Williams TN, White NJ. Improving the diagnosis of severe malaria in African children using platelet counts and plasma PfHRP2 concentrations. Sci Transl Med 2022; 14:eabn5040. [PMID: 35857826 PMCID: PMC7613613 DOI: 10.1126/scitranslmed.abn5040] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Severe malaria caused by Plasmodium falciparum is difficult to diagnose accurately in children in high-transmission settings. Using data from 2649 pediatric and adult patients enrolled in four studies of severe illness in three countries (Bangladesh, Kenya, and Uganda), we fitted Bayesian latent class models using two diagnostic markers: the platelet count and the plasma concentration of P. falciparum histidine-rich protein 2 (PfHRP2). In severely ill patients with clinical features consistent with severe malaria, the combination of a platelet count of ≤150,000/μl and a plasma PfHRP2 concentration of ≥1000 ng/ml had an estimated sensitivity of 74% and specificity of 93% in identifying severe falciparum malaria. Compared with misdiagnosed children, pediatric patients with true severe malaria had higher parasite densities, lower hematocrits, lower rates of invasive bacterial disease, and a lower prevalence of both sickle cell trait and sickle cell anemia. We estimate that one-third of the children enrolled into clinical studies of severe malaria in high-transmission settings in Africa had another cause of their severe illness.
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Affiliation(s)
- James A. Watson
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand,Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK,Corresponding author.
| | - Sophie Uyoga
- KEMRI Wellcome Trust Research Programme, Centre for Geographic Medicine Research, Coast, Kilifi 80108, Kenya
| | - Perpetual Wanjiku
- KEMRI Wellcome Trust Research Programme, Centre for Geographic Medicine Research, Coast, Kilifi 80108, Kenya
| | - Johnstone Makale
- KEMRI Wellcome Trust Research Programme, Centre for Geographic Medicine Research, Coast, Kilifi 80108, Kenya
| | - Gideon M. Nyutu
- KEMRI Wellcome Trust Research Programme, Centre for Geographic Medicine Research, Coast, Kilifi 80108, Kenya
| | - Neema Mturi
- KEMRI Wellcome Trust Research Programme, Centre for Geographic Medicine Research, Coast, Kilifi 80108, Kenya
| | - Elizabeth C. George
- Medical Research Council Clinical Trials Unit, University College London, London, UK
| | - Charles J. Woodrow
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand,Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Nicholas P. J. Day
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand,Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Philip Bejon
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK,KEMRI Wellcome Trust Research Programme, Centre for Geographic Medicine Research, Coast, Kilifi 80108, Kenya
| | - Robert O. Opoka
- Makerere University, Department of Paediatrics and Child Health, Kampala, Uganda
| | - Arjen M. Dondorp
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand,Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Chandy C. John
- Department of Pediatrics, Indiana University, Indiana, IN, USA
| | - Kathryn Maitland
- KEMRI Wellcome Trust Research Programme, Centre for Geographic Medicine Research, Coast, Kilifi 80108, Kenya,Institute of Global Health Innovation, Department of Surgery and Cancer, Imperial College, London, UK
| | - Thomas N. Williams
- KEMRI Wellcome Trust Research Programme, Centre for Geographic Medicine Research, Coast, Kilifi 80108, Kenya,Institute of Global Health Innovation, Department of Surgery and Cancer, Imperial College, London, UK
| | - Nicholas J. White
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand,Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
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Vohra R, Hussain A, Dudyala AK, Pahareeya J, Khan W. Multi-class classification algorithms for the diagnosis of anemia in an outpatient clinical setting. PLoS One 2022; 17:e0269685. [PMID: 35793343 PMCID: PMC9258850 DOI: 10.1371/journal.pone.0269685] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Accepted: 05/26/2022] [Indexed: 11/19/2022] Open
Abstract
Anemia is one of the most pressing public health issues in the world with iron deficiency a major public health issue worldwide. The highest prevalence of anemia is in developing countries. The complete blood count is a blood test used to diagnose the prevalence of anemia. While earlier studies have framed the problem of diagnosis as a binary classification problem, this paper frames it as a multi class (three classes) classification problem with mild, moderate and severe classes. The three classes for the anemia classification (mild, moderate, severe) are so chosen as the world health organization (WHO) guidelines formalize this categorization based on the Haemoglobin (HGB) values of the chosen sample of patients in the Complete Blood Count (CBC) patient data set. Complete blood count test data was collected in an outpatient clinical setting in India. We used Feature selection with Majority voting to identify the key attributes in the input patient data set. In addition, since the original data set was imbalanced we used Synthetic Minority Oversampling Technique (SMOTE) to balance the data set. Four data sets including the original data set were used to perform the data experiments. Six standard machine learning algorithms were utilised to test our four data sets, performing multi class classification. Benchmarking these algorithms was performed and tabulated using both10 fold cross validation and hold out methods. The experimental results indicated that multilayer perceptron network was predominantly giving good recall values across mild and moderate class which are early and middle stages of the disease. With a good prediction model at early stages, medical intervention can provide preventive measure from further deterioration into severe stage or recommend the use of supplements to overcome this problem.
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Affiliation(s)
- Rajan Vohra
- School of Creative Technologies, University of Bolton, Bolton, United Kingdom
- * E-mail:
| | - Abir Hussain
- Department of Electrical Engineering, University of Sharjah, Sharjah, UAE
- Department of Computer Science, Liverpool John Moore’s University, Liverpool, United Kingdom
| | - Anil Kumar Dudyala
- Department of Computer Science, National Institute of Technology Patna (NIT Patna), Patna, India
| | - Jankisharan Pahareeya
- Department of Information Technology, Rustamji Institute of Technology, BSF Academy, Tekanpur, Gwalior, India
| | - Wasiq Khan
- Department of Computer Science, Liverpool John Moore’s University, Liverpool, United Kingdom
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Fernander EM, Adogamhe P, Datta D, Bond C, Zhao Y, Bangirana P, Conroy AL, Opoka RO, John CC. Elevated Plasma Soluble ST2 Levels are Associated With Neuronal Injury and Neurocognitive Impairment in Children With Cerebral Malaria. Pathog Immun 2022; 7:60-80. [PMID: 35800259 PMCID: PMC9254869 DOI: 10.20411/pai.v7i1.499] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Accepted: 05/08/2022] [Indexed: 11/23/2022] Open
Abstract
Background Murine experimental cerebral malaria studies suggest both protective and deleterious central nervous system effects from alterations in the interleukin-33 (IL-33)/ST2 pathway. Methods We assessed whether soluble ST2 (sST2) was associated with neuronal injury or cognitive impairment in a cohort of Ugandan children with cerebral malaria (CM, n=224) or severe malarial anemia (SMA, n=193). Results Plasma concentrations of sST2 were higher in children with CM than in children with SMA or in asymptomatic community children. Cerebrospinal fluid (CSF) sST2 levels were elevated in children with CM compared with North American children. Elevated plasma and CSF ST2 levels in children with CM correlated with increased endothelial activation and increased plasma and CSF levels of tau, a marker of neuronal injury. In children with CM who were ≥5 years of age at the time of their malaria episode, but not in children <5 years of age, elevated risk factor-adjusted plasma levels of sST2 were associated with worse scores for overall cognitive ability and attention over a 2-year follow-up. Conclusions The study findings suggest that sST2 may contribute to neuronal injury and long-term neurocognitive impairment in older children with CM.
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Affiliation(s)
- Elizabeth M. Fernander
- Ryan White Center for Pediatric Infectious Disease and Global Health, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Pontian Adogamhe
- Ryan White Center for Pediatric Infectious Disease and Global Health, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Dibyadyuti Datta
- Ryan White Center for Pediatric Infectious Disease and Global Health, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Caitlin Bond
- Ryan White Center for Pediatric Infectious Disease and Global Health, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Yi Zhao
- Department of Biostatistics and Health Data Science, Indiana University School of Medicine, Indianapolis, IN
| | - Paul Bangirana
- Department of Psychiatry, Makerere University, Kampala, Uganda
| | - Andrea L. Conroy
- Ryan White Center for Pediatric Infectious Disease and Global Health, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Robert O. Opoka
- Department of Paediatrics and Child Health, Makerere University, Kampala, Uganda
| | - Chandy C. John
- Ryan White Center for Pediatric Infectious Disease and Global Health, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA
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25
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Namazzi R, Opoka R, Datta D, Bangirana P, Batte A, Berrens Z, Goings MJ, Schwaderer AL, Conroy AL, John CC. Acute Kidney Injury Interacts With Coma, Acidosis, and Impaired Perfusion to Significantly Increase Risk of Death in Children With Severe Malaria. Clin Infect Dis 2022; 75:1511-1519. [PMID: 35349633 PMCID: PMC9617576 DOI: 10.1093/cid/ciac229] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Mortality in severe malaria remains high in children treated with intravenous artesunate. Acute kidney injury (AKI) is a common complication of severe malaria, but the interactions between AKI and other complications on the risk of mortality in severe malaria are not well characterized. METHODS Between 2014 and 2017, 600 children aged 6-48 months to 4 years hospitalized with severe malaria were enrolled in a prospective clinical cohort study evaluating clinical predictors of mortality in children with severe malaria. RESULTS The mean age of children in this cohort was 2.1 years (standard deviation, 0.9 years) and 338 children (56.3%) were male. Mortality was 7.3%, and 52.3% of deaths occurred within 12 hours of admission. Coma, acidosis, impaired perfusion, AKI, elevated blood urea nitrogen (BUN), and hyperkalemia were associated with increased mortality (all P < .001). AKI interacted with each risk factor to increase mortality (P < .001 for interaction). Children with clinical indications for dialysis (14.4% of all children) had an increased risk of death compared with those with no indications for dialysis (odds ratio, 6.56; 95% confidence interval, 3.41-12.59). CONCLUSIONS AKI interacts with coma, acidosis, or impaired perfusion to significantly increase the risk of death in severe malaria. Among children with AKI, those who have hyperkalemia or elevated BUN have a higher risk of death. A better understanding of the causes of these complications of severe malaria, and development and implementation of measures to prevent and treat them, such as dialysis, are needed to reduce mortality in severe malaria.
