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Nyongesa P, Ekhaguere OA, Marete I, Tenge C, Kemoi M, Bann CM, Bucher SL, Patel AB, Hibberd PL, Naqvi F, Saleem S, Goldenberg RL, Goudar SS, Derman RJ, Krebs NF, Garces A, Chomba E, Carlo WA, Mwenechanya M, Lokangaka A, Tshefu AK, Bauserman M, Koso-Thomas M, Moore JL, McClure EM, Liechty EA, Esamai F. Maternal age extremes and adverse pregnancy outcomes in low-resourced settings. Front Glob Womens Health 2023; 4:1201037. [PMID: 38090046 PMCID: PMC10715413 DOI: 10.3389/fgwh.2023.1201037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Accepted: 11/14/2023] [Indexed: 02/01/2024] Open
Abstract
Introduction Adolescent (<20 years) and advanced maternal age (>35 years) pregnancies carry adverse risks and warrant a critical review in low- and middle-income countries where the burden of adverse pregnancy outcomes is highest. Objective To describe the prevalence and adverse pregnancy (maternal, perinatal, and neonatal) outcomes associated with extremes of maternal age across six countries. Patients and methods We performed a historical cohort analysis on prospectively collected data from a population-based cohort study conducted in the Democratic Republic of Congo, Guatemala, India, Kenya, Pakistan, and Zambia between 2010 and 2020. We included pregnant women and their neonates. We describe the prevalence and adverse pregnancy outcomes associated with pregnancies in these maternal age groups (<20, 20-24, 25-29, 30-35, and >35 years). Relative risks and 95% confidence intervals of each adverse pregnancy outcome comparing each maternal age group to the reference group of 20-24 years were obtained by fitting a Poisson model adjusting for site, maternal age, parity, multiple gestations, maternal education, antenatal care, and delivery location. Analysis by region was also performed. Results We analyzed 602,884 deliveries; 13% (78,584) were adolescents, and 5% (28,677) were advanced maternal age (AMA). The overall maternal mortality ratio (MMR) was 147 deaths per 100,000 live births and increased with advancing maternal age: 83 in the adolescent and 298 in the AMA group. The AMA groups had the highest MMR in all regions. Adolescent pregnancy was associated with an adjusted relative risk (aRR) of 1.07 (1.02-1.11) for perinatal mortality and 1.13 (1.06-1.19) for neonatal mortality. In contrast, AMA was associated with an aRR of 2.55 (1.81 to 3.59) for maternal mortality, 1.58 (1.49-1.67) for perinatal mortality, and 1.30 (1.20-1.41) for neonatal mortality, compared to pregnancy in women 20-24 years. This pattern was overall similar in all regions, even in the <18 and 18-19 age groups. Conclusion The maternal mortality ratio in the LMICs assessed is high and increased with advancing maternal age groups. While less prevalent, AMA was associated with a higher risk of adverse maternal mortality and, like adolescence, was associated with adverse perinatal mortality with little regional variation.
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Affiliation(s)
- Paul Nyongesa
- Department of Obstetrics and Gynecology, Moi University School of Medicine, Eldoret, Kenya
| | - Osayame A. Ekhaguere
- Division of Neonatal-Perinatal Medicine, Indiana University School of Medicine, Indiana University, Indianapolis, IN, United States
| | - Irene Marete
- Department of Child Health and Paediatrics, Moi University School of Medicine, Eldoret, Kenya
| | - Constance Tenge
- Department of Child Health and Paediatrics, Moi University School of Medicine, Eldoret, Kenya
| | - Milsort Kemoi
- Department of Child Health and Paediatrics, Moi University School of Medicine, Eldoret, Kenya
| | - Carla M. Bann
- Social Statistical, and Environmental Sciences Unit, RTI International, Durham, NC, United States
| | - Sherri L. Bucher
- Division of Neonatal-Perinatal Medicine, Indiana University School of Medicine, Indiana University, Indianapolis, IN, United States
- Department of Community and Global Health, Richard M. Fairbanks School of Public Health, IU-Indianapolis, Indianapolis, IN, United States
| | - Archana B. Patel
- Department of Pediatrics, Datta Meghe Institute of Medical Sciences, Wardha, Maharashtra, India
| | - Patricia L. Hibberd
- Department of Global Health, Boston University School of Public Health, Boston, MA, United States
| | - Farnaz Naqvi
- Department of Community Health Sciences, Aga Khan University, Karachi, Pakistan
| | - Sarah Saleem
- Department of Community Health Sciences, Aga Khan University, Karachi, Pakistan
| | - Robert L. Goldenberg
- Department of Obstetrics and Gynecology, Columbia University School of Medicine, New York, NY, United States
| | - Shivaprasad S. Goudar
- Women's and Children's Health Research Unit, J N Medical College Belagavi, KLE Academy Higher Education and Research, Karnataka, India
| | - Richard J. Derman
- Global Affairs, Thomas Jefferson University, Philadelphia, PA, United States
| | - Nancy F. Krebs
- Department of Pediatrics, University of Colorado School of Medicine, Denver, CO, United States
| | - Ana Garces
- Department of Pediatrics, Instituto de Nutrición de Centroamérica y Panamá, Guatemala City, Guatemala
| | - Elwyn Chomba
- Department of Pediatrics, University Teaching Hospital, Lusaka, Zambia
| | - Waldemar A. Carlo
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL, United States
| | | | - Adrien Lokangaka
- Department of Pediatrics, Kinshasa School of Public Health, Kinshasa, Democratic Republic of Congo
| | - Antoinette K. Tshefu
- School of Public Health, University of Kinshasa, Kinshasa, Democratic Republic of Congo
| | - Melissa Bauserman
- Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Marion Koso-Thomas
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MA, United States
| | - Janet L. Moore
- Social Statistical, and Environmental Sciences Unit, RTI International, Durham, NC, United States
| | - Elizabeth M. McClure
- Social Statistical, and Environmental Sciences Unit, RTI International, Durham, NC, United States
| | - Edward A. Liechty
- Division of Neonatal-Perinatal Medicine, Indiana University School of Medicine, Indiana University, Indianapolis, IN, United States
| | - Fabian Esamai
- Department of Child Health and Paediatrics, Moi University School of Medicine, Eldoret, Kenya
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He W, Sendor R, Potlapalli VR, Kashamuka MM, Tshefu AK, Phanzu F, Kalonji A, Ngasala B, Thwai KL, Juliano JJ, Lin JT, Parr JB. A novel duplex qualitative real-time PCR assay for the detection and differentiation of Plasmodium ovale curtisi and Plasmodium ovale wallikeri malaria. medRxiv 2023:2023.10.31.23297819. [PMID: 37961397 PMCID: PMC10635243 DOI: 10.1101/2023.10.31.23297819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/15/2023]
Abstract
Background P. ovale spp. infections are endemic across multiple African countries and are caused by two distinct non-recombining species, P. ovale curtisi (Poc) and P. ovale wallikeri (Pow). These species are thought to differ in clinical symptomatology and latency, but existing diagnostic assays have limited ability to detect and distinguish them. In this study, we developed a new duplex assay for the detection and differentiation of Poc and Pow that can be used to improve our understanding of these parasites. Methods Repetitive sequence motifs were identified in available Poc and Pow genomes and used for assay development and validation. We evaluated the analytical sensitivity and specificity of the best-performing assay using a panel of samples from Tanzania and the Democratic Republic of the Congo (DRC), then validated its performance using 55 P. ovale spp. samples and 40 non-ovale Plasmodium samples from the DRC. Poc and Pow prevalence among symptomatic individuals sampled across three provinces of the DRC were estimated. Results The best-performing Poc and Pow targets had 9 and 8 copies within the reference genomes, respectively. Our duplex assay had 100% specificity and 95% confidence lower limits of detection of 4.2 and 41.2 parasite genome equivalents/μl for Poc and Pow, respectively. Species was determined in 80% of all P. ovale spp.-positive field samples and 100% of those with >10 parasites/μl. Most P. ovale spp. field samples from the DRC were found to be Poc infections. Conclusions We identified promising multi-copy targets for molecular detection and differentiation of Poc and Pow and used them to develop a new duplex real-time PCR assay that performed well when applied to diverse field samples. Though low-density Pow infections are not reliably detected, the assay is highly specific and can be used for high-throughput studies of P. ovale spp. epidemiology among symptomatic cases in malaria-endemic countries like the DRC.
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Affiliation(s)
- Wenqiao He
- Division of Infectious Diseases and Institute for Global Health and Infectious Diseases, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
- Department of Epidemiology, School of Public Health, Guangdong Provincial Key Laboratory of Tropical Disease Research, Southern Medical University, Guangzhou, China
| | - Rachel Sendor
- Department of Epidemiology, Gillings School of Global Public Health, Chapel Hill, NC, United States
| | - Varun R. Potlapalli
- Division of Infectious Diseases and Institute for Global Health and Infectious Diseases, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | | | | | | | | | - Billy Ngasala
- Muhimbili University of Health and Allied Sciences, Dar Es Salaam, Tanzania
| | - Kyaw Lay Thwai
- Division of Infectious Diseases and Institute for Global Health and Infectious Diseases, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Jonathan J. Juliano
- Division of Infectious Diseases and Institute for Global Health and Infectious Diseases, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
- Department of Epidemiology, Gillings School of Global Public Health, Chapel Hill, NC, United States
| | - Jessica T. Lin
- Division of Infectious Diseases and Institute for Global Health and Infectious Diseases, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Jonathan B. Parr
- Division of Infectious Diseases and Institute for Global Health and Infectious Diseases, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
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Rent S, Bauserman M, Laktabai J, Tshefu AK, Taylor SM. Malaria in Pregnancy: Key Points for the Neonatologist. Neoreviews 2023; 24:e539-e552. [PMID: 37653081 DOI: 10.1542/neo.24-9-e539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/02/2023]
Abstract
In malaria-endemic regions, infection with the malaria parasite Plasmodium during pregnancy has been identified as a key modifiable factor in preterm birth, the delivery of low-birthweight infants, and stillbirth. Compared with their nonpregnant peers, pregnant persons are at higher risk for malaria infection. Malaria infection can occur at any time during pregnancy, with negative effects for the pregnant person and the fetus, depending on the trimester in which the infection is contracted. Pregnant patients who are younger, in their first or second pregnancy, and those coinfected with human immunodeficiency virus are at increased risk for malaria. Common infection prevention measures during pregnancy include the use of insecticide-treated bed nets and the use of intermittent preventive treatment with monthly doses of antimalarials, beginning in the second trimester in pregnant patients in endemic areas. In all trimesters, artemisinin-combination therapies are the first-line treatment for uncomplicated falciparum malaria, similar to treatment in nonpregnant adults. The World Health Organization recently revised its recommendations, now listing the specific medication artemether-lumefantrine as first-line treatment for uncomplicated malaria in the first trimester. While strong prevention and detection methods exist, use of these techniques remains below global targets. Ongoing work on approaches to treatment and prevention of malaria during pregnancy remains at the forefront of global maternal child health research.
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Affiliation(s)
- Sharla Rent
- Department of Pediatrics, Duke University School of Medicine, Durham, NC
| | | | | | - Antoinette K Tshefu
- Kinshasa School of Public Health, Kinshasa, Democratic Republic of the Congo
| | - Steve M Taylor
- Department of Medicine, Duke University School of Medicine, Durham, NC
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4
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Tang M, Weaver NE, Frank DN, Ir D, Robertson CE, Kemp JF, Westcott J, Shankar K, Garces AL, Figueroa L, Tshefu AK, Lokangaka AL, Goudar SS, Somannavar M, Aziz S, Saleem S, McClure EM, Hambidge KM, Hendricks AE, Krebs NF. Longitudinal Reduction in Diversity of Maternal Gut Microbiota During Pregnancy Is Observed in Multiple Low-Resource Settings: Results From the Women First Trial. Front Microbiol 2022; 13:823757. [PMID: 35979501 PMCID: PMC9376441 DOI: 10.3389/fmicb.2022.823757] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2021] [Accepted: 06/15/2022] [Indexed: 11/13/2022] Open
Abstract
Objective To characterize the changes in gut microbiota during pregnancy and determine the effects of nutritional intervention on gut microbiota in women from sub-Saharan Africa (the Democratic Republic of the Congo, DRC), South Asia (India and Pakistan), and Central America (Guatemala). Methods Pregnant women in the Women First (WF) Preconception Maternal Nutrition Trial were included in this analysis. Participants were randomized to receive a lipid-based micronutrient supplement either ≥3 months before pregnancy (Arm 1); started the same intervention late in the first trimester (Arm 2); or received no nutrition supplements besides those self-administered or prescribed through local health services (Arm 3). Stool and blood samples were collected during the first and third trimesters. Findings presented here include fecal 16S rRNA gene-based profiling and systemic and intestinal inflammatory biomarkers, including alpha (1)-acid glycoprotein (AGP), C-reactive protein (CRP), fecal myeloperoxidase (MPO), and calprotectin. Results Stool samples were collected from 640 women (DRC, n = 157; India, n = 102; Guatemala, n = 276; and Pakistan, n = 105). Gut microbial community structure did not differ by intervention arm but changed significantly during pregnancy. Richness, a measure of alpha-diversity, decreased over pregnancy. Community composition (beta-diversity) also showed a significant change from first to third trimester in all four sites. Of the top 10 most abundant genera, unclassified Lachnospiraceae significantly decreased in Guatemala and unclassified Ruminococcaceae significantly decreased in Guatemala and DRC. The change in the overall community structure at the genus level was associated with a decrease in the abundances of certain genera with low heterogeneity among the four sites. Intervention arms were not significantly associated with inflammatory biomarkers at 12 or 34 weeks. AGP significantly decreased from 12 to 34 weeks of pregnancy, whereas CRP, MPO, and calprotectin did not significantly change over time. None of these biomarkers were significantly associated with the gut microbiota diversity. Conclusion The longitudinal reduction of individual genera (both commensals and potential pathogens) and alpha-diversity among all sites were consistent and suggested that the effect of pregnancy on the maternal microbiota overrides other influencing factors, such as nutrition intervention, geographical location, diet, race, and other demographical variables.
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Affiliation(s)
- Minghua Tang
- Department of Pediatrics, Section of Nutrition, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Nicholas E. Weaver
- Department of Mathematical and Statistical Sciences, University of Colorado, Denver, Denver, CO, United States
| | - Daniel N. Frank
- Department of Infectious Disease, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Diana Ir
- Department of Infectious Disease, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Charles E. Robertson
- Department of Infectious Disease, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Jennifer F. Kemp
- Department of Pediatrics, Section of Nutrition, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Jamie Westcott
- Department of Pediatrics, Section of Nutrition, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Kartik Shankar
- Department of Pediatrics, Section of Nutrition, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Ana L. Garces
- Institute of Nutrition in Central America and Panama (INCAP), Guatemala City, Guatemala
| | - Lester Figueroa
- Institute of Nutrition in Central America and Panama (INCAP), Guatemala City, Guatemala
| | - Antoinette K. Tshefu
- Institute of Nutrition in Central America and Panama (INCAP), Guatemala City, Guatemala
| | - Adrien L. Lokangaka
- Institute of Nutrition in Central America and Panama (INCAP), Guatemala City, Guatemala
| | - Shivaprasad S. Goudar
- KLE Academy of Higher Education and Research (Deemed-to-be-University), Jawaharlal Nehru Medical College, Belagavi, India
| | - Manjunath Somannavar
- KLE Academy of Higher Education and Research (Deemed-to-be-University), Jawaharlal Nehru Medical College, Belagavi, India
| | - Sumera Aziz
- Department of Community Health Sciences, Aga Khan University, Karachi, Pakistan
| | - Sarah Saleem
- Department of Community Health Sciences, Aga Khan University, Karachi, Pakistan
| | | | - K. Michael Hambidge
- Department of Pediatrics, Section of Nutrition, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Audrey E. Hendricks
- Department of Mathematical and Statistical Sciences, University of Colorado, Denver, Denver, CO, United States
| | - Nancy F. Krebs
- Department of Pediatrics, Section of Nutrition, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
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5
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Krebs NF, Hambidge KM, Westcott JL, Garcés AL, Figueroa L, Tshefu AK, Lokangaka AL, Goudar SS, Dhaded SM, Saleem S, Ali SA, Bauserman MS, Derman RJ, Goldenberg RL, Das A, Chowdhury D. Birth length is the strongest predictor of linear growth status and stunting in the first 2 years of life after a preconception maternal nutrition intervention: the children of the Women First trial. Am J Clin Nutr 2022; 116:86-96. [PMID: 35681255 PMCID: PMC9257468 DOI: 10.1093/ajcn/nqac051] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Accepted: 02/16/2022] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND The multicountry Women First trial demonstrated that nutritional supplementation initiated prior to conception (arm 1) or early pregnancy (arm 2) and continued until delivery resulted in significantly greater length at birth and 6 mo compared with infants in the control arm (arm 3). OBJECTIVES We evaluated intervention effects on infants' longitudinal growth trajectory from birth through 24 mo and identified predictors of length status and stunting at 24 mo. METHODS Infants' anthropometry was obtained at 6, 12, 18, and 24 mo after the Women First trial (registered at clinicaltrials.gov as NCT01883193), which was conducted in low-resource settings: Democratic Republic of Congo, Guatemala, India, and Pakistan. Longitudinal models evaluated intervention effects on infants' growth trajectory from birth to 24 mo, with additional modeling used to identify adjusted predictors for growth trajectories and outcomes at 24 mo. RESULTS Data for 2337 (95% of original live births) infants were evaluated. At 24 mo, stunting rates were 62.8%, 64.8%, and 66.3% for arms 1, 2, and 3, respectively (NS). For the length-for-age z-score (LAZ) trajectory, treatment arm was a significant predictor, with adjusted mean differences of 0.19 SD (95% CI: 0.08, 0.30; P < 0.001) and 0.17 SD (95% CI: 0.07, 0.27; P < 0.001) for arms 1 and 2, respectively. The strongest predictors of LAZ at 24 mo were birth LAZ <-2 and <-1 to ≥-2, with adjusted mean differences of -0.76 SD (95% CI: -0.93, -0.58; P < 0.001) and -0.47 SD (95% CI: -0.56, -0.38; P < 0.001), respectively. For infants with ultrasound-determined gestational age (n = 1329), the strongest predictors of stunting were birth LAZ <-2 and <-1 to ≥- 2: adjusted relative risk of 1.62 (95% CI: 1.39, 1.88; P < 0.001) and 1.46 (95% CI: 1.31, 1.62; P < 0.001), respectively. CONCLUSIONS Substantial improvements in postnatal growth are likely to depend on improved intrauterine growth, especially during early pregnancy.
