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Abstract
Malaria is resurging in many African and South American countries, exacerbated by COVID-19-related health service disruption. In 2021, there were an estimated 247 million malaria cases and 619 000 deaths in 84 endemic countries. Plasmodium falciparum strains partly resistant to artemisinins are entrenched in the Greater Mekong region and have emerged in Africa, while Anopheles mosquito vectors continue to evolve physiological and behavioural resistance to insecticides. Elimination of Plasmodium vivax malaria is hindered by impractical and potentially toxic antirelapse regimens. Parasitological diagnosis and treatment with oral or parenteral artemisinin-based therapy is the mainstay of patient management. Timely blood transfusion, renal replacement therapy, and restrictive fluid therapy can improve survival in severe malaria. Rigorous use of intermittent preventive treatment in pregnancy and infancy and seasonal chemoprevention, potentially combined with pre-erythrocytic vaccines endorsed by WHO in 2021 and 2023, can substantially reduce malaria morbidity. Improved surveillance, better access to effective treatment, more labour-efficient vector control, continued drug development, targeted mass drug administration, and sustained political commitment are required to achieve targets for malaria reduction by the end of this decade.
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Affiliation(s)
- Jeanne Rini Poespoprodjo
- Centre for Child Health and Department of Child Health, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Yogyakarta, Indonesia; Timika Malaria Research Facility, Papuan Health and Community Development Foundation, Timika, Indonesia; Mimika District Hospital and District Health Authority, Timika, Indonesia; Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, NT, Australia.
| | - Nicholas M Douglas
- Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, NT, Australia; Department of Infectious Diseases, Christchurch Hospital, Te Whatu Ora Waitaha, Christchurch, New Zealand; Department of Medicine, University of Otago, Christchurch, New Zealand
| | - Daniel Ansong
- School of Medicine and Dentistry, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Steven Kho
- Timika Malaria Research Facility, Papuan Health and Community Development Foundation, Timika, Indonesia; Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, NT, Australia
| | - Nicholas M Anstey
- Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, NT, Australia; Department of Infectious Diseases, Royal Darwin Hospital, Darwin, NT, Australia
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Kambuaya NN, Rini H, Shanti PAI, Alexander K, Candrawati F, Prayoga P, Leonardo L, Margayani DS, Yayang BTG, Kenangalem E, Buffet PA, Anstey NM, Poespoprodjo JR, Kho S. Case Report: Severe Plasmodium vivax Malaria after Splenectomy. Am J Trop Med Hyg 2023; 109:284-287. [PMID: 37339765 PMCID: PMC10397454 DOI: 10.4269/ajtmh.23-0147] [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] [Received: 04/04/2023] [Accepted: 04/26/2023] [Indexed: 06/22/2023] Open
Abstract
Severe malaria after splenectomy has been reported with infections with Plasmodium falciparum, Plasmodium knowlesi, and Plasmodium malariae, but is less well-characterized with Plasmodium vivax. We describe a case of severe P. vivax malaria with hypotension, prostration, and acute kidney injury occurring 2 months after splenectomy in Papua, Indonesia. The patient was treated successfully with intravenous artesunate.
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Affiliation(s)
- Noy Norman Kambuaya
- Timika Malaria Research Facility, Papuan Health and Community Development Foundation, Timika, Papua, Indonesia
| | - Hasrini Rini
- Timika Malaria Research Facility, Papuan Health and Community Development Foundation, Timika, Papua, Indonesia
| | | | - King Alexander
- Rumah Sakit Umum Daerah Kabupaten Mimika, Timika, Papua, Indonesia
| | - Freis Candrawati
- Timika Malaria Research Facility, Papuan Health and Community Development Foundation, Timika, Papua, Indonesia
| | - Pak Prayoga
- Timika Malaria Research Facility, Papuan Health and Community Development Foundation, Timika, Papua, Indonesia
| | - Leo Leonardo
- Timika Malaria Research Facility, Papuan Health and Community Development Foundation, Timika, Papua, Indonesia
| | - Dewi Sri Margayani
- Timika Malaria Research Facility, Papuan Health and Community Development Foundation, Timika, Papua, Indonesia
| | - Bagus Tesa Gina Yayang
- Timika Malaria Research Facility, Papuan Health and Community Development Foundation, Timika, Papua, Indonesia
| | - Enny Kenangalem
- Timika Malaria Research Facility, Papuan Health and Community Development Foundation, Timika, Papua, Indonesia
- Rumah Sakit Umum Daerah Kabupaten Mimika, Timika, Papua, Indonesia
| | | | - Nicholas M. Anstey
- Global and Tropical Health Division, Menzies School of Health Research and Charles Darwin University, Darwin, Australia
| | - Jeanne Rini Poespoprodjo
- Timika Malaria Research Facility, Papuan Health and Community Development Foundation, Timika, Papua, Indonesia
- Rumah Sakit Umum Daerah Kabupaten Mimika, Timika, Papua, Indonesia
- Department of Pediatrics, Gadjah Mada University, Yogyakarta, Indonesia
| | - Steven Kho
- Timika Malaria Research Facility, Papuan Health and Community Development Foundation, Timika, Papua, Indonesia
- Global and Tropical Health Division, Menzies School of Health Research and Charles Darwin University, Darwin, Australia
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3
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Rahmalia A, Poespoprodjo JR, Landuwulang CUR, Ronse M, Kenangalem E, Burdam FH, Thriemer K, Devine A, Price RN, Peeters Grietens K, Ley B, Gryseels C. Adherence to 14-day radical cure for Plasmodium vivax malaria in Papua, Indonesia: a mixed-methods study. Malar J 2023; 22:162. [PMID: 37210520 PMCID: PMC10199529 DOI: 10.1186/s12936-023-04578-3] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Accepted: 04/25/2023] [Indexed: 05/22/2023] Open
Abstract
BACKGROUND Reducing the risk of recurrent Plasmodium vivax malaria is critical for malaria control and elimination. Primaquine (PQ) is the only widely available drug against P. vivax dormant liver stages, but is recommended as a 14-day regimen, which can undermine adherence to a complete course of treatment. METHODS This is a mixed-methods study to assess socio-cultural factors influencing adherence to a 14-day PQ regimen in a 3-arm, treatment effectiveness trial in Papua, Indonesia. The qualitative strand, consisting of interviews and participant observation was triangulated with a quantitative strand in which trial participants were surveyed using a questionnaire. RESULTS Trial participants differentiated between two types of malaria: tersiana and tropika, equivalent to P. vivax and Plasmodium falciparum infection, respectively. The perceived severity of both types was similar with 44.0% (267/607) perceiving tersiana vs. 45.1% (274/607) perceiving tropika as more severe. There was no perceived differentiation whether malaria episodes were due to a new infection or relapse; and 71.3% (433/607) acknowledged the possibility of recurrence. Participants were familiar with malaria symptoms and delaying health facility visit by 1-2 days was perceived to increase the likelihood of a positive test. Prior to health facility visits, symptoms were treated with leftover drugs kept at home (40.4%; 245/607) or bought over the counter (17.0%; 103/607). Malaria was considered to be cured with 'blue drugs' (referring to dihydroartemisinin-piperaquine). Conversely, 'brown drugs,' referring to PQ, were not considered malaria medication and instead were perceived as supplements. Adherence to malaria treatment was 71.2% (131/184), in the supervised arm, 56.9% (91/160) in the unsupervised arm and 62.4% (164/263) in the control arm; p = 0.019. Adherence was 47.5% (47/99) among highland Papuans, 51.7% (76/147) among lowland Papuans, and 72.9% (263/361) among non-Papuans; p < 0.001. CONCLUSION Adherence to malaria treatment was a socio-culturally embedded process during which patients (re-)evaluated the characteristics of the medicines in relation to the course of the illness, their past experiences with illness, and the perceived benefits of the treatment. Structural barriers that hinder the process of patient adherence are crucial to consider in the development and rollout of effective malaria treatment policies.
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Affiliation(s)
- Annisa Rahmalia
- Timika Malaria Research Programme, Papuan Health and Community Development Foundation, Timika, Indonesia.
- Global and Tropical Health Division, Menzies School of Health Research and Charles Darwin University, Darwin, Australia.
- Institute of Tropical Medicine, Antwerp, Belgium.
| | - Jeanne Rini Poespoprodjo
- Timika Malaria Research Programme, Papuan Health and Community Development Foundation, Timika, Indonesia
- Mimika District Hospital, Timika, Indonesia
- Paediatric Research Office, Department of Child Health, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada/Dr. Sardjito Hospital, Yogyakarta, Indonesia
| | - Chandra U R Landuwulang
- Timika Malaria Research Programme, Papuan Health and Community Development Foundation, Timika, Indonesia
| | - Maya Ronse
- Institute of Tropical Medicine, Antwerp, Belgium
| | - Enny Kenangalem
- Timika Malaria Research Programme, Papuan Health and Community Development Foundation, Timika, Indonesia
- Mimika Regency Health Authority, Timika, Papua, Indonesia
| | - Faustina H Burdam
- Timika Malaria Research Programme, Papuan Health and Community Development Foundation, Timika, Indonesia
- Mimika Regency Health Authority, Timika, Papua, Indonesia
| | - Kamala Thriemer
- Global and Tropical Health Division, Menzies School of Health Research and Charles Darwin University, Darwin, Australia
| | - Angela Devine
- Global and Tropical Health Division, Menzies School of Health Research and Charles Darwin University, Darwin, Australia
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Australia
| | - Ric N Price
- Global and Tropical Health Division, Menzies School of Health Research and Charles Darwin University, Darwin, Australia
- Nuffield Department of Clinical Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
- Mahidol-Oxford Tropical Medicine Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Koen Peeters Grietens
- Institute of Tropical Medicine, Antwerp, Belgium
- School of Tropical Medicine and Global Health, Nagasaki University, Nagasaki, Japan
| | - Benedikt Ley
- Global and Tropical Health Division, Menzies School of Health Research and Charles Darwin University, Darwin, Australia
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Poespoprodjo JR, Hafiidhaturrahmah, Sariyanti N, Indrawanti R, McLean ARD, Simpson JA, Kenangalem E, Burdam FH, Noviyanti R, Trianty L, Fadhilah C, Soenarto Y, Price RN. Intermittent screening and treatment for malaria complementary to routine immunisation in the first year of life in Papua, Indonesia: a cluster randomised superiority trial. BMC Med 2022; 20:190. [PMID: 35672703 PMCID: PMC9175359 DOI: 10.1186/s12916-022-02394-1] [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] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2021] [Accepted: 05/04/2022] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND In Papua (Indonesia), infants with P. falciparum and/or P. vivax malaria are at risk of severe anaemia and death. We hypothesized that in an area of high malaria transmission, intermittent screening and treatment of infants with malaria (ISTi) will reduce morbidity compared to passive case detection (PCDi). METHODS We conducted a cluster randomised, open label, superiority trial. A total of 21 clusters of village health posts (VHP) were randomised 1:1 to either IST for infants coinciding with 4 routine immunisation visits or PCDi. Healthy term infants born to consenting mothers enrolled into a maternal malaria cluster randomised trial were included in the study and followed for 12 months. Point of care malaria rapid diagnostic tests were used to detect peripheral parasitaemia at 2, 3, 4 and 9 months old in all infants in ISTi clusters and when symptomatic in PCDi clusters. Infants with detected peripheral parasitaemia were treated with dihydroartemisinin-piperaquine. The co-primary outcomes were the incidence rate of clinical malaria in the first year of life and the prevalence of parasitaemia at age 12 months. The incidence rate ratio and prevalence ratio between ISTi and PCDi were estimated using mixed-effects Poisson and log-binomial regression modelling (accounting for clustering at VHP level). RESULTS Between May 2014 and February 2017, 757 infants were enrolled into the study, 313 into 10 ISTi clusters, and 444 into 11 PCDi clusters. Overall, 132 episodes of parasitaemia were detected, of whom 17 (12.9%) were in symptomatic infants. Over 12 months, the incidence rate (IR) of clinical malaria was 24 [95% CI, 10-50] per 1000 children-years at risk in the ISTi arm and 19 [95% CI, 8,38] per 1000 children-years in the PCDi arm (adjusted incidence rate ratio [aIRR] 1.77 [95% CI, 0.62-5.01]; p = 0.280). The prevalence of parasitaemia at 12 months was 13% (33/254) in the IST clusters and 15% (57/379) in the PCD clusters (adjusted prevalence ratio (aPR) = 0.92 (95% CI, 0.70-1.21), p = 0.55). There was no difference in the risk of anaemia between treatment arms. CONCLUSIONS In high malaria transmission area outside of Africa, our study suggests that compared to PCDi, ISTi offers no significant benefit in reducing the risk of clinical malaria in infants born to women receiving effective protection from malaria during pregnancy. TRIAL REGISTRATION ClinicalTrials.gov NCT02001428 , registered on 20 Nov 2013.
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Affiliation(s)
- Jeanne Rini Poespoprodjo
- Centre for Child Health and Department of Child Health, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Jl. Kesehatan no.1, Sekip, Yogyakarta, 55284, Indonesia. .,Timika Malaria Research Facility, Papuan Health and Community Development Foundation, Jl. SP2-SP5, RSMM Area, Timika, Papua, 99910, Indonesia. .,Mimika District Hospital and District Health Authority, Jl. Yos Sudarso, Timika, Papua, 99910, Indonesia.
| | - Hafiidhaturrahmah
- Timika Malaria Research Facility, Papuan Health and Community Development Foundation, Jl. SP2-SP5, RSMM Area, Timika, Papua, 99910, Indonesia
| | - Novita Sariyanti
- Timika Malaria Research Facility, Papuan Health and Community Development Foundation, Jl. SP2-SP5, RSMM Area, Timika, Papua, 99910, Indonesia
| | - Ratni Indrawanti
- Centre for Child Health and Department of Child Health, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Jl. Kesehatan no.1, Sekip, Yogyakarta, 55284, Indonesia
| | - Alistair R D McLean
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, University of Melbourne, 207 Bouverie Street, VIC, 3010, Melbourne, Australia
| | - Julie A Simpson
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, University of Melbourne, 207 Bouverie Street, VIC, 3010, Melbourne, Australia
| | - Enny Kenangalem
- Timika Malaria Research Facility, Papuan Health and Community Development Foundation, Jl. SP2-SP5, RSMM Area, Timika, Papua, 99910, Indonesia
| | - Faustina Helena Burdam
- Timika Malaria Research Facility, Papuan Health and Community Development Foundation, Jl. SP2-SP5, RSMM Area, Timika, Papua, 99910, Indonesia.,Mimika District Hospital and District Health Authority, Jl. Yos Sudarso, Timika, Papua, 99910, Indonesia
| | - Rintis Noviyanti
- Eijkman Institute for Molecular Biology, Jl. Diponegoro No.69, Jakarta, 10430, Indonesia
| | - Leily Trianty
- Eijkman Institute for Molecular Biology, Jl. Diponegoro No.69, Jakarta, 10430, Indonesia
| | - Chairunisa Fadhilah
- Eijkman Institute for Molecular Biology, Jl. Diponegoro No.69, Jakarta, 10430, Indonesia
| | - Yati Soenarto
- Centre for Child Health and Department of Child Health, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Jl. Kesehatan no.1, Sekip, Yogyakarta, 55284, Indonesia
| | - Ric N Price
- Global Health Division, Menzies School of Health Research and Charles Darwin University, PO Box 41096, Casuarina, Darwin, NT, 0811, Australia.,Centre for Tropical Medicine, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, OX37LJ, UK.,Mahidol-Oxford Tropical Medicine Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
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Poespoprodjo JR, Burdam FH, Candrawati F, Ley B, Meagher N, Kenangalem E, Indrawanti R, Trianty L, Thriemer K, Price DJ, Simpson JA, Price RN. Supervised versus unsupervised primaquine radical cure for the treatment of falciparum and vivax malaria in Papua, Indonesia: a cluster-randomised, controlled, open-label superiority trial. Lancet Infect Dis 2022; 22:367-376. [PMID: 34710363 PMCID: PMC8866132 DOI: 10.1016/s1473-3099(21)00358-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/14/2021] [Revised: 04/30/2021] [Accepted: 06/07/2021] [Indexed: 01/12/2023]
Abstract
BACKGROUND There is a high risk of Plasmodium vivax recurrence in patients treated for Plasmodium falciparum malaria in co-endemic areas. Primaquine radical cure has the potential to reduce P vivax recurrences in patients presenting with P falciparum as well as P vivax malaria but is undermined by poor adherence to the currently recommended 14-day regimen. We aimed to assess the efficacy and safety of supervised versus unsupervised primaquine radical cure in patients presenting with uncomplicated malaria. METHODS We did a cluster-randomised, controlled, open-label superiority trial in Papua, Indonesia. 21 clusters of village health posts, matched by annual parasite index, were randomly assigned (1:1) to treat patients (age >12 months and body weight >5 kg) presenting with confirmed uncomplicated P falciparum or P vivax malaria with oral dihydroartemisinin-piperaquine plus either a supervised or unsupervised 14-day course of oral primaquine (0·5 mg/kg per day). Patients in the supervised group were supervised taking their primaquine dose on alternate days. Patients were followed-up for 6 months and those who presented again with malaria were retreated with the same drug regimen. Masking was not possible due to the nature of the study. The primary outcome was the incidence risk of P vivax malaria over 6 months, assessed in the modified intention-to-treat population (all patients who were assigned to a treatment group, excluding patients who were lost to follow-up after their first visit). This trial is now complete, and is registered with ClinicalTrials.gov, NCT02787070. FINDINGS Between Sept 14, 2016, and July 31, 2018, 436 patients were screened for eligibility and 419 were enrolled; 223 (53%) patients in 11 clusters were assigned to supervised primaquine treatment and 196 (47%) in ten clusters to unsupervised primaquine treatment. 161 (72%) of 223 patients in the supervised group and 151 (77%) of 196 in the unsupervised group completed 6 months of follow-up. At 6 months, the incidence risk of P vivax recurrence in the supervised group was 29·7% (95% CI 16·4-49·9) versus 55·8% (32·3-81·8) in the unsupervised group (hazard ratio 0·23 [95% CI 0·07-0·76]; p=0·016). The incidence rate for P vivax recurrence was 539 (95% CI 390-747) infections per 1000 person-years in the supervised group versus 859 (673-1096) in the unsupervised group (incidence rate ratio 0·63 [95% CI 0·42-0·94]; p=0·025). The corresponding rates in the 224 patients who presented with P falciparum malaria were 346 (95% CI 213-563) and 660 (446-977; incidence rate ratio 0·52 [95% CI 0·28-0·98]; p=0·043). Seven serious adverse events were reported (three in the supervised group, four in the unsupervised group), none of which were deemed treatment-related, and there were no deaths. INTERPRETATION In this area of moderate malaria transmission, supervision of primaquine radical cure treatment reduced the risk of P vivax recurrence. This finding was apparent for patients presenting with either P falciparum or P vivax malaria. Further studies are warranted to investigate the safety and efficacy of radical cure for patients presenting with uncomplicated falciparum malaria in other co-endemic areas. FUNDING The Bill & Melinda Gates Foundation, Wellcome Trust, and Department of Foreign Affairs and Trade of the Australian Government. TRANSLATION For the Indonesian translation of the abstract see Supplementary Materials section.