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Affiliation(s)
- Ruth Namazzi
- Department of Paediatrics and Child Health, Makerere University College of Health Sciences, Kampala, Uganda,Global Health Uganda, Kampala, Uganda
| | - Robert Opoka
- Department of Paediatrics and Child Health, Makerere University College of Health Sciences, Kampala, Uganda,Global Health Uganda, Kampala, Uganda
| | - Dibyadyuti Datta
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Paul Bangirana
- Global Health Uganda, Kampala, Uganda,Department of Psychiatry, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Anthony Batte
- Child Development Centre, Makerere University, Kampala, Uganda
| | - Zachary Berrens
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Michael J Goings
- Indiana University Center for Global Health, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Andrew L Schwaderer
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Andrea L Conroy
- Correspondence: A. L. Conroy, Department of Pediatrics, Indiana University School of Medicine, 1044 W Walnut St, Indianapolis, IN 46202 ()
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Woolley SD, Marquart L, Woodford J, Chalon S, Moehrle JJ, McCarthy JS, Barber BE. Haematological response in experimental human Plasmodium falciparum and Plasmodium vivax malaria. Malar J 2021; 20:470. [PMID: 34930260 PMCID: PMC8685492 DOI: 10.1186/s12936-021-04003-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Accepted: 12/01/2021] [Indexed: 11/25/2022] Open
Abstract
Background Malaria-associated anaemia, arising from symptomatic, asymptomatic and submicroscopic infections, is a significant cause of morbidity worldwide. Induced blood stage malaria volunteer infection studies (IBSM-VIS) provide a unique opportunity to evaluate the haematological response to early Plasmodium falciparum and Plasmodium vivax infection. Methods This study was an analysis of the haemoglobin, red cell counts, and parasitaemia data from 315 participants enrolled in IBSM-VIS between 2012 and 2019, including 269 participants inoculated with the 3D7 strain of P. falciparum (Pf3D7), 15 with an artemisinin-resistant P. falciparum strain (PfK13) and 46 with P. vivax. Factors associated with the fractional fall in haemoglobin (Hb-FF) were evaluated, and the malaria-attributable erythrocyte loss after accounting for phlebotomy-related losses was estimated. The relative contribution of parasitized erythrocytes to the malaria-attributable erythrocyte loss was also estimated. Results The median peak parasitaemia prior to treatment was 10,277 parasites/ml (IQR 3566–27,815), 71,427 parasites/ml [IQR 33,236–180,213], and 34,840 parasites/ml (IQR 13,302–77,064) in participants inoculated with Pf3D7, PfK13, and P. vivax, respectively. The median Hb-FF was 10.3% (IQR 7.8–13.3), 14.8% (IQR 11.8–15.9) and 11.7% (IQR 8.9–14.5) in those inoculated with Pf3D7, PfK13 and P. vivax, respectively, with the haemoglobin nadir occurring a median 12 (IQR 5–21), 15 (IQR 7–22), and 8 (IQR 7–15) days following inoculation. In participants inoculated with P. falciparum, recrudescence was associated with a greater Hb-FF, while in those with P. vivax, the Hb-FF was associated with a higher pre-treatment parasitaemia and later day of anti-malarial treatment. After accounting for phlebotomy-related blood losses, the estimated Hb-FF was 4.1% (IQR 3.1–5.3), 7.2% (IQR 5.8–7.8), and 4.9% (IQR 3.7–6.1) in participants inoculated with Pf3D7, PfK13, and P. vivax, respectively. Parasitized erythrocytes were estimated to account for 0.015% (IQR 0.006–0.06), 0.128% (IQR 0.068–0.616) and 0.022% (IQR 0.008–0.082) of the malaria-attributable erythrocyte loss in participants inoculated with Pf3D7, PfK13, and P. vivax, respectively. Conclusion Early experimental P. falciparum and P. vivax infection resulted in a small but significant fall in haemoglobin despite parasitaemia only just at the level of microscopic detection. Loss of parasitized erythrocytes accounted for < 0.2% of the total malaria-attributable haemoglobin loss. Supplementary Information The online version contains supplementary material available at 10.1186/s12936-021-04003-7.
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Batte A, Murphy KJ, Namazzi R, Co K, Opoka RO, Ssenkusu JM, John CC, Conroy AL. Evaluating kidney function using a point-of-care creatinine test in Ugandan children with severe malaria: a prospective cohort study. BMC Nephrol 2021; 22:369. [PMID: 34742257 PMCID: PMC8572470 DOI: 10.1186/s12882-021-02573-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Accepted: 10/22/2021] [Indexed: 11/12/2022] Open
Abstract
Background Acute kidney injury (AKI) disproportionately affects individuals in low-and middle-income countries (LMIC). However, LMIC—particularly countries in sub-Saharan Africa— are under-represented in global AKI research. A critical barrier in diagnosing AKI is access to reliable serum creatinine results. We evaluated the utility of a point-of-care test to measure creatinine and diagnose AKI in Ugandan children with malaria. Methods Paired admission creatinine was assessed in 539 Ugandan children 6 months to 4 years of age hospitalized with severe malaria based on blood smear or rapid diagnostic test. Creatinine levels were measured using isotope dilution mass spectrometry (IDMS)-traceable methods. The reference creatinine was measured using the modified Jaffe method by a certified laboratory and the point-of-care testing was conducted using an i-STAT blood analyzer (i-STAT1, with and without adjustment for the partial pressure of carbon dioxide). AKI was defined and staged using the Kidney Disease: Improving Global Outcomes criteria. Results The mean age of children was 2.1 years, and 21.6% of children were stunted. Mortality was 7.6% in-hospital. Over the entire range of measured creatinine values (<0.20mg/dL-8.4mg/dL), the correlation between the reference creatinine and adjusted and unadjusted point-of-care creatinine was high with R2 values of 0.95 and 0.93 respectively; however, the correlation was significantly lower in children with creatinine values <1mg/dL (R2 of 0.44 between the reference and adjusted and unadjusted i-STAT creatinine). The prevalence of AKI was 45.5% using the reference creatinine, and 27.1 and 32.3% using the unadjusted and adjusted point-of-care creatinine values, respectively. There was a step-wise increase in mortality across AKI stages, and all methods were strongly associated with mortality (p<0.0001 for all). AKI defined using the reference creatinine measure was the most sensitive to predict mortality with a sensitivity of 85.4% compared to 70.7 and 63.4% with the adjusted and unadjusted point-of-care creatinine values, respectively. Conclusions Point-of-care assessment of creatinine in lean Ugandan children <4 years of age underestimated creatinine and AKI compared to the clinical reference. Additional studies are needed to evaluate other biomarkers of AKI in LMIC to ensure equitable access to AKI diagnostics globally.
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Affiliation(s)
- Anthony Batte
- Child Health and Development Centre, Makerere University College of Health Sciences, Kampala, Uganda
| | - Kristin J Murphy
- Department of Pediatrics, Ryan White Center for Pediatric Infectious Disease and Global Health, Indiana University School of Medicine, 1044 W. Walnut St., Indianapolis, IN, 46202, USA
| | - Ruth Namazzi
- Department of Paediatrics and Child Health, Makerere University College of Health Sciences, Kampala, Uganda
| | - Katrina Co
- Department of Pediatrics, Ryan White Center for Pediatric Infectious Disease and Global Health, Indiana University School of Medicine, 1044 W. Walnut St., Indianapolis, IN, 46202, USA
| | - Robert O Opoka
- Department of Paediatrics and Child Health, Makerere University College of Health Sciences, Kampala, Uganda
| | - John M Ssenkusu
- Department of Epidemiology and Biostatistics, Makerere University School of Public Health, Kampala, Uganda
| | - Chandy C John
- Department of Pediatrics, Ryan White Center for Pediatric Infectious Disease and Global Health, Indiana University School of Medicine, 1044 W. Walnut St., Indianapolis, IN, 46202, USA
| | - Andrea L Conroy
- Department of Pediatrics, Ryan White Center for Pediatric Infectious Disease and Global Health, Indiana University School of Medicine, 1044 W. Walnut St., Indianapolis, IN, 46202, USA.
