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Getachew H, Demissew A, Abossie A, Habtamu K, Wang X, Zhong D, Zhou G, Lee MC, Hemming-Schroeder E, Bradley L, Degefa T, Hawaria D, Tsegaye A, W Kazura J, Koepfli C, Yan G, Yewhalaw D. Asymptomatic and submicroscopic malaria infections in sugar cane and rice development areas of Ethiopia. Malar J 2023; 22:341. [PMID: 37940948 PMCID: PMC10634149 DOI: 10.1186/s12936-023-04762-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Accepted: 10/22/2023] [Indexed: 11/10/2023] Open
Abstract
BACKGROUND Water resource development projects, such as dams and irrigation schemes, have a positive impact on food security and poverty reduction. However, such projects could increase prevalence of vector borne disease, such as malaria. This study investigate the impact of different agroecosystems and prevalence of malaria infection in Southwest Ethiopia. METHODS Two cross-sectional surveys were conducted in the dry and wet seasons in irrigated and non-irrigated clusters of Arjo sugarcane and Gambella rice development areas of Ethiopia in 2019. A total of 4464 and 2176 study participants from 1449 households in Arjo and 546 households in Gambella enrolled in the study and blood samples were collected, respectively. All blood samples were microscopically examined and a subset of microscopy negative blood samples (n = 2244) were analysed by qPCR. Mixed effect logistic regression and generalized estimating equation were used to determine microscopic and submicroscopic malaria infection and the associated risk factors, respectively. RESULTS Prevalence by microscopy was 2.0% (88/4464) in Arjo and 6.1% (133/2176) in Gambella. In Gambella, prevalence was significantly higher in irrigated clusters (10.4% vs 3.6%) than in non-irrigated clusters (p < 0.001), but no difference was found in Arjo (2.0% vs 2.0%; p = 0.993). On the other hand, of the 1713 and 531 samples analysed by qPCR from Arjo and Gambella the presence of submicroscopic infection was 1.2% and 12.8%, respectively. Plasmodium falciparum, Plasmodium vivax, and Plasmodium ovale were identified by qPCR in both sites. Irrigation was a risk factor for submicroscopic infection in both Arjo and Gambella. Irrigation, being a migrant worker, outdoor job, < 6 months length of stay in the area were risk factors for microscopic infection in Gambella. Moreover, school-age children and length of stay in the area for 1-3 years were significant predictors for submicroscopic malaria in Gambella. However, no ITN utilization was a predictor for both submicroscopic and microscopic infection in Arjo. Season was also a risk factor for microscopic infection in Arjo. CONCLUSION The study highlighted the potential importance of different irrigation practices impacting on submicroscopic malaria transmission. Moreover, microscopic and submicroscopic infections coupled with population movement may contribute to residual malaria transmission and could hinder malaria control and elimination programmes in the country. Therefore, strengthening malaria surveillance and control by using highly sensitive diagnostic tools to detect low-density parasites, screening migrant workers upon arrival and departure, ensuring adequate coverage and proper utilization of vector control tools, and health education for at-risk groups residing or working in such development corridors is needed.
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Affiliation(s)
- Hallelujah Getachew
- Department of Medical Laboratory Technology, Arbaminch College of Health Sciences, Arbaminch, Ethiopia.
- Department of Medical Laboratory Sciences, Institute of Health, Jimma University, Jimma, Ethiopia.
- Tropical and Infectious Diseases Research Center (TIDRC), Jimma University, Jimma, Ethiopia.
| | - Assalif Demissew
- Department of Medical Laboratory Sciences, College of Medicine and Health Sciences, Ambo University, Ambo, Ethiopia
- Aklilu Lemma Institute of Pathobiology, Addis Ababa University, Addis Ababa, Ethiopia
| | - Ashenafi Abossie
- Department of Medical Laboratory Sciences, College of Medicine and Health Science, Arbaminch University, Arbaminch, Ethiopia
- Department of Medical Laboratory Sciences, Institute of Health, Jimma University, Jimma, Ethiopia
- Tropical and Infectious Diseases Research Center (TIDRC), Jimma University, Jimma, Ethiopia
| | - Kassahun Habtamu
- Menelik II Medical & Health Science College, Addis Ababa, Ethiopia
- Department of Microbial, Cellular & Molecular Biology, Addis Ababa University, Addis Ababa, Ethiopia
| | - Xiaoming Wang
- Program in Public Health, University of California at Irvine, Irvine, CA92697, USA
| | - Daibin Zhong
- Program in Public Health, University of California at Irvine, Irvine, CA92697, USA
| | - Guofa Zhou
- Program in Public Health, University of California at Irvine, Irvine, CA92697, USA
| | - Ming-Chieh Lee
- Program in Public Health, University of California at Irvine, Irvine, CA92697, USA
| | - Elizabeth Hemming-Schroeder
- Center for Vector Born Infectious Diseases (CVID), Department of Microbiology Immunology and Pathology, Colorado State University, Fort Collins, USA
| | - Lauren Bradley
- Program in Public Health, University of California at Irvine, Irvine, CA92697, USA
| | - Teshome Degefa
- Department of Medical Laboratory Sciences, Institute of Health, Jimma University, Jimma, Ethiopia
| | - Dawit Hawaria
- School of Environmental Health, Hawassa University, Hawassa, Ethiopia
| | - Arega Tsegaye
- Department of Medical Laboratory Sciences, Institute of Health, Jimma University, Jimma, Ethiopia
- Department of Biology, College of Natural Science, Jimma University, Jimma, Ethiopia
- Tropical and Infectious Diseases Research Center (TIDRC), Jimma University, Jimma, Ethiopia
| | - James W Kazura
- Biomedical Research Case Western Reserve University, Cleveland, OH, USA
- Center for Global Health & Disease School of Medicine Case, Western Reserve University, Cleveland, OH, USA
| | - Cristian Koepfli
- Department of Biological Sciences 319 Galvin Life Sciences, Eck Institute for Global Health, University of Notre Dame, Notre Dame, USA
| | - Guiyun Yan
- Program in Public Health, University of California at Irvine, Irvine, CA92697, USA
| | - Delenasaw Yewhalaw
- Department of Medical Laboratory Sciences, Institute of Health, Jimma University, Jimma, Ethiopia
- Tropical and Infectious Diseases Research Center (TIDRC), Jimma University, Jimma, Ethiopia
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Lufele E, Manning L, Lorry L, Warrel J, Aipit S, Robinson LJ, Laman M. The association of intraleucocytic malaria pigment and disease severity in Papua New Guinean children with severe P. falciparum malaria. Trans R Soc Trop Med Hyg 2023; 117:797-803. [PMID: 37334767 PMCID: PMC10629949 DOI: 10.1093/trstmh/trad037] [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: 01/22/2023] [Revised: 04/10/2023] [Accepted: 05/19/2023] [Indexed: 06/20/2023] Open
Abstract
BACKGROUND Plasmodium falciparum pigment-containing leucocytes (PCLs) are associated with adverse clinical manifestations of severe malaria in African children. However, limited data exist on the association of PCLs in settings outside of Africa. METHODS Thin films on peripheral blood slides obtained from children ages 6 months-10 y with severe malaria were examined for PCLs. The intraleucocytic pigment data were correlated with clinical phenotypic data such as severe anaemia, metabolic acidosis and coma to determine the association of PCLs with clinical phenotypes of severe malaria and outcome. RESULTS Of the 169 children with severe P. falciparum malaria confirmed by microscopy, 76% (129/169) had PCLs. Compared with children without PCLs, the presence (adjusted odds ratio [AOR] 3.2 [95% confidence interval {CI} 1.5 to 6.9], p≤0.01) and quantity (AOR 1.0 [95% CI 1.0 to 1.1], p=0.04) of pigment-containing monocytes (PCMs) was significantly associated with severe anaemia, while the quantity of both PCMs (AOR 1.0 [95% CI 1.0 to 1.1], p≤0.01) and pigment-containing neutrophils (AOR 1.0 [95% CI 1.0 to 1.1], p=0.01) was significantly associated with metabolic acidosis. Plasma P. falciparum histidine-rich protein-2 level negatively correlated with the platelet count (r=-0.5, p≤0.01) in patients with PCLs and no PCLs. CONCLUSIONS In Papua New Guinean children with severe P. falciparum malaria, the presence and quantity of PCLs are predictors of disease severity, severe anaemia and metabolic acidosis.
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Affiliation(s)
- Elvin Lufele
- Vector Borne Diseases Unit, Papua New Guinea Institute of Medical Research, Madang, Papua New Guinea
- Global Tropical Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, NT, Australia
| | - Laurens Manning
- School of Medicine and Pharmacology, University of Western Australia, Perth, WA, Australia
| | - Lina Lorry
- Vector Borne Diseases Unit, Papua New Guinea Institute of Medical Research, Madang, Papua New Guinea
| | - Jonathan Warrel
- Vector Borne Diseases Unit, Papua New Guinea Institute of Medical Research, Madang, Papua New Guinea
| | - Susan Aipit
- Vector Borne Diseases Unit, Papua New Guinea Institute of Medical Research, Madang, Papua New Guinea
- Paediatrics Division, Modilon Hospital, Madang, Papua New Guinea
| | - Leanne J Robinson
- Vector Borne Diseases Unit, Papua New Guinea Institute of Medical Research, Madang, Papua New Guinea
- Vector Borne Diseases and Tropical Public Health Division, Burnet Institute, Melbourne, VIC, Australia
| | - Moses Laman
- Vector Borne Diseases Unit, Papua New Guinea Institute of Medical Research, Madang, Papua New Guinea
- Paediatrics Division, Modilon Hospital, Madang, Papua New Guinea
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Wynberg E, Commons RJ, Humphreys G, Ashurst H, Burrow R, Adjei GO, Adjuik M, Anstey NM, Anvikar A, Baird KJ, Barber BE, Barennes H, Baudin E, Bell DJ, Bethell D, Binh TQ, Borghini-Fuhrer I, Chu CS, Daher A, D’Alessandro U, Das D, Davis TME, de Vries PJ, Djimde AA, Dondorp AM, Dorsey G, Faucher JFF, Fogg C, Gaye O, Grigg M, Hatz C, Kager PA, Lacerda M, Laman M, Mårtensson A, Menan HIE, Monteiro WM, Moore BR, Nosten F, Ogutu B, Osorio L, Penali LK, Pereira DB, Rahim AG, Ramharter M, Sagara I, Schramm B, Seidlein L, Siqueira AM, Sirima SB, Starzengruber P, Sutanto I, Taylor WR, Toure OA, Utzinger J, Valea I, Valentini G, White NJ, William T, Woodrow CJ, Richmond CL, Guerin PJ, Price RN, Stepniewska K. Variability in white blood cell count during uncomplicated malaria and implications for parasite density estimation: a WorldWide Antimalarial Resistance Network individual patient data meta-analysis. Malar J 2023; 22:174. [PMID: 37280686 DOI: 10.1186/s12936-023-04583-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Accepted: 05/07/2023] [Indexed: 06/08/2023] Open
Abstract
BACKGROUND The World Health Organization (WHO) recommends that when peripheral malarial parasitaemia is quantified by thick film microscopy, an actual white blood cell (WBC) count from a concurrently collected blood sample is used in calculations. However, in resource-limited settings an assumed WBC count is often used instead. The aim of this study was to describe the variability in WBC count during acute uncomplicated malaria, and estimate the impact of using an assumed value of WBC on estimates of parasite density and clearance. METHODS Uncomplicated malaria drug efficacy studies that measured WBC count were selected from the WorldWide Antimalarial Resistance Network data repository for an individual patient data meta-analysis of WBC counts. Regression models with random intercepts for study-site were used to assess WBC count variability at presentation and during follow-up. Inflation factors for parasitaemia density, and clearance estimates were calculated for methods using assumed WBC counts (8000 cells/µL and age-stratified values) using estimates derived from the measured WBC value as reference. RESULTS Eighty-four studies enrolling 27,656 patients with clinically uncomplicated malaria were included. Geometric mean WBC counts (× 1000 cells/µL) in age groups < 1, 1-4, 5-14 and ≥ 15 years were 10.5, 8.3, 7.1, 5.7 and 7.5, 7.0, 6.5, 6.0 for individuals with falciparum (n = 24,978) and vivax (n = 2678) malaria, respectively. At presentation, higher WBC counts were seen among patients with higher parasitaemia, severe anaemia and, for individuals with vivax malaria, in regions with shorter regional relapse periodicity. Among falciparum malaria patients, using an assumed WBC count of 8000 cells/µL resulted in parasite density underestimation by a median (IQR) of 26% (4-41%) in infants < 1 year old but an overestimation by 50% (16-91%) in adults aged ≥ 15 years. Use of age-stratified assumed WBC values removed systematic bias but did not improve precision of parasitaemia estimation. Imprecision of parasite clearance estimates was only affected by the within-patient WBC variability over time, and remained < 10% for 79% of patients. CONCLUSIONS Using an assumed WBC value for parasite density estimation from a thick smear may lead to underdiagnosis of hyperparasitaemia and could adversely affect clinical management; but does not result in clinically consequential inaccuracies in the estimation of the prevalence of prolonged parasite clearance and artemisinin resistance.