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Affiliation(s)
- Jeanne Rini Poespoprodjo
- Centre for Child Health and Department of Child Health, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Yogyakarta, Indonesia; Timika Malaria Research Facility, Papuan Health and Community Development Foundation, Timika, Papua, Indonesia; Mimika District Hospital and District Health Authority, Timika, Papua, Indonesia.
| | - Faustina Helena Burdam
- Timika Malaria Research Facility, Papuan Health and Community Development Foundation, Timika, Papua, Indonesia; Mimika District Hospital and District Health Authority, Timika, Papua, Indonesia
| | - Freis Candrawati
- Timika Malaria Research Facility, Papuan Health and Community Development Foundation, Timika, Papua, Indonesia
| | - Benedikt Ley
- Global Health Division, Menzies School of Health Research and Charles Darwin University, Darwin, NT, Australia
| | - Niamh Meagher
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, University of Melbourne, VIC, Australia; Victorian Infectious Diseases Reference Laboratory Epidemiology Unit at the Peter Doherty Institute for Infection and Immunity, University of Melbourne and Royal Melbourne Hospital, VIC, Australia
| | - Enny Kenangalem
- Timika Malaria Research Facility, Papuan Health and Community Development Foundation, Timika, Papua, Indonesia; Mimika District Hospital and District Health Authority, Timika, Papua, Indonesia
| | - Ratni Indrawanti
- Centre for Child Health and Department of Child Health, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Yogyakarta, Indonesia
| | - Leily Trianty
- Eijkman Institute for Molecular Biology, Jakarta, Indonesia
| | - Kamala Thriemer
- Global Health Division, Menzies School of Health Research and Charles Darwin University, Darwin, NT, Australia
| | - David J Price
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, University of Melbourne, VIC, Australia; Victorian Infectious Diseases Reference Laboratory Epidemiology Unit at the Peter Doherty Institute for Infection and Immunity, University of Melbourne and Royal Melbourne Hospital, VIC, Australia
| | - Julie A Simpson
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, University of Melbourne, VIC, Australia
| | - Ric N Price
- Global Health Division, Menzies School of Health Research and Charles Darwin University, Darwin, NT, Australia; Centre for Tropical Medicine, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK; Mahidol-Oxford Tropical Medicine Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
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Lestari T, Kamaludin, Lowbridge C, Kenangalem E, Poespoprodjo JR, Graham SM, Ralph AP. Impacts of tuberculosis services strengthening and the COVID-19 pandemic on case detection and treatment outcomes in Mimika District, Papua, Indonesia: 2014-2021. PLOS Glob Public Health 2022; 2:e0001114. [PMID: 36962674 PMCID: PMC10021881 DOI: 10.1371/journal.pgph.0001114] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Accepted: 09/02/2022] [Indexed: 11/19/2022]
Abstract
Indonesia is a high-burden tuberculosis (TB) country with a wide case detection gap, exacerbated by the COVID-19 pandemic. We aimed to review the epidemiology of TB in a high-endemic setting of Indonesia before and during the implementation of health system strengthening activities for TB, including during the first two years of the COVID-19 pandemic. We analysed TB program data from Mimika District, Papua, Indonesia from 2014 to 2021. Health system strengthening activities to improve the programmatic management of TB were implemented from 2017 onwards. Activities included decentralization of TB services, training and mentoring of healthcare workers, improved screening for co-morbidities, and introduction and optimisation of Xpert testing in 2018. A total of 11,803 TB cases were notified to the Mimika District Health Office over eight years (2014-21). Between 2015 and 2019, there was a 67% increase in annual case notifications, an 89% increase in bacteriologically confirmed cases and the proportion of TB cases detected in primary care increased from 26% to 46%. In 2020, coinciding with the COVID-19 pandemic, investigation of people with presumptive TB fell by 38%, but the proportion of those tested with Xpert increased. TB case notifications decreased by 19% from 1,796 in 2019 to 1,461 in 2020, but then increased by 17% to 1,716 in 2021. Routine screening for co-morbidities (HIV, diabetes) among TB patients improved over time and was not affected by the pandemic. Treatment success overall was 71% and remained relatively unchanged. Loss to follow-up and death were 18% and 3.7% respectively. Improvements in TB case finding were observed over a period in which a range of health system strengthening activities were implemented. While COVID-19 had a negative impact on the TB program in Mimika District, there are encouraging signs of recovery. Further work is needed to improve TB treatment outcomes.
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Affiliation(s)
- Trisasi Lestari
- Center for Tropical Medicine, Universitas Gadjah Mada, Yogyakarta, Indonesia
- Global and Tropical Health, Menzies School of Health Research, Charles Darwin University, Darwin, Northern Territory, Australia
- Timika Research Facility, Papuan Health and Community Development Foundation, Timika, Indonesia
| | - Kamaludin
- Mimika District Health Office, Timika, Indonesia
| | - Christopher Lowbridge
- Global and Tropical Health, Menzies School of Health Research, Charles Darwin University, Darwin, Northern Territory, Australia
| | - Enny Kenangalem
- Timika Research Facility, Papuan Health and Community Development Foundation, Timika, Indonesia
- Mimika District Hospital, Timika, Indonesia
| | - Jeanne Rini Poespoprodjo
- Timika Research Facility, Papuan Health and Community Development Foundation, Timika, Indonesia
- Mimika District Hospital, Timika, Indonesia
| | - Stephen M Graham
- University of Melbourne Department of Paediatrics and Murdoch Children's Research Institute, Royal Children's Hospital, Melbourne, Australia
- The Burnet Institute, Melbourne, Australia
| | - Anna P Ralph
- Global and Tropical Health, Menzies School of Health Research, Charles Darwin University, Darwin, Northern Territory, Australia
- Royal Darwin Hospital, Darwin, Northern Territory, Australia
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Dini S, Douglas N, Poespoprodjo JR, Kenangalem E, Sugiarto P, Plumb I, Price R, Simpson J. 787Multistate modelling to investigate the impact of recurrent malaria episodes on hospital admissions and mortality. Int J Epidemiol 2021. [DOI: 10.1093/ije/dyab168.161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Abstract
Background
Inadequate prevention and treatment of malaria can lead to reinfections and recurrent episodes, and for vivax malaria, further recurrences from the dormant liver stage. This study quantified the impact of recurrent malaria episodes on morbidity and mortality.
Methods
Routinely collected data were available from 68,381 malaria patients presenting to the primary referral hospital in Papua, Indonesia. A multi-state modelling framework, with Cox regression for transition rates, was employed to determine the risks of re-presentation to hospital, receiving in-patient treatment, and early (≤14 days post treatment)/late death following multiple malaria episodes.
Results
The risk of re-presentation to hospital increased from 34.7% (95%CI: 34.4%–35.1%) at first episode to 58.6% (57.5%–59.6%) following the third episode. Infection with vivax malaria increased the rate of re-presentation to hospital by 1.48-fold (Hazard Ratio 1.48; 95%CI 1.44–1.51) and late hospital in-patient admission by 1.17-fold (1.11–1.22), compared to falciparum. Falciparum malaria caused a higher overall rate of early death (1.54 (1.25–1.92)), however, after multiple episodes, there was a trend towards a greater rate of early death for vivax infection (1.91 (0.73–4.97)).
Conclusions
Recurrent episodes of malaria can cause substantial morbidity and mortality, highlighting the importance of prevention and effective treatments for both falciparum and vivax malaria.
Key messages
To achieve elimination of malaria in South-East Asia, where prevalence of vivax malaria is high, we must prioritise the radical cure of vivax to eliminate the liver-stage of this species that causes relapses of infection.
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Affiliation(s)
- Saber Dini
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Australia
| | - Nicholas Douglas
- Global Health Division, Menzies School of Health Research and Charles Darwin University, Darwin, Australia
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
| | - Jeanne Rini Poespoprodjo
- Timika Malaria Research Program, Papuan Health and Community Development Foundation, Timika, Indonesia
- Department of Child Health, Faculty of Medicine, University Gadjah Mada, Yogyakarta, Indonesia
| | - Enny Kenangalem
- Timika Malaria Research Program, Papuan Health and Community Development Foundation, Timika, Indonesia
- Mimika District Health Authority, Timika, Indonesia
| | | | - Ian Plumb
- Global Health Division, Menzies School of Health Research and Charles Darwin University, Darwin, Australia
| | - Ric Price
- Global Health Division, Menzies School of Health Research and Charles Darwin University, Darwin, Australia
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Julie Simpson
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Australia
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Paintain L, Hill J, Ahmed R, Umbu Reku Landuwulang C, Ansariadi A, Rini Poespoprodjo J, Syafruddin D, Khairallah C, Burdam FH, Bonsapia I, Ter Kuile FO, Webster J. Cost-effectiveness of intermittent preventive treatment with dihydroartemisinin-piperaquine versus single screening and treatment for the control of malaria in pregnancy in Papua, Indonesia: a provider perspective analysis from a cluster-randomised trial. Lancet Glob Health 2020; 8:e1524-e1533. [PMID: 33220216 DOI: 10.1016/s2214-109x(20)30386-7] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2019] [Revised: 07/07/2020] [Accepted: 08/07/2020] [Indexed: 01/26/2023]
Abstract
BACKGROUND Malaria infection during pregnancy is associated with serious adverse maternal and birth outcomes. A randomised controlled trial in Papua, Indonesia, comparing the efficacy of intermittent preventive treatment with dihydroartemisinin-piperaquine with the current strategy of single screening and treatment showed that intermittent preventive treatment is a promising alternative treatment for the reduction of malaria in pregnancy. We aimed to estimate the incremental cost-effectiveness of intermittent preventive treatment with dihydroartemisinin-piperaquine compared with single screening and treatment with dihydroartemisinin-piperaquine. METHODS We did a provider perspective analysis. A decision tree model was analysed from a health provider perspective over a lifetime horizon. Model parameters were used in deterministic and probabilistic sensitivity analyses. Simulations were run in hypothetical cohorts of 1000 women who received intermittent preventive treatment or single screening and treatment. Disability-adjusted life-years (DALYs) for fetal loss or neonatal death, low birthweight, moderate or severe maternal anaemia, and clinical malaria were calculated from trial data and cost estimates in 2016 US dollars from observational studies, health facility costings and public procurement databases. The main outcome measure was the incremental cost per DALY averted. FINDINGS Relative to single screening and treatment, intermittent preventive treatment resulted in an incremental cost of US$5657 (95% CI 1827 to 9448) and 107·4 incremental DALYs averted (-719·7 to 904·1) per 1000 women; the average incremental cost-effectiveness ratio was $53 per DALY averted. INTERPRETATION Intermittent preventive treatment with dihydroartemisinin-piperaquine offers a cost-effective alternative to single screening and treatment for the prevention of the adverse effects of malaria infection in pregnancy in the context of the moderate malaria transmission setting of Papua. The higher cost of intermittent preventive treatment was driven by monthly administration, as compared with single-administration single screening and treatment. However, acceptability and feasibility considerations will also be needed to inform decision making. FUNDING Medical Research Council, Department for International Development, and Wellcome Trust.
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Affiliation(s)
- Lucy Paintain
- Disease Control Department, London School of Hygiene and Tropical Medicine, London, UK.
| | - Jenny Hill
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Rukhsana Ahmed
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK; Eijkman Institute for Molecular Biology, Jakarta, Indonesia
| | | | - Ansariadi Ansariadi
- Eijkman Institute for Molecular Biology, Jakarta, Indonesia; Department of Epidemiology, School of Public Health, Hasanuddin University, Makassar, Indonesia
| | - Jeanne Rini Poespoprodjo
- Mimika District Health Authority, Timika, Papua, Indonesia; Timika Malaria Research Program, Papuan Health and Community Development Foundation, Timika, Papua, Indonesia; Pediatric Research Office, Department of Child Health, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Yogyakarta, Indonesia
| | - Din Syafruddin
- Eijkman Institute for Molecular Biology, Jakarta, Indonesia
| | - Carole Khairallah
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | | | - Irene Bonsapia
- Timika Malaria Research Program, Papuan Health and Community Development Foundation, Timika, Papua, Indonesia
| | - Feiko O Ter Kuile
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Jayne Webster
- Disease Control Department, London School of Hygiene and Tropical Medicine, London, UK
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9
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Ashley EA, Poespoprodjo JR. Treatment and prevention of malaria in children. Lancet Child Adolesc Health 2020; 4:775-789. [PMID: 32946831 DOI: 10.1016/s2352-4642(20)30127-9] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/24/2019] [Revised: 03/11/2020] [Accepted: 03/25/2020] [Indexed: 10/23/2022]
Abstract
Malaria disproportionately affects children younger than 5 years. Falciparum malaria is responsible for more than 200 000 child deaths per year in Africa and vivax malaria is well documented as a cause of severe anaemia and excess mortality in children in Asia and Oceania. For the treatment of malaria in children, paediatric dosing recommendations for several agents, including parenteral artesunate and dihydroartemisinin-piperaquine, have belatedly been shown to be suboptimal. Worsening antimalarial resistance in Plasmodium falciparum in the Greater Mekong Subregion threatens to undermine global efforts to control malaria. Triple antimalarial combination therapies are being evaluated to try to impede this threat. The RTS,S/AS01 vaccine gives partial protection against falciparum malaria and is being evaluated in large, pilot studies in Ghana, Malawi, and Kenya as a complementary tool to other preventive measures. Seasonal malaria chemoprevention in west Africa has resulted in declines in malaria incidence and deaths and there is interest in scaling up efforts by expanding the age range of eligible recipients. Preventing relapse in Plasmodium vivax infection with primaquine is challenging because treating children who have G6PD deficiency with primaquine can cause acute haemolytic anaemia. The safety of escalating dose regimens for primaquine is being studied to mitigate this risk.
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Affiliation(s)
- Elizabeth A Ashley
- Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit, Vientiane, Laos; Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK.
| | - Jeanne Rini Poespoprodjo
- Timika Research Facility, Papuan Health and Community Development Foundation, Timika, Indonesia; Department of Child Health, Faculty of Medicine, Public Health and Nursing, Gadjah Mada University, Yogyakarta, Indonesia
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Pfeffer DA, Ley B, Howes RE, Adu P, Alam MS, Bansil P, Boum Y, Brito M, Charoenkwan P, Clements A, Cui L, Deng Z, Egesie OJ, Espino FE, von Fricken ME, Hamid MMA, He Y, Henriques G, Khan WA, Khim N, Kim S, Lacerda M, Lon C, Mekuria AH, Menard D, Monteiro W, Nosten F, Oo NN, Pal S, Palasuwan D, Parikh S, Pitaloka Pasaribu A, Poespoprodjo JR, Price DJ, Roca-Feltrer A, Roh ME, Saunders DL, Spring MD, Sutanto I, Ley-Thriemer K, Weppelmann TA, von Seidlein L, Satyagraha AW, Bancone G, Domingo GJ, Price RN. Quantification of glucose-6-phosphate dehydrogenase activity by spectrophotometry: A systematic review and meta-analysis. PLoS Med 2020; 17:e1003084. [PMID: 32407380 PMCID: PMC7224463 DOI: 10.1371/journal.pmed.1003084] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [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: 07/15/2019] [Accepted: 04/13/2020] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND The radical cure of Plasmodium vivax and P. ovale requires treatment with primaquine or tafenoquine to clear dormant liver stages. Either drug can induce haemolysis in individuals with glucose-6-phosphate dehydrogenase (G6PD) deficiency, necessitating screening. The reference diagnostic method for G6PD activity is ultraviolet (UV) spectrophotometry; however, a universal G6PD activity threshold above which these drugs can be safely administered is not yet defined. Our study aimed to quantify assay-based variation in G6PD spectrophotometry and to explore the diagnostic implications of applying a universal threshold. METHODS AND FINDINGS Individual-level data were pooled from studies that used G6PD spectrophotometry. Studies were identified via PubMed search (25 April 2018) and unpublished contributions from contacted authors (PROSPERO: CRD42019121414). Studies were excluded if they assessed only individuals with known haematological conditions, were family studies, or had insufficient details. Studies of malaria patients were included but analysed separately. Included studies were assessed for risk of bias using an adapted form of the Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2) tool. Repeatability and intra- and interlaboratory variability in G6PD activity measurements were compared between studies and pooled across the dataset. A universal threshold for G6PD deficiency was derived, and its diagnostic performance was compared to site-specific thresholds. Study participants (n = 15,811) were aged between 0 and 86 years, and 44.4% (7,083) were women. Median (range) activity of G6PD normal (G6PDn) control samples was 10.0 U/g Hb (6.3-14.0) for the Trinity assay and 8.3 U/g Hb (6.8-15.6) for the Randox assay. G6PD activity distributions varied significantly between studies. For the 13 studies that used the Trinity assay, the adjusted male median (AMM; a standardised metric of 100% G6PD activity) varied from 5.7 to 12.6 U/g Hb (p < 0.001). Assay precision varied between laboratories, as assessed by variance in control measurements (from 0.1 to 1.5 U/g Hb; p < 0.001) and study-wise mean coefficient of variation (CV) of replicate measures (from 1.6% to 14.9%; p < 0.001). A universal threshold of 100% G6PD activity was defined as 9.4 U/g Hb, yielding diagnostic thresholds of 6.6 U/g Hb (70% activity) and 2.8 U/g Hb (30% activity). These thresholds diagnosed individuals with less than 30% G6PD activity with study-wise sensitivity from 89% (95% CI: 81%-94%) to 100% (95% CI: 96%-100%) and specificity from 96% (95% CI: 89%-99%) to 100% (100%-100%). However, when considering intermediate deficiency (<70% G6PD activity), sensitivity fell to a minimum of 64% (95% CI: 52%-75%) and specificity to 35% (95% CI: 24%-46%). Our ability to identify underlying factors associated with study-level heterogeneity was limited by the lack of availability of covariate data and diverse study contexts and methodologies. CONCLUSIONS Our findings indicate that there is substantial variation in G6PD measurements by spectrophotometry between sites. This is likely due to variability in laboratory methods, with possible contribution of unmeasured population factors. While an assay-specific, universal quantitative threshold offers robust diagnosis at the 30% level, inter-study variability impedes performance of universal thresholds at the 70% level. Caution is advised in comparing findings based on absolute G6PD activity measurements across studies. Novel handheld quantitative G6PD diagnostics may allow greater standardisation in the future.