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Affiliation(s)
- Nancy F Krebs
- Department of Pediatrics, Section of Nutrition, University of Colorado School of Medicine, Denver, CO, USA
| | - K Michael Hambidge
- Department of Pediatrics, Section of Nutrition, University of Colorado School of Medicine, Denver, CO, USA
| | - Jamie L Westcott
- Department of Pediatrics, Section of Nutrition, University of Colorado School of Medicine, Denver, CO, USA
| | - Ana L Garcés
- Unidad de Salud Materno Infantil, Instituto de Nutrición de Centroamérica y Panamá (INCAP), Calzada Roosevelt, Guatemala City, Guatemala
| | - Lester Figueroa
- Unidad de Salud Materno Infantil, Instituto de Nutrición de Centroamérica y Panamá (INCAP), Calzada Roosevelt, Guatemala City, Guatemala
| | - Antoinette K Tshefu
- Kinshasa School of Public Health, Hôpital Général de Kinshasa, Kinshasa, Democratic Republic of the Congo
| | - Adrien L Lokangaka
- Kinshasa School of Public Health, Hôpital Général de Kinshasa, Kinshasa, Democratic Republic of the Congo
| | - Shivaprasad S Goudar
- KLE Academy of Higher Education and Research, Jawaharlal Nehru Medical College, Belagavi, India
| | - Sangappa M Dhaded
- KLE Academy of Higher Education and Research, Jawaharlal Nehru Medical College, Belagavi, India
| | - Sarah Saleem
- Department of Community Health Sciences, Aga Khan University, Karachi, Pakistan
| | - Sumera Aziz Ali
- Department of Community Health Sciences, Aga Khan University, Karachi, Pakistan
| | - Melissa S Bauserman
- Department of Pediatrics Neonatal-Perinatal Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - Richard J Derman
- Department of OBGYN, Thomas Jefferson University, Philadelphia, PA, USA
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6
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Mitchell CL, Janko MM, Mwandagalirwa MK, Tshefu AK, Edwards JK, Pence BW, Juliano JJ, Emch M. Impact of extractive industries on malaria prevalence in the Democratic Republic of the Congo: a population-based cross-sectional study. Sci Rep 2022; 12:1737. [PMID: 35110617 PMCID: PMC8810856 DOI: 10.1038/s41598-022-05777-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Accepted: 01/18/2022] [Indexed: 12/11/2022] Open
Abstract
Extraction of natural resources through mining and logging activities provides revenue and employment across sub-Saharan Africa, a region with the highest burden of malaria globally. The extent to which mining and logging influence malaria transmission in Africa remains poorly understood. Here, we evaluate associations between mining, logging, and malaria in the high transmission setting of the Democratic Republic of the Congo using population-representative malaria survey results and geographic data for environmental features and mining and logging concessions. We find elevated malaria prevalence among individuals in rural areas exposed to mining; however, we also detect significant spatial confounding among locations. Upon correction, effect estimates for mining and logging shifted toward the null and we did not find sufficient evidence to detect an association with malaria. Our findings reveal a complex interplay between mining, logging, space, and malaria prevalence. While mining concessions alone may not drive the high prevalence, unobserved features of mining-exposed areas, such as human migration, changing vector populations, or parasite genetics, may instead be responsible.
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Affiliation(s)
- Cedar L Mitchell
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, 135 Dauer Dr., Chapel Hill, NC, 27599, USA.
| | - Mark M Janko
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Melchior K Mwandagalirwa
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, 135 Dauer Dr., Chapel Hill, NC, 27599, USA.,Kinshasa School of Public Health, Hôpital General Provincial de Reference de Kinshasa, Kinshasa, Democratic Republic of Congo
| | - Antoinette K Tshefu
- Kinshasa School of Public Health, Hôpital General Provincial de Reference de Kinshasa, Kinshasa, Democratic Republic of Congo
| | - Jessie K Edwards
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, 135 Dauer Dr., Chapel Hill, NC, 27599, USA
| | - Brian W Pence
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, 135 Dauer Dr., Chapel Hill, NC, 27599, USA
| | - Jonathan J Juliano
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, 135 Dauer Dr., Chapel Hill, NC, 27599, USA.,Division of Infectious Diseases, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Michael Emch
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, 135 Dauer Dr., Chapel Hill, NC, 27599, USA.,Department of Geography, University of North Carolina, Chapel Hill, NC, USA
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7
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Deutsch-Feldman M, Parr JB, Keeler C, Brazeau NF, Goel V, Emch M, Edwards JK, Kashamuka M, Tshefu AK, Meshnick SR. The Burden of Malaria in the Democratic Republic of the Congo. J Infect Dis 2021; 223:1948-1952. [PMID: 33057671 PMCID: PMC8176632 DOI: 10.1093/infdis/jiaa650#supplementary-data] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Accepted: 10/12/2020] [Indexed: 10/05/2023] Open
Abstract
Despite evidence that older children and adolescents bear the highest burden of malaria, large malaria surveys focus on younger children. We used polymerase chain reaction data from the 2013-2014 Demographic and Health Survey in the Democratic Republic of Congo (including children aged <5 years and adults aged ≥15 years) and a longitudinal study in Kinshasa Province (participants aged 6 months to 98 years) to estimate malaria prevalence across age strata. We fit linear models and estimated prevalences for each age category; adolescents aged 10-14 years had the highest prevalence. We estimate approximately 26 million polymerase chain reaction-detectable infections nationally. Adolescents and older children should be included in surveillance studies.
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Affiliation(s)
- Molly Deutsch-Feldman
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Jonathan B Parr
- Division of Infectious Diseases, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Corinna Keeler
- Department of Geography, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Nicholas F Brazeau
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Varun Goel
- Department of Geography, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Michael Emch
- Department of Geography, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Jessie K Edwards
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Melchior Kashamuka
- Kinshasa School of Public Health, Kinshasa, Democratic Republic of the Congo
| | - Antoinette K Tshefu
- Kinshasa School of Public Health, Kinshasa, Democratic Republic of the Congo
| | - Steven R Meshnick
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina, USA
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8
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Bauserman MS, Bann CM, Hambidge KM, Garces AL, Figueroa L, Westcott JL, Patterson JK, McClure EM, Thorsten VR, Aziz SA, Saleem S, Goldenberg RL, Derman RJ, Herekar V, Somannavar M, Koso-Thomas MW, Lokangaka AL, Tshefu AK, Krebs NF, Bose CL. Gestational weight gain in 4 low- and middle-income countries and associations with birth outcomes: a secondary analysis of the Women First Trial. Am J Clin Nutr 2021; 114:804-812. [PMID: 33876178 PMCID: PMC8326045 DOI: 10.1093/ajcn/nqab086] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Accepted: 03/02/2021] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND Adequate gestational weight gain (GWG) is essential for healthy fetal growth. However, in low- and middle-income countries, where malnutrition is prevalent, little information is available about GWG and how it might be modified by nutritional status and interventions. OBJECTIVE We describe GWG and its associations with fetal growth and birth outcomes. We also examined the extent to which prepregnancy BMI, and preconception and early weight gain modify GWG, and its effects on fetal growth. METHODS This was a secondary analysis of the Women First Trial, including 2331 women within the Democratic Republic of Congo (DRC), Guatemala, India, and Pakistan, evaluating weight gain from enrollment to ∼12 weeks of gestation and GWG velocity (kg/wk) between ∼12 and 32 weeks of gestation. Adequacy of GWG velocity was compared with 2009 Institute of Medicine recommendations, according to maternal BMI. Early weight gain (EWG), GWG velocity, and adequacy of GWG were related to birth outcomes using linear and Poisson models. RESULTS GWG velocity (mean ± SD) varied by site: 0.22 ± 0.15 kg/wk in DRC, 0.30 ± 0.23 in Pakistan, 0.31 ± 0.14 in Guatemala, and 0.39 ± 0.13 in India, (P <0.0001). An increase of 0.1 kg/wk in maternal GWG was associated with a 0.13 cm (95% CI: 0.07, 0.18, P <0.001) increase in birth length and a 0.032 kg (0.022, 0.042, P <0.001) increase in birth weight. Compared to women with inadequate GWG, women who had adequate GWG delivered newborns with a higher mean length and weight: 47.98 ± 2.04 cm compared with 47.40 ± 2.17 cm (P <0.001) and 2.864 ± 0.425 kg compared with 2.764 ± 0.418 kg (P <0.001). Baseline BMI, EWG, and GWG were all associated with birth length and weight. CONCLUSIONS These results underscore the importance of adequate maternal nutrition both before and during pregnancy as a potentially modifiable factor to improve fetal growth.
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Affiliation(s)
| | | | - K Michael Hambidge
- Section of Nutrition, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA
| | - Ana L Garces
- INCAP (Institute of Nutrition of Central America and Panama), Guatemala City, Guatemala
| | - Lester Figueroa
- INCAP (Institute of Nutrition of Central America and Panama), Guatemala City, Guatemala
| | - Jamie L Westcott
- Section of Nutrition, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA
| | - Jackie K Patterson
- Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | | | | | - Sumera Ali Aziz
- Department of Community Health Sciences, Aga Khan University, Karachi, Pakistan
| | - Sarah Saleem
- Department of Community Health Sciences, Aga Khan University, Karachi, Pakistan
| | - Robert L Goldenberg
- Department of Obstetrics and Gynecology, Columbia University, New York, NY, USA
| | - Richard J Derman
- Department of Global Affairs, Thomas Jefferson University, Philadelphia, PA, USA
| | - Veena Herekar
- KLE Academy of Higher Education and Research's Jawaharlal Nehru Medical College, Belagavi, Karnataka, India
| | - Manjunath Somannavar
- KLE Academy of Higher Education and Research's Jawaharlal Nehru Medical College, Belagavi, Karnataka, India
| | | | - Adrien L Lokangaka
- Kinshasa School of Public Health, Kinshasa, Democratic Republic of the Congo
| | - Antoinette K Tshefu
- Kinshasa School of Public Health, Kinshasa, Democratic Republic of the Congo
| | - Nancy F Krebs
- Section of Nutrition, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA
| | - Carl L Bose
- Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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9
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Parr JB, Kieto E, Phanzu F, Mansiangi P, Mwandagalirwa K, Mvuama N, Landela A, Atibu J, Efundu SU, Olenga JW, Thwai KL, Morgan CE, Denton M, Poffley A, Juliano JJ, Mungala P, Likwela JL, Sompwe EM, Rogier E, Tshefu AK, N'Siala A, Kalonji A. Analysis of false-negative rapid diagnostic tests for symptomatic malaria in the Democratic Republic of the Congo. Sci Rep 2021; 11:6495. [PMID: 33753817 PMCID: PMC7985209 DOI: 10.1038/s41598-021-85913-z] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Accepted: 03/08/2021] [Indexed: 11/29/2022] Open
Abstract
The majority of Plasmodium falciparum malaria diagnoses in Africa are made using rapid diagnostic tests (RDTs) that detect histidine-rich protein 2. Increasing reports of false-negative RDT results due to parasites with deletions of the pfhrp2 and/or pfhrp3 genes (pfhrp2/3) raise concern about existing malaria diagnostic strategies. We previously identified pfhrp2-negative parasites among asymptomatic children in the Democratic Republic of the Congo (DRC), but their impact on diagnosis of symptomatic malaria is unknown. We performed a cross-sectional study of false-negative RDTs in symptomatic subjects in 2017. Parasites were characterized by microscopy; RDT; pfhrp2/3 genotyping and species-specific PCR assays; a bead-based immunoassay for Plasmodium antigens; and/or whole-genome sequencing. Among 3627 symptomatic subjects, 427 (11.8%) had RDT-/microscopy + results. Parasites from eight (0.2%) samples were initially classified as putative pfhrp2/3 deletions by PCR, but antigen testing and whole-genome sequencing confirmed the presence of intact genes. 56.8% of subjects had PCR-confirmed malaria. Non-falciparum co-infection with P. falciparum was common (13.2%). Agreement between PCR and HRP2-based RDTs was satisfactory (Cohen's kappa = 0.66) and superior to microscopy (0.33). Symptomatic malaria due to pfhrp2/3-deleted P. falciparum was not observed. Ongoing HRP2-based RDT use is appropriate for the detection of falciparum malaria in the DRC.
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Affiliation(s)
- Jonathan B Parr
- Division of Infectious Diseases, Institute for Global Health and Infectious Diseases, University of North Carolina, 130 Mason Farm Rd, Chapel Hill, NC, 27599, USA.
| | - Eddy Kieto
- SANRU Asbl (Sante Rurale/Global Fund), Kinshasa, Democratic Republic of the Congo
| | - Fernandine Phanzu
- SANRU Asbl (Sante Rurale/Global Fund), Kinshasa, Democratic Republic of the Congo
| | - Paul Mansiangi
- University of Kinshasa School of Public Health, Kinshasa, Democratic Republic of Congo
| | | | - Nono Mvuama
- University of Kinshasa School of Public Health, Kinshasa, Democratic Republic of Congo
| | - Ange Landela
- Institut National Pour La Recherche Biomedicale, Kinshasa, Democratic Republic of the Congo
| | - Joseph Atibu
- University of Kinshasa School of Public Health, Kinshasa, Democratic Republic of Congo
| | | | - Jean W Olenga
- SANRU Asbl (Sante Rurale/Global Fund), Kinshasa, Democratic Republic of the Congo
| | - Kyaw Lay Thwai
- Division of Infectious Diseases, Institute for Global Health and Infectious Diseases, University of North Carolina, 130 Mason Farm Rd, Chapel Hill, NC, 27599, USA
| | - Camille E Morgan
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC, 27599, USA
| | - Madeline Denton
- Division of Infectious Diseases, Institute for Global Health and Infectious Diseases, University of North Carolina, 130 Mason Farm Rd, Chapel Hill, NC, 27599, USA
| | - Alison Poffley
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC, 27599, USA
| | - Jonathan J Juliano
- Division of Infectious Diseases, Institute for Global Health and Infectious Diseases, University of North Carolina, 130 Mason Farm Rd, Chapel Hill, NC, 27599, USA
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC, 27599, USA
| | - Pomie Mungala
- SANRU Asbl (Sante Rurale/Global Fund), Kinshasa, Democratic Republic of the Congo
| | - Joris L Likwela
- SANRU Asbl (Sante Rurale/Global Fund), Kinshasa, Democratic Republic of the Congo
| | - Eric M Sompwe
- Programme National de La Lutte Contre Le Paludisme, Kinshasa, Democratic Republic of Congo
| | - Eric Rogier
- Malaria Branch, Division of Parasitic Diseases and Malaria, Centers for Disease Control and Prevention, Atlanta, GA, 30033, USA
| | - Antoinette K Tshefu
- University of Kinshasa School of Public Health, Kinshasa, Democratic Republic of Congo
| | - Adrien N'Siala
- SANRU Asbl (Sante Rurale/Global Fund), Kinshasa, Democratic Republic of the Congo
| | - Albert Kalonji
- SANRU Asbl (Sante Rurale/Global Fund), Kinshasa, Democratic Republic of the Congo
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10
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Mitchell CL, Topazian HM, Brazeau NF, Deutsch-Feldman M, Muwonga J, Sompwe E, Tshefu AK, Mwandagalirwa MK, Parr JB, Juliano JJ. Household prevalence of P. falciparum, P. vivax, and P. ovale in the Democratic Republic of the Congo, 2013-2014. Clin Infect Dis 2020; 73:e3966-e3969. [PMID: 33238298 DOI: 10.1093/cid/ciaa1772] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Accepted: 11/20/2020] [Indexed: 11/15/2022] Open
Abstract
In a cross-sectional molecular study in the Democratic Republic of Congo, 78% of households had at least one member infected with Plasmodium falciparum, vivax, and/or ovale spp. 47% of children and 33% of adults tested positive for at least one species. Risk factors varied by species and age group.
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Affiliation(s)
- Cedar L Mitchell
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC, USA
| | - Hillary M Topazian
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC, USA
| | - Nicholas F Brazeau
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC, USA.,Medical Scientist Training Program, School of Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - Molly Deutsch-Feldman
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC, USA
| | - Jeremie Muwonga
- Programme National de la Lutte contre le SIDA, Kinshasa, Democratic Republic of Congo
| | - Eric Sompwe
- Programme National de la Lutte contre le Paludisme, Kinshasa, Democratic Republic of Congo
| | - Antoinette K Tshefu
- Kinshasa School of Public Health, University of Kinshasa, Kinshasa, Democratic Republic of the Congo
| | - Melchior K Mwandagalirwa
- Kinshasa School of Public Health, University of Kinshasa, Kinshasa, Democratic Republic of the Congo
| | - Jonathan B Parr
- Division of Infectious Diseases, School of Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - Jonathan J Juliano
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC, USA.,Division of Infectious Diseases, School of Medicine, University of North Carolina, Chapel Hill, NC, USA
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11
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Deutsch-Feldman M, Parr JB, Keeler C, Brazeau NF, Goel V, Emch M, Edwards JK, Kashamuka M, Tshefu AK, Meshnick SR. The Burden of Malaria in the Democratic Republic of the Congo. J Infect Dis 2020; 223:1948-1952. [PMID: 33057671 DOI: 10.1093/infdis/jiaa650] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Accepted: 10/12/2020] [Indexed: 01/31/2023] Open
Abstract
Despite evidence that older children and adolescents bear the highest burden of malaria, large malaria surveys focus on younger children. We used polymerase chain reaction data from the 2013-2014 Demographic and Health Survey in the Democratic Republic of Congo (including children aged <5 years and adults aged ≥15 years) and a longitudinal study in Kinshasa Province (participants aged 6 months to 98 years) to estimate malaria prevalence across age strata. We fit linear models and estimated prevalences for each age category; adolescents aged 10-14 years had the highest prevalence. We estimate approximately 26 million polymerase chain reaction-detectable infections nationally. Adolescents and older children should be included in surveillance studies.
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Affiliation(s)
- Molly Deutsch-Feldman
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Jonathan B Parr
- Division of Infectious Diseases, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Corinna Keeler
- Department of Geography, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Nicholas F Brazeau
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Varun Goel
- Department of Geography, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Michael Emch
- Department of Geography, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Jessie K Edwards
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Melchior Kashamuka
- Kinshasa School of Public Health, Kinshasa, Democratic Republic of the Congo
| | - Antoinette K Tshefu
- Kinshasa School of Public Health, Kinshasa, Democratic Republic of the Congo
| | - Steven R Meshnick
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina, USA
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12
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Mitchell CL, Brazeau NF, Keeler C, Mwandagalirwa MK, Tshefu AK, Juliano JJ, Meshnick SR. Under the Radar: Epidemiology of Plasmodium ovale in the Democratic Republic of the Congo. J Infect Dis 2020; 223:1005-1014. [PMID: 32766832 DOI: 10.1093/infdis/jiaa478] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Accepted: 07/28/2020] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Plasmodium ovale is an understudied malaria species prevalent throughout much of sub-Saharan Africa. Little is known about the distribution of ovale malaria and risk factors for infection in areas of high malaria endemicity. METHODS Using the 2013 Democratic Republic of the Congo (DRC) Demographic and Health Survey, we conducted a risk factor analysis for P. ovale infections. We evaluated geographic clustering of infections and speciated to P. ovale curtisi and P. ovale wallikeri through deep sequencing. RESULTS Of 18 149 adults tested, we detected 143 prevalent P. ovale infections (prevalence estimate 0.8%; 95% confidence interval [CI], .59%-.98%). Prevalence ratios (PR) for significant risk factors were: male sex PR = 2.12 (95% CI, 1.38-3.26), coprevalent P. falciparum PR = 3.52 (95% CI, 2.06-5.99), and rural residence PR = 2.19 (95% CI, 1.31-3.66). P. ovale was broadly distributed throughout the DRC; an elevated cluster of infections was detected in the south-central region. Speciation revealed P. ovale curtisi and P. ovale wallikeri circulating throughout the country. CONCLUSIONS P. ovale persists broadly in the DRC, a high malaria burden country. For successful elimination of all malaria species, P. ovale needs to be on the radar of malaria control programs.
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Affiliation(s)
- Cedar L Mitchell
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Nicholas F Brazeau
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Corinna Keeler
- Department of Geography, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Melchior Kashamuka Mwandagalirwa
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina, USA.,Kinshasa School of Public Health, Faculty of Medicine, University of Kinshasa, Kinshasa, Democratic Republic of Congo
| | - Antoinette K Tshefu
- Kinshasa School of Public Health, Faculty of Medicine, University of Kinshasa, Kinshasa, Democratic Republic of Congo
| | - Jonathan J Juliano
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina, USA.,Division of Infectious Diseases, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA.,Curriculum in Genetics and Molecular Biology, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Steven R Meshnick
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina, USA.,Division of Infectious Diseases, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
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13
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Deutsch-Feldman M, Aydemir O, Carrel M, Brazeau NF, Bhatt S, Bailey JA, Kashamuka M, Tshefu AK, Taylor SM, Juliano JJ, Meshnick SR, Verity R. The changing landscape of Plasmodium falciparum drug resistance in the Democratic Republic of Congo. BMC Infect Dis 2019; 19:872. [PMID: 31640574 PMCID: PMC6805465 DOI: 10.1186/s12879-019-4523-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2019] [Accepted: 09/30/2019] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Drug resistant malaria is a growing concern in the Democratic Republic of the Congo (DRC), where previous studies indicate that parasites resistant to sulfadoxine/pyrimethamine or chloroquine are spatially clustered. This study explores longitudinal changes in spatial patterns to understand how resistant malaria may be spreading within the DRC, using samples from nation-wide population-representative surveys. METHODS We selected 552 children with PCR-detectable Plasmodium falciparum infection and identified known variants in the pfdhps and pfcrt genes associated with resistance. We compared the proportion of mutant parasites in 2013 to those previously reported from adults in 2007, and identified risk factors for carrying a resistant allele using multivariate mixed-effects modeling. Finally, we fit a spatial-temporal model to the observed data, providing smooth allele frequency estimates over space and time. RESULTS The proportion of co-occurring pfdhps K540E/A581G mutations increased by 16% between 2007 and 2013. The spatial-temporal model suggests that the spatial range of the pfdhps double mutants expanded over time, while the prevalence and range of pfcrt mutations remained steady. CONCLUSIONS This study uses population-representative samples to describe the changing landscape of SP resistance within the DRC, and the persistence of chloroquine resistance. Vigilant molecular surveillance is critical for controlling the spread of resistance.