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Getachew H, Demissew A, Abossie A, Habtamu K, Wang X, Zhong D, Zhou G, Lee MC, Hemming-Schroeder E, Bradley L, Degefa T, Hawaria D, Tsegaye A, Kazura JW, Koepfli C, Yan G, Yewhalaw D. Asymptomatic and submicroscopic malaria infections in sugar cane and rice development areas of Ethiopia. RESEARCH SQUARE 2023:rs.3.rs-2692688. [PMID: 36993196 PMCID: PMC10055656 DOI: 10.21203/rs.3.rs-2692688/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/31/2023]
Abstract
Background Water resource development projects such as dams and irrigation schemes have a positive impact on food security and poverty reduction but might result in increased prevalence of malaria. Methods Two cross-sectional surveys were conducted in the dry and wet seasons in irrigated and non-irrigated clusters of Arjo sugarcane and Gambella rice development areas of Ethiopia in 2019. A total of 4464 and 2176 blood samples were collected from Arjo and Gambella. A subset of 2244 microscopy negative blood samples were analyzed by PCR. Results Prevalence by microscopy was 2.0% (88/4464) in Arjo and 6.1% (133/2176) in Gambella. In Gambella, prevalence was significantly higher in irrigated clusters (10.4% vs 3.6%) than in non-irrigated clusters (p < 0.001), but no difference was found in Arjo (2.0% vs 2.0%; p = 0.993). Level of education was an individual risk factors associated with infection in Arjo [AOR: 3.2; 95%CI (1.27-8.16)] and in Gambella [AOR: 1.7; 95%CI (1.06-2.82)]. While duration of stay in the area for < 6 months [AOR: 4.7; 95%CI (1.84-12.15)] and being a migrant worker [AOR: 4.7; 95%CI (3.01-7.17)] were risk factors in Gambella. Season [AOR: 15.9; 95%CI (6.01-42.04)], no ITN utilization [AOR: 22.3; 95%CI (7.74-64.34)] were risk factors in Arjo, and irrigation [AOR: 2.4; 95%CI (1.45-4.07)] and family size [AOR: 2.3; 95%CI (1.30-4.09)] risk factors in Gambella. Of the 1713 and 531 randomly selected smear negative samples from Arjo and Gambella and analyzed by PCR the presence of Plasmodium infection was 1.2% and 12.8%, respectively. P. falciparum, P. vivax, and P. ovale were identified by PCR in both sites. Conclusion Strengthening malaria surveillance and control in project development areas and proper health education for at-risk groups residing or working in such development corridors is needed.
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Affiliation(s)
- Hallelujah Getachew
- Department of Medical Laboratory Technology, Arbaminch College of Health Sciences, Arbaminch
| | - Assalif Demissew
- Department of Medical Laboratory Sciences, College of Medicine and Health Sciences, Ambo University, Ambo
| | - Ashenafi Abossie
- Department of Medical Laboratory Sciences, College of Medicine and Health Science, Arbaminch University, Arbaminch
| | | | - Xiaoming Wang
- Program in Public Health, University of California at Irvine, Irvine, CA 92697
| | - Daibin Zhong
- Program in Public Health, University of California at Irvine, Irvine, CA 92697
| | - Guofa Zhou
- Program in Public Health, University of California at Irvine, Irvine, CA 92697
| | - Ming-Chieh Lee
- Program in Public Health, University of California at Irvine, Irvine, CA 92697
| | - Elizabeth Hemming-Schroeder
- Center for Vector Born Infectious Diseases (CVID), Department of Microbiology Immunology and Pathology, Colorado State University
| | - Lauren Bradley
- Program in Public Health, University of California at Irvine, Irvine, CA 92697
| | - Teshome Degefa
- Department of Medical Laboratory Sciences, Institute of Health, Jimma University, Jimma
| | - Dawit Hawaria
- Hawassa University, School of Environmental Health, Hawassa
| | - Arega Tsegaye
- Department of Biology, College of Natural Science, Jimma University
| | - James W Kazura
- Biomedical Research Case Western Reserve University, Cleveland, Ohio
| | - Cristian Koepfli
- Department of Biological Sciences 319 Galvin Life Sciences, Eck Institute for Global Health, University of Notre Dame, Notre Dame
| | - Guiyun Yan
- Program in Public Health, University of California at Irvine, Irvine, CA 92697
| | - Delenasaw Yewhalaw
- Department of Medical Laboratory Sciences, Institute of Health, Jimma University, Jimma
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Orbán Á, Longley RJ, Sripoorote P, Maneechai N, Nguitragool W, Butykai Á, Mueller I, Sattabongkot J, Karl S, Kézsmárki I. Sensitive detection of Plasmodium vivax malaria by the rotating-crystal magneto-optical method in Thailand. Sci Rep 2021; 11:18547. [PMID: 34535695 PMCID: PMC8448879 DOI: 10.1038/s41598-021-97532-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Accepted: 08/09/2021] [Indexed: 11/29/2022] Open
Abstract
The rotating-crystal magneto-optical detection (RMOD) method has been developed for the rapid and quantitative diagnosis of malaria and tested systematically on various malaria infection models. Very recently, an extended field trial in a high-transmission region of Papua New Guinea demonstrated its great potential for detecting malaria infections, in particular Plasmodium vivax. In the present small-scale field test, carried out in a low-transmission area of Thailand, RMOD confirmed malaria in all samples found to be infected with Plasmodium vivax by microscopy, our reference method. Moreover, the magneto-optical signal for this sample set was typically 1–3 orders of magnitude higher than the cut-off value of RMOD determined on uninfected samples. Based on the serial dilution of the original patient samples, we expect that the method can detect Plasmodium vivax malaria in blood samples with parasite densities as low as \documentclass[12pt]{minimal}
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\begin{document}$$\sim$$\end{document}∼5–10 parasites per microliter, a limit around the pyrogenic threshold of the infection. In addition, by investigating the correlation between the magnitude of the magneto-optical signal, the parasite density and the erythrocytic stage distribution, we estimate the relative hemozoin production rates of the ring and the trophozoite stages of in vivo Plasmodium vivax infections.
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Affiliation(s)
- Ágnes Orbán
- Department of Physics, Budapest University of Technology and Economics, Budapest, Hungary.
| | - Rhea J Longley
- Population Health and Immunity Division, Walter and Eliza Hall Institute of Medical Research, Melbourne, VIC, Australia.,Mahidol Vivax Research Unit, Mahidol University, Bangkok, Thailand.,Department of Medical Biology, University of Melbourne, Melbourne, VIC, Australia
| | | | | | - Wang Nguitragool
- Department of Molecular Tropical Medicine and Genetics, Mahidol University, Bangkok, Thailand
| | - Ádám Butykai
- Department of Physics, Budapest University of Technology and Economics, Budapest, Hungary
| | - Ivo Mueller
- Population Health and Immunity Division, Walter and Eliza Hall Institute of Medical Research, Melbourne, VIC, Australia.,Department of Medical Biology, University of Melbourne, Melbourne, VIC, Australia.,Unité Malaria: Parasites et Hôtes, Département Parasites et Insectes Vecteurs, Institut Pasteur, Paris, France
| | | | - Stephan Karl
- Vector-borne Diseases Unit, PNG Institute of Medical Research, Madang, Madang Province 511, Papua New Guinea.,Australian Institute of Tropical Health and Medicine, James Cook University, Smithfield, QLD, Australia
| | - István Kézsmárki
- Department of Physics, Budapest University of Technology and Economics, Budapest, Hungary.,Experimental Physics 5, Center for Electronic Correlations and Magnetism, University of Augsburg, Augsburg, Germany
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Magneto-optical diagnosis of symptomatic malaria in Papua New Guinea. Nat Commun 2021; 12:969. [PMID: 33579923 PMCID: PMC7881035 DOI: 10.1038/s41467-021-21110-w] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Accepted: 01/07/2021] [Indexed: 11/20/2022] Open
Abstract
Improved methods for malaria diagnosis are urgently needed. Here, we evaluate a novel method named rotating-crystal magneto-optical detection (RMOD) in 956 suspected malaria patients in Papua New Guinea. RMOD tests can be conducted within minutes and at low cost. We systematically evaluate the capability of RMOD to detect infections by directly comparing it with expert light microscopy, rapid diagnostic tests and polymerase chain reaction on capillary blood samples. We show that compared to light microscopy, RMOD exhibits 82% sensitivity and 84% specificity to detect any malaria infection and 87% sensitivity and 88% specificity to detect Plasmodium vivax. This indicates that RMOD could be useful in P. vivax dominated elimination settings. Parasite density correlates well with the quantitative magneto-optical signal. Importantly, residual hemozoin present in malaria-negative patients is also detectable by RMOD, indicating its ability to detect previous infections. This could be exploited to reveal transmission hotspots in low-transmission settings. Here Arndt et al. establish rotating-crystal magneto-optical detection (RMOD) as a near-point-of-care diagnostic tool for malaria detection and report a sensitivity and specificity of 82% and 84%, respectively, as validated by analyzing a clinical population in a high transmission setting in Papua New Guinea.