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28
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Nwaneri DU, Sadoh AE. Effect of health seeking behaviour of caregivers on severe malaria outcome in under-fives seen in a tertiary health institution in Nigeria. Ghana Med J 2021; 54:156-163. [PMID: 33883760 PMCID: PMC8042797 DOI: 10.4314/gmj.v54i3.6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Background Recognition of the symptoms and seeking prompt treatment in a health facility is a major means of reducing morbidity and prevention of mortality from severe malaria in under-fives. Objectives To document the effect of health-seeking behaviour of caregivers and severe malaria outcome in underfives seen in a tertiary health institution in Nigeria. Design A descriptive cross-sectional study carried out from July 2012 – June 2013. Data were obtained using a researcher-administered questionnaire. Subjects Caregivers and children (6 – 59 months) who presented with features of severe malaria according to World Health Organization criteria. Results Of the 120 caregivers mean [SD] age (31.4 [7.0] years) /child pairs (24 [14.7] months), 35 (29%) caregivers had appropriate health-seeking behaviour. The commonest place visited for initial healthcare before presentation was the patent medicine vendors by 87 (73%) caregivers. Seventy-seven per cent of caregivers who did not have appropriate health-seeking behaviour were from the lower family social class (p = 0.03). Caregivers whose children presented with severe anaemia were significantly more likely to have appropriate health-seeking behaviour (p =0.00). The mortality rate of severe malaria was 15 per 1000; of which 94% were children whose caregivers did not have appropriate health-seeking behaviour. Age younger than 2 years (p = 0.02), cerebral malaria (p = 0.01) and jaundice (p = 0.03) significantly predicted mortality in the children irrespective of the caregivers' health-seeking behaviour status. Conclusion Less than a third of the caregivers had appropriate health-seeking behaviour for their under-fives with severe malaria, and the majority of these were from the lower family social class. Cerebral malaria and jaundice significantly predicted mortality in children with severe malaria irrespective of caregivers' health-seeking behaviour status. Funding The study was self-sponsored by the authors
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Affiliation(s)
- Damian U Nwaneri
- Department of Child Health, University Of Benin Teaching Hospital, P.M.B. 1111, Benin City, Nigeria)
| | - Ayebo E Sadoh
- Department of Child Health, University Of Benin Teaching Hospital, P.M.B. 1111, Benin City, Nigeria)
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Batte A, Berrens Z, Murphy K, Mufumba I, Sarangam ML, Hawkes MT, Conroy AL. Malaria-Associated Acute Kidney Injury in African Children: Prevalence, Pathophysiology, Impact, and Management Challenges. Int J Nephrol Renovasc Dis 2021; 14:235-253. [PMID: 34267538 PMCID: PMC8276826 DOI: 10.2147/ijnrd.s239157] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Accepted: 05/26/2021] [Indexed: 01/02/2023] Open
Abstract
Acute kidney injury (AKI) is emerging as a complication of increasing clinical importance associated with substantial morbidity and mortality in African children with severe malaria. Using the Kidney Disease: Improving Global Outcomes (KDIGO) criteria to define AKI, an estimated 24–59% of African children with severe malaria have AKI with most AKI community-acquired. AKI is a risk factor for mortality in pediatric severe malaria with a stepwise increase in mortality across AKI stages. AKI is also a risk factor for post-discharge mortality and is associated with increased long-term risk of neurocognitive impairment and behavioral problems in survivors. Following injury, the kidney undergoes a process of recovery and repair. AKI is an established risk factor for chronic kidney disease and hypertension in survivors and is associated with an increased risk of chronic kidney disease in severe malaria survivors. The magnitude of the risk and contribution of malaria-associated AKI to chronic kidney disease in malaria-endemic areas remains undetermined. Pathways associated with AKI pathogenesis in the context of pediatric severe malaria are not well understood, but there is emerging evidence that immune activation, endothelial dysfunction, and hemolysis-mediated oxidative stress all directly contribute to kidney injury. In this review, we outline the KDIGO bundle of care and highlight how this could be applied in the context of severe malaria to improve kidney perfusion, reduce AKI progression, and improve survival. With increased recognition that AKI in severe malaria is associated with substantial post-discharge morbidity and long-term risk of chronic kidney disease, there is a need to increase AKI recognition through enhanced access to creatinine-based and next-generation biomarker diagnostics. Long-term studies to assess severe malaria-associated AKI’s impact on long-term health in malaria-endemic areas are urgently needed.
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Affiliation(s)
- Anthony Batte
- Child Health and Development Centre, Makerere University College of Health Sciences, Kampala, Uganda
| | - Zachary Berrens
- Department of Pediatrics, Pediatric Critical Care Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Kristin Murphy
- Department of Pediatrics, Ryan White Center for Pediatric Infectious Disease and Global Health, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Ivan Mufumba
- CHILD Research Laboratory, Global Health Uganda, Kampala, Uganda
| | | | - Michael T Hawkes
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Andrea L Conroy
- Department of Pediatrics, Ryan White Center for Pediatric Infectious Disease and Global Health, Indiana University School of Medicine, Indianapolis, IN, USA
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Mzumara G, Leopold S, Marsh K, Dondorp A, Ohuma EO, Mukaka M. Identifying prognostic factors of severe metabolic acidosis and uraemia in African children with severe falciparum malaria: a secondary analysis of a randomized trial. Malar J 2021; 20:282. [PMID: 34172046 PMCID: PMC8234663 DOI: 10.1186/s12936-021-03785-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Accepted: 05/27/2021] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Severe metabolic acidosis and acute kidney injury are major causes of mortality in children with severe malaria but are often underdiagnosed in low resource settings. METHODS A retrospective analysis of the 'Artesunate versus quinine in the treatment of severe falciparum malaria in African children' (AQUAMAT) trial was conducted to identify clinical features of severe metabolic acidosis and uraemia in 5425 children from nine African countries. Separate models were fitted for uraemia and severe metabolic acidosis. Separate univariable and multivariable logistic regression were performed to identify prognostic factors for severe metabolic acidosis and uraemia. Both analyses adjusted for the trial arm. A forward selection approach was used for model building of the logistic models and a threshold of 5% statistical significance was used for inclusion of variables into the final logistic model. Model performance was assessed through calibration, discrimination, and internal validation with bootstrapping. RESULTS There were 2296 children identified with severe metabolic acidosis and 1110 with uraemia. Prognostic features of severe metabolic acidosis among them were deep breathing (OR: 3.94, CI 2.51-6.2), hypoglycaemia (OR: 5.16, CI 2.74-9.75), coma (OR: 1.72 CI 1.17-2.51), respiratory distress (OR: 1.46, CI 1.02-2.1) and prostration (OR: 1.88 CI 1.35-2.59). Features associated with uraemia were coma (3.18, CI 2.36-4.27), Prostration (OR: 1.78 CI 1.37-2.30), decompensated shock (OR: 1.89, CI 1.31-2.74), black water fever (CI 1.58. CI 1.09-2.27), jaundice (OR: 3.46 CI 2.21-5.43), severe anaemia (OR: 1.77, CI 1.36-2.29) and hypoglycaemia (OR: 2.77, CI 2.22-3.46) CONCLUSION: Clinical and laboratory parameters representing contributors and consequences of severe metabolic acidosis and uraemia were independently associated with these outcomes. The model can be useful for identifying patients at high risk of these complications where laboratory assessments are not routinely available.
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Affiliation(s)
- Grace Mzumara
- Malawi Liverpool Wellcome Trust, Queen Elizabeth Central Hospital College of Medicine, Chichiri 3, P.O. Box 30096, Blantyre, Malawi.
- University of Malawi, College of Medicine, Blantyre, Malawi.
- University of Oxford, Oxford, UK.
- Centre for Tropical Medicine and Global Health, Oxford, UK.
| | - Stije Leopold
- Centre for Tropical Medicine and Global Health, Oxford, UK
- Mahidol-Oxford Tropical Medicine Research Unit, Bangkok, Thailand
| | - Kevin Marsh
- Centre for Tropical Medicine and Global Health, Oxford, UK
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
| | - Arjen Dondorp
- Centre for Tropical Medicine and Global Health, Oxford, UK
- Mahidol-Oxford Tropical Medicine Research Unit, Bangkok, Thailand
| | - Eric O Ohuma
- University of Oxford, Oxford, UK
- Centre for Tropical Medicine and Global Health, Oxford, UK
- Maternal, Adolescent, Reproductive and Child Health (MARCH) Centre, School of Hygiene and Tropical Medicine (LSHTM), London, UK
| | - Mavuto Mukaka
- University of Malawi, College of Medicine, Blantyre, Malawi
- University of Oxford, Oxford, UK
- Centre for Tropical Medicine and Global Health, Oxford, UK
- Mahidol-Oxford Tropical Medicine Research Unit, Bangkok, Thailand
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Katsoulis O, Georgiadou A, Cunnington AJ. Immunopathology of Acute Kidney Injury in Severe Malaria. Front Immunol 2021; 12:651739. [PMID: 33968051 PMCID: PMC8102819 DOI: 10.3389/fimmu.2021.651739] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2021] [Accepted: 04/06/2021] [Indexed: 11/13/2022] Open
Abstract
Acute kidney injury (AKI) is a common feature of severe malaria, and an independent risk factor for death. Previous research has suggested that an overactivation of the host inflammatory response is at least partly involved in mediating the kidney damage observed in P. falciparum patients with AKI, however the exact pathophysiology of AKI in severe malaria remains unknown. The purpose of this mini-review is to describe how different aspects of malaria pathology, including parasite sequestration, microvascular obstruction and extensive intravascular hemolysis, may interact with each other and contribute to the development of AKI in severe malaria, by amplifying the damaging effects of the host inflammatory response. Here, we highlight the importance of considering how the systemic effects and multi-organ involvement of malaria are intertwined with the localized effects on the kidney.
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Affiliation(s)
- Orestis Katsoulis
- Section of Paediatric Infectious Disease, Department of Infectious Disease, Imperial College London, London, United Kingdom
| | - Athina Georgiadou
- Section of Paediatric Infectious Disease, Department of Infectious Disease, Imperial College London, London, United Kingdom.,Centre for Paediatrics and Child Health, Imperial College London, London, United Kingdom
| | - Aubrey J Cunnington
- Section of Paediatric Infectious Disease, Department of Infectious Disease, Imperial College London, London, United Kingdom.,Centre for Paediatrics and Child Health, Imperial College London, London, United Kingdom
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Nahrendorf W, Ivens A, Spence PJ. Inducible mechanisms of disease tolerance provide an alternative strategy of acquired immunity to malaria. eLife 2021; 10:e63838. [PMID: 33752799 PMCID: PMC7987336 DOI: 10.7554/elife.63838] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Accepted: 02/19/2021] [Indexed: 12/26/2022] Open
Abstract
Immunity to malaria is often considered slow to develop but this only applies to defense mechanisms that function to eliminate parasites (resistance). In contrast, immunity to severe disease can be acquired quickly and without the need for improved pathogen control (tolerance). Using Plasmodium chabaudi, we show that a single malaria episode is sufficient to induce host adaptations that can minimise inflammation, prevent tissue damage and avert endothelium activation, a hallmark of severe disease. Importantly, monocytes are functionally reprogrammed to prevent their differentiation into inflammatory macrophages and instead promote mechanisms of stress tolerance to protect their niche. This alternative fate is not underpinned by epigenetic reprogramming of bone marrow progenitors but appears to be imprinted within the remodelled spleen. Crucially, all of these adaptations operate independently of pathogen load and limit the damage caused by malaria parasites in subsequent infections. Acquired immunity to malaria therefore prioritises host fitness over pathogen clearance.