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Affiliation(s)
- Daniel A. Pfeffer
- Global and Tropical Health Division, Menzies School of Health Research and Charles Darwin University, Darwin, Australia
- * E-mail:
| | - Benedikt Ley
- Global and Tropical Health Division, Menzies School of Health Research and Charles Darwin University, Darwin, Australia
| | - Rosalind E. Howes
- Malaria Atlas Project, Big Data Institute, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
- Foundation for Innovative New Diagnostics, Geneva, Switzerland
| | - Patrick Adu
- Department of Medical Laboratory Sciences, School of Allied Health Sciences, University of Cape Coast, Cape Coast, Ghana
| | - Mohammad Shafiul Alam
- Infectious Diseases Division, International Centre for Diarrheal Diseases Research, Bangladesh, Mohakhali, Dhaka, Bangladesh
| | - Pooja Bansil
- Diagnostics Program, PATH, Seattle, Washington, United States of America
| | - Yap Boum
- Médecins sans Frontières Epicentre, Mbarara Research Centre, Mbarara, Uganda
- Mbarara University of Science and Technology, Mbarara, Uganda
| | - Marcelo Brito
- Fundação de Medicina Tropical Dr. Heitor Vieira Dourado, Manaus, Amazonas, Brasil
| | - Pimlak Charoenkwan
- Division of Hematology and Oncology, Department of Pediatrics, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Archie Clements
- Faculty of Health Sciences, Curtin University, Bentley, Australia
- Telethon Kids Institute, Nedlands, Australia
| | - Liwang Cui
- Department of Entomology, Pennsylvania State University, University Park, Pennsylvania, United States of America
| | - Zeshuai Deng
- Department of Cell Biology and Medical Genetics, Kunming Medical University, Kunming, Yunnan Province, China
| | - Ochaka Julie Egesie
- Department of Hematology and Blood Transfusion, Faculty of Medical Sciences, University of Jos and Jos University Teaching Hospital, Jos, Plateau State, Nigeria
| | - Fe Esperanza Espino
- Department of Parasitology, Research Institute for Tropical Medicine, Department of Health, Alabang, Muntinlupa City, Philippines
| | - Michael E. von Fricken
- Department of Global and Community Health, George Mason University, Fairfax, Virginia, United States of America
| | - Muzamil Mahdi Abdel Hamid
- Department of Parasitology and Medical Entomology, Institute of Endemic Diseases, University of Khartoum, Khartoum, Republic of the Sudan
| | - Yongshu He
- Department of Cell Biology and Medical Genetics, Kunming Medical University, Kunming, Yunnan Province, China
| | - Gisela Henriques
- Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Wasif Ali Khan
- Infectious Diseases Division, International Centre for Diarrheal Diseases Research, Bangladesh, Mohakhali, Dhaka, Bangladesh
| | - Nimol Khim
- Malaria Molecular Epidemiology Unit, Institut Pasteur du Cambodge, Phnom Penh, Cambodia
| | - Saorin Kim
- Malaria Molecular Epidemiology Unit, Institut Pasteur du Cambodge, Phnom Penh, Cambodia
| | - Marcus Lacerda
- Fundação de Medicina Tropical Dr. Heitor Vieira Dourado, Manaus, Amazonas, Brasil
| | - Chanthap Lon
- Armed Forces Research Institute of Medical Sciences, Bangkok, Thailand
| | | | - Didier Menard
- Malaria Genetics and Resistance Group, Institut Pasteur, Paris, France
| | - Wuelton Monteiro
- Fundação de Medicina Tropical Dr. Heitor Vieira Dourado, Manaus, Amazonas, Brasil
| | - François Nosten
- Shoklo Malaria Research Unit, Mahidol–Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Thailand
- Centre for Tropical Medicine & Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Nwe Nwe Oo
- Department of Medical Research, Lower Myanmar, Yangon, Myanmar
| | - Sampa Pal
- Diagnostics Program, PATH, Seattle, Washington, United States of America
| | - Duangdao Palasuwan
- Oxidation in Red Cell Disorders and Health Research Unit, Department of Clinical Microscopy, Faculty of Allied Health Sciences, Chulalongkorn University, Bangkok, Thailand
| | - Sunil Parikh
- Yale School of Public Health, New Haven, Connecticut, United States of America
| | | | | | - David J. Price
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Australia
- The Peter Doherty Institute for Infection and Immunity, The University of Melbourne and Royal Melbourne Hospital, Melbourne, Australia
| | | | - Michelle E. Roh
- Global Health Group, Malaria Elimination Initiative, University of California, San Francisco, San Francisco, United States of America
| | - David L. Saunders
- Armed Forces Research Institute of Medical Sciences, Bangkok, Thailand
- F. Edward Hebert School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland, United States of America
- US Army Medical Materiel Development Activity, Fort Detrick, Maryland, United States of America
| | - Michele D. Spring
- Armed Forces Research Institute of Medical Sciences, Bangkok, Thailand
| | | | - Kamala Ley-Thriemer
- Global and Tropical Health Division, Menzies School of Health Research and Charles Darwin University, Darwin, Australia
| | - Thomas A. Weppelmann
- Herbert Wertheim College of Medicine, Florida International University, Miami, Florida, United States of America
| | - Lorenz von Seidlein
- Shoklo Malaria Research Unit, Mahidol–Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Thailand
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | | | - Germana Bancone
- Shoklo Malaria Research Unit, Mahidol–Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Thailand
- Centre for Tropical Medicine & Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Gonzalo J. Domingo
- Diagnostics Program, PATH, Seattle, Washington, United States of America
| | - Ric N. Price
- Global and Tropical Health Division, Menzies School of Health Research and Charles Darwin University, Darwin, Australia
- Centre for Tropical Medicine & Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
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11
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Pava Z, Puspitasari AM, Rumaseb A, Handayuni I, Trianty L, Utami RAS, Tirta YK, Burdam F, Kenangalem E, Wirjanata G, Kho S, Trimarsanto H, Anstey NM, Poespoprodjo JR, Noviyanti R, Price RN, Marfurt J, Auburn S. Molecular surveillance over 14 years confirms reduction of Plasmodium vivax and falciparum transmission after implementation of Artemisinin-based combination therapy in Papua, Indonesia. PLoS Negl Trop Dis 2020; 14:e0008295. [PMID: 32379762 PMCID: PMC7237043 DOI: 10.1371/journal.pntd.0008295] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [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: 10/27/2019] [Revised: 05/19/2020] [Accepted: 04/15/2020] [Indexed: 01/13/2023] Open
Abstract
Genetic epidemiology can provide important insights into parasite transmission that can inform public health interventions. The current study compared long-term changes in the genetic diversity and structure of co-endemic Plasmodium falciparum and P. vivax populations. The study was conducted in Papua Indonesia, where high-grade chloroquine resistance in P. falciparum and P. vivax led to a universal policy of Artemisinin-based Combination Therapy (ACT) in 2006. Microsatellite typing and population genetic analyses were undertaken on available isolates collected between 2004 and 2017 from patients with uncomplicated malaria (n = 666 P. falciparum and n = 615 P. vivax). The proportion of polyclonal P. falciparum infections fell from 28% (38/135) before policy change (2004-2006) to 18% (22/125) at the end of the study (2015-2017); p<0.001. Over the same period, polyclonal P. vivax infections fell from 67% (80/119) to 35% (33/93); p<0.001. P. falciparum strains persisted for up to 9 years compared to 3 months for P. vivax, reflecting higher rates of outbreeding in the latter. Sub-structure was observed in the P. falciparum population, but not in P. vivax, confirming different patterns of outbreeding. The P. falciparum population exhibited 4 subpopulations that changed in frequency over time. Notably, a sharp rise was observed in the frequency of a minor subpopulation (K2) in the late post-ACT period, accounting for 100% of infections in late 2016-2017. The results confirm epidemiological evidence of reduced P. falciparum and P. vivax transmission over time. The smaller change in P. vivax population structure is consistent with greater outbreeding associated with relapsing infections and highlights the need for radical cure to reduce recurrent infections. The study emphasizes the challenge in disrupting P. vivax transmission and demonstrates the potential of molecular data to inform on the impact of public health interventions.
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Affiliation(s)
- Zuleima Pava
- Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, Australia
| | | | - Angela Rumaseb
- Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, Australia
| | - Irene Handayuni
- Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, Australia
| | - Leily Trianty
- Eijkman Institute for Molecular Biology, Jakarta, Indonesia
| | | | | | - Faustina Burdam
- Mimika District Health Authority, Timika, Papua, Indonesia
- Timika Malaria Research Programme, Papuan Health and Community Development Foundation, Timika, Papua, Indonesia
| | - Enny Kenangalem
- Mimika District Health Authority, Timika, Papua, Indonesia
- Timika Malaria Research Programme, Papuan Health and Community Development Foundation, Timika, Papua, Indonesia
| | - Grennady Wirjanata
- Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, Australia
| | - Steven Kho
- Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, Australia
| | | | - Nicholas M. Anstey
- Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, Australia
| | - Jeanne Rini Poespoprodjo
- Mimika District Health Authority, Timika, Papua, Indonesia
- Timika Malaria Research Programme, Papuan Health and Community Development Foundation, Timika, Papua, Indonesia
- Pediatric Research Office, Department of Child Health, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Yogyakarta, Indonesia
| | | | - Ric N. Price
- Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, Australia
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, United Kingdom
- Mahidol-Oxford Tropical Medicine Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Jutta Marfurt
- Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, Australia
| | - Sarah Auburn
- Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, Australia
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, United Kingdom
- Mahidol-Oxford Tropical Medicine Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
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12
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Dini S, Douglas NM, Poespoprodjo JR, Kenangalem E, Sugiarto P, Plumb ID, Price RN, Simpson JA. The risk of morbidity and mortality following recurrent malaria in Papua, Indonesia: a retrospective cohort study. BMC Med 2020; 18:28. [PMID: 32075649 PMCID: PMC7031957 DOI: 10.1186/s12916-020-1497-0] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Accepted: 01/15/2020] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND An acute episode of malaria can be followed by multiple recurrent episodes either due to re-infection, recrudescence of a partially treated parasite or, in the case of Plasmodium vivax or P. ovale, relapse from the dormant liver stage of the parasite. The aim of this study was to quantify the impact of recurrent malaria episodes on morbidity and mortality in Papua, Indonesia. METHODS We undertook a retrospective analysis of routinely collected data from malaria patients attending the primary referral hospital in Papua, Indonesia, between April 2004 and December 2013. Multi-state modelling was used to estimate the effect of recurring malaria episodes on re-presentation and admission to hospital and death. The risks of early (≤ 14 days) and late (15 to 365 days) hospital admission and death were estimated separately in our study to distinguish between the direct and indirect effects of malaria recurrence on adverse outcomes. RESULTS A total of 68,361 patients were included in the analysis, of whom 37,168 (54.4%) presented initially with P. falciparum, 22,209 (32.5%) with P. vivax, and 8984 (13.1%) with other species. During 12 months of follow-up after each of the first four malaria episodes, 10,868 (15.9%) patients were admitted to hospital and 897 (1.3%) died. The risk of re-presenting to the hospital with malaria increased from 34.7% (95% CI 34.4%, 35.1%) at first episode to 58.6% (57.5%, 59.6%) following the third episode of malaria. After adjusting for co-factors, infection with P. vivax was a significant risk factor for re-presentation (hazard ratio (HR) = 1.48 (95% CI 1.44, 1.51)) and late admission to hospital (HR = 1.17 (1.11, 1.22)). Patients infected with P. falciparum had a greater overall rate of mortality within 14 days (HR = 1.54 (1.25, 1.92)), but after multiple episodes of malaria, there was a trend towards a higher rate of early death in patients infected with P. vivax compared to P. falciparum (HR = 1.91 (0.73, 4.97)). CONCLUSIONS Compared to patients initially infected with P. falciparum, those infected with P. vivax had significantly more re-presentations to hospital with malaria, and this contributed to a high risk of inpatient admission and death. These findings highlight the importance of radical cure of P. vivax to eliminate the dormant liver stages that trigger relapses.
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Affiliation(s)
- Saber Dini
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, VIC, Australia
| | - Nicholas M Douglas
- Global Health Division, Menzies School of Health Research and Charles Darwin University, Darwin, Northern Territory, Australia.,Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
| | - Jeanne Rini Poespoprodjo
- Timika Malaria Research Program, Papuan Health and Community Development Foundation, Timika, Papua, Indonesia.,Department of Child Health, Faculty of Medicine, University Gadjah Mada, Yogyakarta, Indonesia
| | - Enny Kenangalem
- Timika Malaria Research Program, Papuan Health and Community Development Foundation, Timika, Papua, Indonesia.,Mimika District Health Authority, Timika, Papua, Indonesia
| | | | - Ian D Plumb
- Global Health Division, Menzies School of Health Research and Charles Darwin University, Darwin, Northern Territory, Australia
| | - Ric N Price
- Global Health Division, Menzies School of Health Research and Charles Darwin University, Darwin, Northern Territory, Australia.,Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK.,Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Julie A Simpson
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, VIC, Australia.
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13
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Douglas NM, Kenangalem E, Hasanuddin A, Anstey NM, Sugiarto P, Price RN, Poespoprodjo JR. Malaria-related hospitalization during childhood in Papua, Indonesia: A retrospective cohort study. PLoS One 2020; 15:e0228018. [PMID: 31995581 PMCID: PMC6988973 DOI: 10.1371/journal.pone.0228018] [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] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2019] [Accepted: 01/05/2020] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND In endemic regions, the age distribution of malaria varies according to the infecting Plasmodium species. We aimed to delineate the pattern of malaria-related hospitalization from birth in Timika, Papua-an area co-endemic for P. falciparum and P. vivax. METHODS Between April 2004 and December 2013, infants born at Mitra Masyarakat Hospital, or presenting within the first 7 days of life, were enrolled retrospectively into a cohort study and followed passively using routinely-collected hospital surveillance data. Outcomes were stratified by the presence or absence of Plasmodium parasitemia and included re-presentation to hospital, requirement for hospital admission and death. RESULTS Overall, 11,408 infants were enrolled into the cohort. Median follow-up was 4.3 (maximum 9.7) years. In total, 7,847 (68.9%) infants made 90,766 re-presentations to hospital, 18,105 (19.9%) of which were associated with Plasmodium parasitemia. The incidence of re-presentations with malaria during the first year of life was 213 per 1,000 person-years (py) for P. vivax and 79 per 1,000py for P. falciparum (Incidence Rate Ratio (IRR) = 2.69, 95% Confidence Interval (95%CI): 2.48-2.92). After the age of 5 years, the incidence of P. vivax had fallen to 77/1,000py and the incidence of P. falciparum had risen to 95/1,000py (IRR = 0.80, 95%CI: 0.73-0.88). Overall, 79.7% (14,431/18,105) of malaria re-presentations were recurrences rather than initial infections. Malaria accounted for 31.7% (2,126/3,120) of all hospital admissions. The infant mortality rate in this study was 52 deaths per 1,000 live births. Beyond the early neonatal period, 13.4% of deaths were associated with Plasmodium parasitemia. CONCLUSIONS In Papua, Indonesia, malaria is a major cause of hospital presentation and admission in early life. The initial predominance of P. vivax over P. falciparum inverts after five years of age. Malaria is directly associated with nearly one in seven deaths after the early neonatal period.
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Affiliation(s)
- Nicholas M. Douglas
- Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, Australia
- Division of Infectious Diseases, Royal Darwin Hospital, Darwin, Australia
- * E-mail:
| | - Enny Kenangalem
- Timika Malaria Research Program, Papuan Health and Community Development Foundation, Timika, Papua, Indonesia
- Mimika District Health Authority, Timika, Papua, Indonesia
| | - Afdhal Hasanuddin
- Department of Paediatrics, Rumah Sakit Mitra Masyarakat, Timika, Papua, Indonesia
| | - Nicholas M. Anstey
- Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, Australia
- Division of Infectious Diseases, Royal Darwin Hospital, Darwin, Australia
| | - Paulus Sugiarto
- Department of Paediatrics, Rumah Sakit Mitra Masyarakat, Timika, Papua, Indonesia
| | - Ric N. Price
- Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, Australia
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, United Kingdom
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Jeanne Rini Poespoprodjo
- Timika Malaria Research Program, Papuan Health and Community Development Foundation, Timika, Papua, Indonesia
- Department of Child Health, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Yogyakarta, Indonesia
- Department of Paediatrics, Rumah Sakit Umum Daerah, Kabupaten Mimika, Timika, Papua, Indonesia
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14
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Sikora SA, Poespoprodjo JR, Kenangalem E, Lampah DA, Sugiarto P, Laksono IS, Ahmad RA, Murhandarwati EEH. Intravenous artesunate plus oral dihydroartemisinin-piperaquine or intravenous quinine plus oral quinine for optimum treatment of severe malaria: lesson learnt from a field hospital in Timika, Papua, Indonesia. Malar J 2019; 18:448. [PMID: 31888655 PMCID: PMC6937738 DOI: 10.1186/s12936-019-3085-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [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: 09/18/2019] [Accepted: 12/21/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Intravenous artesunate and its follow on full course dihydroartemisinin-piperaquine are the standard treatment for severe malaria in Indonesia. The current policy suggests that intravenous and oral quinine could be used when standard therapy is not available. Its pragmatic use of both treatment combinations in a field hospital is evaluated. METHODS A retrospective study among hospitalized malaria patients receiving intravenous anti-malarial treatments at Mitra Masyarakat Hospital, Timika from April 2004 to December 2013 was conducted. The length of hospital stay (LoS) and the risk of malaria recurrence within 28 days after hospital admission were compared between patients receiving intravenous artesunate and oral dihydroartemisinin-piperaquine (Iv Art + DHP) and those receiving intravenous and oral quinine (Iv + Oral Qu). RESULTS Of 10,514 patients requiring intravenous therapy, 2759 received Iv + Oral Qu and 7755 received Iv Art + DHP. Plasmodium falciparum infection accounted for 65.8% (6915), while Plasmodium vivax, Mixed infections, Plasmodium malariae and Plasmodium ovale were accounted for 17.0% (1789), 16.4% (1729), 0.8% (79) and 0.01% (2) of the infections, respectively. The majority of severe malaria hospital admissions were highland Papuans (78.0%, 8201/10,501). In total 49% (5158) of patients were older than 15 years and 3463 (32.9%) were children under 5 years old. The median LoS was shorter in patients receiving intravenous artesunate compared to those treated with intravenous quinine (median = 2 [IQR 1-3] versus 3 days [IQR 2-4], p < 0.0001). Patients treated with intravenous quinine had higher risk of being hospitalized longer than 2 days (aOR of 1.70 [95% CI 1.54-1.88], p < 0.0001). The risk of recurrences within 28 days after hospital admission was 1.94 times higher (95% CI aHR 1.57-2.39, p < 0.0001) in patients receiving intravenous quinine with follow on oral quinine treatment than in patients treated with DHP after intravenous artesunate therapy. CONCLUSIONS Intravenous artesunate reduced the LoS of malaria patients and in combination with DHP reduced the risk of malaria recurrence within 28 days after hospital admission compared to those with Iv + Oral Qu treatment. Thus, ensuring continuous supply of intravenous artesunate and artemisinin-based combination therapy (ACT) should be a priority.