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Zhao Y, Wang L, Soe MT, Aung PL, Wei H, Liu Z, Ma T, Huang Y, Menezes LJ, Wang Q, Kyaw MP, Nyunt MH, Cui L, Cao Y. Molecular surveillance for drug resistance markers in Plasmodium vivax isolates from symptomatic and asymptomatic infections at the China-Myanmar border. Malar J 2020; 19:281. [PMID: 32758218 PMCID: PMC7409419 DOI: 10.1186/s12936-020-03354-x] [Citation(s) in RCA: 13] [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: 05/07/2020] [Accepted: 07/28/2020] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND In the Greater Mekong sub-region, Plasmodium vivax has become the predominant species and imposes a major challenge for regional malaria elimination. This study aimed to investigate the variations in genes potentially related to drug resistance in P. vivax populations from the China-Myanmar border area. In addition, this study also wanted to determine whether divergence existed between parasite populations associated with asymptomatic and acute infections. METHODS A total of 66 P. vivax isolates were obtained from patients with acute malaria who attended clinics at the Laiza area, Kachin State, Myanmar in 2015. In addition, 102 P. vivax isolates associated with asymptomatic infections were identified by screening of volunteers without signs or symptoms from surrounding villages. Slide-positive samples were verified with nested PCR detecting the 18S rRNA gene. Multiclonal infections were further excluded by genotyping at msp-3α and msp-3β genes. Parasite DNA from 60 symptomatic cases and 81 asymptomatic infections was used to amplify and sequence genes potentially associated with drug resistance, including pvmdr1, pvcrt-o, pvdhfr, pvdhps, and pvk12. RESULTS The pvmdr1 Y976F and F1076L mutations were present in 3/113 (2.7%) and 97/113 (85.5%) P. vivax isolates, respectively. The K10 insertion in pvcrt-o gene was found in 28.2% of the parasites. Four mutations in the two antifolate resistance genes reached relatively high levels of prevalence: pvdhfr S58R (53.4%), S117N/T (50.8%), pvdhps A383G (75.0%), and A553G (36.3%). Haplotypes with wild-type pvmdr1 (976Y/997K/1076F) and quadruple mutations in pvdhfr (13I/57L/58R/61M/99H/117T/173I) were significantly more prevalent in symptomatic than asymptomatic infections, whereas the pvmdr1 mutant haplotype 976Y/997K/1076L was significantly more prevalent in asymptomatic than symptomatic infections. In addition, quadruple mutations at codons 57, 58, 61 and 117 of pvdhfr and double mutations at codons 383 and 553 of pvdhps were found both in asymptomatic and symptomatic infections with similar frequencies. No mutations were found in the pvk12 gene. CONCLUSIONS Mutations in pvdhfr and pvdhps were prevalent in both symptomatic and asymptomatic P. vivax infections, suggestive of resistance to antifolate drugs. Asymptomatic carriers may act as a silent reservoir sustaining drug-resistant parasite transmission necessitating a rational strategy for malaria elimination in this region.
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Affiliation(s)
- Yan Zhao
- Department of Immunology, College of Basic Medical Sciences, China Medical University, Shenyang, 110122, Liaoning, China
| | - Lin Wang
- Department of Immunology, College of Basic Medical Sciences, China Medical University, Shenyang, 110122, Liaoning, China
| | - Myat Thu Soe
- Myanmar Health Network Organization, Yangon, Myanmar
| | | | - Haichao Wei
- Department of Immunology, College of Basic Medical Sciences, China Medical University, Shenyang, 110122, Liaoning, China
| | - Ziling Liu
- Department of Immunology, College of Basic Medical Sciences, China Medical University, Shenyang, 110122, Liaoning, China
| | - Tongyu Ma
- Department of Immunology, College of Basic Medical Sciences, China Medical University, Shenyang, 110122, Liaoning, China
| | - Yuanyuan Huang
- Department of Immunology, College of Basic Medical Sciences, China Medical University, Shenyang, 110122, Liaoning, China
| | - Lynette J Menezes
- Department of Internal Medicine, Morsani College of Medicine, University of South Florida, 3720 Spectrum Boulevard, Suite 304, Tampa, FL, 33612, USA
| | - Qinghui Wang
- Department of Immunology, College of Basic Medical Sciences, China Medical University, Shenyang, 110122, Liaoning, China
| | | | | | - Liwang Cui
- Department of Internal Medicine, Morsani College of Medicine, University of South Florida, 3720 Spectrum Boulevard, Suite 304, Tampa, FL, 33612, USA.
| | - Yaming Cao
- Department of Immunology, College of Basic Medical Sciences, China Medical University, Shenyang, 110122, Liaoning, China.
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Kattenberg JH, Gumal DL, Ome-Kaius M, Kiniboro B, Philip M, Jally S, Kasian B, Sambale N, Siba PM, Karl S, Barry AE, Felger I, Kazura JW, Mueller I, Robinson LJ. The epidemiology of Plasmodium falciparum and Plasmodium vivax in East Sepik Province, Papua New Guinea, pre- and post-implementation of national malaria control efforts. Malar J 2020; 19:198. [PMID: 32503607 PMCID: PMC7275396 DOI: 10.1186/s12936-020-03265-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Accepted: 05/20/2020] [Indexed: 02/07/2023] Open
Abstract
Background In the past decade, national malaria control efforts in Papua New Guinea (PNG) have received renewed support, facilitating nationwide distribution of free long-lasting insecticidal nets (LLINs), as well as improvements in access to parasite-confirmed diagnosis and effective artemisinin-combination therapy in 2011–2012. Methods To study the effects of these intensified control efforts on the epidemiology and transmission of Plasmodium falciparum and Plasmodium vivax infections and investigate risk factors at the individual and household level, two cross-sectional surveys were conducted in the East Sepik Province of PNG; one in 2005, before the scale-up of national campaigns and one in late 2012-early 2013, after 2 rounds of LLIN distribution (2008 and 2011–2012). Differences between studies were investigated using Chi square (χ2), Fischer’s exact tests and Student’s t-test. Multivariable logistic regression models were built to investigate factors associated with infection at the individual and household level. Results The prevalence of P. falciparum and P. vivax in surveyed communities decreased from 55% (2005) to 9% (2013) and 36% to 6%, respectively. The mean multiplicity of infection (MOI) decreased from 1.8 to 1.6 for P. falciparum (p = 0.08) and from 2.2 to 1.4 for P. vivax (p < 0.001). Alongside these reductions, a shift towards a more uniform distribution of infections and illness across age groups was observed but there was greater heterogeneity across the study area and within the study villages. Microscopy positive infections and clinical cases in the household were associated with high rate infection households (> 50% of household members with Plasmodium infection). Conclusion After the scale-up of malaria control interventions in PNG between 2008 and 2012, there was a substantial reduction in P. falciparum and P. vivax infection rates in the studies villages in East Sepik Province. Understanding the extent of local heterogeneity in malaria transmission and the driving factors is critical to identify and implement targeted control strategies to ensure the ongoing success of malaria control in PNG and inform the development of tools required to achieve elimination. In household-based interventions, diagnostics with a sensitivity similar to (expert) microscopy could be used to identify and target high rate households.
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Affiliation(s)
- Johanna H Kattenberg
- Vector Borne Disease Unit, Papua New Guinea Institute of Medical Research, PO Box 378, Madang, 511, MP, Papua New Guinea.,Division of Population Health and Immunity, Walter and Eliza Hall Institute of Medical Research, 1G Royal Parade, Parkville, VIC, 3052, Australia.,Department of Biomedical Sciences, Institute of Tropical Medicine, Malariology Unit, Nationalestraat 155, 2000, Antwerp, Belgium
| | - Dulcie L Gumal
- Vector Borne Disease Unit, Papua New Guinea Institute of Medical Research, PO Box 378, Madang, 511, MP, Papua New Guinea.,Disease Elimination Program, Vector-borne Diseases and Tropical Public Health Group, Burnet Institute, 85 Commercial Rd, Melbourne, VIC, 3004, Australia
| | - Maria Ome-Kaius
- Vector Borne Disease Unit, Papua New Guinea Institute of Medical Research, PO Box 378, Madang, 511, MP, Papua New Guinea.,Division of Population Health and Immunity, Walter and Eliza Hall Institute of Medical Research, 1G Royal Parade, Parkville, VIC, 3052, Australia
| | - Benson Kiniboro
- Vector Borne Disease Unit, Papua New Guinea Institute of Medical Research, PO Box 378, Madang, 511, MP, Papua New Guinea
| | - Matthew Philip
- Vector Borne Disease Unit, Papua New Guinea Institute of Medical Research, PO Box 378, Madang, 511, MP, Papua New Guinea
| | - Shadrach Jally
- Vector Borne Disease Unit, Papua New Guinea Institute of Medical Research, PO Box 378, Madang, 511, MP, Papua New Guinea
| | - Bernadine Kasian
- Vector Borne Disease Unit, Papua New Guinea Institute of Medical Research, PO Box 378, Madang, 511, MP, Papua New Guinea
| | - Naomi Sambale
- Vector Borne Disease Unit, Papua New Guinea Institute of Medical Research, PO Box 378, Madang, 511, MP, Papua New Guinea
| | - Peter M Siba
- Vector Borne Disease Unit, Papua New Guinea Institute of Medical Research, PO Box 378, Madang, 511, MP, Papua New Guinea
| | - Stephan Karl
- Vector Borne Disease Unit, Papua New Guinea Institute of Medical Research, PO Box 378, Madang, 511, MP, Papua New Guinea.,Division of Population Health and Immunity, Walter and Eliza Hall Institute of Medical Research, 1G Royal Parade, Parkville, VIC, 3052, Australia
| | - Alyssa E Barry
- Division of Population Health and Immunity, Walter and Eliza Hall Institute of Medical Research, 1G Royal Parade, Parkville, VIC, 3052, Australia.,Department of Medical Biology, University of Melbourne, Parkville, VIC, 3010, Australia.,School of Medicine, Deakin University, Geelong and Burnet Institute, Melbourne, VIC, Australia
| | - Ingrid Felger
- Medical Parasitology and Infection Biology, Swiss Tropical & Public Health Institute, Socinstrasse 57, 4051, Basel, Switzerland
| | - James W Kazura
- Center for Global Health and Diseases, Case Western Reserve University, 10900 Euclid Ave, Cleveland, OH, 44106, USA
| | - Ivo Mueller
- Division of Population Health and Immunity, Walter and Eliza Hall Institute of Medical Research, 1G Royal Parade, Parkville, VIC, 3052, Australia.,Department of Medical Biology, University of Melbourne, Parkville, VIC, 3010, Australia.,Department of Parasites and Insect Vectors, Malaria Parasites and Hosts Unit, Pasteur Institute, 25-28 rue du Docteur-Roux, 75724, Paris Cedex 15, France
| | - Leanne J Robinson
- Vector Borne Disease Unit, Papua New Guinea Institute of Medical Research, PO Box 378, Madang, 511, MP, Papua New Guinea. .,Division of Population Health and Immunity, Walter and Eliza Hall Institute of Medical Research, 1G Royal Parade, Parkville, VIC, 3052, Australia. .,Department of Medical Biology, University of Melbourne, Parkville, VIC, 3010, Australia. .,Disease Elimination Program, Vector-borne Diseases and Tropical Public Health Group, Burnet Institute, 85 Commercial Rd, Melbourne, VIC, 3004, Australia.
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9
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A Randomized Open-Label Evaluation of the Antimalarial Prophylactic Efficacy of Azithromycin-Piperaquine versus Sulfadoxine-Pyrimethamine in Pregnant Papua New Guinean Women. Antimicrob Agents Chemother 2019; 63:AAC.00302-19. [PMID: 31405866 DOI: 10.1128/aac.00302-19] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2019] [Accepted: 07/26/2019] [Indexed: 11/20/2022] Open
Abstract
Emerging malaria parasite sulfadoxine-pyrimethamine (SP) resistance has prompted assessment of alternatives for intermittent preventive treatment in pregnancy (IPTp). The objective was to evaluate the tolerability and prophylactic efficacy of azithromycin (AZ) plus piperaquine (PQ) in pregnant women in Papua New Guinea. The study was an open-label, randomized, parallel-group trial. A total of 122 women (median gestation, 26 weeks [range, 14 to 32 weeks]) were randomized 1:1 to three daily doses of 1 g AZ plus 960 mg PQ tetraphosphate or single-dose SP (4,500 mg sulfadoxine plus 225 mg pyrimethamine), based on computer-generated block randomization. Tolerability was assessed to day 7, and efficacy was assessed to day 42 (when participants were returned to usual care) and at delivery. Data for 119 participants (AZ-PQ, n = 61; SP, n = 58) were analyzed. Both regimens were well tolerated, but AZ-PQ was associated with more gastrointestinal side effects (31%) and dizziness (21%). Eight women (6.7%) were parasitemic at recruitment but all were aparasitemic by 72 h. There were no differences in blood smear positivity rates between AZ-PQ and SP up to day 42 (0% versus 5.2%; relative risk [RR], 0.14 [95% confidence interval [CI], 0.01 to 2.58] [P = 0.18]; absolute risk reduction [ARR], 5.2% [95% CI, -1.3 to 11.6%]) and at the time of delivery (0% versus 8.7%; RR, 0.11 [95% CI, 0.01 to 2.01] [P = 0.14]; ARR, 8.7% [95% CI, -0.2 to 17.6%]). Of 92 women who were monitored to parturition, 89 (97%) delivered healthy babies; there were 3 stillbirths (SP, n = 1; AZ-PQ, n = 2 [twins]). There was a higher live birth weight (mean ± standard deviation) in the AZ-PQ group (3.13 ± 0.42 versus 2.88 ± 0.55 kg [P = 0.016]; mean difference, 0.25 kg [95% CI, 0.02 to 0.48 kg]). AZ-PQ is a promising candidate for IPTp.