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Affiliation(s)
- Wiebke Nahrendorf
- Institute of Immunology and Infection Research, University of EdinburghEdinburghUnited Kingdom
| | - Alasdair Ivens
- Institute of Immunology and Infection Research, University of EdinburghEdinburghUnited Kingdom
- Centre for Immunity, Infection and Evolution, University of EdinburghEdinburghUnited Kingdom
| | - Philip J Spence
- Institute of Immunology and Infection Research, University of EdinburghEdinburghUnited Kingdom
- Centre for Immunity, Infection and Evolution, University of EdinburghEdinburghUnited Kingdom
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Piperaquine Pharmacokinetics during Intermittent Preventive Treatment for Malaria in Pregnancy. Antimicrob Agents Chemother 2021; 65:AAC.01150-20. [PMID: 33361303 PMCID: PMC8092554 DOI: 10.1128/aac.01150-20] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Accepted: 12/16/2020] [Indexed: 11/20/2022] Open
Abstract
Dihydroartemisinin-piperaquine (DP) is a long-acting artemisinin combination treatment that provides effective chemoprevention and has been proposed as an alternative antimalarial drug for intermittent preventive therapy in pregnancy (IPTp). Several pharmacokinetic studies have shown that dose adjustment may not be needed for the treatment of malaria in pregnancy with DP. Dihydroartemisinin-piperaquine (DP) is a long-acting artemisinin combination treatment that provides effective chemoprevention and has been proposed as an alternative antimalarial drug for intermittent preventive therapy in pregnancy (IPTp). Several pharmacokinetic studies have shown that dose adjustment may not be needed for the treatment of malaria in pregnancy with DP. However, there are limited data on the optimal dosing for IPTp. This study aimed to evaluate the population pharmacokinetics of piperaquine given as IPTp in pregnant women. Pregnant women were enrolled in clinical trials conducted in Kenya and Indonesia and treated with standard 3-day courses of DP, administered in 4- to 8-week intervals from the second trimester until delivery. Pharmacokinetic blood samples were collected for piperaquine drug measurements before each treatment round, at the time of breakthrough symptomatic malaria, and at delivery. Piperaquine population pharmacokinetic properties were investigated using nonlinear mixed-effects modeling with a prior approach. In total, data from 366 Kenyan and 101 Indonesian women were analyzed. The pharmacokinetic properties of piperaquine were adequately described using a flexible transit absorption (n = 5) followed by a three-compartment disposition model. Gestational age did not affect the pharmacokinetic parameters of piperaquine. After three rounds of monthly IPTp, 9.45% (95% confidence interval [CI], 1.8 to 26.5%) of pregnant women had trough piperaquine concentrations below the suggested target concentration (10.3 ng/ml). Translational simulations suggest that providing the full treatment course of DP at monthly intervals provides sufficient protection to prevent malaria infection. Monthly administration of DP has the potential to offer optimal prevention of malaria during pregnancy. (This study has been registered at ClinicalTrials.gov under identifier NCT01669941 and in the ISRCTN under number ISRCTN34010937.)
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Chandna A, Aderie EM, Ahmad R, Arguni E, Ashley EA, Cope T, Dat VQ, Day NPJ, Dondorp AM, Illanes V, De Jesus J, Jimenez C, Kain K, Suy K, Koshiaris C, Lasry E, Mayxay M, Mondal D, Perera R, Pongvongsa T, Rattanavong S, Rekart M, Richard-Greenblatt M, Shomik M, Souvannasing P, Tallo V, Turner C, Turner P, Waithira N, Watson JA, Yosia M, Burza S, Lubell Y. Prediction of disease severity in young children presenting with acute febrile illness in resource-limited settings: a protocol for a prospective observational study. BMJ Open 2021; 11:e045826. [PMID: 33495264 PMCID: PMC7839891 DOI: 10.1136/bmjopen-2020-045826] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Revised: 12/03/2020] [Accepted: 01/11/2021] [Indexed: 02/06/2023] Open
Abstract
INTRODUCTION In rural and difficult-to-access settings, early and accurate recognition of febrile children at risk of progressing to serious illness could contribute to improved patient outcomes and better resource allocation. This study aims to develop a prognostic clinical prediction tool to assist community healthcare providers identify febrile children who might benefit from referral or admission for facility-based medical care. METHODS AND ANALYSIS This prospective observational study will recruit at least 4900 paediatric inpatients and outpatients under the age of 5 years presenting with an acute febrile illness to seven hospitals in six countries across Asia. A venous blood sample and nasopharyngeal swab is collected from each participant and detailed clinical data recorded at presentation, and each day for the first 48 hours of admission for inpatients. Multianalyte assays are performed at reference laboratories to measure a panel of host biomarkers, as well as targeted aetiological investigations for common bacterial and viral pathogens. Clinical outcome is ascertained on day 2 and day 28.Presenting syndromes, clinical outcomes and aetiology of acute febrile illness will be described and compared across sites. Following the latest guidance in prediction model building, a prognostic clinical prediction model, combining simple clinical features and measurements of host biomarkers, will be derived and geographically externally validated. The performance of the model will be evaluated in specific presenting clinical syndromes and fever aetiologies. ETHICS AND DISSEMINATION The study has received approval from all relevant international, national and institutional ethics committees. Written informed consent is provided by the caretaker of all participants. Results will be shared with local and national stakeholders, and disseminated via peer-reviewed open-access journals and scientific meetings. TRIAL REGISTRATION NUMBER NCT04285021.
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Affiliation(s)
- Arjun Chandna
- Angkor Hospital for Children, Cambodia Oxford Medical Research Unit, Siem Reap, Cambodia
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, Oxfordshire, UK
| | - Endashaw M Aderie
- Médecins Sans Frontières Operational Centre Barcelona, Barcelona, Spain
| | - Riris Ahmad
- Centre for Tropical Medicine, Universitas Gadjah Mada, Yogyakarta, Daerah Istimewa Yogyakart, Indonesia
| | - Eggi Arguni
- Centre for Tropical Medicine, Universitas Gadjah Mada, Yogyakarta, Daerah Istimewa Yogyakart, Indonesia
| | - Elizabeth A Ashley
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, Oxfordshire, UK
- Microbiology Department, Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit, Vientiane, Vientiane, Lao People's Democratic Republic
| | - Tanya Cope
- Faculty of Tropical Medicine, Mahidol-Oxford Tropical Medicine Research Unit, Bangkok, Thailand
| | | | - Nicholas P J Day
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, Oxfordshire, UK
- Faculty of Tropical Medicine, Mahidol-Oxford Tropical Medicine Research Unit, Bangkok, Thailand
| | - Arjen M Dondorp
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, Oxfordshire, UK
- Faculty of Tropical Medicine, Mahidol-Oxford Tropical Medicine Research Unit, Bangkok, Thailand
| | - Victor Illanes
- Médecins Sans Frontières Operational Centre Barcelona, Barcelona, Spain
| | - Joanne De Jesus
- Clinical Trials, Epidemiology and Biostatistics, Research Institute for Tropical Medicine, Muntinlupa City, Philippines
| | - Carolina Jimenez
- Médecins Sans Frontières Operational Centre Barcelona, Barcelona, Spain
| | - Kevin Kain
- Laboratory Medicine & Pathobiology, University of Toronto, Toronto, Ontario, Canada
| | - Keang Suy
- Angkor Hospital for Children, Cambodia Oxford Medical Research Unit, Siem Reap, Cambodia
- Angkor Hospital for Children, Siem Reap, Siem Reap, Cambodia
| | | | - Estrella Lasry
- Médecins Sans Frontières Operational Centre Barcelona, Barcelona, Spain
| | - Mayfong Mayxay
- Microbiology Department, Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit, Vientiane, Vientiane, Lao People's Democratic Republic
- Faculty of Postgraduate Studies, University of Health Sciences, Vientiane, Lao People's Democratic Republic
| | - Dinesh Mondal
- Centre for Nutrition and Food Security (CNFS), icddr,b, Dhaka, Dhaka, Bangladesh
| | - Rafael Perera
- Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Tiengkham Pongvongsa
- Microbiology Department, Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit, Vientiane, Vientiane, Lao People's Democratic Republic
- Savannakhet Provincial Health Department, Savannakhet, Lao People's Democratic Republic
| | - Sayaphet Rattanavong
- Microbiology Department, Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit, Vientiane, Vientiane, Lao People's Democratic Republic
| | - Michael Rekart
- Médecins Sans Frontières Operational Centre Barcelona, Barcelona, Spain
| | | | - Mohammad Shomik
- Centre for Nutrition and Food Security (CNFS), icddr,b, Dhaka, Dhaka, Bangladesh
| | | | - Veronica Tallo
- Clinical Trials, Epidemiology and Biostatistics, Research Institute for Tropical Medicine, Muntinlupa City, Philippines
| | - Claudia Turner
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, Oxfordshire, UK
- Angkor Hospital for Children, Siem Reap, Siem Reap, Cambodia
| | - Paul Turner
- Angkor Hospital for Children, Cambodia Oxford Medical Research Unit, Siem Reap, Cambodia
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, Oxfordshire, UK
| | - Naomi Waithira
- Faculty of Tropical Medicine, Mahidol-Oxford Tropical Medicine Research Unit, Bangkok, Thailand
| | - James A Watson
- Faculty of Tropical Medicine, Mahidol-Oxford Tropical Medicine Research Unit, Bangkok, Thailand
| | - Mikhael Yosia
- Médecins Sans Frontières Operational Centre Barcelona, Barcelona, Spain
| | - Sakib Burza
- Médecins Sans Frontières Operational Centre Barcelona, Barcelona, Spain
| | - Yoel Lubell
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, Oxfordshire, UK
- Faculty of Tropical Medicine, Mahidol-Oxford Tropical Medicine Research Unit, Bangkok, Thailand
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Chandna A, Tan R, Carter M, Van Den Bruel A, Verbakel J, Koshiaris C, Salim N, Lubell Y, Turner P, Keitel K. Predictors of disease severity in children presenting from the community with febrile illnesses: a systematic review of prognostic studies. BMJ Glob Health 2021; 6:e003451. [PMID: 33472837 PMCID: PMC7818824 DOI: 10.1136/bmjgh-2020-003451] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Revised: 11/26/2020] [Accepted: 12/19/2020] [Indexed: 12/23/2022] Open
Abstract
INTRODUCTION Early identification of children at risk of severe febrile illness can optimise referral, admission and treatment decisions, particularly in resource-limited settings. We aimed to identify prognostic clinical and laboratory factors that predict progression to severe disease in febrile children presenting from the community. METHODS We systematically reviewed publications retrieved from MEDLINE, Web of Science and Embase between 31 May 1999 and 30 April 2020, supplemented by hand search of reference lists and consultation with an expert Technical Advisory Panel. Studies evaluating prognostic factors or clinical prediction models in children presenting from the community with febrile illnesses were eligible. The primary outcome was any objective measure of disease severity ascertained within 30 days of enrolment. We calculated unadjusted likelihood ratios (LRs) for comparison of prognostic factors, and compared clinical prediction models using the area under the receiver operating characteristic curves (AUROCs). Risk of bias and applicability of studies were assessed using the Prediction Model Risk of Bias Assessment Tool and the Quality In Prognosis Studies tool. RESULTS Of 5949 articles identified, 18 studies evaluating 200 prognostic factors and 25 clinical prediction models in 24 530 children were included. Heterogeneity between studies precluded formal meta-analysis. Malnutrition (positive LR range 1.56-11.13), hypoxia (2.10-8.11), altered consciousness (1.24-14.02), and markers of acidosis (1.36-7.71) and poor peripheral perfusion (1.78-17.38) were the most common predictors of severe disease. Clinical prediction model performance varied widely (AUROC range 0.49-0.97). Concerns regarding applicability were identified and most studies were at high risk of bias. CONCLUSIONS Few studies address this important public health question. We identified prognostic factors from a wide range of geographic contexts that can help clinicians assess febrile children at risk of progressing to severe disease. Multicentre studies that include outpatients are required to explore generalisability and develop data-driven tools to support patient prioritisation and triage at the community level. PROSPERO REGISTRATION NUMBER CRD42019140542.