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Affiliation(s)
- Silvester Alexandro Sikora
- Postgraduate Programme of Tropical Medicine, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Yogyakarta, Indonesia
| | - Jeanne Rini Poespoprodjo
- Department of Paediatrics, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Yogyakarta, Indonesia.
- Timika Malaria Research Programme, Papuan Health and Community Development Foundation, Timika, Papua, Indonesia.
- Mimika District Hospital, Timika, Papua, Indonesia.
| | - Enny Kenangalem
- Timika Malaria Research Programme, Papuan Health and Community Development Foundation, Timika, Papua, Indonesia
| | - Daniel A Lampah
- Timika Malaria Research Programme, Papuan Health and Community Development Foundation, Timika, Papua, Indonesia
| | | | - Ida Safitri Laksono
- Postgraduate Programme of Tropical Medicine, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Yogyakarta, Indonesia
- Department of Paediatrics, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Yogyakarta, Indonesia
- Center for Tropical Medicine, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Yogyakarta, Indonesia
| | - Riris Andono Ahmad
- Center for Tropical Medicine, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Yogyakarta, Indonesia
- Dept. of Epidemiology, Biostatistics and Population Health, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Yogyakarta, Indonesia
| | - E Elsa Herdiana Murhandarwati
- Postgraduate Programme of Tropical Medicine, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Yogyakarta, Indonesia.
- Center for Tropical Medicine, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Yogyakarta, Indonesia.
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15
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Patriani D, Arguni E, Kenangalem E, Dini S, Sugiarto P, Hasanuddin A, Lampah DA, Douglas NM, Anstey NM, Simpson JA, Price RN, Poespoprodjo JR. Early and late mortality after malaria in young children in Papua, Indonesia. BMC Infect Dis 2019; 19:922. [PMID: 31666012 PMCID: PMC6820991 DOI: 10.1186/s12879-019-4497-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [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: 04/28/2018] [Accepted: 09/23/2019] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND In southern Papua, Indonesia, malaria is highly prevalent in young children and is a significant cause of morbidity and early mortality. The association between malaria and delayed mortality is unknown. METHODS Routinely-collected hospital surveillance data from southern Papua, Indonesia, were used to assess the risk of recurrent malaria and mortality within 12 months of an initial presentation with malaria in all children younger than 5 years old attending the local hospital. Analysis was primarily by Kaplan Meier and Cox regression methods. RESULTS In total 15,716 children presenting with malaria between April 2004 and December 2013 were included in the analysis; 6184 (39.3%) with Plasmodium falciparum, 7499 (47.7%) with P. vivax, 203 (1.3%) with P. malariae, 3 with P. ovale and 1827 (11.6%) with mixed infections. Within 1 year, 48.4% (7620/15,716) of children represented a total of 16,957 times with malaria (range 1 to 11 episodes), with the incidence of malaria being greater in patients initially presenting with P. vivax infection (1334 [95%CI 1307-1361] per 1000 patient years) compared to those with P. falciparum infection (920 [896-944]). In total 266 (1.7%) children died within 1 year of their initial presentation, 129 (48.5%) within 30 days and 137 (51.5%) between 31 and 365 days. There was no significant difference in the mortality risk in patients infected with P. vivax versus P. falciparum either before 30 days (Hazard Ratio (HR) 1.02 [0.69,1.49]) or between 31 and 365 days (HR = 1.30 [0.90,1.88]). Children who died had a greater incidence of malaria, 2280 [95%CI 1946-2671] per 1000 patient years preceding their death, compared to 1141 [95%CI 1124-1158] per 1000 patient years in those surviving. CONCLUSIONS Children under-5 years old with P. vivax malaria, are at significant risk of multiple representations with malaria and of dying within 1 year of their initial presentation. Preventing recurrent malaria must be a public health priority in this vulnerable population.
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Affiliation(s)
- Dewi Patriani
- grid.8570.aDepartment of Child Health, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Jl. Kesehatan no.1, Sekip, Yogyakarta, 55284 Indonesia
| | - Eggi Arguni
- grid.8570.aDepartment of Child Health, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Jl. Kesehatan no.1, Sekip, Yogyakarta, 55284 Indonesia
| | - Enny Kenangalem
- Timika Malaria Research Programme, Papuan Health and Community Development Foundation, Jl. SP2-SP5, RSMM Area, Timika, Papua 99910 Indonesia ,Mimika District Hospital, Jl. Yos Sudarso, Timika, Papua 99910 Indonesia
| | - Saber Dini
- 0000 0001 2179 088Xgrid.1008.9Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, 207 Bouverie Street, The University of Melbourne, Melbourne, Victoria 3010 Australia
| | - Paulus Sugiarto
- Mitra Masyarakat Hospital, Jl. SP2-SP5-Charitas, Timika, 99910 Indonesia
| | - Afdhal Hasanuddin
- Mitra Masyarakat Hospital, Jl. SP2-SP5-Charitas, Timika, 99910 Indonesia
| | - Daniel Adrian Lampah
- Timika Malaria Research Programme, Papuan Health and Community Development Foundation, Jl. SP2-SP5, RSMM Area, Timika, Papua 99910 Indonesia
| | - Nicholas M. Douglas
- 0000 0000 8523 7955grid.271089.5Global and Tropical Health Division, Menzies School of Health Research and Charles Darwin University, PO Box 41096, Casuarina, Darwin, NT 0811 Australia
| | - Nicholas M. Anstey
- 0000 0000 8523 7955grid.271089.5Global and Tropical Health Division, Menzies School of Health Research and Charles Darwin University, PO Box 41096, Casuarina, Darwin, NT 0811 Australia ,grid.240634.7Division of Medicine, Royal Darwin Hospital, Darwin, NT 0810 Australia
| | - Julie Anne Simpson
- Mitra Masyarakat Hospital, Jl. SP2-SP5-Charitas, Timika, 99910 Indonesia
| | - Ric N. Price
- 0000 0000 8523 7955grid.271089.5Global and Tropical Health Division, Menzies School of Health Research and Charles Darwin University, PO Box 41096, Casuarina, Darwin, NT 0811 Australia ,0000 0004 1936 8948grid.4991.5Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, OX37LJ, Oxford, United Kingdom ,0000 0004 1937 0490grid.10223.32Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Jeanne Rini Poespoprodjo
- grid.8570.aDepartment of Child Health, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Jl. Kesehatan no.1, Sekip, Yogyakarta, 55284 Indonesia ,Timika Malaria Research Programme, Papuan Health and Community Development Foundation, Jl. SP2-SP5, RSMM Area, Timika, Papua 99910 Indonesia ,Mimika District Hospital, Jl. Yos Sudarso, Timika, Papua 99910 Indonesia
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16
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Lestari T, Graham S, van den Boogard C, Triasih R, Poespoprodjo JR, Ubra RR, Kenangalem E, Mahendradhata Y, Anstey NM, Bailie RS, Ralph AP. Bridging the knowledge-practice gap in tuberculosis contact management in a high-burden setting: a mixed-methods protocol for a multicenter health system strengthening study. Implement Sci 2019; 14:31. [PMID: 30890160 PMCID: PMC6425655 DOI: 10.1186/s13012-019-0870-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [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: 11/27/2018] [Accepted: 02/12/2019] [Indexed: 01/12/2023] Open
Abstract
Background People in close contact with tuberculosis should have screening and appropriate management, as an opportunity for active case detection and prevention. However, implementation of tuberculosis contact screening and management is limited in high-burden settings. Behaviour change is needed across three levels of the healthcare system—policymakers, healthcare providers, and patients. To bridge the wide policy-practice gap, this study draws on the Consolidated Framework for Implementation Research, the Behaviour Change Wheel, and the RE-AIM model (Reach, Effectiveness, Adoption, Implementation, Maintenance) to respectively understand barriers, implement change, and evaluate process and outcome. Methods This methods paper describes a mixed-methods intervention study in Eastern Indonesia. Quantitative data will be collected during baseline, intervention, and sustainability periods and analyzed using time series analysis. The primary outcome is the number of individuals completing tuberculosis preventive therapy by the end of the two-year intervention phase. Of an estimated 10,000 contacts during this period, we anticipate that a minimum of 416 will be found to have active TB or will complete preventive therapy. Qualitative data (semi-structured interviews, focus group discussions, and observations) will be collected from consenting healthcare providers, patients, and contacts. Activities to promote policy implementation include healthcare provider training, quarterly continuous quality improvement workshops, a social media discussion forum, and promotional materials. The Consolidated Framework for Implementation Research will be used to identify reasons for limited policy implementation at baseline. The Behaviour Change Wheel will be used to ensure that a suitable range of activities are implemented to facilitate change. The RE-AIM model will be used as the evaluation framework. Discussion Use of theoretical frameworks in combination can ensure a comprehensive understanding of, and robust response to, health policy underimplementation. The selected frameworks are highly applicable to this pragmatic intervention study, in a setting where End TB Strategy targets will not be met without substantial behavior change within health systems. Continuous quality improvement cycles will provide a way to engage staff and stakeholders in understanding local data to motivate behavior change. If successful, up to 500 people could be prevented from developing complications of tuberculosis through early case-finding or receiving preventive therapy over a two-year period. Study registration Australian New Zealand Clinical Trials Register 375803.
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Affiliation(s)
- Trisasi Lestari
- Global and Tropical Health, Menzies School of Health Research, Charles Darwin University, Darwin, Northern Territory, Australia. .,Center for Tropical Medicine, Faculty of Medicine, Public Health, and Nursing, Universitas Gadjah Mada, Yogyakarta, Indonesia.
| | - Steve Graham
- Centre for International Child Health, Department of Paediatrics and Murdoch Children's Research Institute, University of Melbourne, Melbourne, Australia.,Burnet Institute, Melbourne, Australia
| | - Christel van den Boogard
- Global and Tropical Health, Menzies School of Health Research, Charles Darwin University, Darwin, Northern Territory, Australia
| | - Rina Triasih
- Center for Tropical Medicine, Faculty of Medicine, Public Health, and Nursing, Universitas Gadjah Mada, Yogyakarta, Indonesia
| | - Jeanne Rini Poespoprodjo
- Center for Tropical Medicine, Faculty of Medicine, Public Health, and Nursing, Universitas Gadjah Mada, Yogyakarta, Indonesia.,Papuan Health and Community Development Foundation, Papua, Indonesia
| | | | - Enny Kenangalem
- Papuan Health and Community Development Foundation, Papua, Indonesia
| | - Yodi Mahendradhata
- Center for Tropical Medicine, Faculty of Medicine, Public Health, and Nursing, Universitas Gadjah Mada, Yogyakarta, Indonesia
| | - Nicholas M Anstey
- Global and Tropical Health, Menzies School of Health Research, Charles Darwin University, Darwin, Northern Territory, Australia.,Division of Medicine, Royal Darwin Hospital, Darwin, Northern Territory, Australia
| | - Ross S Bailie
- University Centre for Rural Health, School of Medicine, University of Sydney, Lismore, Australia
| | - Anna P Ralph
- Global and Tropical Health, Menzies School of Health Research, Charles Darwin University, Darwin, Northern Territory, Australia.,Division of Medicine, Royal Darwin Hospital, Darwin, Northern Territory, Australia
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17
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Webster J, Ansariadi, Burdam FH, Landuwulang CUR, Bruce J, Poespoprodjo JR, Syafruddin D, Ahmed R, Hill J. Evaluation of the implementation of single screening and treatment for the control of malaria in pregnancy in Eastern Indonesia: a systems effectiveness analysis. Malar J 2018; 17:310. [PMID: 30143047 PMCID: PMC6108152 DOI: 10.1186/s12936-018-2448-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [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: 06/11/2018] [Accepted: 08/05/2018] [Indexed: 11/10/2022] Open
Abstract
Background Indonesia introduced single screening and treatment (SST) of pregnant women for the control of malaria in pregnancy in 2012. Under this policy pregnant women are screened for malaria at their first antenatal clinic (ANC) visit and on subsequent visits are tested for malaria only if symptomatic. The implementation of this policy in two districts of Indonesia was evaluated. Cross sectional survey structured observations of the ANC visit and exit interviews with pregnant women were conducted to assess health provider compliance with SST guidelines. Systems effectiveness analysis was performed on components of the strategy. Multiple logistic regression was used to test for predictors of women being screened at their first ANC visit. Results A total of 865 and 895 ANC visits in Mimika and West Sumba across seven and ten health facilities (plus managed health posts) respectively, were included in the study. Adherence to malaria screening at first ANC visit among pregnant women was 51.4% (95% CI 11.9, 89.2) in health facilities in Mimika (94.8% in health centres) and 24.8% (95% CI 10.3, 48.9) in West Sumba (60.0% in health centres). Reported fever was low amongst women presenting for their second and above ANC visit (2.8% in Mimika and 3.5% in West Sumba) with 89.5% and 46.2% of these women tested for malaria in Mimka and West Sumba, respectively. Cumulative systems effectiveness for SST on first visit to ANC was 7.6% for Mimika and 0.1% for West Sumba; and for second or above visits to ANC was 0.7% in Mimika and 0% in West Sumba. Being screened on a 1st visit to ANC was associated with level of health facility in both sites. Conclusion Cumulative systems effectiveness of the SST strategy was poor in both sites. Both elements of the SST strategy, screening on first visit and passive case detection on second and above visits, was driven by the difference in implementation of malaria testing in health centres and health posts, and by low malaria transmission levels and reported fever.
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Affiliation(s)
- Jayne Webster
- Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK.
| | - Ansariadi
- Department of Epidemiology, School of Public Health, Hasanuddin University, Makassar, Indonesia
| | - Faustina Helena Burdam
- Timika Research Facility (Papuan Community and Health Development Foundation), Timika, Indonesia
| | | | - Jane Bruce
- Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
| | - Jeanne Rini Poespoprodjo
- Timika Research Facility (Papuan Community and Health Development Foundation), Timika, Indonesia.,Paediatric Research Office, Department of Child Health, Universitas Gadjah Mada, Yogyakarta, Indonesia.,Mimika District Hospital, Timika, Indonesia
| | - Din Syafruddin
- Eijkman Institute for Molecular Biology, Jakarta, Indonesia
| | - Rukhsana Ahmed
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Jenny Hill
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
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18
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Thriemer K, Bobogare A, Ley B, Gudo CS, Alam MS, Anstey NM, Ashley E, Baird JK, Gryseels C, Jambert E, Lacerda M, Laihad F, Marfurt J, Pasaribu AP, Poespoprodjo JR, Sutanto I, Taylor WR, van den Boogaard C, Battle KE, Dysoley L, Ghimire P, Hawley B, Hwang J, Khan WA, Mudin RNB, Sumiwi ME, Ahmed R, Aktaruzzaman MM, Awasthi KR, Bardaji A, Bell D, Boaz L, Burdam FH, Chandramohan D, Cheng Q, Chindawongsa K, Culpepper J, Das S, Deray R, Desai M, Domingo G, Duoquan W, Duparc S, Floranita R, Gerth-Guyette E, Howes RE, Hugo C, Jagoe G, Sariwati E, Jhora ST, Jinwei W, Karunajeewa H, Kenangalem E, Lal BK, Landuwulang C, Le Perru E, Lee SE, Makita LS, McCarthy J, Mekuria A, Mishra N, Naket E, Nambanya S, Nausien J, Duc TN, Thi TN, Noviyanti R, Pfeffer D, Qi G, Rahmalia A, Rogerson S, Samad I, Sattabongkot J, Satyagraha A, Shanks D, Sharma SN, Sibley CH, Sungkar A, Syafruddin D, Talukdar A, Tarning J, ter Kuile F, Thapa S, Theodora M, Huy TT, Waramin E, Waramori G, Woyessa A, Wongsrichanalai C, Xa NX, Yeom JS, Hermawan L, Devine A, Nowak S, Jaya I, Supargiyono S, Grietens KP, Price RN. Quantifying primaquine effectiveness and improving adherence: a round table discussion of the APMEN Vivax Working Group. Malar J 2018; 17:241. [PMID: 29925430 PMCID: PMC6011582 DOI: 10.1186/s12936-018-2380-8] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2018] [Accepted: 06/08/2018] [Indexed: 01/13/2023] Open
Abstract
The goal to eliminate malaria from the Asia-Pacific by 2030 will require the safe and widespread delivery of effective radical cure of malaria. In October 2017, the Asia Pacific Malaria Elimination Network Vivax Working Group met to discuss the impediments to primaquine (PQ) radical cure, how these can be overcome and the methodological difficulties in assessing clinical effectiveness of radical cure. The salient discussions of this meeting which involved 110 representatives from 18 partner countries and 21 institutional partner organizations are reported. Context specific strategies to improve adherence are needed to increase understanding and awareness of PQ within affected communities; these must include education and health promotion programs. Lessons learned from other disease programs highlight that a package of approaches has the greatest potential to change patient and prescriber habits, however optimizing the components of this approach and quantifying their effectiveness is challenging. In a trial setting, the reactivity of participants results in patients altering their behaviour and creates inherent bias. Although bias can be reduced by integrating data collection into the routine health care and surveillance systems, this comes at a cost of decreasing the detection of clinical outcomes. Measuring adherence and the factors that relate to it, also requires an in-depth understanding of the context and the underlying sociocultural logic that supports it. Reaching the elimination goal will require innovative approaches to improve radical cure for vivax malaria, as well as the methods to evaluate its effectiveness.