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10
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Lufele E, Umbers A, Ordi J, Ome-Kaius M, Wangnapi R, Unger H, Tarongka N, Siba P, Mueller I, Robinson L, Rogerson S. Risk factors and pregnancy outcomes associated with placental malaria in a prospective cohort of Papua New Guinean women. Malar J 2017; 16:427. [PMID: 29065884 PMCID: PMC5655867 DOI: 10.1186/s12936-017-2077-4] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2017] [Accepted: 10/19/2017] [Indexed: 12/19/2022] Open
Abstract
Background Plasmodium falciparum in pregnancy results in substantial poor health outcomes for both mother and child, particularly in young, primigravid mothers who are at greatest risk of placental malaria (PM) infection. Complications of PM include maternal anaemia, low birth weight and preterm delivery, which contribute to maternal and infant morbidity and mortality in coastal Papua New Guinea (PNG). Methods Placental biopsies were examined from 1451 pregnant women who were enrolled in a malaria prevention study at 14–26 weeks gestation. Clinical and demographic information were collected at first antenatal clinic visits and women were followed until delivery. Placental biopsies were collected and examined for PM using histology. The presence of infected erythrocytes and/or the malaria pigment in monocytes or fibrin was used to determine the type of placental infection. Results Of 1451 placentas examined, PM infection was detected in 269 (18.5%), of which 54 (3.7%) were acute, 55 (3.8%) chronic, and 160 (11.0%) were past infections. Risk factors for PM included residing in rural areas (adjusted odds ratio (AOR) 3.65, 95% CI 1.76–7.51; p ≤ 0.001), being primigravid (AOR 2.45, 95% CI 1.26–4.77; p = 0.008) and having symptomatic malaria during pregnancy (AOR 2.05, 95% CI 1.16–3.62; p = 0.013). After adjustment for covariates, compared to uninfected women, acute infections (AOR 1.97, 95% CI 0.98–3.95; p = 0.056) were associated with low birth weight babies, whereas chronic infections were associated with preterm delivery (AOR 3.92, 95% CI 1.64–9.38; p = 0.002) and anaemia (AOR 2.22, 95% CI 1.02–4.84; p = 0.045). Conclusions Among pregnant PNG women receiving at least one dose of intermittent preventive treatment in pregnancy and using insecticide-treated bed nets, active PM infections were associated with adverse outcomes. Improved malaria prevention is required to optimize pregnancy outcomes.
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Affiliation(s)
- Elvin Lufele
- Papua New Guinea Institute of Medical Research, Madang, Papua New Guinea
| | - Alexandra Umbers
- Papua New Guinea Institute of Medical Research, Madang, Papua New Guinea.,Department of Medicine and Radiology, Peter Doherty Institute, University of Melbourne, Melbourne, VIC, Australia
| | - Jaume Ordi
- Barcelona Centre for International Health Research (CRESIB), Barcelona, Spain
| | - Maria Ome-Kaius
- Papua New Guinea Institute of Medical Research, Madang, Papua New Guinea
| | - Regina Wangnapi
- Papua New Guinea Institute of Medical Research, Madang, Papua New Guinea
| | - Holger Unger
- Papua New Guinea Institute of Medical Research, Madang, Papua New Guinea.,Department of Medicine and Radiology, Peter Doherty Institute, University of Melbourne, Melbourne, VIC, Australia
| | - Nandao Tarongka
- Papua New Guinea Institute of Medical Research, Madang, Papua New Guinea
| | - Peter Siba
- Papua New Guinea Institute of Medical Research, Madang, Papua New Guinea
| | - Ivo Mueller
- Population Health and Immunity Division, Walter and Eliza Hall Institute, Melbourne, VIC, Australia.,Institute Pasteur, Paris, France
| | - Leanne Robinson
- Papua New Guinea Institute of Medical Research, Madang, Papua New Guinea.,Population Health and Immunity Division, Walter and Eliza Hall Institute, Melbourne, VIC, Australia.,Burnet Institute, Melbourne, VIC, Australia
| | - Stephen Rogerson
- Department of Medicine and Radiology, Peter Doherty Institute, University of Melbourne, Melbourne, VIC, Australia.
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11
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Zhao Y, Zhao Y, Lv Y, Liu F, Wang Q, Li P, Zhao Z, Liu Y, Cui L, Fan Q, Cao Y. Comparison of methods for detecting asymptomatic malaria infections in the China-Myanmar border area. Malar J 2017; 16:159. [PMID: 28427455 PMCID: PMC5397696 DOI: 10.1186/s12936-017-1813-0] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2017] [Accepted: 04/09/2017] [Indexed: 02/06/2023] Open
Abstract
Background Sensitive methods for detecting asymptomatic malaria infections are essential for identifying potential transmission reservoirs and obtaining an accurate assessment of malaria epidemiology in low-endemicity areas aiming to eliminate malaria. PCR techniques to detect parasite nucleic acids (DNA or RNA) are among the most commonly used molecular methods. However, most of these methods are of low throughput and cannot be used for large-scale molecular epidemiological studies. A recently developed capture and ligation probe-PCR (CLIP-PCR) is claimed to have the sensitivity of molecular techniques and the high throughput capacity needed for screening purposes. This study aimed to compare several molecular methods for detecting asymptomatic and submicroscopic Plasmodium infections in healthy residents of a malaria-hypoendemic region in Southeast Asia, where malaria elimination is in sight. Method This study compared three molecular detection methods side-by-side, namely nested PCR targeting the rRNA genes, nested RT-PCR to detect parasite rRNA, and CLIP-PCR to detect parasite rRNA in 1005 healthy individuals in northeastern Myanmar. For nested PCR and RT-PCR, parasite DNA and total RNA were extracted from ~100 µL of blood, whereas RNA used for CLIP-PCR was from a 3 mm disk of dried blood filter paper. The sensitivity and specificity of these methods were compared with those of conventional light microscopy. In addition, RT-PCR and quantitative RT-PCR (qRT-PCR) targeting the Pvs25 gene in Plasmodium vivax were used to assess gametocyte prevalence in the samples. Results Light microscopy detected Plasmodium infections in only 1.19% of the residents harbouring the parasites. CLIP-PCR had slightly better performance and detected Plasmodium infections in 1.89% of the population. Further improvement was achieved by nested PCR to detect parasite DNA, which detected P. vivax and Plasmodium falciparum infections in 2.39% of the residents. The nested RT-PCR targeting rRNA, however, detected as many as 187 (18.61%) individuals having Plasmodium infections with P. vivax being the predominant species (176 P. vivax, 5 P. falciparum and 6 P. falciparum/P. vivax mixed infections). Of the 210 Plasmodium-positive samples detected by all molecular methods, 115 were Pvs25-positive by qRT-PCR, indicating that a large proportion of asymptomatic individuals were gametocyte carriers. Conclusion Nested RT-PCR based on the detection of asexual-stage parasite rRNA was the most sensitive, with a more than sixfold higher sensitivity than the other two molecular methods of parasite detection. CLIP-PCR has an increased throughput, but its sensitivity in this study was much lower than those of other molecular methods, which may be partially due to the smaller amount of RNA input used. Electronic supplementary material The online version of this article (doi:10.1186/s12936-017-1813-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Yonghong Zhao
- Department of Immunology, China Medical University, Shenyang, Liaoning, China
| | - Yan Zhao
- Department of Immunology, China Medical University, Shenyang, Liaoning, China
| | - Yanmin Lv
- Department of Immunology, China Medical University, Shenyang, Liaoning, China
| | - Fei Liu
- Department of Immunology, China Medical University, Shenyang, Liaoning, China
| | - Qinghui Wang
- Department of Immunology, China Medical University, Shenyang, Liaoning, China
| | - Peipei Li
- Dalian Institute of Biotechnology, Dalian, Liaoning, China
| | - Zhenjun Zhao
- Dalian Institute of Biotechnology, Dalian, Liaoning, China
| | - Yingjie Liu
- Department of Pathogen Biology, China Medical University, Shenyang, Liaoning, China
| | - Liwang Cui
- Department of Entomology, Pennsylvania State University, University Park, PA, USA.
| | - Qi Fan
- Dalian Institute of Biotechnology, Dalian, Liaoning, China.
| | - Yaming Cao
- Department of Immunology, China Medical University, Shenyang, Liaoning, China.
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12
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Karl S, Laman M, Moore BR, Benjamin JM, Salib M, Lorry L, Maripal S, Siba P, Robinson LJ, Mueller I, Davis TME. Risk factors for Plasmodium falciparum and Plasmodium vivax gametocyte carriage in Papua New Guinean children with uncomplicated malaria. Acta Trop 2016; 160:1-8. [PMID: 27056132 DOI: 10.1016/j.actatropica.2016.04.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2016] [Revised: 04/01/2016] [Accepted: 04/02/2016] [Indexed: 01/06/2023]
Abstract
There are limited data on gametocytaemia risk factors before/after treatment with artemisinin combination therapy in children from areas with transmission of multiple Plasmodium species. We utilised data from a randomised trial comparing artemether-lumefantrine (AL) and artemisinin-naphthoquine (AN) in 230 Papua New Guinean children aged 0.5-5 years with uncomplicated malaria in whom determinants of gametocytaemia by light microscopy were assessed at baseline using logistic regression and during follow-up using multilevel mixed effects modelling. Seventy-four (32%) and 18 (8%) children presented with P. falciparum and P. vivax gametocytaemia, respectively. Baseline P. falciparum gametocytaemia was associated with Hackett spleen grade 1 (odds ratio (95% CI) 4.01 (1.60-10.05) vs grade 0; P<0.001) and haemoglobin (0.95 (0.92-0.97) per 1g/L increase; P<0.001), and P. falciparum asexual parasitaemia in slide-positive cases (0.36 (0.19-0.68) for a 10-fold increase; P=0.002). Baseline P. vivax gametocytaemia was associated with Hackett grade 2 (12.66 (1.31-122.56); P=0.028), mixed P. falciparum/vivax infection (0.16 (0.03-1.00); P=0.050), P. vivax asexual parasitaemia (5.68 (0.98-33.04); P=0.053) and haemoglobin (0.94 (0.88-1.00); P=0.056). For post-treatment P. falciparum gametocytaemia, independent predictors were AN vs AL treatment (4.09 (1.43-11.65)), haemoglobin (0.95 (0.93-0.97)), presence/absence of P. falciparum asexual forms (3.40 (1.66-0.68)) and day post-treatment (0.086 (0.82-0.90)) (P<0.001). Post-treatment P. vivax gametocytaemia was predicted by presence of P. vivax asexual forms (596 (12-28,433); P<0.001). Consistent with slow P. falciparum gametocyte maturation, low haemoglobin, low asexual parasite density and higher spleen grading, markers of increased prior infection exposure/immunity, were strong associates of pre-treatment gametocyte positivity. The persistent inverse association between P. falciparum gametocytaemia and haemoglobin during follow-up suggests an important role for bone marrow modulation of gametocytogenesis. In P. vivax infections, baseline and post-treatment gametocyte carriage was positively related to the acute parasite burden, reflecting the close association between the development of asexual and sexual forms.