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Affiliation(s)
- Molly Deutsch-Feldman
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, USA.
| | - Ozkan Aydemir
- Department of Pathology and Laboratory Medicine, Brown University, Providence, RI, USA
| | - Margaret Carrel
- Department of Geographical & Sustainability Sciences, University of Iowa, Iowa City, IA, USA
| | - Nicholas F Brazeau
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, USA
| | - Samir Bhatt
- Medical Research Council Centre for Global Infectious Disease Analysis, Department of Infectious Disease Epidemiology, Imperial College London, London, UK
| | - Jeffrey A Bailey
- Department of Pathology and Laboratory Medicine, Brown University, Providence, RI, USA
| | - Melchior Kashamuka
- Ecole de Santé Publique, , Faculté de Médecine, University of Kinshasa, Kinshasa, Democratic Republic of Congo
| | - Antoinette K Tshefu
- Ecole de Santé Publique, , Faculté de Médecine, University of Kinshasa, Kinshasa, Democratic Republic of Congo
| | - Steve M Taylor
- Division of Infectious Diseases and Duke Global Health Institute, Duke University, Durham, NC, USA
| | - Jonathan J Juliano
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, USA.,Division of Infectious Diseases, University of North Carolina at Chapel Hill, Chapel Hill, USA.,Curriculum in Genetics and Molecular Biology, University of North Carolina at Chapel Hill, Chapel Hill, USA
| | - Steven R Meshnick
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, USA
| | - Robert Verity
- Medical Research Council Centre for Global Infectious Disease Analysis, Department of Infectious Disease Epidemiology, Imperial College London, London, UK
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14
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Brazeau NF, Whitesell AN, Doctor SM, Keeler C, Mwandagalirwa MK, Tshefu AK, Likwela JL, Juliano JJ, Meshnick SR. Plasmodium vivax Infections in Duffy-Negative Individuals in the Democratic Republic of the Congo. Am J Trop Med Hyg 2019; 99:1128-1133. [PMID: 30203741 DOI: 10.4269/ajtmh.18-0277] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
Although Plasmodium vivax has been assumed to be absent from sub-Saharan Africa because of the protective mutation conferring the Duffy-negative phenotype, recent evidence has suggested that P. vivax cases are prevalent in these regions. We selected 292 dried blood spots from children who participated in the 2013-2014 Demographic and Health Survey of the Democratic Republic of the Congo (DRC), to assess for P. vivax infection. Four P. vivax infections were identified by polymerase chain reaction, each in a geographically different survey cluster. Using these as index cases, we tested the remaining 73 samples from the four clusters. With this approach, 10 confirmed cases, three probable cases, and one possible case of P. vivax were identified. Among the 14 P. vivax cases, nine were coinfected with Plasmodium falciparum. All 14 individuals were confirmed to be Duffy-negative by sequencing for the single point mutation in the GATA motif that represses the expression of the Duffy antigen. This finding is consistent with a growing body of literature that suggests that P. vivax can infect Duffy-negative individuals in Africa. Future molecular and sequencing work is needed to understand the relationship of these isolates with other P. vivax samples from Asia and South America and discover variants linked to P. vivax virulence and erythrocyte invasion.
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Affiliation(s)
- Nicholas F Brazeau
- Medical Scientist Training Program, University of North Carolina School of Medicine, Chapel Hill, North Carolina.,Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina
| | - Amy N Whitesell
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina
| | - Stephanie M Doctor
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina
| | - Corinna Keeler
- Department of Geography, University of North Carolina, Chapel Hill, North Carolina
| | | | - Antoinette K Tshefu
- Programme National de la Lutte Contre le Paludisme, Kinshasa, Democratic Republic of Congo
| | - Joris L Likwela
- Kinshasa School of Public Health, Kinshasa, Democratic Republic of the Congo
| | - Jonathan J Juliano
- Division of Infectious Diseases, School of Medicine, University of North Carolina, Chapel Hill, North Carolina.,Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina
| | - Steven R Meshnick
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina
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15
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Althabe F, Chomba E, Tshefu AK, Banda E, Belizán M, Bergel E, Berrueta M, Bertrand J, Bose C, Cafferata ML, Carlo WA, Ciganda A, Donnay F, García Elorrio E, Gibbons L, Klein K, Liljestrand J, Lusamba PD, Mavila AK, Mazzoni A, Nkamba DM, Mwanakalanga FH, Mwapule Tembo A, Mwenechanya M, Pyne-Mercier L, Spira C, Wetshikoy JD, Xiong X, Buekens P. A multifaceted intervention to improve syphilis screening and treatment in pregnant women in Kinshasa, Democratic Republic of the Congo and in Lusaka, Zambia: a cluster randomised controlled trial. Lancet Glob Health 2019; 7:e655-e663. [PMID: 30910531 PMCID: PMC6465956 DOI: 10.1016/s2214-109x(19)30075-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/22/2018] [Revised: 12/19/2018] [Accepted: 01/16/2019] [Indexed: 11/11/2022]
Abstract
Background Despite international recommendations, coverage of syphilis testing in pregnant women and treatment of those found seropositive remains limited in sub-Saharan Africa. We assessed whether combining the provision of supplies with a behavioural intervention was more effective than providing supplies only, to improve syphilis screening and treatment during antenatal care. Methods In this 18-month, cluster randomised controlled trial, we randomly assigned (1:1) 26 urban antenatal care clinics in Kinshasa, Democratic Republic of the Congo, and Lusaka, Zambia, to receive a behavioural intervention (opinion leader selection, academic detailing visits, reminders, audits and feedback, and supportive supervision) plus supplies for syphilis testing and treatment (intervention group) or to receive supplies only (control group). The primary outcomes were proportion of pregnant women who had syphilis screening out of the total who attended the clinic; and the proportion of women who had treatment with benzathine benzylpenicillin out of those who tested positive for syphilis at their first antenatal care visit. This trial is registered at ClinicalTrials.gov, number NCT02353117. Findings The 18-month study period was Feb 1, 2016, to July 14, 2017. 18 357 women were enrolled at the 13 intervention clinics and 17 679 women were enrolled at the 13 control clinics at their first antenatal care visit. Syphilis screening was done in a median of 99·9% (IQR 99·0–100·0) of women in the intervention clinics and 93·8% (85·0–98·9) in the control clinics (absolute difference 6·1% [95% CI 1·1–14·1]; p=0·00092). Syphilis treatment at the first visit was done in a median of 100% (IQR 99·7–100·0) of seropositive women in intervention clinics and 43·2% (2·6–83·2) of seropositive women in control clinics (absolute difference 56·8% [12·8–99·0]; p=0·0028). Interpretation A behavioural intervention, together with the provision of supplies, can lead to more than 95% of women being screened and treated for syphilis. The sole provision of supplies is sufficient to reach such levels of screening coverage but is not sufficient to ensure high levels of treatment. Funding Bill & Melinda Gates Foundation.
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Affiliation(s)
- Fernando Althabe
- Institute for Clinical Effectiveness and Health Policy, Buenos Aires, Argentina; UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction, Department of Reproductive Health and Research, WHO, Geneva, Switzerland
| | - Elwyn Chomba
- University Teaching Hospital of Lusaka, Lusaka, Zambia
| | - Antoinette K Tshefu
- Kinshasa School of Public Health, University of Kinshasa, Kinshasa, Democratic Republic of the Congo
| | - Ernest Banda
- University Teaching Hospital of Lusaka, Lusaka, Zambia
| | - María Belizán
- Institute for Clinical Effectiveness and Health Policy, Buenos Aires, Argentina
| | - Eduardo Bergel
- Institute for Clinical Effectiveness and Health Policy, Buenos Aires, Argentina
| | - Mabel Berrueta
- Institute for Clinical Effectiveness and Health Policy, Buenos Aires, Argentina.
| | - Jane Bertrand
- Tulane University School of Public Health and Tropical Medicine, Los Angeles, CA, USA
| | - Carl Bose
- University of North Carolina (UNC) School of Medicine, UNC Hospitals, Chapel Hill, NC, USA
| | | | - Waldemar A Carlo
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Alvaro Ciganda
- Institute for Clinical Effectiveness and Health Policy, Buenos Aires, Argentina
| | - France Donnay
- Tulane University School of Public Health and Tropical Medicine, Los Angeles, CA, USA
| | | | - Luz Gibbons
- Institute for Clinical Effectiveness and Health Policy, Buenos Aires, Argentina
| | - Karen Klein
- Institute for Clinical Effectiveness and Health Policy, Buenos Aires, Argentina
| | | | - Paul D Lusamba
- Kinshasa School of Public Health, University of Kinshasa, Kinshasa, Democratic Republic of the Congo
| | - Arlette K Mavila
- Kinshasa School of Public Health, University of Kinshasa, Kinshasa, Democratic Republic of the Congo
| | - Agustina Mazzoni
- Institute for Clinical Effectiveness and Health Policy, Buenos Aires, Argentina
| | - Dalau M Nkamba
- Kinshasa School of Public Health, University of Kinshasa, Kinshasa, Democratic Republic of the Congo
| | | | | | | | | | - Cintia Spira
- Institute for Clinical Effectiveness and Health Policy, Buenos Aires, Argentina
| | - Jean D Wetshikoy
- Kinshasa School of Public Health, University of Kinshasa, Kinshasa, Democratic Republic of the Congo
| | - Xu Xiong
- Tulane University School of Public Health and Tropical Medicine, Los Angeles, CA, USA
| | - Pierre Buekens
- Tulane University School of Public Health and Tropical Medicine, Los Angeles, CA, USA
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Aydemir O, Janko M, Hathaway NJ, Verity R, Mwandagalirwa MK, Tshefu AK, Tessema SK, Marsh PW, Tran A, Reimonn T, Ghani AC, Ghansah A, Juliano JJ, Greenhouse BR, Emch M, Meshnick SR, Bailey JA. Drug-Resistance and Population Structure of Plasmodium falciparum Across the Democratic Republic of Congo Using High-Throughput Molecular Inversion Probes. J Infect Dis 2018; 218:946-955. [PMID: 29718283 PMCID: PMC6093412 DOI: 10.1093/infdis/jiy223] [Citation(s) in RCA: 60] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Accepted: 04/26/2018] [Indexed: 11/21/2022] Open
Abstract
A better understanding of the drivers of the spread of malaria parasites and drug resistance across space and time is needed. These drivers can be elucidated using genetic tools. Here, a novel molecular inversion probe (MIP) panel targeting all major drug-resistance mutations and a set of microsatellites was used to genotype Plasmodium falciparum infections of 552 children from the 2013-2014 Demographic and Health Survey conducted in the Democratic Republic of the Congo (DRC). Microsatellite-based analysis of population structure suggests that parasites within the DRC form a homogeneous population. In contrast, sulfadoxine-resistance markers in dihydropteroate synthase show marked spatial structure with ongoing spread of double and triple mutants compared with 2007. These findings suggest that parasites in the DRC remain panmictic despite rapidly spreading antimalarial-resistance mutations. Moreover, highly multiplexed targeted sequencing using MIPs emerges as a cost-effective method for elucidating pathogen genetics in complex infections in large cohorts.
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Affiliation(s)
- Ozkan Aydemir
- Program in Bioinformatics and Integrative Biology, University of Massachusetts, Worcester
| | - Mark Janko
- Department of Geography, University of North Carolina, Chapel Hill
| | - Nick J Hathaway
- Program in Bioinformatics and Integrative Biology, University of Massachusetts, Worcester
| | - Robert Verity
- Medical Research Council Centre for Global Infectious Disease Analysis, Department of Infectious Disease Epidemiology, Imperial College London, United Kingdom
| | | | - Antoinette K Tshefu
- Community Health, Kinshasa School of Public Health, School of Medicine, University of Kinshasa, Democratic Republic of Congo
| | | | - Patrick W Marsh
- Program in Bioinformatics and Integrative Biology, University of Massachusetts, Worcester
| | - Alice Tran
- Program in Bioinformatics and Integrative Biology, University of Massachusetts, Worcester
| | - Thomas Reimonn
- Program in Bioinformatics and Integrative Biology, University of Massachusetts, Worcester
| | - Azra C Ghani
- Medical Research Council Centre for Global Infectious Disease Analysis, Department of Infectious Disease Epidemiology, Imperial College London, United Kingdom
| | - Anita Ghansah
- Department of Parasitology, Noguchi Memorial Institute of Medical Research, Ghana
| | - Jonathan J Juliano
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill
- Division of Infectious Diseases, University of North Carolina, Chapel Hill
- Curriculum in Genetics and Microbiology, University of North Carolina, Chapel Hill
| | | | - Michael Emch
- Department of Geography, University of North Carolina, Chapel Hill
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill
| | - Steven R Meshnick
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill
- Institute for Global Health and Infectious Diseases, School of Medicine, University of North Carolina, Chapel Hill
| | - Jeffrey A Bailey
- Program in Bioinformatics and Integrative Biology, University of Massachusetts, Worcester
- Division of Transfusion Medicine, Department of Medicine, University of Massachusetts Medical School, Worcester
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17
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Toure OA, Mwapasa V, Sagara I, Gaye O, Thompson R, Maheshwar AV, Mishra P, Behra N, Tshefu AK, Das RR, Anvikar AR, Sharma P, Roy A, Sharma SK, Nasa A, Jalali RK, Valecha N. Assessment of Efficacy and Safety of Arterolane Maleate-Piperaquine Phosphate Dispersible Tablets in Comparison With Artemether-Lumefantrine Dispersible Tablets in Pediatric Patients With Acute Uncomplicated Plasmodium falciparum Malaria: A Phase 3, Randomized, Multicenter Trial in India and Africa. Clin Infect Dis 2018; 65:1711-1720. [PMID: 29020247 DOI: 10.1093/cid/cix617] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2017] [Accepted: 07/31/2017] [Indexed: 11/13/2022] Open
Abstract
Background Administration of artemisinin-based combination therapy (ACT) to infant and young children can be challenging. A formulation with accurate dose and ease of administration will improve adherence and compliance in children. The fixed-dose combination dispersible tablet of arterolane maleate (AM) 37.5 mg and piperaquine phosphate (PQP) 187.5 mg can make dosing convenient in children. Methods This multicenter (India and Africa), comparative, parallel-group trial enrolled 859 patients aged 6 months to 12 years with Plasmodium falciparum malaria. Patients were randomized in a ratio of 2:1 to AM-PQP (571 patients) once daily and artemether-lumefantrine (AL) (288 patients) twice daily for 3 days and followed for 42 days. Results The cure rate (ie, polymerase chain reaction-corrected adequate clinical and parasitological response) in the per-protocol population at day 28 was 100.0% and 98.5% (difference, 1.48% [95% confidence interval {CI}, .04%-2.91%]) in the AM-PQP and AL arms, respectively, and 96.0% and 95.8% (difference, 0.14% [95% CI, -2.68% to 2.95%]) in the intention-to-treat (ITT) population. The cure rate was comparable at day 42 in the ITT population (AM-PQP, 94.4% vs AL, 93.1%). The median parasite clearance time was 24 hours in both the arms. The median fever clearance time was 6 hours in AM-PQP and 12 hours in the AL arm. Both the treatments were found to be safe and well tolerated. Overall, safety profile of both the treatments was similar. Conclusions The efficacy and safety of fixed-dose combination of AM and PQP was comparable to AL for the treatment of uncomplicated P. falciparum malaria in pediatric patients. Clinical Trials Registration CTRI/2014/07/004764.
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Affiliation(s)
| | | | - Issaka Sagara
- Malaria Research and Training Center, University of Science, Techniques and Technologies, Bamako, Mali
| | - Oumar Gaye
- Department of Parasitology, University Cheikh Anta Diop, Dakar Fann, Senegal
| | | | | | - Pitabas Mishra
- Pediatric Medicine, Ispat General Hospital, Rourkela, Odisha
| | - Narendra Behra
- Department of Pediatrics, Maharaja Krishna Chandra Gajapati College and Hospital, Berhampur, Odisha, India
| | - Antoinette K Tshefu
- Centre de Recherche Clinique et Epidemiologique du Mont Amba, Centre hospitalier du Mont Amba, Kinshasa, Democratic Republic of Congo
| | - Rashmi R Das
- Department of Pediatrics, All India Institute of Medical Sciences, Bhubaneswar, Odisha
| | | | | | - Arjun Roy
- Medical Affairs and Clinical Research, Sun Pharmaceutical Industries Ltd, Gurgaon, Haryana, India
| | - Sanjay K Sharma
- Medical Affairs and Clinical Research, Sun Pharmaceutical Industries Ltd, Gurgaon, Haryana, India
| | - Amit Nasa
- Medical Affairs and Clinical Research, Sun Pharmaceutical Industries Ltd, Gurgaon, Haryana, India
| | - Rajinder K Jalali
- Medical Affairs and Clinical Research, Sun Pharmaceutical Industries Ltd, Gurgaon, Haryana, India
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18
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Prince-Guerra JL, Cama VA, Wilson N, Thiele EA, Likwela J, Ndakala N, Muzinga Wa Muzinga J, Ayebazibwe N, Ndjakani YD, Pitchouna NA, Mumba D, Tshefu AK, Ogawa G, Cantey PT. Comparison of PCR Methods for Onchocerca volvulus Detection in Skin Snip Biopsies from the Tshopo Province, Democratic Republic of the Congo. Am J Trop Med Hyg 2018; 98:1427-1434. [PMID: 29611501 DOI: 10.4269/ajtmh.17-0809] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
Defining the optimal diagnostic tools for evaluating onchocerciasis elimination efforts in areas co-endemic for other filarial nematodes is imperative. This study compared three published polymerase chain reaction (PCR) methods: the Onchocerca volvulus-specific qPCR-O150, the pan-filarial qPCR melt curve analysis (MCA), and the O150-PCR enzyme-linked immunosorbent assay (ELISA) currently used for vector surveillance in skin snip biopsies (skin snips) collected from the Democratic Republic of the Congo. The pan-filarial qPCR-MCA was compared with species-specific qPCRs for Loa loa and Mansonella perstans. Among the 471 skin snips, 47.5%, 43.5%, and 27.0% were O. volvulus positive by qPCR-O150, qPCR-MCA, and O150-PCR ELISA, respectively. Using qPCR-O150 as the comparator, the sensitivity and specificity of qPCR-MCA were 89.3% and 98.0%, respectively, whereas for O150-PCR ELISA, they were 56.7% and 100%, respectively. Although qPCR-MCA identified the presence of L. loa and Mansonella spp. in skin snips, species-specific qPCRs had greater sensitivity and were needed to identify M. perstans. Most of the qPCR-MCA misclassifications occurred in mixed infections. The reduced sensitivity of O150-PCR ELISA was associated with lower microfilaria burden and with lower amounts of O. volvulus DNA. Although qPCR-MCA identified most of the O. volvulus-positive skin snips, it is not sufficiently robust to be used for stop-mass drug administration (MDA) evaluations in areas co-endemic for other filariae. Because O150-PCR ELISA missed 43.3% of qPCR-O150-positive skin snips, the qPCR-O150 assay is more appropriate for evaluating skin snips of OV-16 + children in stop-MDA assessments. Although improving the sensitivity of the O150-PCR ELISA as an alternative to qPCR might be possible, qPCR-O150 offers distinct advantages aside from increased sensitivity.