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Affiliation(s)
- Kamala Thriemer
- 0000 0000 8523 7955grid.271089.5Global and Tropical Health Division, Menzies School of Health Research and Charles Darwin University, Darwin, Darwin, NT 0810 Australia
| | - Albino Bobogare
- Ministry of Health and Medical Services, National Vector-Borne Disease Control Programme, Honiara, Solomon Islands
| | - Benedikt Ley
- 0000 0000 8523 7955grid.271089.5Global and Tropical Health Division, Menzies School of Health Research and Charles Darwin University, Darwin, Darwin, NT 0810 Australia
| | | | - Mohammad Shafiul Alam
- 0000 0004 0600 7174grid.414142.6International Center for Diarrheal Diseases (ICDDR,B), Dhaka, Bangladesh
| | - Nick M. Anstey
- 0000 0000 8523 7955grid.271089.5Global and Tropical Health Division, Menzies School of Health Research and Charles Darwin University, Darwin, Darwin, NT 0810 Australia
| | - Elizabeth Ashley
- Myanmar-Oxford Clinical Research Unit, Yangon, Myanmar ,0000 0004 1936 8948grid.4991.5Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
| | - J. Kevin Baird
- 0000 0004 1936 8948grid.4991.5Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK ,0000 0004 1795 0993grid.418754.bEijkman-Oxford Clinical Research Unit, Jakarta, Indonesia
| | - Charlotte Gryseels
- 0000 0001 2153 5088grid.11505.30Institute of Tropical Medicine Antwerp, Antwerp, Belgium
| | - Elodie Jambert
- 0000 0004 0432 5267grid.452605.0Medicines for Malaria Venture (MMV), Geneva, Switzerland
| | - Marcus Lacerda
- Instituto Leônidas & Maria Deane (Fiocruz), Manaus, Amazonas Brazil ,0000 0004 0486 0972grid.418153.aFundação de Medicina Tropical Dr, Heitor Vieira Dourado, Manaus, Amazonas Brazil
| | - Ferdinand Laihad
- National Forum on Indonesia RBM/National Forum on Gebrak Malaria, Jakarta, Indonesia
| | - Jutta Marfurt
- 0000 0000 8523 7955grid.271089.5Global and Tropical Health Division, Menzies School of Health Research and Charles Darwin University, Darwin, Darwin, NT 0810 Australia
| | | | | | - Inge Sutanto
- 0000000120191471grid.9581.5University of Indonesia, Jakarta, Indonesia
| | - Walter R. Taylor
- 0000 0004 1936 8948grid.4991.5Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK ,Mahidol Oxford Clinical Research Unit (MORU), Bangkok, Thailand
| | - Christel van den Boogaard
- 0000 0000 8523 7955grid.271089.5Global and Tropical Health Division, Menzies School of Health Research and Charles Darwin University, Darwin, Darwin, NT 0810 Australia
| | - Katherine E. Battle
- 0000 0004 1936 8948grid.4991.5Malaria Atlas Project (MAP), Big Data Institute, University of Oxford, Oxford, UK
| | - Lek Dysoley
- grid.452707.3National Center for Parasitology, Entomology and Malaria Control, Phnom Penh, Cambodia ,grid.436334.5School of Public Health, National Institute of Public Health, Phnom Penh, Cambodia
| | - Prakash Ghimire
- 0000 0001 2114 6728grid.80817.36Microbiology Department, Tribhuvan University, Kathmandu, Nepal
| | - Bill Hawley
- 0000 0001 2163 0069grid.416738.fEntomology Branch, Division of Parasitic Diseases and Malaria, Centers for Disease Control and Prevention, Atlanta, USA
| | - Jimee Hwang
- 0000 0001 2163 0069grid.416738.fPresident’s Malaria Initiative, Malaria Branch, Division of Parasitic Diseases and Malaria, Centers for Disease Control and Prevention, Atlanta, USA ,0000 0001 2297 6811grid.266102.1Global Health Group, University of California San Francisco, San Francisco, USA
| | - Wasif Ali Khan
- 0000 0004 0600 7174grid.414142.6International Center for Diarrheal Diseases (ICDDR,B), Dhaka, Bangladesh
| | - Rose Nani Binti Mudin
- 0000 0001 0690 5255grid.415759.bDisease Control Division, Ministry of Health, Putrajaya, Malaysia
| | | | - Rukhsana Ahmed
- 0000 0004 1936 9764grid.48004.38Liverpool School of Tropical Medicine, Liverpool, UK
| | - M. M. Aktaruzzaman
- grid.466907.aDirectorate General of Health Services, Ministry of Health & Family Welfare Government of the People’s Republic of Bangladesh, Dhaka, Bangladesh
| | | | - Azucena Bardaji
- 0000 0000 9635 9413grid.410458.cISGlobal, Hospital Clínic-Universitat de Barcelona, Barcelona, Spain
| | - David Bell
- 0000 0004 0406 7608grid.471104.7Intellectual Ventures Global Good Fund, Bellevue, USA
| | - Leonard Boaz
- Ministry of Health and Medical Services, National Vector-Borne Disease Control Programme, Honiara, Solomon Islands
| | | | - Daniel Chandramohan
- 0000 0004 0425 469Xgrid.8991.9The London School of Hygiene & Tropical Medicine (LSHTM), London, UK
| | - Qin Cheng
- Australian Defence Force Malaria and Infectious Disease Institute, Enoggera, Australia
| | | | - Janice Culpepper
- 0000 0000 8990 8592grid.418309.7Bill & Melinda Gates Foundation, Seattle, USA
| | - Santasabuj Das
- 0000 0004 1767 225Xgrid.19096.37Indian Council of Medical Research, New Delhi, India
| | - Raffy Deray
- Department of Health, National Centre for Disease Control & Prevention, Manila, Philippines
| | - Meghna Desai
- 0000 0001 2163 0069grid.416738.fMalaria Branch, Division of Parasitic Diseases and Malaria, Centers for Disease Control and Prevention, Atlanta, USA
| | | | - Wang Duoquan
- 0000 0000 8803 2373grid.198530.6National Institute of Parasitic Diseases, China CDC, Shanghai, China
| | - Stephan Duparc
- 0000 0004 0432 5267grid.452605.0Medicines for Malaria Venture (MMV), Geneva, Switzerland
| | | | | | - Rosalind E. Howes
- 0000 0004 1936 8948grid.4991.5Malaria Atlas Project (MAP), Big Data Institute, University of Oxford, Oxford, UK
| | | | - George Jagoe
- 0000 0004 0432 5267grid.452605.0Medicines for Malaria Venture (MMV), Geneva, Switzerland
| | - Elvieda Sariwati
- 0000 0004 0470 8161grid.415709.eMinistry of Health, National Malaria Control Program, Jakarta, Indonesia
| | - Sanya Tahmina Jhora
- grid.466907.aDirectorate General of Health Services, Ministry of Health & Family Welfare Government of the People’s Republic of Bangladesh, Dhaka, Bangladesh
| | - Wu Jinwei
- Tengchong Center for Disease Control and Prevention, Tengchong, China
| | - Harin Karunajeewa
- grid.1042.7Walter and Eliza Hall Institute of Medical Research, Parkville, Australia
| | - Enny Kenangalem
- Yayasan Pengembangan Kesehatan dan Masyarakat, Papua (YPKMP), Papua, Indonesia
| | - Bibek Kumar Lal
- Epidemiology & Disease Control Division, Department of Health Services, Ministry of Health and Population, Kathmandu, Nepal
| | | | | | - Sang-Eun Lee
- 0000 0004 1763 8617grid.418967.5Division of Vectors and Parasitic Diseases, Korea Centers for Disease Control and Prevention, Seoul, South Korea
| | - Leo Sora Makita
- Ministry of Health, National Malaria Control Programme, Port Mosby, Papua New Guinea
| | - James McCarthy
- 0000 0001 2294 1395grid.1049.cQIMR Berghofer Medical Research Institute, Brisbane, Australia
| | - Asrat Mekuria
- 0000 0001 1250 5688grid.7123.7School of Medicine, Addis Ababa University, Addis Ababa, Ethiopia
| | - Neelima Mishra
- 0000 0004 1767 225Xgrid.19096.37Indian Council of Medical Research, New Delhi, India
| | - Esau Naket
- Ministry of Health, Malaria and Other Vector-Borne Diseases Control Program (MOVBDCP), Port Vila, Vanuatu
| | - Simone Nambanya
- Center of Malariology, Parasitology and Entomology, Communicable Diseases Control, Vientiane, Lao PDR
| | - Johnny Nausien
- Ministry of Health, Malaria and Other Vector-Borne Diseases Control Program (MOVBDCP), Port Vila, Vanuatu
| | - Thang Ngo Duc
- grid.452658.8National Institute of Malariology, Parasitology and Entomology (NIMPE), Hanoi, Vietnam
| | - Thuan Nguyen Thi
- grid.452658.8National Institute of Malariology, Parasitology and Entomology (NIMPE), Hanoi, Vietnam
| | - Rinitis Noviyanti
- 0000 0004 1795 0993grid.418754.bEijkman Institute for Molecular Biology, Jakarta, Indonesia
| | - Daniel Pfeffer
- 0000 0000 8523 7955grid.271089.5Global and Tropical Health Division, Menzies School of Health Research and Charles Darwin University, Darwin, Darwin, NT 0810 Australia ,0000 0004 1936 8948grid.4991.5Malaria Atlas Project (MAP), Big Data Institute, University of Oxford, Oxford, UK
| | - Gao Qi
- grid.452515.2Jiangsu Institute of Parasitic Diseases, Wuxi, China ,WHO Collaborative Centre for Research and Training of Malaria Elimination, Wuxi, China
| | - Annisa Rahmalia
- 0000 0004 1796 1481grid.11553.33Tuberculosis-HIV Research Center Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia ,0000000122931605grid.5590.9Radboud University Nijmegen, Nijmegen, The Netherlands
| | - Stephen Rogerson
- 0000 0001 2179 088Xgrid.1008.9Department of Medicine at the Doherty Institute, University of Melbourne, Melbourne, Australia
| | - Iriani Samad
- 0000 0004 0470 8161grid.415709.eMinistry of Health, National Malaria Control Program, Jakarta, Indonesia
| | - Jetsumon Sattabongkot
- 0000 0004 1937 0490grid.10223.32Mahidol Vivax Research Unit, Faculty of Tropical Medicine, Bangok, Thailand
| | - Ari Satyagraha
- 0000 0004 1795 0993grid.418754.bEijkman Institute for Molecular Biology, Jakarta, Indonesia
| | - Dennis Shanks
- Australian Defence Force Malaria and Infectious Disease Institute, Enoggera, Australia
| | - Surender Nath Sharma
- grid.415820.aNational Vector Borne Disease Control Programme Directorate General of Health Services Ministry of Health & Family Welfare, New Delhi, India
| | - Carol Hopkins Sibley
- WorldWide Antimalarial Resistance Network (WWARN), Oxford, UK ,0000000122986657grid.34477.33University of Washington, Seattle, WA USA
| | - Ali Sungkar
- 0000 0004 0470 8161grid.415709.eFamily Health Directorate, Ministry of Health, Jakarta, Indonesia
| | - Din Syafruddin
- 0000 0004 1795 0993grid.418754.bEijkman Institute for Molecular Biology, Jakarta, Indonesia
| | - Arunansu Talukdar
- 0000 0004 1768 2335grid.413204.0Medicine Department, Medical College Kolkata, Kolkata, India
| | - Joel Tarning
- Mahidol Oxford Clinical Research Unit (MORU), Bangkok, Thailand
| | - Feiko ter Kuile
- 0000 0004 1936 9764grid.48004.38Liverpool School of Tropical Medicine, Liverpool, UK ,0000 0001 0155 5938grid.33058.3dKenya Medical Research Institute (KEMRI) Centre for Global Health Research, Kisumu, Kenya
| | | | - Minerva Theodora
- 0000 0004 0470 8161grid.415709.eMinistry of Health, National Malaria Control Program, Jakarta, Indonesia
| | - Tho Tran Huy
- grid.452658.8National Institute of Malariology, Parasitology and Entomology (NIMPE), Hanoi, Vietnam
| | - Edward Waramin
- Family Health Services, Ministry of Health, Port Mosby, Papua New Guinea
| | | | - Adugna Woyessa
- grid.452387.fEthiopian Public Health Institute (EPHI), Addis Ababa, Ethiopia
| | | | - Nguyen Xuan Xa
- grid.452658.8National Institute of Malariology, Parasitology and Entomology (NIMPE), Hanoi, Vietnam
| | - Joon Sup Yeom
- 0000 0004 0470 5454grid.15444.30Yonsei University College of Medicine, Seoul, South Korea
| | - Lukas Hermawan
- 0000 0004 0470 8161grid.415709.eFamily Health Directorate, Ministry of Health, Jakarta, Indonesia
| | - Angela Devine
- 0000 0000 8523 7955grid.271089.5Global and Tropical Health Division, Menzies School of Health Research and Charles Darwin University, Darwin, Darwin, NT 0810 Australia ,0000 0004 1936 8948grid.4991.5Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK ,Mahidol Oxford Clinical Research Unit (MORU), Bangkok, Thailand
| | - Spike Nowak
- 0000 0000 8940 7771grid.415269.dPATH, Seattle, USA
| | - Indra Jaya
- Program and Information Department, Directorate General of Disease Prevention and Control, Jakarta, Indonesia
| | | | - Koen Peeters Grietens
- 0000 0001 2153 5088grid.11505.30Institute of Tropical Medicine Antwerp, Antwerp, Belgium
| | - Ric N. Price
- 0000 0000 8523 7955grid.271089.5Global and Tropical Health Division, Menzies School of Health Research and Charles Darwin University, Darwin, Darwin, NT 0810 Australia ,0000 0004 1936 8948grid.4991.5Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
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19
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Poespoprodjo JR, Kenangalem E, Wafom J, Chandrawati F, Puspitasari AM, Ley B, Trianty L, Korten Z, Surya A, Syafruddin D, Anstey NM, Marfurt J, Noviyanti R, Price RN. Therapeutic Response to Dihydroartemisinin-Piperaquine for P. falciparum and P. vivax Nine Years after Its Introduction in Southern Papua, Indonesia. Am J Trop Med Hyg 2018; 98:677-682. [PMID: 29345221 PMCID: PMC5850981 DOI: 10.4269/ajtmh.17-0662] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [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] [Indexed: 01/12/2023] Open
Abstract
Dihydroartemisinin-piperaquine (DHP) has been the first-line treatment of uncomplicated malaria due to both Plasmodium falciparum and Plasmodium vivax infections in Papua, Indonesia, since March 2006. The efficacy of DHP was reassessed to determine whether there had been any decline following almost a decade of its extensive use. An open-label drug efficacy study of DHP for uncomplicated P. falciparum and P. vivax malaria was carried out between March 2015 and April 2016 in Timika, Papua, Indonesia. Patients with uncomplicated malaria were administered supervised DHP tablets once daily for 3 days. Clinical and laboratory data were collected daily until parasite clearance and then weekly for 6 weeks. Molecular analysis was undertaken for all patients with recurrent parasitemia. A total of 129 study patients were enrolled in the study. At day 42, the polymerase chain reaction-adjusted efficacy was 97.7% (95% confidence intervals [CI]: 87.4-99.9) in the 61 patients with P. falciparum malaria, and 98.2% [95% CI: 90.3-100] in the 56 patients with P. vivax malaria. By day 2, 98% (56/57) of patients with P. falciparum and 96.9% (63/65) of those with P. vivax had cleared their peripheral parasitemia; none of the patients were still parasitaemic on day 3. Molecular analysis of P. falciparum parasites showed that none (0/61) had K13 mutations associated previously with artemisinin resistance or increased copy number of plasmepsin 2-3 (0/61). In the absence of artemisinin resistance, DHP has retained high efficacy for the treatment of uncomplicated malaria despite extensive drug pressure over a 9-year period.
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Affiliation(s)
- Jeanne Rini Poespoprodjo
- Mimika District Hospital, Timika, Indonesia;,Timika Malaria Research Programme, Papuan Health and Community Development Foundation, Timika, Indonesia;,Paediatric Research Office, Department of Child Health, Faculty of Medicine, Universitas Gadjah Mada/Dr. Sardjito Hospital, Yogyakarta, Indonesia;,Address correspondence to Jeanne Rini Poespoprodjo, Timika Malaria Research Programme, Papuan Health and Community Development Foundation, Timika, Indonesia. E-mail:
| | - Enny Kenangalem
- Mimika District Hospital, Timika, Indonesia;,Timika Malaria Research Programme, Papuan Health and Community Development Foundation, Timika, Indonesia
| | - Johny Wafom
- Timika Malaria Research Programme, Papuan Health and Community Development Foundation, Timika, Indonesia
| | - Freis Chandrawati
- Timika Malaria Research Programme, Papuan Health and Community Development Foundation, Timika, Indonesia
| | | | - Benedikt Ley
- Global and Tropical Health Division, Menzies School of Health Research and Charles Darwin University, Darwin, Australia
| | - Leily Trianty
- Eijkman Institute for Molecular Biology, Jakarta, Indonesia
| | - Zoé Korten
- Global and Tropical Health Division, Menzies School of Health Research and Charles Darwin University, Darwin, Australia
| | - Asik Surya
- Indonesian Ministry of Health, National Malaria Control Program, Jakarta, Indonesia
| | - Din Syafruddin
- Eijkman Institute for Molecular Biology, Jakarta, Indonesia
| | - Nicholas M. Anstey
- Global and Tropical Health Division, Menzies School of Health Research and Charles Darwin University, Darwin, Australia
| | - Jutta Marfurt
- Global and Tropical Health Division, Menzies School of Health Research and Charles Darwin University, Darwin, Australia
| | | | - Ric N. Price
- Global and Tropical Health Division, Menzies School of Health Research and Charles Darwin University, Darwin, Australia;,Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, United Kingdom
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20
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Devine A, Kenangalem E, Burdam FH, Anstey NM, Poespoprodjo JR, Price RN, Yeung S. Treatment-Seeking Behavior after the Implementation of a Unified Policy of Dihydroartemisinin-Piperaquine for the Treatment of Uncomplicated Malaria in Papua, Indonesia. Am J Trop Med Hyg 2018; 98:543-550. [PMID: 29280424 PMCID: PMC5810904 DOI: 10.4269/ajtmh.17-0680] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [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: 01/13/2023] Open
Abstract
Artemisinin combination therapy is recommended for the treatment of multidrug resistant Plasmodium falciparum and Plasmodium vivax. In March 2006, antimalarial policy in Indonesia was changed to a unified treatment with dihydroartemisinin-piperaquine for all species of malaria because of the low efficacy of previous drug treatments. In 2013, a randomized cross-sectional household survey in Papua was used to collect data on demographics, parasite positivity, treatment-seeking behavior, diagnosis and treatment of malaria, and household costs. Results were compared with a similar survey undertaken in 2005. A total of 800 households with 4,010 individuals were included in the 2013 survey. The prevalence of malaria parasitemia was 12% (348/2,795). Of the individuals who sought treatment of fever, 67% (66/98) reported attending a public provider at least once compared with 46% (349/764) before policy change (P < 0.001). During the 100 visits to healthcare providers, 95% (95) included a blood test for malaria and 74% (64/86) resulted in the recommended antimalarial for the diagnosed species, the corresponding figures before policy change were 48% (433/894) and 23% (78/336). The proportion of individuals seeking treatment more than once fell from 14% (107/764) before policy change to 2% (2/98) after policy change (P = 0.005). The mean indirect cost per fever episode requiring treatment seeking decreased from US$44.2 in 2005 to US$33.8 in 2013 (P = 0.006). The implementation of a highly effective antimalarial treatment was associated with better adherence of healthcare providers in both the public and private sectors and a reduction in clinical malaria and household costs.