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Affiliation(s)
- Arjun Chandna
- Cambodia-Oxford Medical Research Unit, Angkor Hospital for Children, Siem Reap, Cambodia
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
| | - Rainer Tan
- Unisanté Centre for Primary Care and Public Health, University of Lausanne, Lausanne, Switzerland
- University of Basel, Basel, Switzerland
- Swiss Tropical and Public Health Institute, Basel, Basel-Stadt, Switzerland
| | - Michael Carter
- Department of Women and Children's Health, King's College London, London, UK
| | - Ann Van Den Bruel
- Academic Centre of General Practice, University of Leuven, Leuven, Flanders, Belgium
| | - Jan Verbakel
- Academic Centre of General Practice, University of Leuven, Leuven, Flanders, Belgium
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | | | - Nahya Salim
- Ifakara Health Institute, Dar-es-Salaam, Tanzania
- Department of Pediatrics and Child Health, Muhimbili University Health and Allied Sciences, Dar-es-Salaam, Tanzania
| | - Yoel Lubell
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
- Mahidol-Oxford Tropical Medicine Research Unit, Bangkok, Thailand
| | - Paul Turner
- Cambodia-Oxford Medical Research Unit, Angkor Hospital for Children, Siem Reap, Cambodia
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
| | - Kristina Keitel
- Swiss Tropical and Public Health Institute, Basel, Basel-Stadt, Switzerland
- Division of Emergency Medicine, Department of Pediatrics, University Children's Hospital, Inselpital, University of Bern, Bern, Switzerland
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Zhu W, Ling X, Shang W, Du Y, Liu J, Cao Y, Yang M, Zhu G, Cao J, Huang J. High value of rapid diagnostic tests to diagnose malaria within children: A systematic review and meta-analysis. J Glob Health 2020; 10:010411. [PMID: 32373330 PMCID: PMC7182354 DOI: 10.7189/jogh.10.010411] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
Background Children aged under five years accounted for 61% of all malaria deaths worldwide in 2017, and quicker differential diagnosis of malaria fever is vital for them. Rapid diagnostic tests (RDTs) are strips to detect Plasmodium specific antigens promptly and are helpful in resource-limited areas. Thus, our aim is to assess the diagnostic accuracy of RDTs for malaria in children against the gold standard. Methods MEDLINE, Web of Science, EMBASE, Cochrane Library, the China National Knowledge Infrastructure, Wanfang, and Sinomed databases were systematically searched on August 23, 2019. Studies that compared RDTs with microscopy or polymerase chain reaction in malaria diagnoses for children were eligible. Relevant data were extracted. The quality of studies was evaluated using the revised Quality Assessment of Diagnostic Accuracy Studies instrument. Meta-analyses were carried out to calculate the pooled estimates and 95% confidence intervals of sensitivity and specificity. Results 51 articles were included. For diagnostic accuracy, the pooled estimates of the sensitivity and specificity of RDTs were 0.93 (95% confidence interval (CI) = 0.90, 0.95) and 0.93 (95% CI = 0.90, 0.96) respectively. Studies were highly heterogeneous, and subgroup analyses showed that the application of RDTs in high malaria transmission areas had higher sensitivity but lower specificity than those in low-to-moderate areas. Conclusions RDTs have high accuracy for malaria diagnosis in children, and this characteristic is more prominent in high transmission areas. As they also have the advantages of rapid-detection, are easy-to-use, and can be cost-effective, it is recommended that the wider usage of RDTs should be promoted, especially in resource-limited areas. Further research is required to assess their performance in WHO South-East Asia and Americas Region.
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Affiliation(s)
- Wenjun Zhu
- Key Lab of Health Technology Assessment, National Health Commission; School of Public Health, Fudan University, Shanghai, China
| | - XiaoXiao Ling
- Department of Statistical Science, University College London, London, UK
| | - Wenru Shang
- Key Lab of Health Technology Assessment, National Health Commission; School of Public Health, Fudan University, Shanghai, China
| | - Yanqiu Du
- Key Lab of Health Technology Assessment, National Health Commission; School of Public Health, Fudan University, Shanghai, China
| | - Jinyu Liu
- Key Lab of Health Technology Assessment, National Health Commission; School of Public Health, Fudan University, Shanghai, China
| | - Yuanyuan Cao
- National Health Commission Key Laboratory of Parasitic Disease Control and Prevention, Jiangsu Provincial Key Laboratory on Parasite and Vector Control Technology, Jiangsu Institute of Parasitic Diseases, Wuxi, Jiangsu, China
| | - Mengmeng Yang
- National Health Commission Key Laboratory of Parasitic Disease Control and Prevention, Jiangsu Provincial Key Laboratory on Parasite and Vector Control Technology, Jiangsu Institute of Parasitic Diseases, Wuxi, Jiangsu, China
| | - Guoding Zhu
- National Health Commission Key Laboratory of Parasitic Disease Control and Prevention, Jiangsu Provincial Key Laboratory on Parasite and Vector Control Technology, Jiangsu Institute of Parasitic Diseases, Wuxi, Jiangsu, China.,Center for Global Health, School of Public Health, Nanjing Medical University, Nanjing, Jiangsu, China.,Public Health Research Center, Jiangnan University, Wuxi, Jiangsu, China
| | - Jun Cao
- National Health Commission Key Laboratory of Parasitic Disease Control and Prevention, Jiangsu Provincial Key Laboratory on Parasite and Vector Control Technology, Jiangsu Institute of Parasitic Diseases, Wuxi, Jiangsu, China.,Center for Global Health, School of Public Health, Nanjing Medical University, Nanjing, Jiangsu, China.,Public Health Research Center, Jiangnan University, Wuxi, Jiangsu, China
| | - Jiayan Huang
- Key Lab of Health Technology Assessment, National Health Commission; School of Public Health, Fudan University, Shanghai, China
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Patel H, Dunican C, Cunnington AJ. Predictors of outcome in childhood Plasmodium falciparum malaria. Virulence 2020; 11:199-221. [PMID: 32063099 PMCID: PMC7051137 DOI: 10.1080/21505594.2020.1726570] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Revised: 01/16/2020] [Accepted: 01/20/2020] [Indexed: 12/16/2022] Open
Abstract
Plasmodium falciparum malaria is classified as either uncomplicated or severe, determining clinical management and providing a framework for understanding pathogenesis. Severe malaria in children is defined by the presence of one or more features associated with adverse outcome, but there is wide variation in the predictive value of these features. Here we review the evidence for the usefulness of these features, alone and in combination, to predict death and other adverse outcomes, and we consider the role that molecular biomarkers may play in augmenting this prediction. We also examine whether a more personalized approach to predicting outcome for specific presenting syndromes of severe malaria, particularly cerebral malaria, has the potential to be more accurate. We note a general need for better external validation in studies of outcome predictors and for the demonstration that predictors can be used to guide clinical management in a way that improves survival and long-term health.
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Affiliation(s)
- Harsita Patel
- Section of Paediatric Infectious Disease, Department of Infectious Disease, Imperial College London, London, UK
| | - Claire Dunican
- Section of Paediatric Infectious Disease, Department of Infectious Disease, Imperial College London, London, UK
| | - Aubrey J. Cunnington
- Section of Paediatric Infectious Disease, Department of Infectious Disease, Imperial College London, London, UK
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Ashley EA, Poespoprodjo JR. Treatment and prevention of malaria in children. THE LANCET CHILD & ADOLESCENT HEALTH 2020; 4:775-789. [PMID: 32946831 DOI: 10.1016/s2352-4642(20)30127-9] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/24/2019] [Revised: 03/11/2020] [Accepted: 03/25/2020] [Indexed: 10/23/2022]
Abstract
Malaria disproportionately affects children younger than 5 years. Falciparum malaria is responsible for more than 200 000 child deaths per year in Africa and vivax malaria is well documented as a cause of severe anaemia and excess mortality in children in Asia and Oceania. For the treatment of malaria in children, paediatric dosing recommendations for several agents, including parenteral artesunate and dihydroartemisinin-piperaquine, have belatedly been shown to be suboptimal. Worsening antimalarial resistance in Plasmodium falciparum in the Greater Mekong Subregion threatens to undermine global efforts to control malaria. Triple antimalarial combination therapies are being evaluated to try to impede this threat. The RTS,S/AS01 vaccine gives partial protection against falciparum malaria and is being evaluated in large, pilot studies in Ghana, Malawi, and Kenya as a complementary tool to other preventive measures. Seasonal malaria chemoprevention in west Africa has resulted in declines in malaria incidence and deaths and there is interest in scaling up efforts by expanding the age range of eligible recipients. Preventing relapse in Plasmodium vivax infection with primaquine is challenging because treating children who have G6PD deficiency with primaquine can cause acute haemolytic anaemia. The safety of escalating dose regimens for primaquine is being studied to mitigate this risk.