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Affiliation(s)
- Jessica L Prince-Guerra
- American Society for Microbiology/Centers for Disease Control and Prevention Postdoctoral Research Fellowship, Atlanta, Georgia
| | - Vitaliano A Cama
- Division of Parasitic Diseases and Malaria, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Nana Wilson
- Division of Parasitic Diseases and Malaria, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Elizabeth A Thiele
- Division of Parasitic Diseases and Malaria, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Josias Likwela
- Programme National de la Lutte contre l'Onchocercose, Kisangani, Congo, Democratic Republic of the Congo
| | - Nestor Ndakala
- Field Epidemiology and Laboratory Training Program, Kinshasa, Democratic Republic of the Congo
| | | | | | - Yassa D Ndjakani
- Division of Global Health Protection, Centers for Disease Control and Prevention, Kinshasa, Democratic Republic of the Congo
| | - Naomi A Pitchouna
- Programme Nationale de la Lutte contre l'Onchocercose, Kinshasa, Democratic Republic of the Congo
| | - Dieudonne Mumba
- Institut National de Recherche Biomédicale, Kinshasa, Congo, Democratic Republic of the Congo
| | | | - Guilherme Ogawa
- Division of Parasitic Diseases and Malaria, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Paul T Cantey
- Division of Parasitic Diseases and Malaria, Centers for Disease Control and Prevention, Atlanta, Georgia
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19
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Janko MM, Irish SR, Reich BJ, Peterson M, Doctor SM, Mwandagalirwa MK, Likwela JL, Tshefu AK, Meshnick SR, Emch ME. The links between agriculture, Anopheles mosquitoes, and malaria risk in children younger than 5 years in the Democratic Republic of the Congo: a population-based, cross-sectional, spatial study. Lancet Planet Health 2018; 2:e74-e82. [PMID: 29457150 PMCID: PMC5809714 DOI: 10.1016/s2542-5196(18)30009-3] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
BACKGROUND The relationship between agriculture, Anopheles mosquitoes, and malaria in Africa is not fully understood, but it is important for malaria control as countries consider expanding agricultural projects to address population growth and food demand. Therefore, we aimed to assess the effect of agriculture on Anopheles biting behaviour and malaria risk in children in rural areas of the Democratic Republic of the Congo (DR Congo). METHODS We did a population-based, cross-sectional, spatial study of rural children (<5 years) in the DR Congo. We used information about the presence of malaria parasites in each child, as determined by PCR analysis of dried-blood spots from the 2013-14 DR Congo Demographic and Health Survey (DHS). We also used data from the DHS, a longitudinal entomological study, and available land cover and climate data to evaluate the relationships between agriculture, Anopheles biting behaviour, and malaria prevalence. Satellite imagery was used to measure the percentage of agricultural land cover around DHS villages and Anopheles sites. Anopheles biting behaviour was assessed by Human Landing Catch. We used probit regression to assess the relationship between agriculture and the probability of malaria infection, as well as the relationship between agriculture and the probability that a mosquito was caught biting indoors. FINDINGS Between Aug 13, 2013, and Feb 13, 2014, a total of 9790 dried-blood spots were obtained from the DHS, of which 4612 participants were included in this study. Falciparum malaria infection prevalence in rural children was 38·7% (95% uncertainty interval [UI] 37·3-40·0). Increasing exposure to agriculture was associated with increasing malaria risk with a high posterior probability (estimate 0·07, 95% UI -0·04 to 0·17; posterior probability [estimate >0]=0·89), with the probability of malaria infection increased between 0·2% (95% UI -0·1 to 3·4) and 2·6% (-1·5 to 6·6) given a 15% increase in agricultural cover, depending on other risk factors. The models predicted that large increases in agricultural cover (from 0% to 75%) increase the probability of infection by as much as 13·1% (95% UI -7·3 to 28·9). Increased risk might be due to Anopheles gambiae sensu lato, whose probability of biting indoors increased between 11·3% (95% UI -15·3 to 25·6) and 19·7% (-12·1 to 35·9) with a 15% increase in agriculture. INTERPRETATION Malaria control programmes must consider the possibility of increased risk due to expanding agriculture. Governments considering initiating large-scale agricultural projects should therefore also consider accompanying additional malaria control measures. FUNDING National Institutes of Health, National Science Foundation, Bill & Melinda Gates Foundation, President's Malaria Initiative, and Royster Society of Fellows at the University of North Carolina at Chapel Hill.
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Affiliation(s)
- Mark M Janko
- Duke Global Health Institute, Duke University, Durham, NC, USA; Department of Geography, Chapel Hill, NC, USA; Department of Biostatistics, Chapel Hill, NC, USA; Carolina Population Center, Chapel Hill, NC, USA.
| | - Seth R Irish
- University of North Carolina, Chapel Hill, NC, USA; President's Malaria Initiative and Entomology Branch, Division of Parasitic Diseases and Malaria, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Brian J Reich
- Department of Statistics, North Carolina State University, Raleigh, NC, USA
| | | | | | | | - Joris L Likwela
- Programme National de Lutte contre le Paludisme, Kinshasa, Democratic Republic of the Congo
| | - Antoinette K Tshefu
- Department of Community Health, Ecole de Santé Publique, Faculté de Médecine, University of Kinshasa, Kinshasa, Democratic Republic of the Congo
| | | | - Michael E Emch
- Department of Geography, Chapel Hill, NC, USA; Carolina Population Center, Chapel Hill, NC, USA; Department of Epidemiology, Chapel Hill, NC, USA
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20
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Verity R, Hathaway NJ, Waltmann A, Doctor SM, Watson OJ, Patel JC, Mwandagalirwa K, Tshefu AK, Bailey JA, Ghani AC, Juliano JJ, Meshnick SR. Plasmodium falciparum genetic variation of var2csa in the Democratic Republic of the Congo. Malar J 2018; 17:46. [PMID: 29361940 PMCID: PMC5782373 DOI: 10.1186/s12936-018-2193-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2017] [Accepted: 01/17/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The Democratic Republic of the Congo (DRC) bears a high burden of malaria, which is exacerbated in pregnant women. The VAR2CSA protein plays a crucial role in pregnancy-associated malaria (PAM), and hence quantifying diversity at the var2csa locus in the DRC is important in understanding the basic epidemiology of PAM, and in developing a robust vaccine against PAM. METHODS Samples were taken from the 2013-14 Demographic and Health Survey conducted in the DRC, focusing on children under 5 years of age. A short subregion of the var2csa gene was sequenced in 115 spatial clusters, giving country-wide estimates of sequence polymorphism and spatial population structure. RESULTS Results indicate that var2csa is highly polymorphic, and that diversity is being maintained through balancing selection, however, there is no clear signal of phylogenetic or geographic structure to this diversity. Linear modelling demonstrates that the number of var2csa variants in a cluster correlates directly with cluster prevalence, but not with other epidemiological factors such as urbanicity. CONCLUSIONS Results suggest that the DRC fits within the global pattern of high var2csa diversity and little genetic differentiation between regions. A broad multivalent VAR2CSA vaccine candidate could benefit from targeting stable regions and common variants to address the substantial genetic diversity.
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Affiliation(s)
- Robert Verity
- Medical Research Council Centre for Outbreak Analysis & Modelling, Department of Infectious Disease Epidemiology, Imperial College London, London, UK.
| | - Nicholas J Hathaway
- Program in Bioinformatics and Integrative Biology, University of Massachusetts, Worcester, MA, USA
- Division of Transfusion Medicine, Department of Medicine, University of Massachusetts, Worcester, MA, USA
| | - Andreea Waltmann
- Institute for Global Health and Infectious Diseases, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, USA
| | - Stephanie M Doctor
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, USA
| | - Oliver J Watson
- Medical Research Council Centre for Outbreak Analysis & Modelling, Department of Infectious Disease Epidemiology, Imperial College London, London, UK
| | - Jaymin C Patel
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, USA
| | - Kashamuka Mwandagalirwa
- Kinshasa School of Public Health, Hôpital General Provincial de Reference de Kinshasa, Kinshasa, Democratic Republic of Congo
| | - Antoinette K Tshefu
- Community Health, Kinshasa School of Public Health, School of Medicine, University of Kinshasa, Kinshasa, Democratic Republic of Congo
| | - Jeffrey A Bailey
- Program in Bioinformatics and Integrative Biology, University of Massachusetts, Worcester, MA, USA
- Division of Transfusion Medicine, Department of Medicine, University of Massachusetts, Worcester, MA, USA
| | - Azra C Ghani
- Medical Research Council Centre for Outbreak Analysis & Modelling, Department of Infectious Disease Epidemiology, Imperial College London, London, UK
| | - Jonathan J Juliano
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, USA
- Division of Infectious Diseases, University of North Carolina at Chapel Hill, 130 Mason Farm Road, Chapel Hill, 27599, USA
- Curriculum in Genetics and Microbiology, University of North Carolina at Chapel Hill, 321 South Columbia Street, Chapel Hill, NC, 27516, USA
| | - Steven R Meshnick
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, USA
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21
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Levitz L, Janko M, Mwandagalirwa K, Thwai KL, Likwela JL, Tshefu AK, Emch M, Meshnick SR. Effect of individual and community-level bed net usage on malaria prevalence among under-fives in the Democratic Republic of Congo. Malar J 2018; 17:39. [PMID: 29347953 PMCID: PMC5774036 DOI: 10.1186/s12936-018-2183-y] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2017] [Accepted: 01/10/2018] [Indexed: 11/10/2022] Open
Abstract
Background Understanding the contribution of community-level long-lasting, insecticidal net (LLIN) coverage to malaria control is critical to planning and assessing intervention campaigns. The Democratic Republic of Congo (DRC), which has one of the highest burdens of malaria cases and deaths and has dramatically scaled up LLIN ownership in recent years thus it is an ideal setting to evaluate the effect of individual versus community-level use to prevent malaria among children under the age of 5. Results Data were derived from the 2013–2014 DRC Demographic and Health Survey. Community-level LLIN usage was significantly associated with protection against malaria, even when individual-level LLIN usage was included in the model. In stratified analysis, higher levels of community LLIN coverage enhanced the protective effect of individual LLIN usage, resulting in lower malaria prevalence among individuals who used a LLIN. A sub-analysis of individual LLIN usage by insecticide type revealed deltamethrin-treated nets were more protective than permethrin-treated nets, suggesting that mosquitoes in the DRC are more susceptible to deltamethrin. Conclusions This study examines the effects of individual and community-level LLIN usage in young children in an area of high ITN usage. Individual and community LLIN usage were significantly associated with protection against malaria in children under 5 in the DRC. Importantly, the protective effect of individual LLIN usage against malaria is enhanced when community LLIN coverage is higher, demonstrating the importance of increasing community-level LLIN usage. LLINs treated with deltamethrin were shown to be more protective against malaria than LLINs treated with permethrin. Demographic and Health Surveys are thus a novel and important means of surveillance for insecticide resistance.
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Affiliation(s)
- Lauren Levitz
- Department of Epidemiology, University of North Carolina, Gillings School of Global Public Health, 135 Dauer Drive, 3113 Michael Hooker Research Building, Chapel Hill, NC, 27599, USA
| | - Mark Janko
- Department of Geography, University of North Carolina Gillings School of Global Public Health, Chapel Hill, NC, 27599, USA
| | | | - Kyaw L Thwai
- Department of Epidemiology, University of North Carolina, Gillings School of Global Public Health, 135 Dauer Drive, 3113 Michael Hooker Research Building, Chapel Hill, NC, 27599, USA
| | - Joris L Likwela
- Programme National de la Lutte contre le Paludisme, Kinshasa, Democratic Republic of Congo
| | - Antoinette K Tshefu
- University of Kinshasa School of Public Health, Kinshasa, Democratic Republic of Congo
| | - Michael Emch
- Department of Geography, University of North Carolina Gillings School of Global Public Health, Chapel Hill, NC, 27599, USA
| | - Steven R Meshnick
- Department of Epidemiology, University of North Carolina, Gillings School of Global Public Health, 135 Dauer Drive, 3113 Michael Hooker Research Building, Chapel Hill, NC, 27599, USA.
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22
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Berrueta M, Cafferata ML, Mwenechanya M, Nkamba Mukadi D, Althabe F, Bergel E, Gibbons L, Ciganda A, Klein K, Mwapule Tembo A, Habulembe Mwanakalanga F, Banda E, Mavila Kilonga A, Lusamba Dikassa P, Xiong X, Chomba E, Tshefu AK, Buekens P. Syphilis screening and treatment in pregnant women in Kinshasa, Democratic Republic of the Congo and in Lusaka, Zambia: a cross-sectional study. Gates Open Res 2017; 1:13. [PMID: 29355227 PMCID: PMC5764227 DOI: 10.12688/gatesopenres.12768.1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/11/2018] [Indexed: 11/20/2022] Open
Abstract
Background: Congenital syphilis is associated with perinatal deaths, preterm births and congenital malformations. Low rates of syphilis screening during pregnancy and treatment of those found seropositive have been reported in the Democratic Republic of the Congo (DRC) and Zambia. We report the rates on antenatal syphilis screening, the seroprevalence of syphilis infection, and the frequency of antibiotic treatment in pregnant women screened positive for syphilis during their attendance at antenatal care (ANC) clinics in Kinshasa, DRC and Lusaka, Zambia. Methods: Women attending their first ANC were enrolled consecutively during a 9-month period in 16 and 13 ANC clinics in Kinshasa and Lusaka respectively, in the context of the baseline period of a cluster trial. Study personnel collected data on women’s characteristics, the syphilis screening practices, the test results, and the frequency of treatment, that were done under routine ANC conditions and registered in the clinic records. Results: 4,153 women in Kinshasa and 18,097 women in Lusaka were enrolled. The frequency of screening at the first visit was 59.7% (n= 2,479) in Kinshasa, and 27.8% (n=5,025) in Lusaka. Screening test availability varied. In the periods in which tests were available the screening rates were 92.8% in Kinshasa and 52.0% in Lusaka. The frequency of women screened seropositive was 0.4% (n=10) in Kinshasa and 2.2% (n=109) in Lusaka. Respectively, 10% (n=1) and 11.9% (n= 13) among seropositive women received treatment at the first visit. Conclusions: The results of the study show that screening for syphilis in pregnancy is not universal even when supplies are available. Our ongoing trial will evaluate the impact of a behavioral intervention on changing health providers’ practices to increase screening and treatment rates when supplies are available.
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Affiliation(s)
- Mabel Berrueta
- Institute for Clinical Effectiveness and Health Policy (IECS), Dr. Emilio Ravignani 2024, Buenos Aires, 1414 CABA, Argentina
| | - Maria Luisa Cafferata
- Institute for Clinical Effectiveness and Health Policy (IECS), Dr. Emilio Ravignani 2024, Buenos Aires, 1414 CABA, Argentina
| | - Musaku Mwenechanya
- University Teaching Hospital of Lusaka, Private Bag RW1X Ridgeway, Nationalist Road, Lusaka, Zambia
| | - Dalau Nkamba Mukadi
- Kinshasa School of Public Health, University of Kinshasa, Kinshasa, Congo, Democratic Republic
| | - Fernando Althabe
- Institute for Clinical Effectiveness and Health Policy (IECS), Dr. Emilio Ravignani 2024, Buenos Aires, 1414 CABA, Argentina
| | - Eduardo Bergel
- Institute for Clinical Effectiveness and Health Policy (IECS), Dr. Emilio Ravignani 2024, Buenos Aires, 1414 CABA, Argentina
| | - Luz Gibbons
- Institute for Clinical Effectiveness and Health Policy (IECS), Dr. Emilio Ravignani 2024, Buenos Aires, 1414 CABA, Argentina
| | - Alvaro Ciganda
- Institute for Clinical Effectiveness and Health Policy (IECS), Dr. Emilio Ravignani 2024, Buenos Aires, 1414 CABA, Argentina
| | - Karen Klein
- Institute for Clinical Effectiveness and Health Policy (IECS), Dr. Emilio Ravignani 2024, Buenos Aires, 1414 CABA, Argentina
| | - Abigail Mwapule Tembo
- University Teaching Hospital of Lusaka, Private Bag RW1X Ridgeway, Nationalist Road, Lusaka, Zambia
| | | | - Ernest Banda
- University Teaching Hospital of Lusaka, Private Bag RW1X Ridgeway, Nationalist Road, Lusaka, Zambia
| | - Arlette Mavila Kilonga
- Kinshasa School of Public Health, University of Kinshasa, Kinshasa, Congo, Democratic Republic
| | - Paul Lusamba Dikassa
- Kinshasa School of Public Health, University of Kinshasa, Kinshasa, Congo, Democratic Republic
| | - Xu Xiong
- Tulane University School of Public Health and Tropical Medicine, 6823 St Charles Ave, New Orleans, LA 70118, USA
| | - Elwyn Chomba
- University Teaching Hospital of Lusaka, Private Bag RW1X Ridgeway, Nationalist Road, Lusaka, Zambia
| | - Antoinette K Tshefu
- Kinshasa School of Public Health, University of Kinshasa, Kinshasa, Congo, Democratic Republic
| | - Pierre Buekens
- Tulane University School of Public Health and Tropical Medicine, 6823 St Charles Ave, New Orleans, LA 70118, USA
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Parr JB, Verity R, Doctor SM, Janko M, Carey-Ewend K, Turman BJ, Keeler C, Slater HC, Whitesell AN, Mwandagalirwa K, Ghani AC, Likwela JL, Tshefu AK, Emch M, Juliano JJ, Meshnick SR. Pfhrp2-Deleted Plasmodium falciparum Parasites in the Democratic Republic of the Congo: A National Cross-sectional Survey. J Infect Dis 2017; 216:36-44. [PMID: 28177502 DOI: 10.1093/infdis/jiw538] [Citation(s) in RCA: 80] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2016] [Accepted: 11/02/2016] [Indexed: 11/14/2022] Open
Abstract
Background Rapid diagnostic tests (RDTs) account for more than two-thirds of malaria diagnoses in Africa. Deletions of the Plasmodium falciparum hrp2 (pfhrp2) gene cause false-negative RDT results and have never been investigated on a national level. Spread of pfhrp2-deleted P. falciparum mutants, resistant to detection by HRP2-based RDTs, would represent a serious threat to malaria elimination efforts. Methods Using a nationally representative cross-sectional study of 7,137 children under five years of age from the Democratic Republic of Congo (DRC), we tested 783 subjects with RDT-/PCR+ results using PCR assays to detect and confirm deletions of the pfhrp2 gene. Spatial and population genetic analyses were employed to examine the distribution and evolution of these parasites. Results We identified 149 pfhrp2-deleted parasites, representing 6.4% of all P. falciparum infections country-wide (95% confidence interval 5.1-8.0%). Bayesian spatial analyses identified statistically significant clustering of pfhrp2 deletions near Kinshasa and Kivu. Population genetic analysis revealed significant genetic differentiation between wild-type and pfhrp2-deleted parasite populations (GST = .046, p ≤ .00001). Conclusions Pfhrp2-deleted P. falciparum is a common cause of RDT-/PCR+ malaria among asymptomatic children in the DRC and appears to be clustered within select communities. Surveillance for these deletions is needed, and alternatives to HRP2-specific RDTs may be necessary.