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Affiliation(s)
- Angela Devine
- Mahidol-Oxford Tropical Medicine Research Unit, Mahidol University, Bangkok, Thailand;,Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, United Kingdom
| | - Enny Kenangalem
- Timika Malaria Research Program, Papuan Health and Community Development Foundation, Timika, Papua, Indonesia;,Mimika District Health Authority, Timika, Papua, Indonesia
| | | | - Nicholas M. Anstey
- Global and Tropical Health Division, Menzies School of Health Research and Charles Darwin University, Darwin, Northern Territory, Australia
| | - Jeanne Rini Poespoprodjo
- Timika Malaria Research Program, Papuan Health and Community Development Foundation, Timika, Papua, Indonesia;,Mimika District Health Authority, Timika, Papua, Indonesia;,Department of Child Health, Faculty of Medicine, University Gadjah Mada, Yogyakarta, Indonesia
| | - Ric N. Price
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, United Kingdom;,Global and Tropical Health Division, Menzies School of Health Research and Charles Darwin University, Darwin, Northern Territory, Australia;,Address correspondence to Ric N. Price, Menzies School of Health Research, P.O. Box 41096, Casuarina, Darwin, NT 0811, Australia. E-mail:
| | - Shunmay Yeung
- Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, United Kingdom
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21
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Pava Z, Handayuni I, Trianty L, Utami RAS, Tirta YK, Puspitasari AM, Burdam F, Kenangalem E, Wirjanata G, Kho S, Trimarsanto H, Anstey N, Poespoprodjo JR, Noviyanti R, Price RN, Marfurt J, Auburn S. Passively versus Actively Detected Malaria: Similar Genetic Diversity but Different Complexity of Infection. Am J Trop Med Hyg 2017; 97:1788-1796. [PMID: 29016343 PMCID: PMC5790166 DOI: 10.4269/ajtmh.17-0364] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [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] [Indexed: 01/12/2023] Open
Abstract
The surveillance of malaria is generally undertaken on the assumption that samples passively collected at health facilities are comparable to or representative of the broader Plasmodium reservoir circulating in the community. Further characterization and comparability of the hidden asymptomatic parasite reservoir are needed to inform on the potential impact of sampling bias. This study explores the impact of sampling strategy on molecular surveillance by comparing the genetic make-up of Plasmodium falciparum and Plasmodium vivax isolates collected by passive versus active case detection. Sympatric isolates of P. falciparum and P. vivax were collected from a large community survey and ongoing clinical surveillance studies undertaken in the hypomesoendemic setting of Mimika District (Papua, Indonesia). Plasmodium falciparum isolates were genotyped at nine microsatellite loci and P. vivax at eight loci. Measures of diversity and differentiation were used to compare different patient and parasitological sample groups. The results demonstrated that passively detected cases (symptomatic) had comparable population diversity to those circulating in the community (asymptomatic) in both species. In addition, asymptomatic patent infections were as diverse as subpatent infections. However, a significant difference in multiplicity of infection (MOI) and percentage of polyclonal infections was observed between actively and passively detected P. vivax cases (mean MOI: 1.7 ± 0.7 versus 1.4 ± 1.4, respectively; P = 0.001). The study findings infer that, in hypomesoendemic settings, passive sampling is appropriate for molecular parasite surveillance strategies using the predominant clone in any given infection; however, the findings suggest caution when analyzing complexity of infection. Further evaluation is required in other endemic settings.
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Affiliation(s)
- Zuleima Pava
- Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, Northern Territory, Australia
| | - Irene Handayuni
- Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, Northern Territory, Australia
| | - Leily Trianty
- Eijkman Institute for Molecular Biology, Jakarta, Indonesia
| | | | | | | | - Faustina Burdam
- Mimika District Health Authority, Timika, Papua, Indonesia;,Timika Malaria Research Programme, Papuan Health and Community Development Foundation, Timika, Papua, Indonesia;,Maternal and Child Health and Reproductive Health, Department of Public Health, Faculty of Medicine, Universitas Gadjah Mada, Yogyakarta, Indonesia
| | - Enny Kenangalem
- Mimika District Health Authority, Timika, Papua, Indonesia;,Timika Malaria Research Programme, Papuan Health and Community Development Foundation, Timika, Papua, Indonesia
| | - Grennady Wirjanata
- Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, Northern Territory, Australia
| | - Steven Kho
- Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, Northern Territory, Australia
| | | | - Nicholas Anstey
- Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, Northern Territory, Australia
| | - Jeanne Rini Poespoprodjo
- Mimika District Health Authority, Timika, Papua, Indonesia;,Timika Malaria Research Programme, Papuan Health and Community Development Foundation, Timika, Papua, Indonesia;,Maternal and Child Health and Reproductive Health, Department of Public Health, Faculty of Medicine, Universitas Gadjah Mada, Yogyakarta, Indonesia
| | | | - Ric N. Price
- Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, Northern Territory, Australia;,Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, United Kingdom
| | - Jutta Marfurt
- Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, Northern Territory, Australia
| | - Sarah Auburn
- Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, Northern Territory, Australia;,Address correspondence to Sarah Auburn, Menzies School of Health Research, PO Box 41096, Casuarina, Darwin, NT 0811, Australia. E-mail:
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22
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Douglas NM, Poespoprodjo JR, Patriani D, Malloy MJ, Kenangalem E, Sugiarto P, Simpson JA, Soenarto Y, Anstey NM, Price RN. Unsupervised primaquine for the treatment of Plasmodium vivax malaria relapses in southern Papua: A hospital-based cohort study. PLoS Med 2017; 14:e1002379. [PMID: 28850568 PMCID: PMC5574534 DOI: 10.1371/journal.pmed.1002379] [Citation(s) in RCA: 57] [Impact Index Per Article: 8.1] [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: 02/23/2017] [Accepted: 07/27/2017] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Primaquine is the only licensed drug for eradicating Plasmodium vivax hypnozoites and, therefore, preventing relapses of vivax malaria. It is a vital component of global malaria elimination efforts. Primaquine is efficacious when supervised in clinical trials, but its effectiveness in real-world settings is unknown. We aimed to determine whether unsupervised primaquine was effective for preventing re-presentation to hospital with vivax malaria in southern Papua, Indonesia. METHODS AND FINDINGS Routinely-collected hospital surveillance data were used to undertake a pragmatic comparison of the risk of re-presentation to hospital with vivax malaria in patients prescribed dihydroartemisinin-piperaquine (DHP) combined with primaquine versus those patients prescribed DHP alone. The omission of primaquine was predominantly due to 3 stock outages. Individual clinical, pharmacy, and laboratory data were merged using individual hospital identification numbers and the date of presentation to hospital. Between April 2004 and December 2013, there were 86,797 documented episodes of vivax malaria, of which 62,492 (72.0%) were included in the analysis. The risk of re-presentation with vivax malaria within 1 year was 33.8% (95% confidence Interval [CI] 33.1%-34.5%) after initial monoinfection with P. vivax and 29.2% (95% CI 28.1%-30.4%) after mixed-species infection. The risk of re-presentation with P. vivax malaria was higher in children 1 to <5 years of age (49.6% [95% CI 48.4%-50.9%]) compared to patients 15 years of age or older (24.2% [95% CI 23.4-24.9%]); Adjusted Hazard Ratio (AHR) = 2.23 (95% CI 2.15-2.31), p < 0.001. Overall, the risk of re-presentation was 37.2% (95% CI 35.6%-38.8%) in patients who were prescribed no primaquine compared to 31.6% (95% CI 30.9%-32.3%) in those prescribed either a low (≥1.5 mg/kg and <5 mg/kg) or high (≥5 mg/kg) dose of primaquine (AHR = 0.90 [95% CI 0.86-0.95, p < 0.001]). Limiting the comparison to high dose versus no primaquine in the period during and 12 months before and after a large stock outage resulted in minimal change in the estimated clinical effectiveness of primaquine (AHR 0.91, 95% CI 0.85-0.97, p = 0.003). Our pragmatic study avoided the clinical influences associated with prospective study involvement but was subject to attrition bias caused by passive follow-up. CONCLUSIONS Unsupervised primaquine for vivax malaria, prescribed according to the current World Health Organization guidelines, was associated with a minimal reduction in the risk of clinical recurrence within 1 year in Papua, Indonesia. New strategies for the effective radical cure of vivax malaria are needed in resource-poor settings.
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Affiliation(s)
- Nicholas M. Douglas
- Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, Northern Territory, Australia
- Division of Infectious Diseases, Christchurch Hospital, Christchurch, New Zealand
| | - Jeanne Rini Poespoprodjo
- Timika Malaria Research Program, Papuan Health and Community Development Foundation, Timika, Papua, Indonesia
- Department of Child Health, Faculty of Medicine, University Gadjah Mada, Yogyakarta, Indonesia
| | - Dewi Patriani
- Department of Child Health, Faculty of Medicine, University Gadjah Mada, Yogyakarta, Indonesia
| | - Michael J. Malloy
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Victoria, Australia
- Victorian Cytology Service Ltd., Melbourne, Victoria, Australia
| | - Enny Kenangalem
- Timika Malaria Research Program, Papuan Health and Community Development Foundation, Timika, Papua, Indonesia
- Mimika District Hospital, Timika, Papua, Indonesia
| | | | - Julie A. Simpson
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Victoria, Australia
| | - Yati Soenarto
- Department of Child Health, Faculty of Medicine, University Gadjah Mada, Yogyakarta, Indonesia
| | - Nicholas M. Anstey
- Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, Northern Territory, Australia
| | - Ric N. Price
- Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, Northern Territory, Australia
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, United Kingdom
- * E-mail:
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23
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Karyana M, Devine A, Kenangalem E, Burdarm L, Poespoprodjo JR, Vemuri R, Anstey NM, Tjitra E, Price RN, Yeung S. Treatment-seeking behaviour and associated costs for malaria in Papua, Indonesia. Malar J 2016; 15:536. [PMID: 27821127 PMCID: PMC5100266 DOI: 10.1186/s12936-016-1588-8] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [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: 07/22/2016] [Accepted: 10/28/2016] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Malaria remains a significant public health issue in Eastern Indonesia, where multidrug resistant Plasmodium falciparum and Plasmodium vivax are highly prevalent. The objective of this study was to describe treatment-seeking behaviour and household costs prior to a change to a unified treatment policy of dihydroartemisinin-piperaquine in Mimika district, Papua province in 2006. METHODS In 2005 a randomized cross-sectional household survey was conducted to collect data on demographics, socio-economic status (SES), treatment-seeking, case management, and household costs. Information on the cost of illness was also collected from patients exiting health facilities, in order to compare the cost of episodes diagnosed as P. vivax compared with those diagnosed as P. falciparum. RESULTS 825 households were included in the survey. Of the 764 individuals who sought treatment for fever outside the home in the last month, 46% (349/764) went to a public health facility. Of the 894 reported visits to healthcare providers, 48% (433) resulted in a blood test, of which 78% (337) were reportedly positive. Only 10% (17/177) of individuals who reported testing positive for P. falciparum or mixed infection received the first-line treatment of chloroquine with SP, and 38% (61/159) of those with a diagnosis of P. vivax reportedly received the first-line treatment of chloroquine and primaquine. Overall, public facilities were more likely to prescribe the correct prevailing first-line drug combinations than private providers (OR = 3.77 [95% CI 2.31-6.14], p < 0.001). The mean cost to the household of an episode of P. vivax was similar to the cost of P. falciparum [US$44.50 (SD: 46.23) vs US$48.58 (SD: 64.65)]. CONCLUSIONS Private providers were a popular source of treatment for malaria, but adherence to the national guidelines was low and the economic burden of malaria for both P. falciparum and P. vivax infections was substantial. Engagement with the private sector is needed to ensure that patients have access to affordable good quality, effective diagnostics and anti-malarials for both P. falciparum and P. vivax.
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Affiliation(s)
- Muhammad Karyana
- National Institute of Health Research and Development, Ministry of Health, Jakarta, Indonesia
| | - Angela Devine
- Mahidol-Oxford Tropical Medicine Research Unit, Mahidol University, Bangkok, Thailand
- Nuffield Department of Clinical Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
| | - Enny Kenangalem
- Timika Malaria Research Program, Papuan Health and Community Development Foundation, Timika, Papua Indonesia
- Mimika District Health Authority, Timika, Papua Indonesia
| | - Lenny Burdarm
- Mimika District Health Authority, Timika, Papua Indonesia
| | - Jeanne Rini Poespoprodjo
- Timika Malaria Research Program, Papuan Health and Community Development Foundation, Timika, Papua Indonesia
- Mimika District Health Authority, Timika, Papua Indonesia
- Department of Child Health, Faculty of Medicine, University Gadjah Mada, Yogyakarta, Indonesia
| | - Ram Vemuri
- Business School, Charles Darwin University, Darwin, Australia
| | - Nicholas M. Anstey
- Global and Tropical Health Division, Menzies School of Health Research and Charles Darwin University, Darwin, Australia
| | - Emiliana Tjitra
- National Institute of Health Research and Development, Ministry of Health, Jakarta, Indonesia
| | - Ric N. Price
- Nuffield Department of Clinical Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
- Global and Tropical Health Division, Menzies School of Health Research and Charles Darwin University, Darwin, Australia
| | - Shunmay Yeung
- Department of Clinical Research, Faculty of Infectious and Tropical Disease, London School of Hygiene & Tropical Medicine, London, UK
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24
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Burdam FH, Hakimi M, Thio F, Kenangalem E, Indrawanti R, Noviyanti R, Trianty L, Marfurt J, Handayuni I, Soenarto Y, Douglas NM, Anstey NM, Price RN, Poespoprodjo JR. Asymptomatic Vivax and Falciparum Parasitaemia with Helminth Co-Infection: Major Risk Factors for Anaemia in Early Life. PLoS One 2016; 11:e0160917. [PMID: 27504828 PMCID: PMC4978495 DOI: 10.1371/journal.pone.0160917] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [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: 03/22/2016] [Accepted: 07/27/2016] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Anaemia in children under five years old is associated with poor health, growth and developmental outcomes. In Papua, Indonesia, where the burden of anaemia in infants is high, we conducted a community survey to assess the association between Plasmodium infection, helminth carriage and the risk of anaemia. METHODS A cross sectional household survey was carried out between April and July 2013 in 16 villages in the District of Mimika using a multistage sampling procedure. A total of 629 children aged 1-59 months from 800 households were included in the study. Demographic, symptom and anthropometry data were recorded using a standardized questionnaire. Blood and stool samples were collected for examination. RESULTS Of the 533 children with blood film examination, 8.8% (47) had P. vivax parasitaemia and 3.9% (21) had P. falciparum; the majority of children with malaria were asymptomatic (94.4%, 68/72). Soil transmitted helminth (STH) infection was present in 43% (105/269) of children assessed; those with STH were at significantly greater risk of P. vivax parasitaemia compared to those without STH (OR = 3.7 [95%CI 1.5-9.2], p = 0.004). Anaemia (Hb<10 g/dl) was present in 24.5% (122/497) of children and associated with P. vivax parasitaemia (OR = 2.9 [95%CI, 1.7-4.9], p = 0.001), P. falciparum parasitaemia (OR = 4.3 [95%CI, 2.0-9.4], p<0.001), hookworm carriage (OR = 2.6 [95%CI, 1.2-5.8], p = 0.026), Plasmodium-helminth coinfection (OR 4.0 [95%CI, 1.4-11.3], p = 0.008) and severe stunting (OR = 1.9 ([95%CI, 1.1-3.3], p = 0.012). CONCLUSIONS Asymptomatic P. vivax and P. falciparum infections and hookworm all contribute to risk of paediatric anaemia in coendemic areas and should be targeted with prevention and treatment programs. The relationship between helminth infections and the increased risk of P. vivax parasitaemia should be explored prospectively.
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Affiliation(s)
- Faustina Helena Burdam
- Mimika District Health Authority, Timika, Papua, Indonesia
- Timika Malaria Research Programme, Papuan Health and Community Development Foundation, Timika, Papua, Indonesia
- Maternal and Child Health and Reproductive Health, Department of Public Health, Faculty of Medicine, Universitas Gadjah Mada, Yogyakarta, Indonesia
| | - Mohammad Hakimi
- Maternal and Child Health and Reproductive Health, Department of Public Health, Faculty of Medicine, Universitas Gadjah Mada, Yogyakarta, Indonesia
| | - Franciscus Thio
- Mimika District Hospital, Timika, Papua, Indonesia
- Timika Malaria Research Programme, Papuan Health and Community Development Foundation, Timika, Papua, Indonesia
| | - Enny Kenangalem
- Mimika District Health Authority, Timika, Papua, Indonesia
- Mimika District Hospital, Timika, Papua, Indonesia
- Timika Malaria Research Programme, Papuan Health and Community Development Foundation, Timika, Papua, Indonesia
| | - Ratni Indrawanti
- Department of Child Health, Faculty of Medicine, Universitas Gadjah Mada/Dr. Sardjito Hospital, Yogyakarta, Indonesia
| | | | - Leily Trianty
- Eijkman Institute for Molecular Biology, Jakarta, Indonesia
| | - Jutta Marfurt
- Global and Tropical Health Division, Menzies School of Health Research and Charles Darwin University, Darwin, Australia
| | - Irene Handayuni
- Global and Tropical Health Division, Menzies School of Health Research and Charles Darwin University, Darwin, Australia
| | - Yati Soenarto
- Department of Child Health, Faculty of Medicine, Universitas Gadjah Mada/Dr. Sardjito Hospital, Yogyakarta, Indonesia
| | - Nicholas M. Douglas
- Global and Tropical Health Division, Menzies School of Health Research and Charles Darwin University, Darwin, Australia
| | - Nicholas M. Anstey
- Global and Tropical Health Division, Menzies School of Health Research and Charles Darwin University, Darwin, Australia
| | - Ric N. Price
- Global and Tropical Health Division, Menzies School of Health Research and Charles Darwin University, Darwin, Australia
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, United Kingdom
| | - Jeanne Rini Poespoprodjo
- Mimika District Hospital, Timika, Papua, Indonesia
- Timika Malaria Research Programme, Papuan Health and Community Development Foundation, Timika, Papua, Indonesia
- Department of Child Health, Faculty of Medicine, Universitas Gadjah Mada/Dr. Sardjito Hospital, Yogyakarta, Indonesia
- * E-mail:
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Kenangalem E, Karyana M, Burdarm L, Yeung S, Simpson JA, Tjitra E, Anstey NM, Poespoprodjo JR, Price RN, Douglas NM. Plasmodium vivax infection: a major determinant of severe anaemia in infancy. Malar J 2016; 15:321. [PMID: 27306221 PMCID: PMC4910236 DOI: 10.1186/s12936-016-1373-8] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [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: 03/22/2016] [Accepted: 06/04/2016] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Most malarious countries outside of Africa are co-endemic for Plasmodium falciparum and Plasmodium vivax. The comparative burden of anaemia in the community caused by these two species is incompletely characterized. METHODS A three-stage, cross-sectional, community survey was used to determine the proportion of moderate or severe anaemia (haemoglobin <7 g/dL) attributable to patent P. vivax, P. falciparum and mixed parasitaemia in Papua, Indonesia. Adjusted population-attributable fractions were calculated from multivariable logistic regression models. Eight hundred and twenty-five households were surveyed with a total of 5255 occupants, 3890 (74 %) of whom were present and provided a blood sample. Plasmodium falciparum parasitaemia was present in 8.1 % (n = 315) of participants, P. vivax in 6.4 % (n = 250) and mixed infections in 1.9 % (n = 72). Overall, P. falciparum was associated with a mean reduction in haemoglobin of 1.16 g/dL compared to those without patent parasitaemia [95 % confidence interval (95 % CI) 0.91, 1.41 g/dL]. The corresponding values for P. vivax and mixed infections were 0.66 g/dL (95 % CI 0.35, 0.96) and 1.25 g/dL (0.71, 1.80), respectively. Overall, 16.7 % (95 % CI 8.52, 24.2 %) of haemoglobin concentrations <7 g/dL in the community were estimated to be attributable to patent parasitaemia. The fractions for infants and 1-5 years old were 34.4 % (95 % CI -3.30, 58.3 %) and 23.2 % (95 % CI 3.34, 39.0 %), respectively. Plasmodium vivax was associated with a greater than threefold higher attributable fraction of anaemia in infants compared with P. falciparum [27.6 % (95 % CI -3.20, 49.2 %) versus 7.94 % (-5.87, 20.0 %)]. CONCLUSION Despite comparatively low-level endemicity, malaria is associated with a significant proportion of all cases of community anaemia in southern Papua. Contrary to its benign reputation, P. vivax is an important and preventable risk factor for anaemia during infancy-a probable consequence of relapsing disease prior to the development of immunity.