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Affiliation(s)
- Elizabeth A Ashley
- Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit, Vientiane, Laos; Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK.
| | - Jeanne Rini Poespoprodjo
- Timika Research Facility, Papuan Health and Community Development Foundation, Timika, Indonesia; Department of Child Health, Faculty of Medicine, Public Health and Nursing, Gadjah Mada University, Yogyakarta, Indonesia
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Olupot-Olupot P, Engoru C, Nteziyaremye J, Chebet M, Ssenyondo T, Muhindo R, Nyutu G, Macharia AW, Uyoga S, Ndila CM, Karamagi C, Maitland K, Williams TN. The clinical spectrum of severe childhood malaria in Eastern Uganda. Malar J 2020; 19:322. [PMID: 32883291 PMCID: PMC7470679 DOI: 10.1186/s12936-020-03390-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Accepted: 08/25/2020] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND Few recent descriptions of severe childhood malaria have been published from high-transmission regions. In the current study, the clinical epidemiology of severe malaria in Mbale, Eastern Uganda, is described, where the entomological inoculation rate exceeds 100 infective bites per year. METHODS A prospective descriptive study was conducted to determine the prevalence, clinical spectrum and outcome of severe Plasmodium falciparum malaria at Mbale Regional Referral Hospital in Eastern Uganda. All children aged 2 months-12 years who presented on Mondays to Fridays between 8.00 am and 5.00 pm from 5th May 2011 until 30th April 2012 were screened for parasitaemia. Clinical and laboratory data were then collected from all P. falciparum positive children with features of WHO-defined severe malaria by use of a standardized proforma. RESULTS A total of 10 208 children were screened of which 6582 (64%) had a positive blood film. Of these children, 662 (10%) had clinical features of severe malaria and were consented for the current study. Respiratory distress was the most common severity feature (554; 83.7%), while 365/585 (62.4%) had hyperparasitaemia, 177/662 (26.7%) had clinical jaundice, 169 (25.5%) had severe anaemia, 134/660 (20.2%) had hyperlactataemia (lactate ≥ 5 mmol/L), 93 (14.0%) had passed dark red or black urine, 52 (7.9%) had impaired consciousness and 49/662 (7.4%) had hypoxaemia (oxygen saturations < 90%). In-hospital mortality was 63/662 (9.5%) overall but was higher in children with either cerebral malaria (33.3%) or severe anaemia (19.5%). Factors that were independently associated with mortality on multivariate analysis included severe anaemia [odds ratio (OR) 5.36; 2.16-1.32; P = 0.0002], hyperlactataemia (OR 3.66; 1.72-7.80; P = 0.001), hypoxaemia (OR) 3.64 (95% CI 1.39-9.52; P = 0.008), and hepatomegaly (OR 2.29; 1.29-4.06; P = 0.004). No independent association was found between mortality and either coma or hyperparasitaemia. CONCLUSIONS Severe childhood malaria remains common in Eastern Uganda where it continues to be associated with high mortality. An unusually high proportion of children with severe malaria had jaundice or gave a history of having recently passed dark red or black urine, an issue worthy of further investigation.
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Affiliation(s)
- Peter Olupot-Olupot
- Faculty of Health Sciences, Busitema University, Mbale Campus, P.O. Box 1460, Mbale, Uganda.
- Mbale Clinical Research Institute, P.O. Box 1966, Mbale, Uganda.
| | - Charles Engoru
- Soroti Regional Referral Hospital, P.O. Box 289, Soroti, Uganda
| | - Julius Nteziyaremye
- Faculty of Health Sciences, Busitema University, Mbale Campus, P.O. Box 1460, Mbale, Uganda
- Mbale Clinical Research Institute, P.O. Box 1966, Mbale, Uganda
| | - Martin Chebet
- Faculty of Health Sciences, Busitema University, Mbale Campus, P.O. Box 1460, Mbale, Uganda
- Mbale Clinical Research Institute, P.O. Box 1966, Mbale, Uganda
| | - Tonny Ssenyondo
- Mbale Clinical Research Institute, P.O. Box 1966, Mbale, Uganda
| | - Rita Muhindo
- Mbale Clinical Research Institute, P.O. Box 1966, Mbale, Uganda
| | - Gideon Nyutu
- KEMRI-Wellcome Trust Research Programme, Centre for Geographic Medicine Research-Coast, Kilifi, Kenya
| | - Alexander W Macharia
- KEMRI-Wellcome Trust Research Programme, Centre for Geographic Medicine Research-Coast, Kilifi, Kenya
| | - Sophie Uyoga
- KEMRI-Wellcome Trust Research Programme, Centre for Geographic Medicine Research-Coast, Kilifi, Kenya
| | - Carolyne M Ndila
- KEMRI-Wellcome Trust Research Programme, Centre for Geographic Medicine Research-Coast, Kilifi, Kenya
| | - Charles Karamagi
- Makerere University College of Health Sciences, P.O. Box 7072, Kampala, Uganda
| | - Kathryn Maitland
- KEMRI-Wellcome Trust Research Programme, Centre for Geographic Medicine Research-Coast, Kilifi, Kenya
- Institute of Global Health Innovation, Imperial College, Medical School Building St Mary's Campus, Imperial College, London, W2 1PG, UK
| | - Thomas N Williams
- KEMRI-Wellcome Trust Research Programme, Centre for Geographic Medicine Research-Coast, Kilifi, Kenya
- Institute of Global Health Innovation, Imperial College, Medical School Building St Mary's Campus, Imperial College, London, W2 1PG, UK
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Varo R, Chaccour C, Bassat Q. Update on malaria. Med Clin (Barc) 2020; 155:395-402. [PMID: 32620355 DOI: 10.1016/j.medcli.2020.05.010] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Revised: 04/30/2020] [Accepted: 05/01/2020] [Indexed: 01/25/2023]
Abstract
Despite recent successful efforts to reduce the global malaria burden, this disease remains a significant global health problem. Only in 2018, malaria caused 228 million clinical episodes, 2-4 million of which were severe malaria cases, and 405,000 were fatal. Most of the malaria attributable mortality occurred among children in sub-Saharan Africa. Nowadays, rapid diagnostic tests and artemisinin derivatives are two of the main pillars for the management of malaria. However, considering the current situation, these strategies are not sufficient to maintain a reducing trend in malaria incidence and mortality. New insights into the pathophysiology of malaria have highlighted the importance of the host response to infection. Understanding this response would help to develop new diagnostic and therapeutic tools. Vector and parasite drug resistance are two major challenges for malaria control that require special attention. The most advanced malaria vaccine (RTS,S) is currently being piloted in 3 African countries.
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Affiliation(s)
- Rosauro Varo
- ISGlobal, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain; Centro de Investigação em Saúde de Manhiça (CISM), Maputo, Mozambique
| | - Carlos Chaccour
- ISGlobal, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain; Centro de Investigação em Saúde de Manhiça (CISM), Maputo, Mozambique; Ifakara Health Institute, Ifakara, United Republic of Tanzania; Facultad de Medicina, Universidad de Navarra, Pamplona, Spain
| | - Quique Bassat
- ISGlobal, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain; Centro de Investigação em Saúde de Manhiça (CISM), Maputo, Mozambique; ICREA, Pg. Lluís Companys 23, 08010 Barcelona, Spain; Pediatric Infectious Diseases Unit, Pediatrics Department, Hospital Sant Joan de Deu (University of Barcelona), Barcelona, Spain; Consorcio de Investigación Biomédica en Red de Epidemiología y Salud Publica (CIBERESP), Madrid, Spain.
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Mourão LC, Cardoso-Oliveira GP, Braga ÉM. Autoantibodies and Malaria: Where We Stand? Insights Into Pathogenesis and Protection. Front Cell Infect Microbiol 2020; 10:262. [PMID: 32596165 PMCID: PMC7300196 DOI: 10.3389/fcimb.2020.00262] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2020] [Accepted: 05/04/2020] [Indexed: 12/16/2022] Open
Abstract
Autoantibodies are frequently reported in patients with malaria, but whether they contribute to protection or to pathology is an issue of debate. A large body of evidence indicates that antibodies against host-self components are associated to malaria clinical outcomes such as cerebral malaria, renal dysfunction and anemia. Nonetheless, self-reactive immunoglobulins induced during an infection can also mediate protection. In light of these controversies, we summarize here the latest findings in our understanding of autoimmune responses in malaria, focusing on Plasmodium falciparum and Plasmodium vivax. We review the main targets of self-antibody responses in malaria as well as the current, but still limited, knowledge of their role in disease pathogenesis or protection.