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Affiliation(s)
- Stephan Karl
- Population Health and Immunity Division, Walter and Eliza Hall Institute, Parkville, Victoria, Australia; Department of Medical Biology, University of Melbourne, Melbourne, Victoria, Australia
| | - Moses Laman
- Papua New Guinea Institute of Medical Research, Madang, Papua New Guinea
| | - Brioni R Moore
- School of Medicine and Pharmacology, University of Western Australia, Perth, Western Australia, Australia
| | - John M Benjamin
- Papua New Guinea Institute of Medical Research, Madang, Papua New Guinea
| | - Mary Salib
- Papua New Guinea Institute of Medical Research, Madang, Papua New Guinea
| | - Lina Lorry
- Papua New Guinea Institute of Medical Research, Madang, Papua New Guinea
| | - Samuel Maripal
- Papua New Guinea Institute of Medical Research, Madang, Papua New Guinea
| | - Peter Siba
- Papua New Guinea Institute of Medical Research, Madang, Papua New Guinea
| | - Leanne J Robinson
- Population Health and Immunity Division, Walter and Eliza Hall Institute, Parkville, Victoria, Australia; Department of Medical Biology, University of Melbourne, Melbourne, Victoria, Australia; Papua New Guinea Institute of Medical Research, Madang, Papua New Guinea
| | - Ivo Mueller
- Population Health and Immunity Division, Walter and Eliza Hall Institute, Parkville, Victoria, Australia; Department of Medical Biology, University of Melbourne, Melbourne, Victoria, Australia
| | - Timothy M E Davis
- School of Medicine and Pharmacology, University of Western Australia, Perth, Western Australia, Australia.
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13
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Moore BR, Benjamin JM, Auyeung SO, Salman S, Yadi G, Griffin S, Page-Sharp M, Batty KT, Siba PM, Mueller I, Rogerson SJ, Davis TM. Safety, tolerability and pharmacokinetic properties of coadministered azithromycin and piperaquine in pregnant Papua New Guinean women. Br J Clin Pharmacol 2016; 82:199-212. [PMID: 26889763 PMCID: PMC4917786 DOI: 10.1111/bcp.12910] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2015] [Revised: 02/09/2016] [Accepted: 02/14/2016] [Indexed: 12/14/2022] Open
Abstract
AIMS The aim of the present study was to investigate the safety, tolerability and pharmacokinetics of coadministered azithromycin (AZI) and piperaquine (PQ) for treating malaria in pregnant Papua New Guinean women. METHODS Thirty pregnant women (median age 22 years; 16-32 weeks' gestation) were given three daily doses of 1 g AZI plus 960 mg PQ tetraphosphate with detailed monitoring/blood sampling over 42 days. Plasma AZI and PQ were assayed using liquid chromatography-mass spectrometry and high-performance liquid chromatography, respectively. Pharmacokinetic analysis was by population-based compartmental models. RESULTS The treatment was well tolerated. The median (interquartile range) increase in the rate-corrected electrocardiographic QT interval 4 h postdose [12 (6-26) ms(0) (.5) ] was similar to that found in previous studies of AZI given in pregnancy with other partner drugs. Six women with asymptomatic malaria cleared their parasitaemias within 72 h. Two apararasitaemic women developed late uncomplicated Plasmodium falciparum infections on Days 42 and 83. Compared with previous pregnancy studies, the area under the concentration-time curve (AUC0-∞ ) for PQ [38818 (24354-52299) μg h l(-1) ] was similar to published values but there was a 52% increase in relative bioavailability with each dose. The AUC0-∞ for AZI [46799 (43526-49462) μg h l(-1) ] was at least as high as reported for higher-dose regimens, suggesting saturable absorption and/or concentration-dependent tissue uptake and clearance from the central compartment. CONCLUSIONS AZI-PQ appears to be well tolerated and safe in pregnancy. Based on the present/other data, total AZI doses higher than 3 g for the treatment and prevention of malaria may be unnecessary in pregnant women, while clearance of parasitaemia could improve the relative bioavailability of PQ.
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Affiliation(s)
- Brioni R Moore
- School of Medicine and Pharmacology, The University of Western Australia, Crawley, Western Australia, Australia
- Papua New Guinea Institute of Medical Research, Madang, Madang Province, Papua New Guinea
| | - John M Benjamin
- Papua New Guinea Institute of Medical Research, Madang, Madang Province, Papua New Guinea
| | - Siu On Auyeung
- School of Medicine and Pharmacology, The University of Western Australia, Crawley, Western Australia, Australia
| | - Sam Salman
- School of Medicine and Pharmacology, The University of Western Australia, Crawley, Western Australia, Australia
| | - Gumul Yadi
- Papua New Guinea Institute of Medical Research, Madang, Madang Province, Papua New Guinea
| | - Suzanne Griffin
- Papua New Guinea Institute of Medical Research, Madang, Madang Province, Papua New Guinea
| | - Madhu Page-Sharp
- School of Pharmacy, Curtin University of Technology, Bentley, Western Australia, Australia
| | - Kevin T Batty
- School of Pharmacy, Curtin University of Technology, Bentley, Western Australia, Australia
| | - Peter M Siba
- Papua New Guinea Institute of Medical Research, Madang, Madang Province, Papua New Guinea
| | - Ivo Mueller
- Infection and Immunity, Walter and Eliza Hall Institute, Melbourne, Victoria, Australia
- Barcelona Institute for Global Health (ISGLOBAL), Barcelona, Spain
| | - Stephen J Rogerson
- Department of Medicine (RMH), The University of Melbourne, Parkville, Victoria, Australia
| | - Timothy Me Davis
- School of Medicine and Pharmacology, The University of Western Australia, Crawley, Western Australia, Australia
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14
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Liu H, Feng G, Zeng W, Li X, Bai Y, Deng S, Ruan Y, Morris J, Li S, Yang Z, Cui L. A more appropriate white blood cell count for estimating malaria parasite density in Plasmodium vivax patients in northeastern Myanmar. Acta Trop 2016; 156:152-6. [PMID: 26802490 DOI: 10.1016/j.actatropica.2016.01.018] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2015] [Revised: 01/15/2016] [Accepted: 01/18/2016] [Indexed: 10/22/2022]
Abstract
The conventional method of estimating parasite densities employ an assumption of 8000 white blood cells (WBCs)/μl. However, due to leucopenia in malaria patients, this number appears to overestimate parasite densities. In this study, we assessed the accuracy of parasite density estimated using this assumed WBC count in eastern Myanmar, where Plasmodium vivax has become increasingly prevalent. From 256 patients with uncomplicated P. vivax malaria, we estimated parasite density and counted WBCs by using an automated blood cell counter. It was found that WBC counts were not significantly different between patients of different gender, axillary temperature, and body mass index levels, whereas they were significantly different between age groups of patients and the time points of measurement. The median parasite densities calculated with the actual WBC counts (1903/μl) and the assumed WBC count of 8000/μl (2570/μl) were significantly different. We demonstrated that using the assumed WBC count of 8000 cells/μl to estimate parasite densities of P. vivax malaria patients in this area would lead to an overestimation. For P. vivax patients aged five years and older, an assumed WBC count of 5500/μl best estimated parasite densities. This study provides more realistic assumed WBC counts for estimating parasite densities in P. vivax patients from low-endemicity areas of Southeast Asia.
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15
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Umbers AJ, Unger HW, Rosanas-Urgell A, Wangnapi RA, Kattenberg JH, Jally S, Silim S, Lufele E, Karl S, Ome-Kaius M, Robinson LJ, Rogerson SJ, Mueller I. Accuracy of an HRP-2/panLDH rapid diagnostic test to detect peripheral and placental Plasmodium falciparum infection in Papua New Guinean women with anaemia or suspected malaria. Malar J 2015; 14:412. [PMID: 26480941 PMCID: PMC4617889 DOI: 10.1186/s12936-015-0927-5] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2015] [Accepted: 09/25/2015] [Indexed: 12/30/2022] Open
Abstract
Background The diagnosis of malaria during pregnancy is complicated by placental sequestration, asymptomatic infection, and low-density peripheral parasitaemia. Where intermittent preventive treatment (IPT) with sulfadoxine-pyrimethamine is threatened by drug resistance, or is inappropriate due to low transmission, intermittent screening and treatment (ISTp) with rapid diagnostic tests for malaria (RDT) could be a valuable alternative. Therefore, the accuracy of RDTs to detect peripheral and placental infection was assessed in a declining transmission setting in Papua New Guinea (PNG). Methods The performance of a combination RDT detecting histidine-rich protein-2 (HRP-2) and Plasmodium lactate dehydrogenase (pLDH), and light microscopy (LM), to diagnose peripheral Plasmodium falciparum and Plasmodium vivax infections during pregnancy, were assessed using quantitative real-time PCR (qPCR) as the reference standard. Participants in a malaria prevention trial in PNG with a haemoglobin ≤90 g/L, or symptoms suggestive of malaria, were tested. Ability of RDT and LM to detect active placental infection on histology was evaluated in some participants. Results Among 876 women, 1162 RDTs were undertaken (anaemia: 854 [73.5 %], suspected malaria: 308 [26.5 %]). qPCR detected peripheral infection during 190 RDT episodes (165 P. falciparum, 19 P. vivax, 6 mixed infections). Overall, RDT detected peripheral P. falciparum infection with 45.6 % sensitivity (95 % CI 38.0–53.4), a specificity of 96.4 % (95.0–97.4), a positive predictive value of 68.4 % (59.1–76.8), and a negative predictive value of 91.1 % (89.2–92.8). RDT performance to detect P. falciparum was inferior to LM, more so amongst anaemic women (18.6 vs 45.3 % sensitivity, Liddell’s exact test, P < 0.001) compared to symptomatic women (72.9 vs 82.4 % sensitivity, P = 0.077). RDT and LM missed 88.0 % (22/25) and 76.0 % (19/25) of P. vivax infections, respectively. In a subset of women tested at delivery and who had placental histology (n = 158) active placental infection was present in 19.6 %: all three peripheral blood infection detection methods (RDT, LM, qPCR) missed >50 % of these infections. Conclusions In PNG, HRP-2/pLDH RDTs may be useful to diagnose peripheral P. falciparum infections in symptomatic pregnant women. However, they are not sufficiently sensitive for use in intermittent screening amongst asymptomatic (anaemic) women. These findings have implications for the management of malaria in pregnancy. The adverse impact of infections undetected by RDT or LM on pregnancy outcomes needs further evaluation. Electronic supplementary material The online version of this article (doi:10.1186/s12936-015-0927-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Alexandra J Umbers
- Department of Medicine at the Doherty Institute, The University of Melbourne, Melbourne, Australia. .,Papua New Guinea Institute of Medical Research (PNG IMR), Goroka, Papua New Guinea.
| | - Holger W Unger
- Department of Medicine at the Doherty Institute, The University of Melbourne, Melbourne, Australia. .,Papua New Guinea Institute of Medical Research (PNG IMR), Goroka, Papua New Guinea.
| | - Anna Rosanas-Urgell
- Papua New Guinea Institute of Medical Research (PNG IMR), Goroka, Papua New Guinea. .,Institute of Tropical Medicine, Antwerp, Belgium.
| | - Regina A Wangnapi
- Papua New Guinea Institute of Medical Research (PNG IMR), Goroka, Papua New Guinea.
| | - Johanna H Kattenberg
- Papua New Guinea Institute of Medical Research (PNG IMR), Goroka, Papua New Guinea. .,Walter and Eliza Hall Institute of Medical Research (WEHI), Melbourne, Australia.
| | - Shadrach Jally
- Papua New Guinea Institute of Medical Research (PNG IMR), Goroka, Papua New Guinea.
| | - Selina Silim
- Papua New Guinea Institute of Medical Research (PNG IMR), Goroka, Papua New Guinea.
| | - Elvin Lufele
- Papua New Guinea Institute of Medical Research (PNG IMR), Goroka, Papua New Guinea.
| | - Stephan Karl
- Walter and Eliza Hall Institute of Medical Research (WEHI), Melbourne, Australia.
| | - Maria Ome-Kaius
- Papua New Guinea Institute of Medical Research (PNG IMR), Goroka, Papua New Guinea.
| | - Leanne J Robinson
- Papua New Guinea Institute of Medical Research (PNG IMR), Goroka, Papua New Guinea. .,Walter and Eliza Hall Institute of Medical Research (WEHI), Melbourne, Australia.
| | - Stephen J Rogerson
- Department of Medicine at the Doherty Institute, The University of Melbourne, Melbourne, Australia.
| | - Ivo Mueller
- Walter and Eliza Hall Institute of Medical Research (WEHI), Melbourne, Australia. .,Barcelona Institute for Global Health (ISGLOBAL), Barcelona, Spain.