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Affiliation(s)
- Enny Kenangalem
- Timika Malaria Research Program, Papuan Health and Community Development Foundation, Timika, Papua Indonesia ,Mimika District Health Authority, Timika, Papua Indonesia
| | - Muhammad Karyana
- National Institute of Health Research and Development, Ministry of Health, Jakarta, Indonesia
| | - Lenny Burdarm
- Mimika District Health Authority, Timika, Papua Indonesia
| | - Shunmay Yeung
- Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Julie A. Simpson
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Australia
| | - Emiliana Tjitra
- National Institute of Health Research and Development, Ministry of Health, Jakarta, Indonesia
| | - Nicholas M. Anstey
- Global and Tropical Health Division, Menzies School of Health Research and Charles Darwin University, PO Box 41096, Casuarina, Darwin, 0811 Australia ,Division of Medicine, Royal Darwin Hospital, Darwin, NT Australia
| | - Jeanne Rini Poespoprodjo
- Timika Malaria Research Program, Papuan Health and Community Development Foundation, Timika, Papua Indonesia ,Global and Tropical Health Division, Menzies School of Health Research and Charles Darwin University, PO Box 41096, Casuarina, Darwin, 0811 Australia ,Department of Child Health, Faculty of Medicine, University Gadjah Mada, Yogyakarta, Indonesia
| | - Ric N. Price
- Global and Tropical Health Division, Menzies School of Health Research and Charles Darwin University, PO Box 41096, Casuarina, Darwin, 0811 Australia ,Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
| | - Nicholas M. Douglas
- Global and Tropical Health Division, Menzies School of Health Research and Charles Darwin University, PO Box 41096, Casuarina, Darwin, 0811 Australia ,Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK ,Division of Medicine, Christchurch Hospital, Christchurch, New Zealand
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Wirjanata G, Handayuni I, Zaloumis SG, Chalfein F, Prayoga P, Kenangalem E, Poespoprodjo JR, Noviyanti R, Simpson JA, Price RN, Marfurt J. Analysis of ex vivo drug response data of Plasmodium clinical isolates: the pros and cons of different computer programs and online platforms. Malar J 2016; 15:137. [PMID: 26935745 PMCID: PMC4776429 DOI: 10.1186/s12936-016-1173-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [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: 08/18/2015] [Accepted: 02/17/2016] [Indexed: 11/30/2022] Open
Abstract
Background In vitro drug susceptibility testing of malaria parasites remains an important component of surveillance for anti-malarial drug resistance. The half-maximal inhibition of growth (IC50) is the most commonly reported parameter expressing drug susceptibility, derived by a variety of statistical approaches, each with its own advantages and disadvantages. Methods In this study, licensed computer programs WinNonlin and GraphPad Prism 6.0, and the open access programs HN-NonLin, Antimalarial ICEstimator (ICE), and In Vitro Analysis and Reporting Tool (IVART) were tested for their ease of use and ability to estimate reliable IC50 values from raw drug response data from 31 Plasmodium falciparum and 29 P. vivax clinical isolates tested with five anti-malarial agents: chloroquine, amodiaquine, piperaquine, mefloquine, and artesunate. Results The IC50 and slope estimates were similar across all statistical packages for all drugs tested in both species. There was good correlation of results derived from alternative statistical programs and non-linear mixed-effects modelling (NONMEM) which models all isolate data simultaneously. The user-friendliness varied between packages. While HN-NonLin and IVART allow users to enter the data in 96-well format, IVART and GraphPad Prism 6.0 are capable to analyse multiple isolates and drugs in parallel. WinNonlin, GraphPad Prism 6.0, IVART, and ICE provide alerts for non-fitting data and incorrect data entry, facilitating data interpretation. Data analysis using WinNonlin or ICE took the longest computationally, whilst the offline ability of GraphPad Prism 6.0 to analyse multiple isolates and drugs simultaneously made it the fastest among the programs tested. Conclusion IC50 estimates obtained from the programs tested were comparable. In view of processing time and ease of analysis, GraphPad Prism 6.0 or IVART are best suited for routine and large-scale drug susceptibility testing. Electronic supplementary material The online version of this article (doi:10.1186/s12936-016-1173-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Grennady Wirjanata
- Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, PO Box 41096, Casuarina, Darwin, NT, 0811, Australia.
| | - Irene Handayuni
- Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, PO Box 41096, Casuarina, Darwin, NT, 0811, Australia.
| | - Sophie G Zaloumis
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Australia.
| | - Ferryanto Chalfein
- Papuan Health and Community Development Foundation (PHCDF), Timika, Papua, Indonesia.
| | - Pak Prayoga
- Papuan Health and Community Development Foundation (PHCDF), Timika, Papua, Indonesia.
| | - Enny Kenangalem
- Papuan Health and Community Development Foundation (PHCDF), Timika, Papua, Indonesia. .,District Health Authority, Timika, Papua, Indonesia.
| | - Jeanne Rini Poespoprodjo
- Papuan Health and Community Development Foundation (PHCDF), Timika, Papua, Indonesia. .,District Health Authority, Timika, Papua, Indonesia. .,Department of Paediatrics, Faculty of Medicine, Gadjah Mada University, Yogyakarta, Indonesia.
| | - Rintis Noviyanti
- Eijkman Institute for Molecular Biology, Jl. Diponegoro 69, 10430, Jakarta, Indonesia.
| | - Julie A Simpson
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Australia.
| | - Ric N Price
- Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, PO Box 41096, Casuarina, Darwin, NT, 0811, Australia. .,Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK.
| | - Jutta Marfurt
- Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, PO Box 41096, Casuarina, Darwin, NT, 0811, Australia.
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Langford S, Douglas NM, Lampah DA, Simpson JA, Kenangalem E, Sugiarto P, Anstey NM, Poespoprodjo JR, Price RN. Plasmodium malariae Infection Associated with a High Burden of Anemia: A Hospital-Based Surveillance Study. PLoS Negl Trop Dis 2015; 9:e0004195. [PMID: 26720002 PMCID: PMC4697806 DOI: 10.1371/journal.pntd.0004195] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.7] [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: 07/24/2015] [Accepted: 10/05/2015] [Indexed: 11/23/2022] Open
Abstract
Background Plasmodium malariae is a slow-growing parasite with a wide geographic distribution. Although generally regarded as a benign cause of malaria, it has been associated with nephrotic syndrome, particularly in young children, and can persist in the host for years. Morbidity associated with P. malariae infection has received relatively little attention, and the risk of P. malariae-associated nephrotic syndrome is unknown. Methodology/Principal Findings We used data from a very large hospital-based surveillance system incorporating information on clinical diagnoses, blood cell parameters and treatment to describe the demographic distribution, morbidity and mortality associated with P. malariae infection in southern Papua, Indonesia. Between April 2004 and December 2013 there were 1,054,674 patient presentations to Mitra Masyarakat Hospital of which 196,380 (18.6%) were associated with malaria and 5,097 were with P. malariae infection (constituting 2.6% of all malaria cases). The proportion of malaria cases attributable to P. malariae increased with age from 0.9% for patients under one year old to 3.1% for patients older than 15 years. Overall, 8.5% of patients with P. malariae infection required admission to hospital and the median length of stay for these patients was 2.5 days (Interquartile Range: 2.0–4.0 days). Patients with P. malariae infection had a lower mean hemoglobin concentration (9.0g/dL) than patients with P. falciparum (9.5g/dL), P. vivax (9.6g/dL) and mixed species infections (9.3g/dL). There were four cases of nephrotic syndrome recorded in patients with P. malariae infection, three of which were in children younger than 5 years old, giving a risk in this age group of 0.47% (95% Confidence Interval; 0.10% to 1.4%). Overall, 2.4% (n = 16) of patients hospitalized with P. malariae infection subsequently died in hospital, similar to the proportions for the other endemic Plasmodium species (range: 0% for P. ovale to 1.6% for P. falciparum). Conclusions/Significance Plasmodium malariae infection is relatively uncommon in Papua, Indonesia but is associated with significant morbidity from anemia and a similar risk of mortality to patients hospitalized with P. falciparum and P. vivax infection. In our large hospital database, one in 200 children under the age of 5 years with P. malariae infection were recorded as having nephrotic syndrome. Plasmodium malariae is a relatively rare, but widely distributed, cause of malaria. It can persist in the human host for years, often without causing significant symptoms. As a result, P. malariae will be a very difficult species to eradicate. Our study used data from a routine hospital-based surveillance system in southern Papua, Indonesia to describe the clinical epidemiology of P. malariae infections. Over a 10-year period there were 5,097 patient presentations to Mitra Masyarakat Hospital associated with P. malariae infection constituting 2.6% of all malaria cases. Patients with P. malariae malaria had a significantly older age distribution than those with P. vivax infections. They also had lower mean hemoglobin concentrations than patients infected with P. falciparum, P. vivax or mixed Plasmodium species. We speculate that this may be due to chronic hemolysis of parasitized and non-parasitized red cells as a result of persistent infection. One in 200 children under the age of 5 years with P. malariae infection were recorded as having nephrotic syndrome, a well-known but to date unquantified complication. Overall, 0.3% of patients with P. malariae malaria died. These findings emphasize the need to consider this parasite when designing comprehensive malaria elimination strategies.
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Affiliation(s)
- Siobhan Langford
- Global and Tropical Health Division, Menzies School of Health Research and Charles Darwin University, Casuarina, Darwin, Northern Territory, Australia
| | - Nicholas M. Douglas
- Global and Tropical Health Division, Menzies School of Health Research and Charles Darwin University, Casuarina, Darwin, Northern Territory, Australia
- Division of Medicine, Christchurch Hospital, Christchurch, New Zealand
| | - Daniel A. Lampah
- Timika Malaria Research Program, Papuan Health and Community Development Foundation, Timika, Papua, Indonesia
| | - Julie A. Simpson
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Australia
| | - Enny Kenangalem
- Timika Malaria Research Program, Papuan Health and Community Development Foundation, Timika, Papua, Indonesia
- Mimika District Health Authority, Timika, Papua, Indonesia
| | | | - Nicholas M. Anstey
- Global and Tropical Health Division, Menzies School of Health Research and Charles Darwin University, Casuarina, Darwin, Northern Territory, Australia
- Division of Medicine, Royal Darwin Hospital, Darwin, Australia
| | - Jeanne Rini Poespoprodjo
- Timika Malaria Research Program, Papuan Health and Community Development Foundation, Timika, Papua, Indonesia
- Mimika District Health Authority, Timika, Papua, Indonesia
- Department of Child Health, Faculty of Medicine, University Gadjah Mada, Yogyakarta, Indonesia
| | - Ric N. Price
- Global and Tropical Health Division, Menzies School of Health Research and Charles Darwin University, Casuarina, Darwin, Northern Territory, Australia
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, United Kingdom
- * E-mail:
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Wirjanata G, Handayuni I, Prayoga P, Apriyanti D, Chalfein F, Sebayang BF, Kho S, Noviyanti R, Kenangalem E, Campo B, Poespoprodjo JR, Price RN, Marfurt J. Quantification of Plasmodium ex vivo drug susceptibility by flow cytometry. Malar J 2015; 14:417. [PMID: 26498665 PMCID: PMC4619360 DOI: 10.1186/s12936-015-0940-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [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: 08/17/2015] [Accepted: 10/11/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The emergence and spread of multidrug-resistant Plasmodium falciparum and Plasmodium vivax highlights the need for objective measures of ex vivo drug susceptibility. Flow cytometry (FC) has potential to provide a robust and rapid quantification of ex vivo parasite growth. METHODS Field isolates from Papua, Indonesia, underwent ex vivo drug susceptibility testing against chloroquine, amodiaquine, piperaquine, mefloquine, and artesunate. A single nucleic acid stain (i.e., hydroethidine (HE) for P. falciparum and SYBR Green I (SG) for P. vivax) was used to quantify infected red blood cells by FC-based signal detection. Data derived by FC were compared to standard quantification by light microscopy (LM). A subset of isolates was used to compare single and double staining techniques. RESULTS In total, 57 P. falciparum and 23 P. vivax field isolates were collected for ex vivo drug susceptibility testing. Reliable paired data between LM and FC was obtained for 88 % (295/334) of these assays. The median difference of derived IC50 values varied from -5.4 to 6.1 nM, associated with 0.83-1.23 fold change in IC50 values between LM and FC. In 15 assays (5.1 %), the derived difference of IC50 estimates was beyond the 95 % limits of agreement; in eleven assays (3.7 %), this was attributable to low parasite growth (final schizont count < 40 %), and in four assays (1.4 %) due to low initial parasitaemia at the start of assay (<2000 µl(-1)). In a subset of seven samples, LM, single and double staining FC techniques generated similar IC50 values. CONCLUSIONS A single staining FC-based assay using a portable cytometer provides a simple, fast and versatile platform for field surveillance of ex vivo drug susceptibility in clinical P. falciparum and P. vivax isolates.
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Affiliation(s)
- Grennady Wirjanata
- Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, PO Box 41096, Casuarina, 0811, Darwin, Australia. .,Papuan Health and Community Development Foundation (PHCDF), Timika, Papua, Indonesia.
| | - Irene Handayuni
- Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, PO Box 41096, Casuarina, 0811, Darwin, Australia.
| | - Pak Prayoga
- Papuan Health and Community Development Foundation (PHCDF), Timika, Papua, Indonesia.
| | - Dwi Apriyanti
- Eijkman Institute for Molecular Biology, Jl. Diponegoro 69, Jakarta, 10430, Indonesia.
| | - Ferryanto Chalfein
- Papuan Health and Community Development Foundation (PHCDF), Timika, Papua, Indonesia.
| | - Boni F Sebayang
- Eijkman Institute for Molecular Biology, Jl. Diponegoro 69, Jakarta, 10430, Indonesia.
| | - Steven Kho
- Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, PO Box 41096, Casuarina, 0811, Darwin, Australia.
| | - Rintis Noviyanti
- Eijkman Institute for Molecular Biology, Jl. Diponegoro 69, Jakarta, 10430, Indonesia.
| | - Enny Kenangalem
- Papuan Health and Community Development Foundation (PHCDF), Timika, Papua, Indonesia. .,District Health Authority, Timika, Papua, Indonesia.
| | - Brice Campo
- Medicines for Malaria Venture (MMV), 20 rte de Pré-Bois, PO Box 1826, 1215, Geneva 15, Switzerland.
| | - Jeanne Rini Poespoprodjo
- Papuan Health and Community Development Foundation (PHCDF), Timika, Papua, Indonesia. .,District Health Authority, Timika, Papua, Indonesia. .,Department of Paediatrics, Faculty of Medicine, Gadjah Mada University, Yogyakarta, Indonesia.
| | - Ric N Price
- Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, PO Box 41096, Casuarina, 0811, Darwin, Australia. .,Nuffield Department of Clinical Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK.
| | - Jutta Marfurt
- Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, PO Box 41096, Casuarina, 0811, Darwin, Australia.