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Affiliation(s)
- Luiza Carvalho Mourão
- Departamento de Parasitologia, Instituto de Ciências Biológicas, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | | | - Érika Martins Braga
- Departamento de Parasitologia, Instituto de Ciências Biológicas, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
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Graham H, Bakare AA, Ayede AI, Oyewole OB, Gray A, Neal E, Qazi SA, Duke T, Falade AG. Diagnosis of pneumonia and malaria in Nigerian hospitals: A prospective cohort study. Pediatr Pulmonol 2020; 55 Suppl 1:S37-S50. [PMID: 32074408 PMCID: PMC7318580 DOI: 10.1002/ppul.24691] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2019] [Accepted: 01/30/2020] [Indexed: 11/10/2022]
Abstract
BACKGROUND Pneumonia and malaria are the leading causes of global childhood mortality. We describe the clinical presentation of children diagnosed with pneumonia and/or malaria, and identify possible missed cases and diagnostic predictors. METHODS Prospective cohort study involving children (aged 28 days to 15 years) admitted to 12 secondary-level hospitals in south-west Nigeria, from November 2015 to October 2017. We described children diagnosed with malaria and/or pneumonia on admission and identified potential missed cases using WHO criteria. We used logistic regression models to identify associations between clinical features and severe pneumonia and malaria diagnoses. RESULTS Of 16 432 admitted children, 16 184 (98.5%) had adequate data for analysis. Two-thirds (10 561, 65.4%) of children were diagnosed with malaria and/or pneumonia by the admitting doctor; 31.5% (567/1799) of those with pneumonia were also diagnosed with malaria. Of 1345 (8.3%) children who met WHO severe pneumonia criteria, 557 (41.4%) lacked a pneumonia diagnosis. Compared with "potential missed" diagnoses of severe pneumonia, children with "detected" severe pneumonia were more likely to receive antibiotics (odds ratio [OR], 4.03; 2.63-6.16, P < .001), and less likely to die (OR, 0.72; 0.51-1.02, P = .067). Of 2299 (14.2%) children who met WHO severe malaria criteria, 365 (15.9%) lacked a malaria diagnosis. Compared with "potential missed" diagnoses of severe malaria, children with "detected" severe malaria were less likely to die (OR, 0.59; 0.38-0.91, P = 0.017), with no observed difference in antimalarial administration (OR, 0.29; 0.87-1.93, P = .374). We identified predictors of severe pneumonia and malaria diagnosis. CONCLUSION Pneumonia should be considered in all severely unwell children with respiratory signs, regardless of treatment for malaria or other conditions.
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Affiliation(s)
- Hamish Graham
- Centre for International Child Health, MCRI, Royal Children's Hospital, University of Melbourne, Parkville, Victoria, Australia.,Department of Paediatrics, University College Hospital, Ibadan, Nigeria
| | - Ayobami A Bakare
- Department of Community Medicine, University College Hospital, Ibadan, Nigeria
| | - Adejumoke I Ayede
- Department of Paediatrics, University College Hospital, Ibadan, Nigeria.,Department of Paediatrics, University of Ibadan, Ibadan, Nigeria
| | - Oladapo B Oyewole
- Department of Paediatrics, University College Hospital, Ibadan, Nigeria
| | - Amy Gray
- Centre for International Child Health, MCRI, Royal Children's Hospital, University of Melbourne, Parkville, Victoria, Australia
| | - Eleanor Neal
- Centre for International Child Health, MCRI, Royal Children's Hospital, University of Melbourne, Parkville, Victoria, Australia.,Infection & Immunity, MCRI, Royal Children's Hospital, Parkville, Victoria, Australia
| | - Shamim A Qazi
- Department of Maternal, Newborn, Child and Adolescent Health, World Health Organization, Geneva, Switzerland
| | - Trevor Duke
- Centre for International Child Health, MCRI, Royal Children's Hospital, University of Melbourne, Parkville, Victoria, Australia
| | - Adegoke G Falade
- Department of Paediatrics, University College Hospital, Ibadan, Nigeria.,Department of Paediatrics, University of Ibadan, Ibadan, Nigeria
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Wångdahl A, Wyss K, Saduddin D, Bottai M, Ydring E, Vikerfors T, Färnert A. Severity of Plasmodium falciparum and Non-falciparum Malaria in Travelers and Migrants: A Nationwide Observational Study Over 2 Decades in Sweden. J Infect Dis 2020; 220:1335-1345. [PMID: 31175365 PMCID: PMC6743839 DOI: 10.1093/infdis/jiz292] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2019] [Accepted: 06/05/2019] [Indexed: 12/23/2022] Open
Abstract
Background The aim was to assess factors affecting disease severity in imported P. falciparum and non-falciparum malaria. Methods We reviewed medical records from 2793/3260 (85.7%) of all episodes notified in Sweden between 1995 and 2015 and performed multivariable logistic regression. Results Severe malaria according to WHO 2015 criteria was found in P. falciparum (9.4%), P. vivax (7.7%), P. ovale (5.3%), P. malariae (3.3%), and mixed P. falciparum episodes (21.1%). Factors associated with severe P. falciparum malaria were age <5 years and >40 years, origin in nonendemic country, pregnancy, HIV, region of diagnosis, and health care delay. Moreover, oral treatment of P. falciparum episodes with parasitemia ≥2% without severe signs at presentation was associated with progress to severe malaria with selected criteria. In non-falciparum, age >60 years, health care delay and endemic origin were identified as risk factors for severe disease. Among patients originating in endemic countries, a higher risk for severe malaria, both P. falciparum and non-falciparum, was observed among newly arrived migrants. Conclusions Severe malaria was observed in P. falciparum and non-falciparum episodes. Current WHO criteria for severe malaria may need optimization to better guide the management of malaria of different species in travelers and migrants in nonendemic areas.
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Affiliation(s)
- Andreas Wångdahl
- Division of Infectious Diseases, Department of Medicine Solna, Stockholm.,Department of Infectious Diseases, Västerås Hospital, Västerås
| | - Katja Wyss
- Division of Infectious Diseases, Department of Medicine Solna, Stockholm.,Department of Infectious Diseases, Karolinska University Hospital, Stockholm
| | - Dashti Saduddin
- Division of Infectious Diseases, Department of Medicine Solna, Stockholm
| | - Matteo Bottai
- Unit of Biostatistics, Institute for Environmental Medicine, Karolinska Institutet, Stockholm
| | | | - Tomas Vikerfors
- Department of Infectious Diseases, Västerås Hospital, Västerås
| | - Anna Färnert
- Division of Infectious Diseases, Department of Medicine Solna, Stockholm.,Department of Infectious Diseases, Karolinska University Hospital, Stockholm
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Severe malaria. Current concepts and practical overview: What every intensivist should know. Intensive Care Med 2020; 46:907-918. [PMID: 32347322 DOI: 10.1007/s00134-020-06019-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2019] [Accepted: 03/19/2020] [Indexed: 10/24/2022]
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Jajosky RP, Jajosky AN, Jajosky PG. ABO blood group should be considered and reported when red blood cell exchange transfusion is used to treat Plasmodiumfalciparum Malaria patients. Transfus Clin Biol 2020; 27:179-184. [PMID: 32360095 DOI: 10.1016/j.tracli.2020.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2019] [Revised: 03/13/2020] [Accepted: 03/24/2020] [Indexed: 10/24/2022]
Abstract
Laboratory and epidemiologic studies have clarified how persons born with malaria-resistant red blood cells (RBCs)-like group-O, sickle-trait, and C-trait RBCs-are protected against death or severe disease due to Plasmodiumfalciparum (Pf) infection. Compared to malaria-promoting RBCs-like non-O or hemoglobin-AA RBCs-inborn RBC protection against severe Pf malaria can be profound: up to 10-fold greater. Given that "the Berlin patient" success showed patients do not have to be born with disease-resistant cells to benefit from them, why have the biologically plausible benefits of exchange transfusion (ET) of malaria-resistant RBCs not yet been evaluated? Unfortunately, a 2013 ET-for-malaria meta-analysis could not quantify the impact on mortality of ET of malaria-resistant RBCs because RBC malaria resistance variables (ABO group, hemoglobin type, enzyme levels, etc.) had not been reported in any of the ET studies used in that meta-analysis. To promote evaluation of the therapeutic impact of specific malaria-resistant RBCs, we urge clinicians to always report ABO blood group (and all other RBC malaria-resistance variables they are aware of) when they use ET to rescue Pf-infected patients. Prudent selection of donor RBCs has successfully optimized ET for sickle cell disease patients, and this precedent suggests selection of special malaria-resistant donor RBCs may optimize ET for Pf-malaria patients. Given that ET is used worldwide as a rescue adjunct, we feel it is most prudent to now assume-until proven otherwise-that considering and reporting the Pf-malaria-resistance variables of the RBCs to be transfused-at least ABO status-will help optimize ET-for-malaria.
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Affiliation(s)
- Ryan Philip Jajosky
- Emory University, Department of Pathology and Laboratory Medicine, Atlanta, GA, USA; Biconcavity Inc., Lilburn, GA, USA.
| | - Audrey N Jajosky
- Case Western Reserve University, University Hospitals Cleveland Medical Center, Department of Pathology, Cleveland, OH, USA.
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Brown DD, Solomon S, Lerner D, Del Rio M. Malaria and acute kidney injury. Pediatr Nephrol 2020; 35:603-608. [PMID: 30706124 DOI: 10.1007/s00467-018-4191-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2018] [Revised: 12/19/2018] [Accepted: 12/28/2018] [Indexed: 10/27/2022]
Abstract
Malaria is a parasitic infection transmitted by mosquitos, resulting in significant morbidity and mortality. It affects 212 million worldwide, causing death in up to 303,000 children annually. In the USA, up to 1700 people are affected yearly. Although the prevalence in developed countries is less than in developing countries, travelers from low transmission areas, and those from endemic areas who later return, are very susceptible to malaria and its complications. Severe malaria can cause significant multiorgan dysfunction including acute kidney injury (AKI). The pathogenesis is not clearly understood but proposed mechanisms include acute tubular necrosis (ATN) due to impediments in renal microcirculation, infection-triggered proinflammatory reactions within the kidney, and metabolic disturbances. Providers must consider malarial infection in cases of AKI in someone with a travel history, as early recognition and treatment are crucial to improving outcomes. This article will review malaria-induced AKI in order to provide a better understanding of this infection's effect on the kidneys.