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Robinson LJ, Wampfler R, Betuela I, Karl S, White MT, Li Wai Suen CSN, Hofmann NE, Kinboro B, Waltmann A, Brewster J, Lorry L, Tarongka N, Samol L, Silkey M, Bassat Q, Siba PM, Schofield L, Felger I, Mueller I. Strategies for understanding and reducing the Plasmodium vivax and Plasmodium ovale hypnozoite reservoir in Papua New Guinean children: a randomised placebo-controlled trial and mathematical model. PLoS Med 2015; 12:e1001891. [PMID: 26505753 PMCID: PMC4624431 DOI: 10.1371/journal.pmed.1001891] [Citation(s) in RCA: 189] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2014] [Accepted: 09/17/2015] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND The undetectable hypnozoite reservoir for relapsing Plasmodium vivax and P. ovale malarias presents a major challenge for malaria control and elimination in endemic countries. This study aims to directly determine the contribution of relapses to the burden of P. vivax and P. ovale infection, illness, and transmission in Papua New Guinean children. METHODS AND FINDINGS From 17 August 2009 to 20 May 2010, 524 children aged 5-10 y from East Sepik Province in Papua New Guinea (PNG) participated in a randomised double-blind placebo-controlled trial of blood- plus liver-stage drugs (chloroquine [CQ], 3 d; artemether-lumefantrine [AL], 3 d; and primaquine [PQ], 20 d, 10 mg/kg total dose) (261 children) or blood-stage drugs only (CQ, 3 d; AL, 3 d; and placebo [PL], 20 d) (263 children). Participants, study staff, and investigators were blinded to the treatment allocation. Twenty children were excluded during the treatment phase (PQ arm: 14, PL arm: 6), and 504 were followed actively for 9 mo. During the follow-up time, 18 children (PQ arm: 7, PL arm: 11) were lost to follow-up. Main primary and secondary outcome measures were time to first P. vivax infection (by qPCR), time to first clinical episode, force of infection, gametocyte positivity, and time to first P. ovale infection (by PCR). A basic stochastic transmission model was developed to estimate the potential effect of mass drug administration (MDA) for the prevention of recurrent P. vivax infections. Targeting hypnozoites through PQ treatment reduced the risk of having at least one qPCR-detectable P. vivax or P. ovale infection during 8 mo of follow-up (P. vivax: PQ arm 0.63/y versus PL arm 2.62/y, HR = 0.18 [95% CI 0.14, 0.25], p < 0.001; P. ovale: 0.06 versus 0.14, HR = 0.31 [95% CI 0.13, 0.77], p = 0.011) and the risk of having at least one clinical P. vivax episode (HR = 0.25 [95% CI 0.11, 0.61], p = 0.002). PQ also reduced the molecular force of P. vivax blood-stage infection in the first 3 mo of follow-up (PQ arm 1.90/y versus PL arm 7.75/y, incidence rate ratio [IRR] = 0.21 [95% CI 0.15, 0.28], p < 0.001). Children who received PQ were less likely to carry P. vivax gametocytes (IRR = 0.27 [95% CI 0.19, 0.38], p < 0.001). PQ had a comparable effect irrespective of the presence of P. vivax blood-stage infection at the time of treatment (p = 0.14). Modelling revealed that mass screening and treatment with highly sensitive quantitative real-time PCR, or MDA with blood-stage treatment alone, would have only a transient effect on P. vivax transmission levels, while MDA that includes liver-stage treatment is predicted to be a highly effective strategy for P. vivax elimination. The inclusion of a directly observed 20-d treatment regime maximises the efficiency of hypnozoite clearance but limits the generalisability of results to real-world MDA programmes. CONCLUSIONS These results suggest that relapses cause approximately four of every five P. vivax infections and at least three of every five P. ovale infections in PNG children and are important in sustaining transmission. MDA campaigns combining blood- and liver-stage treatment are predicted to be a highly efficacious intervention for reducing P. vivax and P. ovale transmission. TRIAL REGISTRATION ClinicalTrials.gov NCT02143934.
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Affiliation(s)
- Leanne J. Robinson
- Vector Borne Diseases Unit, Papua New Guinea Institute of Medical Research, Madang and Maprik, Papua New Guinea
- Population Health and Immunity Division, Walter and Eliza Hall Institute of Medical Research, Parkville, Victoria, Australia
- Department of Medical Biology, University of Melbourne, Melbourne, Victoria, Australia
| | - Rahel Wampfler
- Molecular Diagnostics Unit, Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | - Inoni Betuela
- Vector Borne Diseases Unit, Papua New Guinea Institute of Medical Research, Madang and Maprik, Papua New Guinea
| | - Stephan Karl
- Population Health and Immunity Division, Walter and Eliza Hall Institute of Medical Research, Parkville, Victoria, Australia
- Department of Medical Biology, University of Melbourne, Melbourne, Victoria, Australia
| | - Michael T. White
- MRC Centre for Outbreak Analysis and Modelling, Imperial College London, London, United Kingdom
| | - Connie S. N. Li Wai Suen
- Population Health and Immunity Division, Walter and Eliza Hall Institute of Medical Research, Parkville, Victoria, Australia
- Department of Medical Biology, University of Melbourne, Melbourne, Victoria, Australia
| | - Natalie E. Hofmann
- Molecular Diagnostics Unit, Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | - Benson Kinboro
- Vector Borne Diseases Unit, Papua New Guinea Institute of Medical Research, Madang and Maprik, Papua New Guinea
| | - Andreea Waltmann
- Population Health and Immunity Division, Walter and Eliza Hall Institute of Medical Research, Parkville, Victoria, Australia
- Department of Medical Biology, University of Melbourne, Melbourne, Victoria, Australia
| | - Jessica Brewster
- Population Health and Immunity Division, Walter and Eliza Hall Institute of Medical Research, Parkville, Victoria, Australia
| | - Lina Lorry
- Vector Borne Diseases Unit, Papua New Guinea Institute of Medical Research, Madang and Maprik, Papua New Guinea
| | - Nandao Tarongka
- Vector Borne Diseases Unit, Papua New Guinea Institute of Medical Research, Madang and Maprik, Papua New Guinea
| | - Lornah Samol
- Vector Borne Diseases Unit, Papua New Guinea Institute of Medical Research, Madang and Maprik, Papua New Guinea
| | - Mariabeth Silkey
- Molecular Diagnostics Unit, Swiss Tropical and Public Health Institute, Basel, Switzerland
| | - Quique Bassat
- Australian Institute of Tropical Health and Medicine, James Cook University, Cairns, Queensland, Australia
| | - Peter M. Siba
- Vector Borne Diseases Unit, Papua New Guinea Institute of Medical Research, Madang and Maprik, Papua New Guinea
- School of Veterinary and Biomedical Sciences, James Cook University, Townsville, Queensland, Australia
| | - Louis Schofield
- Population Health and Immunity Division, Walter and Eliza Hall Institute of Medical Research, Parkville, Victoria, Australia
- Department of Medical Biology, University of Melbourne, Melbourne, Victoria, Australia
- Australian Institute of Tropical Health and Medicine, James Cook University, Cairns, Queensland, Australia
| | - Ingrid Felger
- Molecular Diagnostics Unit, Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | - Ivo Mueller
- Population Health and Immunity Division, Walter and Eliza Hall Institute of Medical Research, Parkville, Victoria, Australia
- Department of Medical Biology, University of Melbourne, Melbourne, Victoria, Australia
- ISGlobal, Barcelona Centre for International Health Research (CRESIB), Hospital Clínic–University of Barcelona, Barcelona, Spain
- * E-mail:
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Unger HW, Wangnapi RA, Ome-Kaius M, Boeuf P, Karl S, Mueller I, Rogerson SJ. Azithromycin-containing intermittent preventive treatment in pregnancy affects gestational weight gain, an important predictor of birthweight in Papua New Guinea - an exploratory analysis. MATERNAL AND CHILD NUTRITION 2015; 12:699-712. [PMID: 26373537 DOI: 10.1111/mcn.12215] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
In Papua New Guinea, intermittent preventive treatment with sulphadoxine-pyrimethamine and azithromycin (SPAZ-IPTp) increased birthweight despite limited impact on malaria and sexually transmitted infections. To explore possible nutrition-related mechanisms, we evaluated associations between gestational weight gain (GWG), enrolment body mass index (BMI) and mid-upper arm circumference (MUAC), and birthweight. We investigated whether the increase in birthweight associated with SPAZ-IPTp may partly be driven by a treatment effect on GWG. The mean GWG rate was 393 g/week (SD 250; n = 948). A 100 g/week increase in GWG was associated with a 14 g (95% CI 2.6, 25.4) increase in birthweight (P = 0.016). Enrolment BMI and MUAC also positively correlated with birthweight. SPAZ-IPTp was associated with increased GWG [58 g/week (26, 900), P < 0.001, n = 948] and with increased birthweight [48 g, 95% CI (8, 880), P = 0.019] when all eligible women were considered (n = 1947). Inclusion of GWG reduced the birthweight coefficient associated with SPAZ-IPTp by 18% from 44 to 36 g (n = 948), although SPAZ-IPTp was not significantly associated with birthweight among women for whom GWG data were available (P = 0.13, n = 948). One month post-partum, fewer women who had received SPAZ-IPTp had a low post-partum BMI (<18.5 kg m(-2) ) [adjusted risk ratio: 0.55 (95% CI 0.36, 0.82), P = 0.004] and their babies had a reduced risk of wasting [risk ratio 0.39 (95% CI 0.21, 0.72), P = 0.003]. SPAZ-IPTp increased GWG, which could explain its impact on birthweight and maternal post-partum BMI. Future trials of SPAZ-IPTp must incorporate detailed anthropometric evaluations to investigate mechanisms of effects on maternal and child health.
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Affiliation(s)
- Holger W Unger
- Department of Medicine, The University of Melbourne, Melbourne, Victoria, Australia.,Vector Borne Diseases Unit, Papua New Guinea Institute of Medical Research (PNG IMR), Goroka, Papua New Guinea
| | - Regina A Wangnapi
- Vector Borne Diseases Unit, Papua New Guinea Institute of Medical Research (PNG IMR), Goroka, Papua New Guinea
| | - Maria Ome-Kaius
- Vector Borne Diseases Unit, Papua New Guinea Institute of Medical Research (PNG IMR), Goroka, Papua New Guinea
| | - Philippe Boeuf
- Department of Medicine, The University of Melbourne, Melbourne, Victoria, Australia.,Victorian Infectious Diseases Service, Melbourne Health, Melbourne, Victoria, Australia
| | - Stephan Karl
- Infection and Immunity Division, Walter and Eliza Hall Institute of Medical Research (WEHI), Melbourne, Victoria, Australia.,Department of Medical Biology, University of Melbourne, Melbourne, Victoria, Australia
| | - Ivo Mueller
- Infection and Immunity Division, Walter and Eliza Hall Institute of Medical Research (WEHI), Melbourne, Victoria, Australia.,Department of Medical Biology, University of Melbourne, Melbourne, Victoria, Australia.,Barcelona Centre for International Health Research (CRESIB), Barcelona, Spain
| | - Stephen J Rogerson
- Department of Medicine, The University of Melbourne, Melbourne, Victoria, Australia. .,Victorian Infectious Diseases Service, Melbourne Health, Melbourne, Victoria, Australia.