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Affiliation(s)
- Jonathan B Parr
- Division of Infectious Diseases, University of North Carolina, Chapel Hill, NC 27599, USA
| | - Robert Verity
- Department of Infectious Disease Epidemiology, Imperial College, London, United Kingdom
| | - Stephanie M Doctor
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC 27599, USA
| | - Mark Janko
- Department of Geography, University of North Carolina, Chapel Hill, NC 27599, USA
| | - Kelly Carey-Ewend
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC 27599, USA
| | - Breanna J Turman
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC 27599, USA
| | - Corinna Keeler
- Department of Geography, University of North Carolina, Chapel Hill, NC 27599, USA
| | - Hannah C Slater
- Department of Infectious Disease Epidemiology, Imperial College, London, United Kingdom
| | - Amy N Whitesell
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC 27599, USA
| | - Kashamuka Mwandagalirwa
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC 27599, USA
- University of Kinshasa School of Public Health, Kinshasa, Democratic Republic of Congo
| | - Azra C Ghani
- Department of Infectious Disease Epidemiology, Imperial College, London, United Kingdom
| | - Joris L Likwela
- Programme National de la Lutte contre le Paludisme, Kinshasa, Democratic Republic of Congo
| | - Antoinette K Tshefu
- University of Kinshasa School of Public Health, Kinshasa, Democratic Republic of Congo
| | - Michael Emch
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC 27599, USA
- Department of Geography, University of North Carolina, Chapel Hill, NC 27599, USA
| | - Jonathan J Juliano
- Division of Infectious Diseases, University of North Carolina, Chapel Hill, NC 27599, USA
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC 27599, USA
| | - Steven R Meshnick
- Division of Infectious Diseases, University of North Carolina, Chapel Hill, NC 27599, USA
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC 27599, USA
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Harrison MS, Pasha O, Saleem S, Ali S, Chomba E, Carlo WA, Garces AL, Krebs NF, Hambidge KM, Goudar SS, Kodkany B, Dhaded S, Derman RJ, Patel A, Hibberd PL, Esamai F, Liechty EA, Tshefu AK, Bauserman M, Moore JL, Wallace D, McClure EM, Miodovnik M, Koso-Thomas M, Belizan J, Goldenberg RL. A prospective study of maternal, fetal and neonatal outcomes in the setting of cesarean section in low- and middle-income countries. Acta Obstet Gynecol Scand 2017; 96:410-420. [PMID: 28107771 PMCID: PMC5665564 DOI: 10.1111/aogs.13098] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2016] [Accepted: 01/09/2017] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Cesarean section (CS) rates are increasing globally with an unclear effect on pregnancy outcomes. The study objective was to quantify maternal and perinatal morbidity and mortality associated with CS compared with vaginal delivery (VD) both within and across sites in low- and middle-income countries. MATERIAL AND METHODS A prospective population-based study including home and facility births in 337 153 women with a VD and 47 308 women with a CS from 2010 to 2015 was performed in Guatemala, India, Kenya, Pakistan, Zambia and Democratic Republic of Congo. Women were enrolled during pregnancy; delivery and 6-week follow-up data were collected. RESULTS Across all sites, CS rates increased from 8.6% to 15.2%, but remained low in African sites. Younger, nulliparous women were more likely to have a CS, as were women with higher education and those delivering an infant weighing 1500-2499 g. Across all sites, maternal and neonatal mortality was higher, and stillbirths were lower, in pregnancies delivered by CS. Antepartum and postpartum complications as well as obstetric interventions and treatments were more common among women who underwent CS. In stratified analyses, all outcomes were worse in women with a CS compared with VD in African compared to non-African sites. CONCLUSIONS CS rates increased across all sites during the study period, but at more pronounced rates in the non-African sites. CS was associated with reduced postpartum hemorrhage and lower rates of stillbirths in the non-African sites. In the African sites, CS was associated with an increase in all adverse outcomes. Further studies are necessary to better understand the increase in adverse outcomes with CS in the African sites.
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Affiliation(s)
- Margo S. Harrison
- Department of Obstetrics and Gynecology, Columbia University, New York, NY, USA
| | - Omrana Pasha
- Department of Community Health Sciences, Aga Khan University, Karachi, Pakistan
| | - Sarah Saleem
- Department of Community Health Sciences, Aga Khan University, Karachi, Pakistan
| | - Sumera Ali
- Department of Community Health Sciences, Aga Khan University, Karachi, Pakistan
| | - Elwyn Chomba
- University Teaching Hospital, University of Zambia, Lusaka, Zambia
| | | | - Ana L. Garces
- Planning Unit, Institute of Nutrition of Central America and Panama (INCAP), Guatemala City, Guatemala
| | - Nancy F. Krebs
- School of Medicine, University of Colorado, Denver, CO, USA
| | | | | | - Bhala Kodkany
- Jawaharlal Nehru Medical College, KLE University, Belgaum, India
| | - Sangappa Dhaded
- Jawaharlal Nehru Medical College, KLE University, Belgaum, India
| | - Richard J. Derman
- Department of Obstetrics and Gynecology, Thomas Jefferson University, Philadelphia, PA, USA
| | | | | | | | | | - Antoinette K Tshefu
- Kinshasa School of Public Health, Kinshasa, Democratic Republic of the Congo
| | - Melissa Bauserman
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | | | | | | | - Menachem Miodovnik
- Pregnancy and Perinatology Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD, USA
| | - Marion Koso-Thomas
- Pregnancy and Perinatology Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD, USA
| | - Jose Belizan
- Institute for Clinical Effectiveness and Health Policy, Buenos Aires, Argentina
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25
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Ferrari G, Ntuku HMT, Ross A, Schmidlin S, Kalemwa DM, Tshefu AK, Lengeler C. Identifying risk factors for Plasmodium infection and anaemia in Kinshasa, Democratic Republic of Congo. Malar J 2016; 15:362. [PMID: 27417676 PMCID: PMC4946241 DOI: 10.1186/s12936-016-1412-5] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2016] [Accepted: 07/01/2016] [Indexed: 12/02/2022] Open
Abstract
Background There is little data on the risk factors for malaria infection in large cities in central Africa and in all age groups. There may be different associations with the risk factors for areas with different malaria transmission intensities such as the effect of fever or age. This study aimed at identifying risk factors associated with Plasmodium infection and anaemia among children 6–59 months and individuals aged older than 5 years in Kinshasa, a large city with heterogeneity in malaria prevalence. Methods This study analysed data from 3342 children aged 6–59 months from 25 non-rural health zones (HZs) and for 816 individuals aged older than 5 years from two HZs in Kinshasa (non-rural), collected during a cross sectional malaria survey in 2011. Logistic regression with random effects was used to investigate predictors for malaria and anaemia. Differences in risk factors in areas with a prevalence of less than 10 and 10 % or greater were investigated. Results There was evidence of a different age-pattern in the two transmission settings. For children under 5 years, the highest prevalence of malaria was observed in the 48–59 months group in both transmission settings, but it increased more gently for the lower transmission HZs (p = 0.009). In a separate analysis in children over 5 years in two selected HZs, the peak prevalence was in 5–9 years old in the higher transmission setting and in 15–19 years old in the lower transmission setting. Reported fever was associated with malaria in both transmission strata, with no evidence of a difference in these associations (p = 0.71); however in children older than 5 years there was a significant interaction with a stronger association in the low transmission HZ. Insecticide-treated net (ITN) use was associated with a lower risk of malaria infection in children 6–59 months in the high transmission HZs. Similar estimates were found in children over 5 years and the lower transmission HZ but the associations there were not significant. There was no evidence of a difference in these associations by strata. The risk of anaemia decreased with increasing age in all strata, whereas it increased with malaria infection and reported fever. ITN use did not show evidence of protection against anaemia. Low socio-economic status was associated with malaria in high transmission setting in children 6–59 months and anaemia in low transmission setting. Conclusions This study shows that in areas of low transmission in Kinshasa, the peak prevalence occurs in older age groups however ITN use was highest in children under 5 years. Targeted distribution of ITN to all age groups should be continued. For most risk factors, there was no evidence of an interaction with transmission intensity however the associations with age and with fever in the last 2 weeks did vary significantly.
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Affiliation(s)
- Giovanfrancesco Ferrari
- Swiss Tropical and Public Health Institute, P.O. Box, 4002, Basel, Switzerland. .,University of Basel, Basel, Switzerland.
| | - Henry M T Ntuku
- Swiss Tropical and Public Health Institute, P.O. Box, 4002, Basel, Switzerland.,University of Basel, Basel, Switzerland.,Kinshasa School of Public Health, Kinshasa, Democratic Republic of the Congo
| | - Amanda Ross
- Swiss Tropical and Public Health Institute, P.O. Box, 4002, Basel, Switzerland.,University of Basel, Basel, Switzerland
| | - Sandro Schmidlin
- Swiss Tropical and Public Health Institute, P.O. Box, 4002, Basel, Switzerland.,University of Basel, Basel, Switzerland
| | - Didier M Kalemwa
- Swiss Tropical and Public Health Institute, P.O. Box, 4002, Basel, Switzerland.,University of Basel, Basel, Switzerland
| | - Antoinette K Tshefu
- Kinshasa School of Public Health, Kinshasa, Democratic Republic of the Congo
| | - Christian Lengeler
- Swiss Tropical and Public Health Institute, P.O. Box, 4002, Basel, Switzerland.,University of Basel, Basel, Switzerland
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Liu Y, Griffin JB, Muehlenbachs A, Rogerson SJ, Bailis AJ, Sharma R, Sullivan DJ, Tshefu AK, Landis SH, Kabongo JMM, Taylor SM, Meshnick SR. Diagnosis of placental malaria in poorly fixed and processed placental tissue. Malar J 2016; 15:272. [PMID: 27165119 PMCID: PMC4863337 DOI: 10.1186/s12936-016-1314-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2015] [Accepted: 04/27/2016] [Indexed: 11/17/2022] Open
Abstract
Background Placental histopathology has been considered the gold standard for diagnosis of malaria during pregnancy. However, in under-resourced areas placental tissue is often improperly fixed and processed; the resulting formalin pigment is difficult to distinguish from malaria pigment. This study examines two alternative diagnostic methods: polymerase chain reaction (PCR) and a novel immunohistochemistry (IHC)-based method using an antibody against histidine-rich protein 2 (HRP2). Methods Placental histopathology from 151 pregnant women in Kinshasa was assessed by two blinded microscopists and compared with peripheral blood PCR and IHC for HRP2. The Cohen’s kappa coefficients were calculated to assess the test agreement. The sensitivity and specificity of individual tests were calculated using PCR or IHC as the reference standard as well as latent class analysis (LCA). Results PCR and IHC correlated fairly well. The correlation between the two blinded microscopists was poor, as there was widespread formalin pigment. Using LCA, all of the tests had high specificities. The most sensitive test was IHC (67.7 %), with PCR as second-best (56.1 %). Conclusions PCR and/or IHC are suitable diagnostics when the presence of formalin pigment substantially compromises placental histopathology.
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Affiliation(s)
- Yunhao Liu
- Department of Epidemiology, UNC Gillings School of Global Public Health, Chapel Hill, NC, USA. .,Department of Statistics and Operations Research, University of North Carolina, Chapel Hill, NC, USA.
| | | | | | - Stephen J Rogerson
- Department of Medicine at Peter Doherty Institute, University of Melbourne, Melbourne, Australia
| | - Anya J Bailis
- Division of Maternal-Fetal Medicine, Department of Gynecology & Obstetrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Rajni Sharma
- Immunopathology Laboratory, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - David J Sullivan
- W. Harry Feinstone Department of Molecular Microbiology and Immunology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Antoinette K Tshefu
- Kinshasa School of Public Health, Kinshasa, Democratic Republic of the Congo
| | - Sarah H Landis
- Glaxo-Smith-Kline, Worldwide Epidemiology, Uxbridge, Middlesex, UK
| | - Jean-Marie M Kabongo
- Department of Medical Biology, Service of Pathology, University of Kinshasa Medical School and University Hospital, Kinshasa, Democratic Republic of the Congo
| | - Steve M Taylor
- Division of Infectious Diseases & International Health and Duke Global Health Institute, Duke University Medical Center, Durham, NC, USA
| | - Steven R Meshnick
- Department of Epidemiology, UNC Gillings School of Global Public Health, Chapel Hill, NC, USA
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27
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Carrel M, Janko M, Mwandagalirwa MK, Morgan C, Fwamba F, Muwonga J, Tshefu AK, Meshnick S, Emch M. Changing spatial patterns and increasing rurality of HIV prevalence in the Democratic Republic of the Congo between 2007 and 2013. Health Place 2016; 39:79-85. [PMID: 26974234 DOI: 10.1016/j.healthplace.2016.02.009] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2015] [Revised: 01/19/2016] [Accepted: 02/28/2016] [Indexed: 10/22/2022]
Abstract
The Democratic Republic of the Congo (DRC) has one of the lowest HIV prevalence in sub-Saharan Africa, estimated at 1.1% [0.9-1.3] of adults aged 15-49 in 2013 (UNAIDS). Within the 2 million km(2) country, however, there exists spatial variation in HIV prevalence, with the highest HIV prevalence observed in the large cities of Kinshasa and Lubumbashi. Globally, HIV is an increasingly rural disease, diffusing outwards from urban centers of high HIV prevalence to places where HIV was previously absent or present at very low levels. Utilizing data collected during Demographic and Health Surveillance (DHS) in 2007 and 2013 in the DRC, we sought to update the map of HIV prevalence in the DRC as well as to explore whether HIV in the DRC is an increasingly rural disease or remains confined to urban areas. Bayesian kriging and regression indicate that HIV prevalence in rural areas of the DRC is higher in 2013 than in 2007 and that increased distance to an urban area is no longer protective against HIV as it was in 2007. These findings suggest that HIV education, testing and prevention efforts need to diffuse from urban to rural areas just as HIV is doing.
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Affiliation(s)
- Margaret Carrel
- Department of Geographical & Sustainability Sciences, 303 Jessup Hall, University of Iowa, Iowa City, IA 52245, USA; Department of Epidemiology, University of Iowa, Iowa City, IA, USA.
| | - Mark Janko
- Department of Geography, CB3220, Carolina Hall, University of North Carolina-Chapel Hill, Chapel Hill, NC, USA; Department of Biostatistics, CB7420, McGavran-Greenberg Hall, University of North Carolina-Chapel Hill, Chapel Hill, NC, USA
| | | | - Camille Morgan
- Department of Biostatistics, CB7420, McGavran-Greenberg Hall, University of North Carolina-Chapel Hill, Chapel Hill, NC, USA
| | - Franck Fwamba
- National AIDS Control Program (PNLS), Kinshasa, Democratic Republic of the Congo
| | - Jérémie Muwonga
- National AIDS Control Program (PNLS), Kinshasa, Democratic Republic of the Congo
| | - Antoinette K Tshefu
- Ecole de Sante Publique, Faculte de Medecine, University of Kinshasa, Kinshasa, Democratic Republic of the Congo
| | - Steven Meshnick
- Department of Epidemiology, CB7435, McGavran-Greenberg Hall, University of North Carolina-Chapel Hill, Chapel Hill, NC, USA
| | - Michael Emch
- Department of Geography, CB3220, Carolina Hall, University of North Carolina-Chapel Hill, Chapel Hill, NC, USA; Department of Epidemiology, CB7435, McGavran-Greenberg Hall, University of North Carolina-Chapel Hill, Chapel Hill, NC, USA
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28
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Toure OA, Valecha N, Tshefu AK, Thompson R, Krudsood S, Gaye O, Rao BHK, Sagara I, Bose TK, Mohanty S, Rao BS, Anvikar AR, Mwapasa V, Noedl H, Arora S, Roy A, Iyer SS, Sharma P, Saha N, Jalali RK, Tiacoh L, Enosse S, Tangpukdee N, Kokolomami J, Ndiaye JL, Rao D, Yumva NN, Sidibe B, Mohanty R, Jha AC, Nyirenda M, Starzengruber P, Swoboda P. A Phase 3, Double-Blind, Randomized Study of Arterolane Maleate-Piperaquine Phosphate vs Artemether-Lumefantrine for Falciparum Malaria in Adolescent and Adult Patients in Asia and Africa. Clin Infect Dis 2016; 62:964-971. [PMID: 26908796 DOI: 10.1093/cid/ciw029] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2015] [Accepted: 01/18/2016] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Artemisinins, which are derived from plants, are subject to risk of supply interruption due to climatic changes. Consequently, an effort to identify a new synthetic antimalarial was initiated. A fixed-dose combination of arterolane maleate (AM), a new synthetic trioxolane, with piperaquine phosphate (PQP), a long half-life bisquinoline, was evaluated in patients with uncomplicatedPlasmodium falciparummalaria. METHODS In this multicenter, randomized, double-blind, comparative, parallel-group trial, 1072 patients aged 12-65 years withP. falciparummonoinfection received either AM-PQP (714 patients) once daily or artemether-lumefantrine (A-L; 358 patients) twice daily for 3 days. All patients were followed up until day 42. RESULTS Of the 714 patients in the AM-PQP group, 638 (89.4%) completed the study; of the 358 patients in the A-L group, 301(84.1%) completed the study. In both groups, the polymerase chain reaction corrected adequate clinical and parasitological response (PCR-corrected ACPR) on day 28 in intent-to-treat (ITT) and per-protocol (PP) populations was 92.86% and 92.46% and 99.25% and 99.07%, respectively. The corresponding figures on day 42 in the ITT and PP populations were 90.48% and 91.34%, respectively. After adjusting for survival ITT, the PCR-corrected ACPR on day 42 was >98% in both groups. The overall incidence of adverse events was comparable. CONCLUSIONS AM-PQP showed comparable efficacy and safety to A-L in the treatment of uncomplicatedP. falciparummalaria in adolescent and adult patients. AM-PQP demonstrated high clinical and parasitological response rates as well as rapid parasite clearance. CLINICAL TRIALS REGISTRATION India. CTRI/2009/091/000101.
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Affiliation(s)
| | - Neena Valecha
- Epidemiology and Clinical Research Division, National Institute of Malaria Research, New Delhi, India
| | - Antoinette K Tshefu
- Centre de recherches cliniques et epidemiologiques de Mont Amba, Centre hospitalier de Mont Amba, Ecole de Sante Publique, Universite de Kinshasa, Democratic Republic of Congo
| | | | - Srivicha Krudsood
- Bangkok Hospital for Tropical Diseases, Faculty of Tropical Medicine, Mahidol University, Thailand
| | - Oumar Gaye
- Department of Parasitology Guediawaye District Hospital, University Cheikh Anta Diop, Dakar Fann, Senegal
| | | | - Issaka Sagara
- Malaria Research and Training Center, University of Science, Techniques and Technologies Bamako, Mali
| | | | | | | | - Anupkumar R Anvikar
- Epidemiology and Clinical Research Division, National Institute of Malaria Research, New Delhi, India
| | | | - Harald Noedl
- Malaria Research Initiative Bandarban, Sadar District Hospital, Bangladesh.,Institute of Specific Prophylaxis and Tropical Medicine, Medical University of Vienna, Austria
| | | | - Arjun Roy
- CDM & Biostatistics, Medical Affairs & Clinical Research
| | | | | | | | - Rajinder K Jalali
- Medical Affairs & Clinical Research, Sun Pharmaceutical Industries Limited (erstwhile Ranbaxy Laboratories Ltd), Gurgaon, Haryana, India
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Ferrari G, Ntuku HM, Schmidlin S, Diboulo E, Tshefu AK, Lengeler C. A malaria risk map of Kinshasa, Democratic Republic of Congo. Malar J 2016; 15:27. [PMID: 26762532 PMCID: PMC4712518 DOI: 10.1186/s12936-015-1074-8] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2015] [Accepted: 12/23/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In Kinshasa, malaria remains a major public health problem but its spatial epidemiology has not been assessed for decades now. The city's growth and transformation, as well as recent control measures, call for an update. To identify highly exposed communities and areas where control measures are less critically needed, detailed risk maps are required to target control and optimize resource allocation. METHODS In 2009 (end of the dry season) and 2011 (end of the rainy season), two cross-sectional surveys were conducted in Kinshasa to determine malaria prevalence, anaemia, history of fever, bed net ownership and use among children 6-59 months. Geo-referenced data for key parameters were mapped at the level of the health area (HA) by means of a geographic information system (GIS). RESULTS Among 7517 children aged 6-59 months from 33 health zones (HZs), 6661 (3319 in 2009 and 3342 in 2011) were tested for both malaria (by Rapid Diagnostic Tests) and anaemia, and 856 (845 in 2009 and 11 in 2011) were tested for anaemia only. Fifteen HZs were sampled in 2009, 25 in 2011, with seven HZs sampled in both surveys. Mean prevalence for malaria and anaemia was 6.4% (5.6-7.4) and 65.1% (63.7-66.6) in 2009, and 17.0% (15.7-18.3) and 64.2% (62.6-65.9) in 2011. In two HZs sampled in both surveys, malaria prevalence was 14.1 % and 26.8% in Selembao (peri-urban), in the 2009 dry season and 2011 rainy season respectively, and it was 1.0 % and 0.8% in Ngiri Ngiri (urban). History of fever during the preceding two weeks was 13.2% (12.5-14.3) and 22.3% (20.8-23.4) in 2009 and 2011. Household ownership of at least one insecticide-treated net (ITN) was 78.7% (77.4-80.0) and 65.0% (63.7-66.3) at both time points, while use was 57.7% (56.0-59.9) and 45.0% (43.6-46.8), respectively. CONCLUSIONS This study presents the first malaria risk map of Kinshasa, a mega city of roughly 10 million inhabitants and located in a highly endemic malaria zone. Prevalence of malaria, anaemia and reported fever was lower in urban areas, whereas low coverage of ITN and sub-optimal net use were frequent in peri-urban areas.