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Affiliation(s)
- Denver D Brown
- Department of Pediatric Nephrology at The Children's Hospital at Montefiore, 3326 Bainbridge Ave, Bronx, NY, 10029, USA.
| | - Sonia Solomon
- Department of Pediatric Nephrology at The Children's Hospital at Montefiore, 3326 Bainbridge Ave, Bronx, NY, 10029, USA
| | - Daniele Lerner
- Department of Pediatric Nephrology at The Children's Hospital at Montefiore, 3326 Bainbridge Ave, Bronx, NY, 10029, USA
| | - Marcela Del Rio
- Department of Pediatric Nephrology at The Children's Hospital at Montefiore, 3326 Bainbridge Ave, Bronx, NY, 10029, USA
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Oshomah-Bello EO, Esezobor CI, Solarin AU, Njokanma FO. Acute Kidney Injury in Children with Severe Malaria Is Common and Associated with Adverse Hospital Outcomes. J Trop Pediatr 2020; 66:218-225. [PMID: 31505001 DOI: 10.1093/tropej/fmz057] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
BACKGROUND The prevalence of acute kidney injury (AKI) in children with severe malaria in sub-Saharan African may have been underestimated. The study aimed to determine the prevalence of AKI in children with severe malaria and its association with adverse hospital outcomes. METHODS At presentation, we measured complete blood count, serum bilirubin, and serum electrolytes, urea and creatinine in children with severe malaria. At 24 h after hospitalization, we repeated serum creatinine measurement. Urine passed in the first 24 h of hospitalization was also measured. We defined AKI and its severity using the Kidney Disease: Improving Global Outcome AKI guidelines. RESULTS The study involved 244 children (53.3% males) with a median age of 3.5 (1.9-7.0) years. One hundred and forty-four (59%) children had AKI, and it reached maximum Stages 1, 2 and 3 in 56 (23%), 45 (18.4%) and 43 (17.6%) children, respectively. The majority (86.1%) with AKI had only elevated serum creatinine. Mortality increased with increasing severity of AKI on univariate analysis but weakened on multiple logistic regression. Mortality was also higher in those with both oliguria and elevated serum creatinine than in those with elevated serum creatinine only (50% vs. 4.8%, p < 0.001). Furthermore, children with AKI spent three days more in hospital than those without AKI (p < 0.001). CONCLUSIONS Acute kidney injury complicates severe malaria in 6 out of every 10 children and is commonly identified using elevated serum creatinine. It is also associated with adverse hospital outcome.
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Affiliation(s)
- Eunice O Oshomah-Bello
- Department of Paediatrics, Lagos State University Teaching Hospital, Ikeja, Lagos State, Nigeria
| | - Christopher I Esezobor
- Department of Paediatrics, Faculty of Clinical Sciences, College of Medicine, University of Lagos, Mushin, Lagos State, Nigeria.,Department of Paediatrics, Lagos University Teaching Hospital, Mushin, Lagos State, Nigeria
| | - Adaobi U Solarin
- Department of Paediatrics, Lagos State University College of Medicine, Ikeja, Lagos State, Nigeria
| | - Fidelis O Njokanma
- Department of Paediatrics, Lagos State University Teaching Hospital, Ikeja, Lagos State, Nigeria.,Department of Paediatrics, Lagos State University College of Medicine, Ikeja, Lagos State, Nigeria
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Ouédraogo M, Kangoye DT, Samadoulougou S, Rouamba T, Donnen P, Kirakoya-Samadoulougou F. Malaria Case Fatality Rate among Children under Five in Burkina Faso: An Assessment of the Spatiotemporal Trends Following the Implementation of Control Programs. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:E1840. [PMID: 32178354 PMCID: PMC7143776 DOI: 10.3390/ijerph17061840] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Revised: 03/04/2020] [Accepted: 03/09/2020] [Indexed: 12/14/2022]
Abstract
Reducing the 2015 level of malaria mortality by 90% by 2030 is a goal set by the World Health Organization (WHO). In Burkina Faso, several malaria control programs proven to be effective were implemented over the last decade. In parallel, the progressive strengthening of the health surveillance system is generating valuable data, which represents a great opportunity for analyzing the trends in malaria burden and assessing the effect of these control programs. Complementary programs were rolled out at different time points and paces, and the present work aims at investigating both the spatial and temporal pattern of malaria case fatality rate (mCFR) by considering the effect of combining specific and unspecific malaria control programs. To this end, data on severe malaria cases and malaria deaths, aggregated at health district level between January 2013 and December 2018, were extracted from the national health data repository (ENDOS-BF). A Bayesian spatiotemporal zero-inflated Poisson model was fitted to quantify the strength of the association of malaria control programs with monthly mCFR trends at health district level. The model was adjusted for contextual variables. We found that monthly mCFR decreased from 2.0 (95% IC 1.9-2.1%) to 0.9 (95% IC 0.8-1.0%) deaths for 100 severe malaria cases in 2013 and 2018, respectively. Health districts with high mCFR were identified in the northern, northwestern and southwestern parts of the country. The availability of malaria rapid diagnosis tests (IRR: 0.54; CrI: 0.47, 0.62) and treatment (IRR: 0.50; CrI: 0.41, 0.61) were significantly associated with a reduction in the mCFR. The risk of dying from malaria was lower in the period after the free healthcare policy compared with the period before (IRR: 0.47; CrI: 0.38, 0.58). Our findings highlighted locations that are most in need of targeted interventions and the necessity to sustain and strengthen the launched health programs to further reduce the malaria deaths in Burkina Faso.
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Affiliation(s)
- Mady Ouédraogo
- Centre de Recherche en Epidémiologie, Biostatistiques et Recherche Clinique, Ecole de Santé Publique, Université Libre de Bruxelles, 1070 Brussels, Belgium; (M.O.); (T.R.); (P.D.)
- Institut de Recherche Santé et Sociétés, Faculté de Santé Publique, Université catholique de Louvain, 1200 Brussels, Belgium
- Institut National de la Statistique et de la Démographie [INSD], 01 BP 374 Ouagadougou 01, Burkina Faso
| | - David Tiga Kangoye
- Centre National de Recherche et de Formation sur le Paludisme [CNRFP], 01 BP 2208 Ouagadougou 101, Burkina Faso;
| | - Sékou Samadoulougou
- Evaluation Platform on Obesity Prevention, Quebec Heart and Lung Institute, Quebec, QC G1V 4G5, Canada;
- Centre for Research on Planning and Development (CRAD), Université Laval, Quebec, QC G1V 0A6, Canada
| | - Toussaint Rouamba
- Centre de Recherche en Epidémiologie, Biostatistiques et Recherche Clinique, Ecole de Santé Publique, Université Libre de Bruxelles, 1070 Brussels, Belgium; (M.O.); (T.R.); (P.D.)
- Unité de Recherche Clinique de Nanoro, Institut de Recherche en Sciences de la Santé, Centre National de la Recherche Scientifique et Technologique, 42 Avenue Kumda-Yonre, Ouagadougou, Kadiogo 11 BP 218 Ouagadougou CMS 11, Burkina Faso
| | - Philippe Donnen
- Centre de Recherche en Epidémiologie, Biostatistiques et Recherche Clinique, Ecole de Santé Publique, Université Libre de Bruxelles, 1070 Brussels, Belgium; (M.O.); (T.R.); (P.D.)
- Centre de Recherche en Politiques et systèmes de santé-Santé internationale, École de Santé Publique Université Libre de Bruxelles, 1070 Brussels, Belgium
| | - Fati Kirakoya-Samadoulougou
- Centre de Recherche en Epidémiologie, Biostatistiques et Recherche Clinique, Ecole de Santé Publique, Université Libre de Bruxelles, 1070 Brussels, Belgium; (M.O.); (T.R.); (P.D.)
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Sacomboio ENM, Santos Sebastião CD, Tchivango AT, Pecoits-Filho R, Calice-Silva V. Does parasitemia level increase the risk of acute kidney injury in patients with malaria? Results from an observational study in Angola. SCIENTIFIC AFRICAN 2020. [DOI: 10.1016/j.sciaf.2019.e00232] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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Jajosky RP, Jajosky AN, Jajosky PG. "Dual-gene" malaria-resistance: Therapeutically-rational exchange (T-REX) of group-O sickle trait and group-O C-traittrait red blood cells can be evaluated in Benin and Nigeria. Transfus Apher Sci 2020; 59:102733. [PMID: 32019737 DOI: 10.1016/j.transci.2020.102733] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Revised: 01/06/2020] [Accepted: 01/17/2020] [Indexed: 11/17/2022]
Abstract
BACKGROUND Using indicators of disease severity, clinicians can predict which Plasmodium falciparum (Pf) malaria patients being treated with artesunate or quinine are likely to die despite these drugs. Effective "rescue adjuncts" are needed when drugs alone are inadequate. "Therapeutically-rational exchange" (T-REX) of special malaria-resistant red blood cells (RBCs) has been proposed to optimize adjunctive exchange transfusion. METHODS Studies were reviewed that (1) quantified how group-O status and "sickle-trait" (HbAS) and "C-trait" (HbAC) hemoglobins affect Pf mortality, risk of thrombosis, or birth outcomes for women with pregnancy associated malaria (PAM), (2) reported prevalences of "dual-gene" malaria-resistant RBCs, or (3) reflected the level of exchange-transfusion and malaria-related expertise in Benin and Nigeria. RESULTS Data show that the malaria- and thrombosis-resistance of RBCs depend on specific genes and the patient's clinical status and medical history. In malaria-endemic Benin and Nigeria, prevalences of "dual-gene" malaria-resistant group-O HbAS and group-O HbAC RBCs are substantial, and both malaria- and exchange-related expertise are outstanding. CONCLUSIONS T-REX of "dual-gene" malaria-resistant RBCs is feasible in Benin and Nigeria and warrants evaluation as a rescue adjunct for 3 subsets of Pf-malaria patients. For therapeutic use, group-O HbAS RBCs are likely to be more effective than non-O HbAS RBCs for Pf-infected patients who (1) have a history of thrombosis or (2) are taking birth-control hormones while group-O HbAC RBCs may substantially improve birth outcomes for women with PAM. Studies suggest it is prudent to assume - until proven otherwise - that T-REX of "dual-gene" malaria-resistant RBCs can improve ("personalize") rescue of these patient subsets.
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Affiliation(s)
- Ryan Philip Jajosky
- Emory University, Department of Pathology and Laboratory Medicine, Atlanta, GA, USA; Biconcavity Inc., Retired USPHS Officer at Centers for Disease Control and Prevention,1106 Spring Mill Dr. SW, Lilburn, GA 30047, USA.
| | - Audrey N Jajosky
- Case Western Reserve University, University Hospitals Cleveland Medical Center, Department of Pathology, 11100 Euclid Avenue, Cleveland, OH 44106, USA.
| | - Philip G Jajosky
- Biconcavity Inc., Retired USPHS Officer at Centers for Disease Control and Prevention,1106 Spring Mill Dr. SW, Lilburn, GA 30047, USA.
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