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18
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Laman M, Aipit S, Bona C, Siba PM, Robinson LJ, Manning L, Davis TME. Ultrasonographic assessment of splenic volume at presentation and after anti-malarial therapy in children with malarial anaemia. Malar J 2015; 14:219. [PMID: 26017395 PMCID: PMC4448319 DOI: 10.1186/s12936-015-0741-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2015] [Accepted: 05/20/2015] [Indexed: 11/20/2022] Open
Abstract
Background Splenic enlargement is a component of the host response to malaria and may also influence the genesis and progression of malarial anaemia. Few cross-sectional and no longitudinal studies have assessed the relationship between splenic volume measured ultrasonographically and haemoglobin concentrations in children with malaria. Methods Fifteen Papua New Guinean children with severe malarial anaemia (SMA; haemoglobin <50 g/L) and ten with moderate malarial anaemia (MMA; 51–99 g/L) were recruited. The SMA patients were given intramuscular artemether followed by oral artemisinin combination therapy (ACT), and were transfused one unit of packed cells 0.3-4.0 days post-admission. The MMA patients were treated with ACT. Splenic enlargement (Hackett’s grade, subcostal distance and ultrasonographically determined volume) and haemoglobin concentrations were measured on days 0, 1, 2, 3, 7, 14, 28, and 42. Results Associations between Hackett’s grade, subcostal distance and splenic volume were modest (rs ≤ 0.62, P <0.001). Baseline splenic volume was not associated with age or haemoglobin (P ≥0.90). Mean splenic volume had fallen by approximately 50 % at day 14 in children with MMA (P ≤0.011 vs days 0, 1 and 2), but there was no change in the SMA group (P ≥0.30). There was no change in haemoglobin in the MMA group during follow-up but a rise in the SMA group to day 7 (P ≤0.05 vs days 0, 1, 2, and 3) which paralleled the packed cell volume transfused. Conclusions Clinical assessment of splenomegaly is imprecise compared with ultrasonography. Serial splenic volumes and haemoglobin concentrations suggest that the spleen does not influence post-treatment haemoglobin, including after transfusion.
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Affiliation(s)
- Moses Laman
- School of Medicine and Pharmacology, University of Western Australia, Fremantle Hospital, PO Box 480, Fremantle, 6959, WA, Australia. .,Papua New Guinea Institute of Medical Research, Madang, Papua New Guinea.
| | - Susan Aipit
- Papua New Guinea Institute of Medical Research, Madang, Papua New Guinea.
| | - Cathy Bona
- Papua New Guinea Institute of Medical Research, Madang, Papua New Guinea.
| | - Peter M Siba
- Papua New Guinea Institute of Medical Research, Madang, Papua New Guinea. .,Department of Microbiology, Division of Veterinary and Biomedical Sciences, James Cook University, Townsville, Australia.
| | - Leanne J Robinson
- Papua New Guinea Institute of Medical Research, Madang, Papua New Guinea. .,Infection and Immunity Division, Walter and Eliza Hall Institute, Parkville, VIC, Australia. .,Department of Medical Biology, University of Melbourne, Melbourne, VIC, Australia.
| | - Laurens Manning
- School of Medicine and Pharmacology, University of Western Australia, Fremantle Hospital, PO Box 480, Fremantle, 6959, WA, Australia.
| | - Timothy M E Davis
- School of Medicine and Pharmacology, University of Western Australia, Fremantle Hospital, PO Box 480, Fremantle, 6959, WA, Australia.
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Koepfli C, Robinson LJ, Rarau P, Salib M, Sambale N, Wampfler R, Betuela I, Nuitragool W, Barry AE, Siba P, Felger I, Mueller I. Blood-Stage Parasitaemia and Age Determine Plasmodium falciparum and P. vivax Gametocytaemia in Papua New Guinea. PLoS One 2015; 10:e0126747. [PMID: 25996916 PMCID: PMC4440770 DOI: 10.1371/journal.pone.0126747] [Citation(s) in RCA: 79] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2014] [Accepted: 04/07/2015] [Indexed: 12/18/2022] Open
Abstract
A better understanding of human-to-mosquito transmission is crucial to control malaria. In order to assess factors associated with gametocyte carriage, 2083 samples were collected in a cross-sectional survey in Papua New Guinea. Plasmodium species were detected by light microscopy and qPCR and gametocytes by detection of pfs25 and pvs25 mRNA transcripts by reverse-transcriptase PCR (qRT-PCR). The parasite prevalence by PCR was 18.5% for Plasmodium falciparum and 13.0% for P. vivax. 52.5% of all infections were submicroscopic. Gametocytes were detected in 60% of P. falciparum-positive and 51% of P. vivax-positive samples. Each 10-fold increase in parasite density led to a 1.8-fold and 3.3-fold increase in the odds of carrying P. falciparum and P. vivax gametocytes. Thus the proportion of gametocyte positive and gametocyte densities was highest in young children carrying high asexual parasite densities and in symptomatic individuals. Dilution series of gametocytes allowed absolute quantification of gametocyte densities by qRT-PCR and showed that pvs25 expression is 10-20 fold lower than pfs25 expression. Between 2006 and 2010 parasite prevalence in the study site has decreased by half. 90% of the remaining infections were asymptomatic and likely constitute an important reservoir of transmission. However, mean gametocyte densities were low (approx. 1-2 gametocyte/μL) and it remains to be determined to what extent low-density gametocyte positive individuals are infective to mosquitos.
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Affiliation(s)
- Cristian Koepfli
- Walter and Eliza Hall Institute, Population Health and Immunity Division, Parkville, Victoria, Australia
- University of Melbourne, Department of Medical Biology, Parkville, Victoria, Australia
| | - Leanne J. Robinson
- Walter and Eliza Hall Institute, Population Health and Immunity Division, Parkville, Victoria, Australia
- University of Melbourne, Department of Medical Biology, Parkville, Victoria, Australia
- Papua New Guinea Institute of Medical Research, Vector Borne Diseases Unit, Madang, Papua New Guinea
| | - Patricia Rarau
- Papua New Guinea Institute of Medical Research, Vector Borne Diseases Unit, Madang, Papua New Guinea
| | - Mary Salib
- Papua New Guinea Institute of Medical Research, Vector Borne Diseases Unit, Madang, Papua New Guinea
| | - Naomi Sambale
- Papua New Guinea Institute of Medical Research, Vector Borne Diseases Unit, Madang, Papua New Guinea
| | - Rahel Wampfler
- Swiss Tropical and Public Health Institute, Medical Parasitology and Infection Biology, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | - Inoni Betuela
- Papua New Guinea Institute of Medical Research, Vector Borne Diseases Unit, Madang, Papua New Guinea
| | - Wang Nuitragool
- Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Alyssa E. Barry
- Walter and Eliza Hall Institute, Population Health and Immunity Division, Parkville, Victoria, Australia
- University of Melbourne, Department of Medical Biology, Parkville, Victoria, Australia
| | - Peter Siba
- Papua New Guinea Institute of Medical Research, Vector Borne Diseases Unit, Madang, Papua New Guinea
| | - Ingrid Felger
- Swiss Tropical and Public Health Institute, Medical Parasitology and Infection Biology, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | - Ivo Mueller
- Walter and Eliza Hall Institute, Population Health and Immunity Division, Parkville, Victoria, Australia
- University of Melbourne, Department of Medical Biology, Parkville, Victoria, Australia
- ISGlobal, Barcelona Centre for International Health Research, Barcelona, Spain
- * E-mail:
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Population pharmacokinetics, tolerability, and safety of dihydroartemisinin-piperaquine and sulfadoxine-pyrimethamine-piperaquine in pregnant and nonpregnant Papua New Guinean women. Antimicrob Agents Chemother 2015; 59:4260-71. [PMID: 25963981 DOI: 10.1128/aac.00326-15] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2015] [Accepted: 05/02/2015] [Indexed: 01/01/2023] Open
Abstract
The tolerability, safety, and disposition of dihydroartemisinin (DHA) and piperaquine (PQ) were assessed in 32 pregnant (second/third trimester) and 33 nonpregnant Papua New Guinean women randomized to adult treatment courses of DHA-PQ (three daily doses) or sulfadoxine-pyrimethamine (SP)-PQ (three daily PQ doses, single dose of SP). All dose adminstrations were observed, and subjects fasted for 2 h postdose. Plasma PQ was assayed by using high-performance liquid chromatography, and DHA was assessed by using liquid chromatography-mass spectrometry. Compartmental pharmacokinetic models were developed using a population-based approach. Both regimens were well tolerated. There was an expected increase in the rate-corrected electrocardiographic QT interval which was independent of pregnancy and treatment. Two pregnant and two nonpregnant women had Plasmodium falciparum parasitemia which cleared within 48 h, and no other subject became slide positive for malaria during 42 days of follow-up. Of 30 pregnant women followed to delivery, 27 (90%) delivered healthy babies and 3 (10%) had stillbirths; these obstetric outcomes are consistent with those in the general population. The area under the plasma PQ concentration-time curve (AUC0-∞) was lower in the pregnant patients (median [interquartile range], 23,721 μg · h/liter [21,481 to 27,951 μg · h/liter] versus 35,644 μg · h/liter [29,546 to 39,541 μg · h/liter]; P < 0.001) in association with a greater clearance relative to bioavailability (73.5 liters/h [69.4 to 78.4] versus 53.8 liters/h [49.7 to 58.2]; P < 0.001), but pregnancy did not influence the pharmacokinetics of DHA. The apparent pharmacokinetic differences between the present study and results from other studies of women with uncomplicated malaria that showed no effect of pregnancy on the AUC0-∞ of PQ and greater bioavailability may reflect differences in postdose fat intake, proportions of women with malaria, and/or racial differences in drug disposition.
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21
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Kaddumukasa M, Lwanira C, Lugaajju A, Katabira E, Persson KEM, Wahlgren M, Kironde F. Parasite Specific Antibody Increase Induced by an Episode of Acute P. falciparum Uncomplicated Malaria. PLoS One 2015; 10:e0124297. [PMID: 25906165 PMCID: PMC4408068 DOI: 10.1371/journal.pone.0124297] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2014] [Accepted: 03/11/2015] [Indexed: 11/30/2022] Open
Abstract
Introduction There is no approved vaccine for malaria, and precisely how human antibody responses to malaria parasite components and potential vaccine molecules are developed and maintained remains poorly defined. In this study, antibody anamnestic or memory response elicited by a single episode of P. falciparum infection was investigated. Methods This study involved 362 malaria patients aged between 6 months to 60 years, of whom 19% were early-diagnosed people living with HIV/AIDS (PLWHA). On the day malaria was diagnosed and 42 days later, blood specimens were collected. Parasite density, CD4+ cells, and antibodies specific to synthetic peptides representing antigenic regions of the P. falciparum proteins GLURP, MSP3 and HRPII were measured. Results On the day of malaria diagnosis, Immunoglobulin (IgG) antibodies against GLURP, MSP3 and HRP II peptides were present in the blood of 75%, 41% and 60% of patients, respectively. 42 days later, the majority of patients had boosted their serum IgG antibody more than 1.2 fold. The increase in level of IgG antibody against the peptides was not affected by parasite density at diagnosis. The median CD4+ cell counts of PLWHAs and HIV negative individuals were not statistically different, and median post-infection increases in anti-peptide IgG were similar in both groups of patients. Conclusion In the majority (70%) of individuals, an infection of P. falciparum elicits at least 20% increase in level of anti-parasite IgG. This boost in anti-P. falciparum IgG is not affected by parasite density on the day of malaria diagnosis, or by HIV status.