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Affiliation(s)
- Giovanfrancesco Ferrari
- Swiss Tropical and Public Health Institute, Basel, Switzerland. .,University of Basel, Basel, Switzerland.
| | - Henry M Ntuku
- Swiss Tropical and Public Health Institute, Basel, Switzerland. .,University of Basel, Basel, Switzerland. .,Kinshasa School of Public Health, Kinshasa, Democratic Republic of the Congo.
| | - Sandro Schmidlin
- Swiss Tropical and Public Health Institute, Basel, Switzerland. .,University of Basel, Basel, Switzerland.
| | - Eric Diboulo
- Swiss Tropical and Public Health Institute, Basel, Switzerland. .,University of Basel, Basel, Switzerland.
| | - Antoinette K Tshefu
- Kinshasa School of Public Health, Kinshasa, Democratic Republic of the Congo.
| | - Christian Lengeler
- Swiss Tropical and Public Health Institute, Basel, Switzerland. .,University of Basel, Basel, Switzerland.
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30
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Ntuku HMT, Ferrari G, Burri C, Tshefu AK, Kalemwa DM, Lengeler C. Feasibility and acceptability of injectable artesunate for the treatment of severe malaria in the Democratic Republic of Congo. Malar J 2016; 15:18. [PMID: 26747281 PMCID: PMC4706670 DOI: 10.1186/s12936-015-1072-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2015] [Accepted: 12/23/2015] [Indexed: 11/23/2022] Open
Abstract
Background The Democratic Republic of the Congo (DRC) changed its national policy for the treatment of severe malaria in both children and adults in 2012 from intravenous quinine to injectable artesunate. The country is now planning to deploy nationwide injectable artesunate as the preferred treatment for the management of severe malaria. To support this process, the feasibility and acceptability of the use of injectable artesunate in the context of the DRC was assessed, from the perspective of both health care providers and patients/caretakers. Methods Questionnaires and observations were used to collect information from health care providers and patients/caretakers in eight health facilities in the Province of Kinshasa and in the Province of Bas-Congo. Results A total of 31 health care providers and 134 patients/care takers were interviewed. Seventy five percent (75 %) of health care providers found it less difficult to prepare injectable artesunate compared to quinine. None of them encountered problems during preparation and administration of injectable artesunate. The large majority of care providers (93 %) and patients/caretakers (93 %) answered that injectable artesunate took less time than quinine to cure the symptoms of the patients. 26 (84 %) health care providers reported that the personnel workload had diminished with the use of injectable artesunate. 7 (22.6 %) health workers reported adverse drug reactions, of which a decrease in the haemoglobin rate was the most common (71.4 %). All care providers and the vast majority of patients/caretakers (96 %, N = 128) were either satisfied or very satisfied with injectable artesunate. Conclusions These findings show that the use of injectable artesunate for the treatment of severe malaria is feasible and acceptable in the context of DRC, with appropriate training of care providers. Both care providers and patients/caretakers perceived injectable artesunate to be effective and safe, thus promoting acceptability.
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Affiliation(s)
- Henry M T Ntuku
- Kinshasa School of Public Health, Kinshasa, Democratic Republic of the Congo. .,Swiss Tropical and Public Health Institute, Basel, Switzerland. .,University of Basel, Basel, Switzerland.
| | - Gianfrancesco Ferrari
- Swiss Tropical and Public Health Institute, Basel, Switzerland. .,University of Basel, Basel, Switzerland.
| | - Christian Burri
- Swiss Tropical and Public Health Institute, Basel, Switzerland. .,University of Basel, Basel, Switzerland.
| | - Antoinette K Tshefu
- Kinshasa School of Public Health, Kinshasa, Democratic Republic of the Congo.
| | - Didier M Kalemwa
- Swiss Tropical and Public Health Institute, Basel, Switzerland. .,University of Basel, Basel, Switzerland.
| | - Christian Lengeler
- Swiss Tropical and Public Health Institute, Basel, Switzerland. .,University of Basel, Basel, Switzerland.
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Ferrari G, Ntuku HM, Burri C, Tshefu AK, Duparc S, Hugo P, Mitembo DK, Ross A, Ngwala PL, Luwawu JN, Musafiri PN, Ngoie SE, Lengeler C. An operational comparative study of quinine and artesunate for the treatment of severe malaria in hospitals and health centres in the Democratic Republic of Congo: the MATIAS study. Malar J 2015; 14:226. [PMID: 26024661 PMCID: PMC4455055 DOI: 10.1186/s12936-015-0732-1] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2014] [Accepted: 02/20/2015] [Indexed: 11/23/2022] Open
Abstract
Background The Democratic Republic of the Congo (DRC) has the highest number of severe malaria cases in the world. In early 2012, the National Malaria Control Programme (NMCP) changed the policy for treating severe malaria in children and adults from injectable quinine to injectable artesunate. To inform the scaling up of injectable artesunate nationwide, operational research is needed to identify constraints and challenges in the DRC’s specific setting. Methods The implementation of injectable quinine treatment in 350 patients aged 2 months or older in eight health facilities from October 2012 to January 2013 and injectable artesunate in 399 patients in the same facilities from April to June 2013 was compared. Since this was an implementation study, concurrent randomized controls were not possible. Four key components were evaluated during each phase: 1) clinical assessment, 2) time and motion, 3) feasibility and acceptability, and 4) financial cost. Results The time to discharge was lower in the artesunate (median = 2, 90 % central range 1–9) compared to the quinine group (3 (1–9) days; p <0.001). Similarly, the interval between admission and the start of intravenous (IV) treatment (2 (0–15) compared to 3 (0–20) hours; p <0.001) and parasite clearance time (23 (11–49) compared to 24 (10–82) hours; p <0.001) were lower in the artesunate group. The overall staff pre-administration time (13 (6–38) compared to 20 (7–50) minutes; p <0.001) and the personnel time spent on patient management (9 (1–24) compared to 12 (3–52) minutes; p <0.001) were lower in the artesunate group. In hospitals and health centres, the mean (standard deviation, SD) total cost per patient treated for severe malaria with injectable artesunate was USD 51.94 (16.20) and 19.51 (9.58); and USD 60.35 (17.73) and 20.36 (6.80) with injectable quinine. Conclusions This study demonstrates that injectable artesunate in the DRC is easier to use and it costs less than injectable quinine. These findings provide the basis for practical recommendations for rapid national deployment of injectable artesunate in the DRC. Electronic supplementary material The online version of this article (doi:10.1186/s12936-015-0732-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Giovanfrancesco Ferrari
- Swiss Tropical & Public Health Institute, Basel, Switzerland. .,University of Basel, Basel, Switzerland.
| | - Henry M Ntuku
- Kinshasa School of Public Health, Kinshasa, Democratic Republic of the Congo.
| | - Christian Burri
- Swiss Tropical & Public Health Institute, Basel, Switzerland. .,University of Basel, Basel, Switzerland.
| | - Antoinette K Tshefu
- Kinshasa School of Public Health, Kinshasa, Democratic Republic of the Congo.
| | | | - Pierre Hugo
- Medicines for Malaria Venture, Geneva, Switzerland.
| | - Didier K Mitembo
- Swiss Tropical & Public Health Institute, Basel, Switzerland. .,University of Basel, Basel, Switzerland.
| | - Amanda Ross
- Swiss Tropical & Public Health Institute, Basel, Switzerland. .,University of Basel, Basel, Switzerland.
| | - Philippe L Ngwala
- Zone de Santé de Kimpese, Kimpese, Democratic Republic of the Congo.
| | - Joseph N Luwawu
- Zone de Santé Rurale de Kisantu, Kisantu, Democratic Republic of the Congo.
| | - Papa N Musafiri
- Zone de Santé de Maluku, Maluku, Democratic Republic of the Congo.
| | - Symphorien E Ngoie
- Centre Hospitalier Roi Baudouin 1er Masina, Kinshasa, Democratic Republic of the Congo.
| | - Christian Lengeler
- Swiss Tropical & Public Health Institute, Basel, Switzerland. .,University of Basel, Basel, Switzerland.
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Taylor SM, Antonia AL, Harrington WE, Goheen MM, Mwapasa V, Chaluluka E, Fried M, Kabyemela E, Madanitsa M, Khairallah C, Kalilani-Phiri L, Tshefu AK, Rogerson SJ, Ter Kuile FO, Duffy PE, Meshnick SR. Independent lineages of highly sulfadoxine-resistant Plasmodium falciparum haplotypes, eastern Africa. Emerg Infect Dis 2015; 20:1140-8. [PMID: 24960247 PMCID: PMC4073871 DOI: 10.3201/eid2007.131720] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Parasites with increased resistance to sulfadoxine might undermine malaria control measures. Sulfadoxine-resistant Plasmodium falciparum undermines malaria prevention with sulfadoxine/pyrimethamine. Parasites with a highly resistant mutant dihydropteroate synthase (dhps) haplotype have recently emerged in eastern Africa; they negated preventive benefits of sulfadoxine/pyrimethamine, and might exacerbate placental malaria. We explored emerging lineages of dhps mutant haplotypes in Malawi, the Democratic Republic of the Congo, and Tanzania by using analyses of genetic microsatellites flanking the dhps locus. In Malawi, a triple-mutant dhps SGEG (mutant amino acids are underlined) haplotype emerged in 2010 that was closely related to pre-existing double-mutant SGEA haplotypes, suggesting local origination in Malawi. When we compared mutant strains with parasites from the Democratic Republic of the Congo and Tanzania by multiple independent analyses, we found that SGEG parasites were partitioned into separate lineages by country. These findings support a model of local origination of SGEGdhps haplotypes, rather than geographic diffusion, and have implications for investigations of emergence and effects of parasite drug resistance.
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Taylor SM, Parobek CM, DeConti DK, Kayentao K, Coulibaly SO, Greenwood BM, Tagbor H, Williams J, Bojang K, Njie F, Desai M, Kariuki S, Gutman J, Mathanga DP, Mårtensson A, Ngasala B, Conrad MD, Rosenthal PJ, Tshefu AK, Moormann AM, Vulule JM, Doumbo OK, ter Kuile FO, Meshnick SR, Bailey JA, Juliano JJ. Absence of putative artemisinin resistance mutations among Plasmodium falciparum in Sub-Saharan Africa: a molecular epidemiologic study. J Infect Dis 2015; 211:680-8. [PMID: 25180240 PMCID: PMC4402372 DOI: 10.1093/infdis/jiu467] [Citation(s) in RCA: 218] [Impact Index Per Article: 24.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2014] [Accepted: 07/21/2014] [Indexed: 11/12/2022] Open
Abstract
Plasmodium falciparum parasites that are resistant to artemisinins have been detected in Southeast Asia. Resistance is associated with several polymorphisms in the parasite's K13-propeller gene. The molecular epidemiology of these artemisinin resistance genotypes in African parasite populations is unknown. We developed an assay to quantify rare polymorphisms in parasite populations that uses a pooled deep-sequencing approach to score allele frequencies, validated it by evaluating mixtures of laboratory parasite strains, and then used it to screen P. falciparum parasites from >1100 African infections collected since 2002 from 14 sites across sub-Saharan Africa. We found no mutations in African parasite populations that are associated with artemisinin resistance in Southeast Asian parasites. However, we observed 15 coding mutations, including 12 novel mutations, and limited allele sharing between parasite populations, consistent with a large reservoir of naturally occurring K13-propeller variation. Although polymorphisms associated with artemisinin resistance in P. falciparum in Southeast Asia are not prevalent in sub-Saharan Africa, numerous K13-propeller coding polymorphisms circulate in Africa. Although their distributions do not support a widespread selective sweep for an artemisinin-resistant phenotype, the impact of these mutations on artemisinin susceptibility is unknown and will require further characterization. Rapid, scalable molecular surveillance offers a useful adjunct in tracking and containing artemisinin resistance.
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Affiliation(s)
- Steve M. Taylor
- Division of Infectious Diseases, Department of Medicine
- Duke Global Health Institute, Duke University Medical Center, Durham
- Department of Epidemiology, Gillings School of Global Public Health
| | | | | | - Kassoum Kayentao
- Department of Epidemiology of Parasitic Diseases, Malaria Research and Training Center, Faculty of Medicine, Pharmacy, and Odontostomatology, University of Science, Techniques, and Technologies of Bamako, Mali
- Department of Clinical Sciences, Liverpool School of Tropical Medicine
| | | | - Brian M. Greenwood
- Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, United Kingdom
| | - Harry Tagbor
- Department of Community Health, School of Medical Sciences, Kwame Nkrumah University of Science and Technology, Kumasi
| | - John Williams
- Navrongo Health Research Centre, Ghana Health Service, Navrongo
| | - Kalifa Bojang
- Medical Research Council Laboratories, Banjul, Gambia
| | - Fanta Njie
- Medical Research Council Laboratories, Banjul, Gambia
| | - Meghna Desai
- Malaria Branch, Division of Parasitic Diseases and Malaria, Center for Global Health, Centers for Disease Control and Prevention (CDC), Atlanta, Georgia
- CDC–Kenya
| | | | - Julie Gutman
- Malaria Branch, Division of Parasitic Diseases and Malaria, Center for Global Health, Centers for Disease Control and Prevention (CDC), Atlanta, Georgia
| | - Don P. Mathanga
- Malaria Alert Center, University of Malawi College of Medicine, Blantyre
- Department of Community Health, College of Medicine, Lilongwe, Malawi
| | - Andreas Mårtensson
- Malaria Research, Department of Medicine Solna
- Global Health, Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden
| | - Billy Ngasala
- Department of Parasitology, Muhumbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | | | | | - Antoinette K. Tshefu
- Ecole de Sante Publique, Faculte de Medicine, University of Kinshasa, Democratic Republic of the Congo
| | | | | | - Ogobara K. Doumbo
- Department of Epidemiology of Parasitic Diseases, Malaria Research and Training Center, Faculty of Medicine, Pharmacy, and Odontostomatology, University of Science, Techniques, and Technologies of Bamako, Mali
| | - Feiko O. ter Kuile
- Department of Clinical Sciences, Liverpool School of Tropical Medicine
- Center for Global Health Research, KEMRI, Kisumu, Kenya
| | | | - Jeffrey A. Bailey
- Division of Transfusion Medicine
- Program in Bioinformatics and Integrative Biology, University of Massachusetts School of Medicine, Worcester
| | - Jonathan J. Juliano
- Curriculum in Genetics and Molecular Biology
- Divison of Infectious Diseases, School of Medicine, University of North Carolina, Chapel Hill
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Patel JC, Taylor SM, Juliao PC, Parobek CM, Janko M, Gonzalez LD, Ortiz L, Padilla N, Tshefu AK, Emch M, Udhayakumar V, Lindblade K, Meshnick SR. Genetic Evidence of Importation of Drug-Resistant Plasmodium falciparum to Guatemala from the Democratic Republic of the Congo. Emerg Infect Dis 2015; 20:932-40. [PMID: 24856348 PMCID: PMC4036788 DOI: 10.3201/eid2006.131204] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Molecular markers and population genetics were effective tracking tools. Imported malaria threatens control and elimination efforts in countries that have low rates of transmission. In 2010, an outbreak of Plasmodium falciparum malaria was reported among United Nations peacekeeping soldiers from Guatemala who had recently returned from the Democratic Republic of the Congo (DRC). Epidemiologic evidence suggested that the soldiers were infected in the DRC, but local transmission could not be ruled out in all cases. We used population genetic analyses of neutral microsatellites to determine the outbreak source. Genetic relatedness was compared among parasites found in samples from the soldiers and parasite populations collected in the DRC and Guatemala; parasites identified in the soldiers were more closely related to those from the DRC. A phylogenetic clustering analysis confirms this identification with >99.9% confidence. Thus, results support the hypothesis that the soldiers likely imported malaria from the DRC. This study demonstrates the utility of molecular genotyping in outbreak investigations.
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Carrel M, Patel J, Taylor SM, Janko M, Mwandagalirwa MK, Tshefu AK, Escalante AA, McCollum A, Alam MT, Udhayakumar V, Meshnick S, Emch M. The geography of malaria genetics in the Democratic Republic of Congo: A complex and fragmented landscape. Soc Sci Med 2014; 133:233-41. [PMID: 25459204 DOI: 10.1016/j.socscimed.2014.10.037] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2014] [Revised: 08/27/2014] [Accepted: 10/17/2014] [Indexed: 11/28/2022]
Abstract
Understanding how malaria parasites move between populations is important, particularly given the potential for malaria to be reintroduced into areas where it was previously eliminated. We examine the distribution of malaria genetics across seven sites within the Democratic Republic of Congo (DRC) and two nearby countries, Ghana and Kenya, in order to understand how the relatedness of malaria parasites varies across space, and whether there are barriers to the flow of malaria parasites within the DRC or across borders. Parasite DNA was retrieved from dried blood spots from 7 Demographic and Health Survey sample clusters in the DRC. Malaria genetic characteristics of parasites from Ghana and Kenya were also obtained. For each of 9 geographic sites (7 DRC, 1 Ghana and 1 Kenya), a pair-wise RST statistic was calculated, indicating the genetic distance between malaria parasites found in those locations. Mapping genetics across the spatial extent of the study area indicates a complex genetic landscape, where relatedness between two proximal sites may be relatively high (RST > 0.64) or low (RST < 0.05), and where distal sites also exhibit both high and low genetic similarity. Mantel's tests suggest that malaria genetics differ as geographic distances increase. Principal Coordinate Analysis suggests that genetically related samples are not co-located. Barrier analysis reveals no significant barriers to gene flow between locations. Malaria genetics in the DRC have a complex and fragmented landscape. Limited exchange of genes across space is reflected in greater genetic distance between malaria parasites isolated at greater geographic distances. There is, however, evidence for close genetic ties between distally located sample locations, indicating that movement of malaria parasites and flow of genes is being driven by factors other than distance decay. This research demonstrates the contributions that spatial disease ecology and landscape genetics can make to understanding the evolutionary dynamics of infectious diseases.