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Affiliation(s)
- Mark Kaddumukasa
- Department of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
| | | | - Allan Lugaajju
- College of Health Sciences, Makerere University, Kampala, Uganda
| | - Elly Katabira
- Department of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Kristina E M Persson
- Department of Microbiology, Tumour and Cell Biology, Karolinska Institutet, Stockholm, Sweden; Department of Laboratory Medicine, Lund University, Stockholm, Sweden
| | - Mats Wahlgren
- Department of Microbiology, Tumour and Cell Biology, Karolinska Institutet, Stockholm, Sweden
| | - Fred Kironde
- College of Health Sciences, Makerere University, Kampala, Uganda; Habib Medical School, IUIU, Kampala, Uganda
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Rishikesh K, Madivala SK, Prabhu P, Kamath A, Ashok H, Vidyasagar S, Shastry AB, Saravu K. Surmised total leucocyte counts miscalculate the parasite index of Plasmodium vivax malaria patients of tertiary and primary care settings in South-Western India. Malar J 2015; 14:163. [PMID: 25888823 PMCID: PMC4405837 DOI: 10.1186/s12936-015-0669-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2014] [Accepted: 03/16/2015] [Indexed: 11/18/2022] Open
Abstract
Background For the calculation of parasite index (PI) by microscopy method, an assumed total leucocyte count (TLC) of 8,000/μL is used conventionally. However, due to obvious variation in the population and individual TLCs, use of 8,000/μL may result in either over/underestimation of the PI. Methods This study was aimed at ascertaining the utility of 8,000/μL TLC, as well as other assumed TLCs, with respect to measured TLC for the calculation of PI. A tertiary care hospital and five primary health centres were the base for the prospective study conducted among microscopically proven, symptomatic Plasmodium vivax mono-infection patients aged ≥18 years. PIs calculated by assumed TLCs ranging from 4,000-11,000/μL were compared with those calculated by measured TLCs. Geometric mean with 95% confidence interval, Bland-Altman plot and Wilcoxon signed rank test were used for statistical analysis. Results A total of 284 P. vivax mono-infection patients, including 156 from a tertiary care hospital and 128 from five primary health centres, were recruited in the study. Assumed TLCs below 5,000 cell/μL and above 5,500 cell/μL in tertiary care setting resulted in significant (p <0.05) underestimation and overestimation, respectively. However, in primary health centres, it was an assumed TLC of 5,000 cell/μL, below and above which there was significant (p <0.05) underestimation and overestimation observed, respectively. Conclusions Assumed TLC of 8,000/μL is not suitable for the calculation of PI. Either actual TLC of the patient should be measured or a representative TLC should be derived for the population under investigation for any study requiring calculated PI by microscopy.
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Affiliation(s)
- Kumar Rishikesh
- Department of Medicine, Kasturba Medical College, Manipal University, Manipal, Karnataka, India.
| | - Sathish Kitta Madivala
- Department of Medicine, Kasturba Medical College, Manipal University, Manipal, Karnataka, India.
| | - Prashantha Prabhu
- Department of Medicine, Kasturba Medical College, Manipal University, Manipal, Karnataka, India.
| | - Asha Kamath
- Department of Community Medicine, Kasturba Medical College, Manipal University, Manipal, Karnataka, India.
| | | | - Sudha Vidyasagar
- Department of Medicine, Kasturba Medical College, Manipal University, Manipal, Karnataka, India.
| | | | - Kavitha Saravu
- Department of Medicine, Kasturba Medical College, Manipal University, Manipal, Karnataka, India.
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23
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Laman M, Benjamin JM, Moore BR, Salib M, Tawat S, Davis WA, Siba PM, Robinson LJ, Davis TME. Artemether-lumefantrine versus artemisinin-naphthoquine in Papua New Guinean children with uncomplicated malaria: a six months post-treatment follow-up study. Malar J 2015; 14:121. [PMID: 25889150 PMCID: PMC4374335 DOI: 10.1186/s12936-015-0624-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2015] [Accepted: 02/20/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In a recent trial of artemisinin-naphthoquine (artemisinin-NQ) and artemether-lumefantrine (AM-LM) therapy in young children from Papua New Guinea (PNG), there were no treatment failures in artemisinin-NQ-treated children with Plasmodium falciparum or Plasmodium vivax compared with 2.2% and 30.0%, respectively, in AM-LM-treated children during 42 days of follow-up. To determine whether, consistent with the long elimination half-life of NQ, this difference in efficacy would be more durable, clinical episodes of malaria were assessed in a subset of trial patients followed for six months post-treatment. METHODS For children completing trial procedures and who were assessable at six months, all within-trial and subsequent clinical malaria episodes were ascertained, the latter by clinic attendances and/or review of hand-held health records. Presentations with non-malarial illness were also recorded. Differences between allocated treatments for pre-specified endpoints were determined using Kaplan-Meier survival analysis. RESULTS Of 247 children who were followed to Day 42, 176 (71.3%) were included in the present sub-study, 87 allocated to AM-LM and 89 to artemisinin-NQ. Twenty children in the AM-LM group (32.8%) had a first episode of clinical malaria within six months compared with 10 (16.4%) in the artemisinin-NQ group (P = 0.033, log rank test). The median (interquartile range) time to first episode of clinical malaria was 64 (50-146) vs 116 (77-130) days, respectively (P = 0.20). There were no between-group differences in the incidence of first presentation with non-malarial illness (P = 0.31). CONCLUSIONS The greater effectiveness of artemisinin-NQ over conventional AM-LM extends to at least six months post-treatment for clinical malaria but not non-malarial illness. TRIAL REGISTRATION Australian New Zealand Clinical Trials Registry ACTRN12610000913077 .
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Affiliation(s)
- Moses Laman
- School of Medicine and Pharmacology, University of Western Australia, Fremantle Hospital, PO Box 480, Fremantle, 6959, WA, Australia. .,Papua New Guinea Institute of Medical Research, Madang, Papua New Guinea.
| | - John M Benjamin
- Papua New Guinea Institute of Medical Research, Madang, Papua New Guinea.
| | - Brioni R Moore
- School of Medicine and Pharmacology, University of Western Australia, Fremantle Hospital, PO Box 480, Fremantle, 6959, WA, Australia. .,Papua New Guinea Institute of Medical Research, Madang, Papua New Guinea.
| | - Mary Salib
- Papua New Guinea Institute of Medical Research, Madang, Papua New Guinea.
| | - Somoyang Tawat
- Papua New Guinea Institute of Medical Research, Madang, Papua New Guinea.
| | - Wendy A Davis
- School of Medicine and Pharmacology, University of Western Australia, Fremantle Hospital, PO Box 480, Fremantle, 6959, WA, Australia.
| | - Peter M Siba
- Papua New Guinea Institute of Medical Research, Madang, Papua New Guinea.
| | - Leanne J Robinson
- Papua New Guinea Institute of Medical Research, Madang, Papua New Guinea. .,Infection and Immunity Division, Walter and Eliza Hall Institute, Parkville, VIC, Australia. .,Department of Medical Biology, University of Melbourne, Melbourne, VIC, Australia.
| | - Timothy M E Davis
- School of Medicine and Pharmacology, University of Western Australia, Fremantle Hospital, PO Box 480, Fremantle, 6959, WA, Australia.
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24
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Karl S, Laman M, Koleala T, Ibam C, Kasian B, N'Drewei N, Rosanas-Urgell A, Moore BR, Waltmann A, Koepfli C, Siba PM, Betuela I, Woodward RC, St Pierre TG, Mueller I, Davis TME. Comparison of three methods for detection of gametocytes in Melanesian children treated for uncomplicated malaria. Malar J 2014; 13:319. [PMID: 25123055 PMCID: PMC4139605 DOI: 10.1186/1475-2875-13-319] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2014] [Accepted: 08/08/2014] [Indexed: 01/22/2023] Open
Abstract
Background Gametocytes are the transmission stages of Plasmodium parasites, the causative agents of malaria. As their density in the human host is typically low, they are often undetected by conventional light microscopy. Furthermore, application of RNA-based molecular detection methods for gametocyte detection remains challenging in remote field settings. In the present study, a detailed comparison of three methods, namely light microscopy, magnetic fractionation and reverse transcriptase polymerase chain reaction for detection of Plasmodium falciparum and Plasmodium vivax gametocytes was conducted. Methods Peripheral blood samples from 70 children aged 0.5 to five years with uncomplicated malaria who were treated with either artemether-lumefantrine or artemisinin-naphthoquine were collected from two health facilities on the north coast of Papua New Guinea. The samples were taken prior to treatment (day 0) and at pre-specified intervals during follow-up. Gametocytes were measured in each sample by three methods: i) light microscopy (LM), ii) quantitative magnetic fractionation (MF) and, iii) reverse transcriptase PCR (RTPCR). Data were analysed using censored linear regression and Bland and Altman techniques. Results MF and RTPCR were similarly sensitive and specific, and both were superior to LM. Overall, there were approximately 20% gametocyte-positive samples by LM, whereas gametocyte positivity by MF and RTPCR were both more than two-fold this level. In the subset of samples collected prior to treatment, 29% of children were positive by LM, and 85% were gametocyte positive by MF and RTPCR, respectively. Conclusions The present study represents the first direct comparison of standard LM, MF and RTPCR for gametocyte detection in field isolates. It provides strong evidence that MF is superior to LM and can be used to detect gametocytaemic patients under field conditions with similar sensitivity and specificity as RTPCR. Electronic supplementary material The online version of this article (doi:10.1186/1475-2875-13-319) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Stephan Karl
- School of Medicine and Pharmacology, University of Western Australia, Fremantle Hospital, Fremantle, Western Australia, Australia.
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Effect of coadministered fat on the tolerability, safety, and pharmacokinetic properties of dihydroartemisinin-piperaquine in Papua New Guinean children with uncomplicated malaria. Antimicrob Agents Chemother 2014; 58:5784-94. [PMID: 25049242 DOI: 10.1128/aac.03314-14] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Coadministration of dihydroartemisinin-piperaquine (DHA-PQ) with fat may improve bioavailability and antimalarial efficacy, but it might also increase toxicity. There have been no studies of these potential effects in the pediatric age group. The tolerability, safety, efficacy, and pharmacokinetics of DHA-PQ administered with or without 8.5 g fat were investigated in 30 Papua New Guinean children aged 5 to 10 years diagnosed with uncomplicated falciparum malaria. Three daily 2.5:11.5-mg-base/kg doses were given with water (n = 14, group A) or milk (n = 16, group B), with regular clinical/laboratory assessment and blood sampling over 42 days. Plasma PQ was assayed by high-performance liquid chromatography with UV detection, and DHA was assayed using liquid chromatography-mass spectrometry. Compartmental pharmacokinetic models for PQ and DHA were developed using a population-based approach. DHA-PQ was generally well tolerated, and initial fever and parasite clearance were prompt. There were no differences in the areas under the concentration-time curve (AUC0-∞) for PQ (median, 41,906 versus 36,752 μg · h/liter in groups A and B, respectively; P = 0.24) or DHA (4,047 versus 4,190 μg · h/liter; P = 0.67). There were also no significant between-group differences in prolongation of the corrected electrocardiographic QT interval (QTc) initially during follow-up, but the QTc tended to be higher in group B children at 24 h (mean ± standard deviation [SD], 15 ± 10 versus 6 ± 15 ms(0.5) in group A, P = 0.067) and 168 h (10 ± 18 versus 1 ± 23 ms(0.5), P = 0.24) when plasma PQ concentrations were relatively low. A small amount of fat does not change the bioavailability of DHA-PQ in children, but a delayed persistent effect on ventricular repolarization cannot be excluded.
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