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Affiliation(s)
- Margaret Carrel
- Department of Geographical & Sustainability Sciences, University of Iowa, Iowa City, IA, USA.
| | - Jaymin Patel
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina- Chapel Hill Chapel Hill, NC, USA
| | - Steve M Taylor
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina- Chapel Hill Chapel Hill, NC, USA; Division of Infectious Diseases and International Health, Duke University Medical Center, Durham, NC, USA; Duke Global Health Institute, Durham, NC, USA
| | - Mark Janko
- Department of Geography, University of North Carolina-Chapel Hill, Chapel Hill, NC, USA
| | - Melchior Kashamuka Mwandagalirwa
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina- Chapel Hill Chapel Hill, NC, USA
| | - Antoinette K Tshefu
- Ecole de Sante Publique, Faculte de Medecine, University of Kinshasa, Kinshasa, Democratic Republic of the Congo
| | - Ananias A Escalante
- Center for Evolutionary Medicine & Informatics, The Biodesign Institute, Arizona State University, Tempe, AZ, USA
| | - Andrea McCollum
- Malaria Branch, Division of Parasitic Diseases and Malaria, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Md Tauqeer Alam
- Malaria Branch, Division of Parasitic Diseases and Malaria, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Venkatachalam Udhayakumar
- Malaria Branch, Division of Parasitic Diseases and Malaria, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Steven Meshnick
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina- Chapel Hill Chapel Hill, NC, USA
| | - Michael Emch
- Department of Geography, University of North Carolina-Chapel Hill, Chapel Hill, NC, USA
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Ashley EA, Dhorda M, Fairhurst RM, Amaratunga C, Lim P, Suon S, Sreng S, Anderson JM, Mao S, Sam B, Sopha C, Chuor CM, Nguon C, Sovannaroth S, Pukrittayakamee S, Jittamala P, Chotivanich K, Chutasmit K, Suchatsoonthorn C, Runcharoen R, Hien TT, Thuy-Nhien NT, Thanh NV, Phu NH, Htut Y, Han KT, Aye KH, Mokuolu OA, Olaosebikan RR, Folaranmi OO, Mayxay M, Khanthavong M, Hongvanthong B, Newton PN, Onyamboko MA, Fanello CI, Tshefu AK, Mishra N, Valecha N, Phyo AP, Nosten F, Yi P, Tripura R, Borrmann S, Bashraheil M, Peshu J, Faiz MA, Ghose A, Hossain MA, Samad R, Rahman MR, Hasan MM, Islam A, Miotto O, Amato R, MacInnis B, Stalker J, Kwiatkowski DP, Bozdech Z, Jeeyapant A, Cheah PY, Sakulthaew T, Chalk J, Intharabut B, Silamut K, Lee SJ, Vihokhern B, Kunasol C, Imwong M, Tarning J, Taylor WJ, Yeung S, Woodrow CJ, Flegg JA, Das D, Smith J, Venkatesan M, Plowe CV, Stepniewska K, Guerin PJ, Dondorp AM, Day NP, White NJ. Spread of artemisinin resistance in Plasmodium falciparum malaria. N Engl J Med 2014; 371:411-23. [PMID: 25075834 PMCID: PMC4143591 DOI: 10.1056/nejmoa1314981] [Citation(s) in RCA: 1491] [Impact Index Per Article: 149.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Artemisinin resistance in Plasmodium falciparum has emerged in Southeast Asia and now poses a threat to the control and elimination of malaria. Mapping the geographic extent of resistance is essential for planning containment and elimination strategies. METHODS Between May 2011 and April 2013, we enrolled 1241 adults and children with acute, uncomplicated falciparum malaria in an open-label trial at 15 sites in 10 countries (7 in Asia and 3 in Africa). Patients received artesunate, administered orally at a daily dose of either 2 mg per kilogram of body weight per day or 4 mg per kilogram, for 3 days, followed by a standard 3-day course of artemisinin-based combination therapy. Parasite counts in peripheral-blood samples were measured every 6 hours, and the parasite clearance half-lives were determined. RESULTS The median parasite clearance half-lives ranged from 1.9 hours in the Democratic Republic of Congo to 7.0 hours at the Thailand-Cambodia border. Slowly clearing infections (parasite clearance half-life >5 hours), strongly associated with single point mutations in the "propeller" region of the P. falciparum kelch protein gene on chromosome 13 (kelch13), were detected throughout mainland Southeast Asia from southern Vietnam to central Myanmar. The incidence of pretreatment and post-treatment gametocytemia was higher among patients with slow parasite clearance, suggesting greater potential for transmission. In western Cambodia, where artemisinin-based combination therapies are failing, the 6-day course of antimalarial therapy was associated with a cure rate of 97.7% (95% confidence interval, 90.9 to 99.4) at 42 days. CONCLUSIONS Artemisinin resistance to P. falciparum, which is now prevalent across mainland Southeast Asia, is associated with mutations in kelch13. Prolonged courses of artemisinin-based combination therapies are currently efficacious in areas where standard 3-day treatments are failing. (Funded by the U.K. Department of International Development and others; ClinicalTrials.gov number, NCT01350856.).
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Antonia AL, Taylor SM, Janko M, Emch M, Tshefu AK, Meshnick SR. A cross-sectional survey of Plasmodium falciparum pfcrt mutant haplotypes in the Democratic Republic of Congo. Am J Trop Med Hyg 2014; 90:1094-7. [PMID: 24732459 DOI: 10.4269/ajtmh.13-0378] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
In the Democratic Republic of the Congo (DRC), artesunate-amodiaquine is first-line therapy for falciparum malaria; little is known about the prevalence of molecular markers of parasite drug resistance. Across the DRC, we genotyped 166 parasites in Plasmodium falciparum chloroquine resistance transporter (pfcrt) using polymerase chain reaction (PCR) and sequencing. Of these parasites, 73 (44%) parasites were pure wild-type CVMNK, 55 (31%) parasites were chloroquine-resistant CVIET: , 35 (21.1%) parasites were mixed CVMNK and CVIET: , and 3 parasites were other genotypes. Ninety-two infections (55.4%) harbored the pfcrt K76T: substitution that is highly correlated with chloroquine failure. The amodiaquine-resistant S: VMNT: haplotype was absent. Geographically, pfcrt haplotypes were not clearly clustered. Chloroquine accounted for 19.4% of antimalarial use, and amodiaquine accounted for 15.3% of antimalarial use; there were no associations between drug use and mutant haplotype prevalence. In the DRC, our molecular survey indicates that resistance to chloroquine is substantial but that resistance to amodiaquine is absent. These contrasting findings highlight the need for molecular surveillance of drug resistance to inform malaria control policies.
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Affiliation(s)
- Alejandro L Antonia
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina; Division of Infectious Diseases and International Health, Duke University Medical Center, Durham, North Carolina; Department of Geography, University of North Carolina, Chapel Hill, North Carolina; Carolina Population Center, University of North Carolina, Chapel Hill, North Carolina; Ecole de Sante Publique, Faculte de Medicine, University of Kinshasa, Kinshasa, Democratic Republic of the Congo
| | - Steve M Taylor
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina; Division of Infectious Diseases and International Health, Duke University Medical Center, Durham, North Carolina; Department of Geography, University of North Carolina, Chapel Hill, North Carolina; Carolina Population Center, University of North Carolina, Chapel Hill, North Carolina; Ecole de Sante Publique, Faculte de Medicine, University of Kinshasa, Kinshasa, Democratic Republic of the Congo
| | - Mark Janko
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina; Division of Infectious Diseases and International Health, Duke University Medical Center, Durham, North Carolina; Department of Geography, University of North Carolina, Chapel Hill, North Carolina; Carolina Population Center, University of North Carolina, Chapel Hill, North Carolina; Ecole de Sante Publique, Faculte de Medicine, University of Kinshasa, Kinshasa, Democratic Republic of the Congo
| | - Michael Emch
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina; Division of Infectious Diseases and International Health, Duke University Medical Center, Durham, North Carolina; Department of Geography, University of North Carolina, Chapel Hill, North Carolina; Carolina Population Center, University of North Carolina, Chapel Hill, North Carolina; Ecole de Sante Publique, Faculte de Medicine, University of Kinshasa, Kinshasa, Democratic Republic of the Congo
| | - Antoinette K Tshefu
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina; Division of Infectious Diseases and International Health, Duke University Medical Center, Durham, North Carolina; Department of Geography, University of North Carolina, Chapel Hill, North Carolina; Carolina Population Center, University of North Carolina, Chapel Hill, North Carolina; Ecole de Sante Publique, Faculte de Medicine, University of Kinshasa, Kinshasa, Democratic Republic of the Congo
| | - Steven R Meshnick
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina; Division of Infectious Diseases and International Health, Duke University Medical Center, Durham, North Carolina; Department of Geography, University of North Carolina, Chapel Hill, North Carolina; Carolina Population Center, University of North Carolina, Chapel Hill, North Carolina; Ecole de Sante Publique, Faculte de Medicine, University of Kinshasa, Kinshasa, Democratic Republic of the Congo
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Hromatka BS, Ngeleza S, Adibi JJ, Niles RK, Tshefu AK, Fisher SJ. Histopathologies, immunolocalization, and a glycan binding screen provide insights into Plasmodium falciparum interactions with the human placenta. Biol Reprod 2013; 88:154. [PMID: 23575149 PMCID: PMC4070867 DOI: 10.1095/biolreprod.112.106195] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2012] [Revised: 01/06/2013] [Accepted: 03/29/2013] [Indexed: 11/01/2022] Open
Abstract
During pregnancy, Plasmodium falciparum-infected erythrocytes cytoadhere to the placenta. Infection is likely initiated at two sites where placental trophoblasts contact maternal blood: 1) via syncytiotrophoblast (STB), a multicellular transporting and biosynthetic layer that forms the surface of chorionic villi and lines the intervillous space, and 2) through invasive cytotrophoblasts, which line uterine vessels that divert blood to the placenta. Here, we investigated mechanisms of infected erythrocyte sequestration in relationship to the microanatomy of the maternal-fetal interface. Histological analyses revealed STB denudation in placental malaria, which brought the stromal cores of villi in direct contact with maternal blood. STB denudation was associated with hemozoin deposition (P = 0.01) and leukocyte infiltration (P = 0.001) and appeared to be a feature of chronic placental malaria. Immunolocalization of infected red blood cell receptors (CD36, ICAM1/CD54, and chondroitin sulfate A) in placentas from uncomplicated pregnancies showed that STB did not stain, while the underlying villous stroma was immunopositive. Invasive cytotrophoblasts expressed ICAM1. In malaria, STB denudation exposed CD36 and chondroitin sulfate A in the villous cores to maternal blood, and STB expressed ICAM1. Finally, we investigated infected erythrocyte adherence to novel receptors by screening an array of 377 glycans. Infected erythrocytes bound Lewis antigens that immunolocalized to STB. Our results suggest that P. falciparum interactions with STB-associated Lewis antigens could initiate placental malaria. Subsequent pathologies, which expose CD36, ICAM1, and chondroitin sulfate A, might propagate the infection.
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Affiliation(s)
- Bethann S. Hromatka
- Departments of Obstetrics and Gynecology, Anatomy, the Center for Reproductive Sciences, and The Eli and Edythe Broad Center of Regeneration Medicine and Stem Cell Research, University of California, San Francisco, San Francisco, California
| | - Sadiki Ngeleza
- Kinshasa School of Public Health, Kinshasa, Democratic Republic of the Congo
| | - Jennifer J. Adibi
- Departments of Obstetrics and Gynecology, Anatomy, the Center for Reproductive Sciences, and The Eli and Edythe Broad Center of Regeneration Medicine and Stem Cell Research, University of California, San Francisco, San Francisco, California
| | - Richard K. Niles
- Departments of Obstetrics and Gynecology, Anatomy, the Center for Reproductive Sciences, and The Eli and Edythe Broad Center of Regeneration Medicine and Stem Cell Research, University of California, San Francisco, San Francisco, California
| | | | - Susan J. Fisher
- Departments of Obstetrics and Gynecology, Anatomy, the Center for Reproductive Sciences, and The Eli and Edythe Broad Center of Regeneration Medicine and Stem Cell Research, University of California, San Francisco, San Francisco, California
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Taylor SM, Antonia AL, Parobek CM, Juliano JJ, Janko M, Emch M, Alam MT, Udhayakumar V, Tshefu AK, Meshnick SR. Plasmodium falciparum sulfadoxine resistance is geographically and genetically clustered within the DR Congo. Sci Rep 2013; 3:1165. [PMID: 23372922 PMCID: PMC3558697 DOI: 10.1038/srep01165] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2012] [Accepted: 12/13/2012] [Indexed: 11/10/2022] Open
Abstract
Understanding the spatial clustering of Plasmodium falciparum populations can assist efforts to contain drug-resistant parasites and maintain the efficacy of future drugs. We sequenced single nucleotide polymorphisms (SNPs) in the dihydropteroate synthase gene (dhps) associated with sulfadoxine resistance and 5 microsatellite loci flanking dhps in order to investigate the genetic backgrounds, genetic relatedness, and geographic clustering of falciparum parasites in the Democratic Republic of the Congo (DRC). Resistant haplotypes were clustered into subpopulations: one in the northeast DRC, and the other in the balance of the DRC. Network and clonal lineage analyses of the flanking microsatellites indicate that geographically-distinct mutant dhps haplotypes derive from separate lineages. The DRC is therefore a watershed for haplotypes associated with sulfadoxine resistance. Given the importance of central Africa as a corridor for the spread of antimalarial resistance, the identification of the mechanisms of this transit can inform future policies to contain drug-resistant parasite strains.
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Affiliation(s)
- Steve M Taylor
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina , Chapel Hill, USA.
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Kayentao K, Doumbo OK, Pénali LK, Offianan AT, Bhatt KM, Kimani J, Tshefu AK, Kokolomami JHT, Ramharter M, de Salazar PM, Tiono AB, Ouédraogo A, Bustos MDG, Quicho F, Borghini-Fuhrer I, Duparc S, Shin CS, Fleckenstein L. Pyronaridine-artesunate granules versus artemether-lumefantrine crushed tablets in children with Plasmodium falciparum malaria: a randomized controlled trial. Malar J 2012; 11:364. [PMID: 23113947 PMCID: PMC3566922 DOI: 10.1186/1475-2875-11-364] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2012] [Accepted: 10/18/2012] [Indexed: 11/29/2022] Open
Abstract
Background Children are most vulnerable to malaria. A pyronaridine-artesunate pediatric granule formulation is being developed for the treatment of uncomplicated Plasmodium falciparum malaria. Methods This phase III, multi-center, comparative, open-label, parallel-group, controlled clinical trial included patients aged ≤12 years, bodyweight ≥5 to <25 kg, with a reported history of fever at inclusion or in the previous 24 h and microscopically-confirmed uncomplicated P. falciparum malaria. Patients were randomized (2:1) to pyronaridine-artesunate granules (60/20 mg) once daily or artemether-lumefantrine crushed tablets (20/120 mg) twice daily, both dosed by bodyweight, orally (liquid suspension) for three days. Results Of 535 patients randomized, 355 received pyronaridine-artesunate and 180 received artemether-lumefantrine. Day-28 adequate clinical and parasitological response (ACPR), corrected for re-infection using polymerase chain reaction (PCR) genotyping (per-protocol population) was 97.1% (329/339; 95% CI 94.6, 98.6) for pyronaridine-artesunate; 98.8% (165/167; 95% CI 95.7, 99.9) for artemether-lumefantrine. The primary endpoint was achieved: pyronaridine-artesunate PCR-corrected day-28 ACPR was statistically significantly >90% (P < .0001). Pyronaridine-artesunate was non-inferior to artemether-lumefantrine: treatment difference -1.8% (95% CI -4.3 to 1.6). The incidence of drug-related adverse events was 37.2% (132/355) with pyronaridine-artesunate, 44.4% (80/180) with artemether-lumefantrine. Clinical biochemistry results showed similar mean changes versus baseline in the two treatment groups. From day 3 until study completion, one patient in each treatment group had peak alanine aminotransferase (ALT) >3 times the upper limit of normal (ULN) and peak total bilirubin >2xULN (i.e. within the Hy’s law definition). Conclusions The pyronaridine-artesunate pediatric granule formulation was efficacious and was non-inferior to artemether-lumefantrine. The adverse event profile was similar for the two comparators. Pyronaridine-artesunate should be considered for inclusion in paediatric malaria treatment programmes. Trial registration ClinicalTrials.gov: identifier NCT00541385
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Affiliation(s)
- Kassoum Kayentao
- Malaria Research and Training Center, Faculté de Médecine de Pharmacie et d'Odonto-Stomatologie, Bamako, Mali
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Alao MJ, Gbadoè AD, Tshefu AK, Meremikwu M, Tiono AB, Cousin M, Harried K. Uncomplicated Plasmodium falciparum malaria in infants <5 kg: retrospective surveillance of hospital records in five Sub-Saharan African countries. Malar J 2012. [PMCID: PMC3472702 DOI: 10.1186/1475-2875-11-s1-p4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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Griffin JB, Lokomba V, Landis SH, Thorp JM, Herring AH, Tshefu AK, Rogerson SJ, Meshnick SR. Plasmodium falciparum parasitaemia in the first half of pregnancy, uterine and umbilical artery blood flow, and foetal growth: a longitudinal Doppler ultrasound study. Malar J 2012; 11:319. [PMID: 22963509 PMCID: PMC3496585 DOI: 10.1186/1475-2875-11-319] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2012] [Accepted: 09/05/2012] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND During early pregnancy, the placenta develops to meet the metabolic demands of the foetus. The objective of this analysis was to examine the effect of malaria parasitaemia prior to 20 weeks' gestation on subsequent changes in uterine and umbilical artery blood flow and intrauterine growth restriction. METHODS Data were analysed from 548 antenatal visits after 20 weeks' gestation of 128 women, which included foetal biometric measures and interrogation of uterine and umbilical artery blood flow. Linear mixed effect models estimated the effect of early pregnancy malaria parasitaemia on uterine and umbilical artery resistance indices. Log-binomial models with generalized estimating equations estimated the effect of early pregnancy malaria parasitaemia on the risk of intrauterine growth restriction. RESULTS There were differential effects of early pregnancy malaria parasitaemia on uterine artery resistance by nutritional status, with decreased uterine artery resistance among nourished women with early pregnancy malaria and increased uterine artery resistance among undernourished women with early pregnancy malaria. Among primigravidae, early pregnancy malaria parasitaemia decreased umbilical artery resistance in the late third trimester, likely reflecting adaptive villous angiogenesis. In fully adjusted models, primigravidae with early pregnancy malaria parasitaemia had 3.6 times the risk of subsequent intrauterine growth restriction (95% CI: 2.1, 6.2) compared to the referent group of multigravidae with no early pregnancy malaria parasitaemia. CONCLUSIONS Early pregnancy malaria parasitaemia affects uterine and umbilical artery blood flow, possibly due to alterations in placentation and angiogenesis, respectively. Among primigravidae, early pregnancy malaria parasitaemia increases the risk of intrauterine growth restriction. The findings support the initiation of malaria parasitaemia prevention and control efforts earlier in pregnancy.
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Affiliation(s)
- Jennifer B Griffin
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, McGavran-Greenberg Hall, Campus Box 7435, Chapel Hill, 27599-7435, USA
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Ramutton T, Hendriksen ICE, Mwanga-Amumpaire J, Mtove G, Olaosebikan R, Tshefu AK, Onyamboko MA, Karema C, Maitland K, Gomes E, Gesase S, Reyburn H, Silamut K, Chotivanich K, Promnares K, Fanello CI, von Seidlein L, Day NPJ, White NJ, Dondorp AM, Imwong M, Woodrow CJ. Sequence variation does not confound the measurement of plasma PfHRP2 concentration in African children presenting with severe malaria. Malar J 2012; 11:276. [PMID: 22898068 PMCID: PMC3480887 DOI: 10.1186/1475-2875-11-276] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2012] [Accepted: 08/13/2012] [Indexed: 11/12/2022] Open
Abstract
Background Plasmodium falciparum histidine-rich protein PFHRP2 measurement is used widely for diagnosis, and more recently for severity assessment in falciparum malaria. The Pfhrp2 gene is highly polymorphic, with deletion of the entire gene reported in both laboratory and field isolates. These issues potentially confound the interpretation of PFHRP2 measurements. Methods Studies designed to detect deletion of Pfhrp2 and its paralog Pfhrp3 were undertaken with samples from patients in seven countries contributing to the largest hospital-based severe malaria trial (AQUAMAT). The quantitative relationship between sequence polymorphism and PFHRP2 plasma concentration was examined in samples from selected sites in Mozambique and Tanzania. Results There was no evidence for deletion of either Pfhrp2 or Pfhrp3 in the 77 samples with lowest PFHRP2 plasma concentrations across the seven countries. Pfhrp2 sequence diversity was very high with no haplotypes shared among 66 samples sequenced. There was no correlation between Pfhrp2 sequence length or repeat type and PFHRP2 plasma concentration. Conclusions These findings indicate that sequence polymorphism is not a significant cause of variation in PFHRP2 concentration in plasma samples from African children. This justifies the further development of plasma PFHRP2 concentration as a method for assessing African children who may have severe falciparum malaria. The data also add to the existing evidence base supporting the use of rapid diagnostic tests based on PFHRP2 detection.
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Affiliation(s)
- Thiranut Ramutton
- Department of Clinical Tropical Medicine, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
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von Seidlein L, Olaosebikan R, Hendriksen ICE, Lee SJ, Adedoyin OT, Agbenyega T, Nguah SB, Bojang K, Deen JL, Evans J, Fanello CI, Gomes E, Pedro AJ, Kahabuka C, Karema C, Kivaya E, Maitland K, Mokuolu OA, Mtove G, Mwanga-Amumpaire J, Nadjm B, Nansumba M, Ngum WP, Onyamboko MA, Reyburn H, Sakulthaew T, Silamut K, Tshefu AK, Umulisa N, Gesase S, Day NPJ, White NJ, Dondorp AM. Predicting the clinical outcome of severe falciparum malaria in african children: findings from a large randomized trial. Clin Infect Dis 2012; 54:1080-90. [PMID: 22412067 PMCID: PMC3309889 DOI: 10.1093/cid/cis034] [Citation(s) in RCA: 125] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Four predictors were independently associated with an increased risk of death: acidosis, cerebral manifestations of malaria, elevated blood urea nitrogen, or signs of chronic illness. The standard base deficit was found to be the single most relevant predictor of death. Background. Data from the largest randomized, controlled trial for the treatment of children hospitalized with severe malaria were used to identify such predictors of a poor outcome from severe malaria. Methods. African children (<15 years) with severe malaria participated in a randomized comparison of parenteral artesunate and parenteral quinine in 9 African countries. Detailed clinical assessment was performed on admission. Parasite densities were assessed in a reference laboratory. Predictors of death were examined using a multivariate logistic regression model. Results. Twenty indicators of disease severity were assessed, out of which 5 (base deficit, impaired consciousness, convulsions, elevated blood urea, and underlying chronic illness) were associated independently with death. Tachypnea, respiratory distress, deep breathing, shock, prostration, low pH, hyperparasitemia, severe anemia, and jaundice were statistically significant indicators of death in the univariate analysis but not in the multivariate model. Age, glucose levels, axillary temperature, parasite density, heart rate, blood pressure, and blackwater fever were not related to death in univariate models. Conclusions. Acidosis, cerebral involvement, renal impairment, and chronic illness are key independent predictors for a poor outcome in African children with severe malaria. Mortality is markedly increased in cerebral malaria combined with acidosis. Clinical Trial Registration. ISRCTN50258054.
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Affiliation(s)
- Lorenz von Seidlein
- Department of Global Health, Menzies School of Health Research, Casuarina, Northern Territory, Australia.
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Hendriksen ICE, Mwanga-Amumpaire J, von Seidlein L, Mtove G, White LJ, Olaosebikan R, Lee SJ, Tshefu AK, Woodrow C, Amos B, Karema C, Saiwaew S, Maitland K, Gomes E, Pan-Ngum W, Gesase S, Silamut K, Reyburn H, Joseph S, Chotivanich K, Fanello CI, Day NPJ, White NJ, Dondorp AM. Diagnosing severe falciparum malaria in parasitaemic African children: a prospective evaluation of plasma PfHRP2 measurement. PLoS Med 2012; 9:e1001297. [PMID: 22927801 PMCID: PMC3424256 DOI: 10.1371/journal.pmed.1001297] [Citation(s) in RCA: 105] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2012] [Accepted: 07/13/2012] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND In African children, distinguishing severe falciparum malaria from other severe febrile illnesses with coincidental Plasmodium falciparum parasitaemia is a major challenge. P. falciparum histidine-rich protein 2 (PfHRP2) is released by mature sequestered parasites and can be used to estimate the total parasite burden. We investigated the prognostic significance of plasma PfHRP2 and used it to estimate the malaria-attributable fraction in African children diagnosed with severe malaria. METHODS AND FINDINGS Admission plasma PfHRP2 was measured prospectively in African children (from Mozambique, The Gambia, Kenya, Tanzania, Uganda, Rwanda, and the Democratic Republic of the Congo) aged 1 month to 15 years with severe febrile illness and a positive P. falciparum lactate dehydrogenase (pLDH)-based rapid test in a clinical trial comparing parenteral artesunate versus quinine (the AQUAMAT trial, ISRCTN 50258054). In 3,826 severely ill children, Plasmadium falciparum PfHRP2 was higher in patients with coma (p = 0.0209), acidosis (p<0.0001), and severe anaemia (p<0.0001). Admission geometric mean (95%CI) plasma PfHRP2 was 1,611 (1,350-1,922) ng/mL in fatal cases (n = 381) versus 1,046 (991-1,104) ng/mL in survivors (n = 3,445, p<0.0001), without differences in parasitaemia as assessed by microscopy. There was a U-shaped association between log(10) plasma PfHRP2 and risk of death. Mortality increased 20% per log(10) increase in PfHRP2 above 174 ng/mL (adjusted odds ratio [AOR] 1.21, 95%CI 1.05-1.39, p = 0.009). A mechanistic model assuming a PfHRP2-independent risk of death in non-malaria illness closely fitted the observed data and showed malaria-attributable mortality less than 50% with plasma PfHRP2≤174 ng/mL. The odds ratio (OR) for death in artesunate versus quinine-treated patients was 0.61 (95%CI 0.44-0.83, p = 0.0018) in the highest PfHRP2 tertile, whereas there was no difference in the lowest tertile (OR 1.05; 95%CI 0.69-1.61; p = 0.82). A limitation of the study is that some conclusions are drawn from a mechanistic model, which is inherently dependent on certain assumptions. However, a sensitivity analysis of the model indicated that the results were robust to a plausible range of parameter estimates. Further studies are needed to validate our findings. CONCLUSIONS Plasma PfHRP2 has prognostic significance in African children with severe falciparum malaria and provides a tool to stratify the risk of "true" severe malaria-attributable disease as opposed to other severe illnesses in parasitaemic African children.
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Affiliation(s)
- Ilse C. E. Hendriksen
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine, Churchill Hospital, University of Oxford, Oxford, United Kingdom
| | | | | | - George Mtove
- National Institute for Medical Research, Amani Centre, Tanga, Tanzania
| | - Lisa J. White
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine, Churchill Hospital, University of Oxford, Oxford, United Kingdom
| | | | - Sue J. Lee
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine, Churchill Hospital, University of Oxford, Oxford, United Kingdom
| | - Antoinette K. Tshefu
- Kinshasa School of Public Health, Kingasani Research Centre, Kinshasa, Democratic Republic of the Congo
| | - Charles Woodrow
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine, Churchill Hospital, University of Oxford, Oxford, United Kingdom
| | - Ben Amos
- Teule Hospital, Muheza, Tanzania
| | - Corine Karema
- Malaria Control Program, Ministry of Health, Kigali, Rwanda
| | - Somporn Saiwaew
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Kathryn Maitland
- Kenya Medical Research Institute (KEMRI)–Wellcome Trust Research Programme, Kilifi, Kenya
| | | | - Wirichada Pan-Ngum
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Samwel Gesase
- National Institute for Medical Research, Tanga Medical Research Centre, Tanga, Tanzania
| | - Kamolrat Silamut
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Hugh Reyburn
- London School of Tropical Medicine & Hygiene, London, United Kingdom
| | - Sarah Joseph
- Medical Research Council, London, United Kingdom
| | - Kesinee Chotivanich
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Caterina I. Fanello
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine, Churchill Hospital, University of Oxford, Oxford, United Kingdom
| | - Nicholas P. J. Day
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine, Churchill Hospital, University of Oxford, Oxford, United Kingdom
| | - Nicholas J. White
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine, Churchill Hospital, University of Oxford, Oxford, United Kingdom
| | - Arjen M. Dondorp
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine, Churchill Hospital, University of Oxford, Oxford, United Kingdom
- * E-mail:
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Taylor SM, van Eijk AM, Hand CC, Mwandagalirwa K, Messina JP, Tshefu AK, Atua B, Emch M, Muwonga J, Meshnick SR, Ter Kuile FO. Quantification of the burden and consequences of pregnancy-associated malaria in the Democratic Republic of the Congo. J Infect Dis 2011; 204:1762-71. [PMID: 21990422 DOI: 10.1093/infdis/jir625] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Pregnancy-associated malaria (PAM) produces poor birth outcomes, but its prevalence is commonly estimated in convenience samples. METHODS We assessed the prevalence of malaria using real-time polymerase chain reaction (PCR) and estimated the consequences of infection on birth outcomes, using specimens from a nationally representative sample of 4570 women of childbearing age (WOCBA) responding to the 2007 Demographic and Health Survey in Democratic Republic of the Congo (DRC). RESULTS Overall, 31.2% (95% confidence interval [CI], 29.2-33.1) of WOCBA were parasitemic, which was significantly more common in pregnant (37.2% [31.0-43.5]) than nonpregnant women (30.4% [CI, 28.4-32.5], prevalence ratio [PR] 1.22 [1.02-1.47]). Plasmodium falciparum was highest among pregnant women (36.6% vs 28.8%, PR 1.27 [1.05-1.53]). By contrast, P malariae was less common in pregnant (0.6%) compared with nonpregnant women (2.7%, PR 0.23 [0.09-0.56]). Extrapolation of the prevalence estimate to the population at risk of malaria in DRC suggests 1.015 million births are affected by P falciparum infection annually, and that adherence to preventive measures could prevent up to 549 000 episodes of pregnancy-associated malaria and 47 000 low-birth-weight births. CONCLUSIONS Pregnancy-associated malaria and its consequences are highly prevalent in the DRC. Increasing the uptake of malaria preventive measures represents a significant opportunity to improve birth outcomes and neonatal health.
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Affiliation(s)
- Steve M Taylor
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC, USA.
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Messina JP, Taylor SM, Meshnick SR, Linke AM, Tshefu AK, Atua B, Mwandagalirwa K, Emch M. Population, behavioural and environmental drivers of malaria prevalence in the Democratic Republic of Congo. Malar J 2011; 10:161. [PMID: 21658268 PMCID: PMC3146438 DOI: 10.1186/1475-2875-10-161] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2011] [Accepted: 06/09/2011] [Indexed: 11/26/2022] Open
Abstract
Background Malaria is highly endemic in the Democratic Republic of Congo (DRC), but the limits and intensity of transmission within the country are unknown. It is important to discern these patterns as well as the drivers which may underlie them in order for effective prevention measures to be carried out. Methods By applying high-throughput PCR analyses on leftover dried blood spots from the 2007 Demographic and Health Survey (DHS) for the DRC, prevalence estimates were generated and ecological drivers of malaria were explored using spatial statistical analyses and multilevel modelling. Results Of the 7,746 respondents, 2268 (29.3%) were parasitaemic; prevalence ranged from 0-82% within geographically-defined survey clusters. Regional variation in these rates was mapped using the inverse-distance weighting spatial interpolation technique. Males were more likely to be parasitaemic than older people or females (p < 0.0001), while wealthier people were at a lower risk (p < 0.001). Increased community use of bed nets (p = 0.001) and community wealth (p < 0.05) were protective against malaria at the community level but not at the individual level. Paradoxically, the number of battle events since 1994 surrounding one's community was negatively associated with malaria risk (p < 0.0001). Conclusions This research demonstrates the feasibility of using population-based behavioural and molecular surveillance in conjunction with DHS data and geographic methods to study endemic infectious diseases. This study provides the most accurate population-based estimates to date of where illness from malaria occurs in the DRC and what factors contribute to the estimated spatial patterns. This study suggests that spatial information and analyses can enable the DRC government to focus its control efforts against malaria.
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Affiliation(s)
- Jane P Messina
- Department of Geography, University of North Carolina, Chapel Hill, NC, USA.
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Morris CA, Onyamboko MA, Capparelli E, Koch MA, Atibu J, Lokomba V, Douoguih M, Hemingway-Foday J, Wesche D, Ryder RW, Bose C, Wright L, Tshefu AK, Meshnick S, Fleckenstein L. Population pharmacokinetics of artesunate and dihydroartemisinin in pregnant and non-pregnant women with malaria. Malar J 2011; 10:114. [PMID: 21548983 PMCID: PMC3098207 DOI: 10.1186/1475-2875-10-114] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2010] [Accepted: 05/08/2011] [Indexed: 11/24/2022] Open
Abstract
Background The World Health Organization endorses the use of artemisinin-based combination therapy for treatment of acute uncomplicated falciparum malaria in the second and third trimesters of pregnancy. However, the effects of pregnancy on the pharmacokinetics of artemisinin derivatives, such as artesunate (AS), are poorly understood. In this analysis, the population pharmacokinetics of oral AS, and its active metabolite dihydroartemisinin (DHA), were studied in pregnant and non-pregnant women at the Kingasani Maternity Clinic in the DRC. Methods Data were obtained from 26 pregnant women in the second (22 - 26 weeks) or the third (32 - 36 weeks) trimester of pregnancy and from 25 non-pregnant female controls. All subjects received 200 mg AS. Plasma AS and DHA were measured using a validated LC-MS method. Estimates for pharmacokinetic and variability parameters were obtained through nonlinear mixed effects modelling. Results A simultaneous parent-metabolite model was developed consisting of mixed zero-order, lagged first-order absorption of AS, a one-compartment model for AS, and a one-compartment model for DHA. Complete conversion of AS to DHA was assumed. The model displayed satisfactory goodness-of-fit, stability, and predictive ability. Apparent clearance (CL/F) and volume of distribution (V/F) estimates, with 95% bootstrap confidence intervals, were as follows: 195 L (139-285 L) for AS V/F, 895 L/h (788-1045 L/h) for AS CL/F, 91.4 L (78.5-109 L) for DHA V/F, and 64.0 L/h (55.1-75.2 L/h) for DHA CL/F. The effect of pregnancy on DHA CL/F was determined to be significant, with a pregnancy-associated increase in DHA CL/F of 42.3% (19.7 - 72.3%). Conclusions In this analysis, pharmacokinetic modelling suggests that pregnant women have accelerated DHA clearance compared to non-pregnant women receiving orally administered AS. These findings, in conjunction with a previous non-compartmental analysis of the modelled data, provide further evidence that higher AS doses would be required to maintain similar DHA levels in pregnant women as achieved in non-pregnant controls.
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Affiliation(s)
- Carrie A Morris
- University of Iowa, College of Pharmacy, 115 South Grand Avenue, Iowa City, IA 52242, USA
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Onyamboko MA, Meshnick SR, Fleckenstein L, Koch MA, Atibu J, Lokomba V, Douoguih M, Hemingway-Foday J, Wesche D, Ryder RW, Bose C, Wright LL, Tshefu AK, Capparelli EV. Pharmacokinetics and pharmacodynamics of artesunate and dihydroartemisinin following oral treatment in pregnant women with asymptomatic Plasmodium falciparum infections in Kinshasa DRC. Malar J 2011; 10:49. [PMID: 21352601 PMCID: PMC3056842 DOI: 10.1186/1475-2875-10-49] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2010] [Accepted: 02/28/2011] [Indexed: 11/17/2022] Open
Abstract
Background In many malaria-endemic countries, increasing resistance may soon compromise the efficacy of sulphadoxine-pyrimethamine (SP) for intermittent preventative treatment (IPT) of malaria in pregnancy. Artemisinin-based IPT regimens represent a promising potential alternative to SP. Pharmacokinetic and safety data supporting the use of artemisinin derivatives in pregnancy are urgently needed. Methods Subjects included pregnant women with asymptomatic falciparum parasitaemia between 22-26 weeks (n = 13) or 32-36 weeks gestation (n = 13), the same women at three months postpartum, and 25 non-pregnant parasitaemic controls. All subjects received 200 mg orally administered AS. Plasma total and free levels of AS and its active metabolite DHA were determined using a validated LC-MS method. Non-compartmental pharmacokinetic analysis was performed using standard methods. Results All pregnant women delivered live babies. The median birth weight was 3025 grams [range 2130, 3620]; 2 of 26 babies had birth weights less than 2500 grams. Rates of parasite clearance by 12 hours post-dose were high and comparable among the groups. Rapid elimination of AS was observed in all three groups. The 90% CI for the pregnancy:postpartum ratio of geometric means for total and free AUC fell within the pre-specified 0.66 - 1.50 therapeutic equivalence interval. However, more pronounced pharmacokinetic differences were observed between the pregnancy and control subjects, with the 90% CI for the pregnancy:control ratio of geometric means for both total 0.68 (90% CI 0.57-0.81) and free AUC 0.78 (90% CI 0.63-0.95) not fully contained within the 0.66 - 1.50 interval. All subjects cleared parasites rapidly, and there was no difference in the percentage of women who were parasitaemic 12 hours after dosing. Conclusions A single dose of orally administered AS was found to be both effective and without adverse effects in this study of second and third trimester pregnant women in the DRC. Although DHA AUC during pregnancy and postpartum were similar, the AUC for the pregnant group was less than the non-pregnant controls. The findings of this study suggest that additional studies on the pharmacokinetics of AS in pregnant women are needed. Trial Registration ClinicalTrials.gov: NCT00538382
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Affiliation(s)
- Marie A Onyamboko
- Kinshasa School of Public Health, Kinshasa, The Democratic Republic of Congo
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Taylor SM, Messina JP, Hand CC, Juliano JJ, Muwonga J, Tshefu AK, Atua B, Emch M, Meshnick SR. Molecular malaria epidemiology: mapping and burden estimates for the Democratic Republic of the Congo, 2007. PLoS One 2011; 6:e16420. [PMID: 21305011 PMCID: PMC3031549 DOI: 10.1371/journal.pone.0016420] [Citation(s) in RCA: 63] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2010] [Accepted: 12/15/2010] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Epidemiologic data on malaria are scant in many high-burden countries including the Democratic Republic of the Congo (DRC), which suffers the second-highest global burden of malaria. Malaria control efforts in regions with challenging infrastructure require reproducible and efficient surveillance. We employed new high-throughput molecular testing to characterize the state of malaria control in the DRC and estimate childhood mortality attributable to excess malaria transmission. METHODS AND FINDINGS The Demographic and Health Survey was a cross-sectional, population-based cluster household survey of adults aged 15-59 years in 2007 employing structured questionnaires and dried blood spot collection. Parasitemia was detected by real-time PCR, and survey responses measured adoption of malaria control measures and under-5 health indices. The response rate was 99% at the household level, and 8,886 households were surveyed in 300 clusters; from 8,838 respondents molecular results were available. The overall prevalence of parasitemia was 33.5% (95% confidence interval [C.I.] 32-34.9); P. falciparum was the most prevalent species, either as monoinfection (90.4%; 95% C.I. 88.8-92.1) or combined with P. malariae (4.9%; 95% C.I. 3.7-5.9) or P. ovale (0.6%; 95% C.I. 0.1-0.9). Only 7.7% (95% CI 6.8-8.6) of households with children under 5 owned an insecticide-treated bednet (ITN), and only 6.8% (95% CI 6.1-7.5) of under-fives slept under an ITN the preceding night. The overall under-5 mortality rate was 147 deaths per 1,000 live births (95% C.I. 141-153) and between clusters was associated with increased P. falciparum prevalence; based on the population attributable fraction, 26,488 yearly under-5 deaths were attributable to excess malaria transmission. CONCLUSIONS Adult P. falciparum prevalence is substantial in the DRC and is associated with under-5 mortality. Molecular testing offers a new, generalizable, and efficient approach to characterizing malaria endemicity in underserved countries.
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Affiliation(s)
- Steve M Taylor
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina, United States of America.
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