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Poespoprodjo JR, Fobia W, Kenangalem E, Lampah DA, Sugiarto P, Tjitra E, Anstey NM, Price RN. Treatment policy change to dihydroartemisinin-piperaquine contributes to the reduction of adverse maternal and pregnancy outcomes. Malar J 2015; 14:272. [PMID: 26169783 PMCID: PMC4501192 DOI: 10.1186/s12936-015-0794-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [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: 04/06/2015] [Accepted: 07/03/2015] [Indexed: 11/15/2022] Open
Abstract
Background In Papua, Indonesia, maternal malaria is prevalent, multidrug resistant and associated with adverse outcomes for mother and baby. In March 2006, anti-malarial policy was revised for the second and third trimester of pregnancy to dihydroartemisinin–piperaquine (DHP) for all species of malaria. This study presents the temporal analysis of adverse outcomes in pregnancy and early life following this policy change. Methods From April 2004 to May 2010, a standardized questionnaire was used to collect information from all pregnant women admitted to the maternity ward. A physical examination was performed on all live birth newborns. The relative risks (RR) and the associated population attributable risks (PAR) of adverse outcomes in women with a history of malaria treatment to the risk in those without a history of malaria during the current pregnancy were examined to evaluate the temporal trends before and after DHP deployment. Results Of 6,556 women enrolled with known pregnancy outcome, 1,018 (16%) reported prior anti-malarial treatment during their pregnancy. The proportion of women with malaria reporting treatment with DHP rose from 0% in 2004 to 64% (121/189) in 2010. In those with history of malaria during pregnancy, the increasing use of DHP was associated with a 54% fall in the proportion of maternal malaria at delivery and a 98% decrease in congenital malaria (from 7.1% prior to 0.1% after policy change). Overall policy change to more effective treatment was associated with an absolute 2% reduction of maternal severe anaemia and absolute 4.5% decrease in low birth weight babies. Conclusions Introduction of highly effective treatment in pregnancy was associated with a reduction of maternal malaria at delivery and improved neonatal outcomes. Ensuring universal access to arteminisin combination therapy (ACT) in pregnancy in an area of multidrug resistance has potential to impact significantly on maternal and infant health. Electronic supplementary material The online version of this article (doi:10.1186/s12936-015-0794-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Jeanne Rini Poespoprodjo
- Mimika District Health Authority, District Government Building, Jl. Cendrawasih, Timika, 99910, Papua, Indonesia. .,Timika Malaria Research Programme, Papuan Health and Community Development Foundation, Jl. SP2-SP5, RSMM Area, Timika, 99910, Papua, Indonesia. .,Department of Child Health, Faculty of Medicine, University Gadjah Mada, Jl. Kesehatan no 1, Sekip, Yogyakarta, 55284, Indonesia.
| | - Wendelina Fobia
- Timika Malaria Research Programme, Papuan Health and Community Development Foundation, Jl. SP2-SP5, RSMM Area, Timika, 99910, Papua, Indonesia.
| | - Enny Kenangalem
- Mimika District Health Authority, District Government Building, Jl. Cendrawasih, Timika, 99910, Papua, Indonesia. .,Timika Malaria Research Programme, Papuan Health and Community Development Foundation, Jl. SP2-SP5, RSMM Area, Timika, 99910, Papua, Indonesia.
| | - Daniel A Lampah
- Timika Malaria Research Programme, Papuan Health and Community Development Foundation, Jl. SP2-SP5, RSMM Area, Timika, 99910, Papua, Indonesia.
| | - Paulus Sugiarto
- Mitra Masyarakat Hospital, Jl. SP2-SP5-Charitas, Timika, 99910, Indonesia.
| | - Emiliana Tjitra
- National Institute of Health Research and Development, Ministry of Health, Jl. Percetakan Negara, Jakarta, 10560, Indonesia.
| | - Nicholas M Anstey
- Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, PO Box 41096, Casuarina, NT, 0811, Australia. .,Division of Medicine, Royal Darwin Hospital, Darwin, NT, 0810, Australia.
| | - Richard N Price
- Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, PO Box 41096, Casuarina, NT, 0811, Australia. .,Nuffield Department of Clinical Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, OX37LJ, UK.
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Douglas NM, Pontororing GJ, Lampah DA, Yeo TW, Kenangalem E, Poespoprodjo JR, Ralph AP, Bangs MJ, Sugiarto P, Anstey NM, Price RN. Mortality attributable to Plasmodium vivax malaria: a clinical audit from Papua, Indonesia. BMC Med 2014; 12:217. [PMID: 25406857 PMCID: PMC4264333 DOI: 10.1186/s12916-014-0217-z] [Citation(s) in RCA: 76] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2014] [Accepted: 10/22/2014] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Plasmodium vivax causes almost half of all malaria cases in Asia and is recognised as a significant cause of morbidity. In recent years it has been associated with severe and fatal disease. The extent to which P. vivax contributes to death is not known. METHODS To define the epidemiology of mortality attributable to vivax malaria in southern Papua, Indonesia, a retrospective clinical records-based audit was conducted of all deaths in patients with vivax malaria at a tertiary referral hospital. RESULTS Between January 2004 and September 2009, hospital surveillance identified 3,495 inpatients with P. vivax monoinfection and 65 (1.9%) patients who subsequently died. Charts for 54 of these 65 patients could be reviewed, 40 (74%) of whom had pure P. vivax infections on cross-checking. Using pre-defined conservative criteria, vivax malaria was the primary cause of death in 6 cases, a major contributor in 17 cases and a minor contributor in a further 13 cases. Extreme anaemia was the most common primary cause of death. Malnutrition, sepsis with respiratory and gastrointestinal manifestations, and chronic diseases were the commonest attributed causes of death for patients in the latter two categories. There were an estimated 293,763 cases of pure P. vivax infection in the community during the study period giving an overall minimum case fatality of 0.12 per 1,000 infections. The corresponding case fatality in hospitalised patients was 10.3 per 1,000 infections. CONCLUSIONS Although uncommonly directly fatal, vivax malaria is an important indirect cause of death in southern Papua in patients with malnutrition, sepsis syndrome and chronic diseases, including HIV infection.
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Affiliation(s)
- Nicholas M Douglas
- Global Health Division, Menzies School of Health Research and Charles Darwin University, PO Box 41096, Casuarina, Darwin, NT 0811, Australia. .,Centre for Tropical Medicine, Nuffield Department of Medicine, University of Oxford, Oxford, UK.
| | - Gysje J Pontororing
- Papuan Health and Community Development Foundation, Timika, Papua, Indonesia.
| | - Daniel A Lampah
- Papuan Health and Community Development Foundation, Timika, Papua, Indonesia.
| | - Tsin W Yeo
- Global Health Division, Menzies School of Health Research and Charles Darwin University, PO Box 41096, Casuarina, Darwin, NT 0811, Australia.
| | - Enny Kenangalem
- Papuan Health and Community Development Foundation, Timika, Papua, Indonesia. .,District Health Authority, Timika, Papua, Indonesia.
| | - Jeanne Rini Poespoprodjo
- Papuan Health and Community Development Foundation, Timika, Papua, Indonesia. .,District Health Authority, Timika, Papua, Indonesia. .,Department of Paediatrics, Faculty of Medicine, Gadjah Mada University, Yogyakarta, Indonesia.
| | - Anna P Ralph
- Global Health Division, Menzies School of Health Research and Charles Darwin University, PO Box 41096, Casuarina, Darwin, NT 0811, Australia. .,Division of Medicine, Royal Darwin Hospital, Darwin, Australia.
| | - Michael J Bangs
- Public Health & Malaria Control Department, International SOS, PT Freeport Indonesia, Kuala Kencana, Papua, Indonesia. .,Department of Entomology, Faculty of Agriculture, Kasetsart University, Bangkok, 10900, Thailand.
| | | | - Nicholas M Anstey
- Global Health Division, Menzies School of Health Research and Charles Darwin University, PO Box 41096, Casuarina, Darwin, NT 0811, Australia. .,Division of Medicine, Royal Darwin Hospital, Darwin, Australia.
| | - Ric N Price
- Global Health Division, Menzies School of Health Research and Charles Darwin University, PO Box 41096, Casuarina, Darwin, NT 0811, Australia. .,Centre for Tropical Medicine, Nuffield Department of Medicine, University of Oxford, Oxford, UK.
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Lampah DA, Yeo TW, Malloy M, Kenangalem E, Douglas NM, Ronaldo D, Sugiarto P, Simpson JA, Poespoprodjo JR, Anstey NM, Price RN. Severe malarial thrombocytopenia: a risk factor for mortality in Papua, Indonesia. J Infect Dis 2014; 211:623-34. [PMID: 25170106 PMCID: PMC4305266 DOI: 10.1093/infdis/jiu487] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [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] [Indexed: 12/24/2022] Open
Abstract
Background The significance of thrombocytopenia to the morbidity and mortality of malaria is poorly defined. We compared the platelet counts and clinical correlates of patients with and those without malaria in southern Papua, Indonesia. Methods Data were collated on patients presenting to a referral hospital between April 2004 and December 2012. Results Platelet measurements were available in 215 479 patients (23.4%), 66 421 (30.8%) of whom had clinical malaria. Patients with Plasmodium falciparum monoinfection had the lowest platelet counts and greatest risk of severe thrombocytopenia (platelet count, <50 000 platelets/µL), compared with those without malaria (adjusted odds ratio [OR], 6.03; 95% confidence interval [CI], 5.77–6.30]). The corresponding risks were 5.4 (95% CI, 5.02–5.80) for mixed infections, 3.73 (95% CI, 3.51–3.97) for Plasmodium vivax infection, and 2.16 (95% CI, 1.78–2.63) for Plasmodium malariae infection (P < .001). In total, 1.3% of patients (2701 of 215 479) died. Patients with severe malarial anemia alone (hemoglobin level, <5 g/dL) had an adjusted OR for death of 4.93 (95% CI, 3.79–6.42), those with severe malarial thrombocytopenia alone had an adjusted OR of 2.77 (95% CI, 2.20–3.48), and those with both risk factors had an adjusted OR of 13.76 (95% CI, 10.22–18.54; P < .001). Conclusions Severe thrombocytopenia identifies both children and adults at increased risk of death from falciparum or vivax malaria, particularly in those with concurrent severe anemia.
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Affiliation(s)
- Daniel A Lampah
- Timika Malaria Research Program, Papuan Health and Community Development Foundation Mimika District Health Authority
| | - Tsin W Yeo
- Global and Tropical Health Division, Menzies School of Health Research and Charles Darwin University Lee Kong Chian School of Medicine, Nanyang Technological University Institute of Infectious Disease and Epidemiology, Tan Tock Seng Hospital, Singapore
| | - Michael Malloy
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, University of Melbourne Victorian Cytology Service, Carlton, Australia
| | - Enny Kenangalem
- Timika Malaria Research Program, Papuan Health and Community Development Foundation Mimika District Health Authority
| | - Nicholas M Douglas
- Global and Tropical Health Division, Menzies School of Health Research and Charles Darwin University Division of Medicine, Christchurch Hospital, New Zealand
| | - Donny Ronaldo
- Department of Pediatrics, Faculty of Medicine, Gadjah Mada University, Yogyakarta, Indonesia
| | | | - Julie A Simpson
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, University of Melbourne
| | - Jeanne Rini Poespoprodjo
- Timika Malaria Research Program, Papuan Health and Community Development Foundation Mimika District Health Authority
| | - Nicholas M Anstey
- Global and Tropical Health Division, Menzies School of Health Research and Charles Darwin University Division of Medicine, Royal Darwin Hospital, Darwin
| | - Ric N Price
- Global and Tropical Health Division, Menzies School of Health Research and Charles Darwin University Centre for Tropical Medicine, Nuffield Department of Clinical Medicine, University of Oxford, United Kingdom
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Poespoprodjo JR, Fobia W, Kenangalem E, Lampah DA, Sugiarto P, Tjitra E, Anstey NM, Price RN. Dihydroartemisinin-piperaquine treatment of multidrug resistant falciparum and vivax malaria in pregnancy. PLoS One 2014; 9:e84976. [PMID: 24465458 PMCID: PMC3894943 DOI: 10.1371/journal.pone.0084976] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [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: 09/09/2013] [Accepted: 11/28/2013] [Indexed: 11/19/2022] Open
Abstract
Background Artemisinin combination therapy (ACT) is recommended for the treatment of multidrug resistant malaria in the second and third trimesters of pregnancy, but the experience with ACTs is limited. We review the exposure of pregnant women to the combination dihydroartemisinin-piperaquine over a 6 year period. Methods From April 2004–June 2009, a prospective hospital-based surveillance screened all pregnant women for malaria and documented maternal and neonatal outcomes. Results Data were available on 6519 pregnant women admitted to hospital; 332 (5.1%) women presented in the first trimester, 324 (5.0%) in the second, 5843 (89.6%) in the third, and in 20 women the trimester was undocumented. Peripheral parasitaemia was confirmed in 1682 women, of whom 106 (6.3%) had severe malaria. Of the 1217 women admitted with malaria in the second and third trimesters without an impending adverse outcome, those treated with DHP were more likely to be discharged with an ongoing pregnancy compared to those treated with a non-ACT regimen (Odds Ratio OR = 2.48 [1.26–4.86]); p = 0.006. However in the first trimester 63% (5/8) of women treated with oral DHP miscarried compared to 2.6% (1/38) of those receiving oral quinine; p<0.001. Of the 847 women admitted for delivery those reporting a history of malaria during their pregnancy who had been treated with quinine-based regimens rather than DHP had a higher risk of malaria at delivery (adjusted OR = 1.56 (95%CI 0.97–2.5), p = 0.068) and perinatal mortality (adjusted OR = 3.17 [95%CI: 1.17–8.60]; p = 0.023). Conclusions In the second and third trimesters of pregnancy, a three day course of DHP simplified antimalarial treatment and had significant benefits over quinine-based regimens in reducing recurrent malaria and poor fetal outcome. These data provide reassuring evidence for the rational design of prospective randomized clinical trials and pharmacokinetic studies.
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Affiliation(s)
- Jeanne Rini Poespoprodjo
- District Health Authority, Timika, Papua, Indonesia
- Menzies School of Health Research-National Institute of Health Research and Development Research Program, Timika, Papua, Indonesia
| | - Wendy Fobia
- Menzies School of Health Research-National Institute of Health Research and Development Research Program, Timika, Papua, Indonesia
| | - Enny Kenangalem
- District Health Authority, Timika, Papua, Indonesia
- Menzies School of Health Research-National Institute of Health Research and Development Research Program, Timika, Papua, Indonesia
| | - Daniel A. Lampah
- District Health Authority, Timika, Papua, Indonesia
- Menzies School of Health Research-National Institute of Health Research and Development Research Program, Timika, Papua, Indonesia
| | | | - Emiliana Tjitra
- National Institute of Health Research and Development, Ministry of Health, Jakarta, Indonesia
| | - Nicholas M. Anstey
- Global Health Division, Menzies School of Health Research and Charles Darwin University, Darwin, Northern Territory, Australia
- Division of Medicine, Royal Darwin Hospital, Darwin, Northern Territory, Australia
| | - Ric N. Price
- Global Health Division, Menzies School of Health Research and Charles Darwin University, Darwin, Northern Territory, Australia
- Division of Medicine, Royal Darwin Hospital, Darwin, Northern Territory, Australia
- Centre for Tropical Medicine, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, United Kingdom
- * E-mail:
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Douglas NM, Simpson JA, Phyo AP, Siswantoro H, Hasugian AR, Kenangalem E, Poespoprodjo JR, Singhasivanon P, Anstey NM, White NJ, Tjitra E, Nosten F, Price RN. Gametocyte dynamics and the role of drugs in reducing the transmission potential of Plasmodium vivax. J Infect Dis 2013; 208:801-12. [PMID: 23766527 PMCID: PMC3733516 DOI: 10.1093/infdis/jit261] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [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] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Designing interventions that will reduce transmission of vivax malaria requires knowledge of Plasmodium vivax gametocyte dynamics. METHODS We analyzed data from a randomized controlled trial in northwestern Thailand and 2 trials in Papua, Indonesia, to identify and compare risk factors for vivax gametocytemia at enrollment and following treatment. RESULTS A total of 492 patients with P. vivax infections from Thailand and 476 patients (162 with concurrent falciparum parasitemia) from Indonesia were evaluable. Also, 84.3% (415/492) and 66.6% (209/314) of patients with monoinfection were gametocytemic at enrollment, respectively. The ratio of gametocytemia to asexual parasitemia did not differ between acute and recurrent infections (P = .48 in Thailand, P = .08 in Indonesia). High asexual parasitemia was associated with an increased risk of gametocytemia during follow-up in both locations. In Thailand, the cumulative incidence of gametocytemia between day 7 and day 42 following dihydroartemisinin + piperaquine (DHA + PIP) was 6.92% vs 29.1% following chloroquine (P < .001). In Indonesia, the incidence of gametocytemia was 33.6% following artesunate + amodiaquine (AS + AQ), 7.42% following artemether + lumefantrine, and 6.80% following DHA + PIP (P < .001 for DHA + PIP vs AS + AQ). CONCLUSIONS P. vivax gametocyte carriage mirrors asexual-stage infection. Prevention of relapses, particularly in those with high asexual parasitemia, is likely the most important strategy for interrupting P. vivax transmission.
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Affiliation(s)
- Nicholas M Douglas
- Global Health Division, Menzies School of Health Research, Charles Darwin University, Darwin 0811, Australia
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Poespoprodjo JR, Fobia W, Kenangalem E, Hasanuddin A, Sugiarto P, Tjitra E, Anstey NM, Price RN. Highly effective therapy for maternal malaria associated with a lower risk of vertical transmission. J Infect Dis 2011; 204:1613-9. [PMID: 21908728 PMCID: PMC3192188 DOI: 10.1093/infdis/jir558] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [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] [Indexed: 11/14/2022] Open
Abstract
Background. The epidemiology of congenital malaria was investigated in a hospital-based malaria surveillance study in Papua, Indonesia. Methods. From April 2005 to January 2010, 4878 delivering women and their newborns underwent prospective clinical review and malaria screening by peripheral blood microscopy. Findings. Congenital malaria occurred in 8 per 1000 (38/4884) live births, with Plasmodium falciparum accounting for 76.3% (29) and P. vivax for 15.8% (6) of infections. Maternal malaria at delivery (adjusted odds ratio [AOR], 9.5; 95% confidence interval [CI], 4.2–21.5; P < .001), age ≤ 16 years (AOR, 4; 95% CI, 1.4–12.1; P = .011), and prior malaria during pregnancy (AOR, 2.2; 95% CI, 1.1–4.4, P = .022) were independent risk factors for vertical transmission. Of 29 mothers and neonates with contemporaneous peripheral parasitemia, 17% (5) had discordant parasite species, suggesting possible antenatal malaria transmission. Newborns with malaria were at significantly greater risk of low birth weight (AOR, 2.8; 95% CI, 1.2–6.6; P = .002). Following introduction of dihydroartemisinin-piperaquine for uncomplicated malaria in the second and third trimesters of pregnancy, congenital malaria incidence fell from 3.2% to 0.2% (odds ratio, 0.07; 95% CI, .03–.15; P < .001). Conclusions. Congenital malaria is an important cause of neonatal morbidity in this region co-endemic for P. falciparum and P. vivax malaria. The introduction of artemisinin-combination therapy was associated with a significant risk reduction in the vertical transmission of malaria.
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Poespoprodjo JR, Fobia W, Kenangalem E, Lampah DA, Warikar N, Seal A, McGready R, Sugiarto P, Tjitra E, Anstey NM, Price RN. Adverse pregnancy outcomes in an area where multidrug-resistant plasmodium vivax and Plasmodium falciparum infections are endemic. Clin Infect Dis 2008; 46:1374-81. [PMID: 18419439 DOI: 10.1086/586743] [Citation(s) in RCA: 113] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND Plasmodium falciparum infection exerts a considerable burden on pregnant women, but less is known about the adverse consequences of Plasmodium vivax infection. METHODS In Papua, Indonesia, where multiple drug resistance to both species has emerged, we conducted a cross-sectional hospital-based study to quantify the risks and consequences of maternal malaria. RESULTS From April 2004 through December 2006, 3046 pregnant women were enrolled in the study. The prevalence of parasitemia at delivery was 16.8% (432 of 2570 women had infections), with 152 (35.2%) of these 432 infections being associated with fever. The majority of infections were attributable to P. falciparum (250 [57.9%]); 146 (33.8%) of the infections were attributable to P. vivax, and 36 (8.3%) were coinfections with both species. At delivery, P. falciparum infection was associated with severe anemia (hemoglobin concentration, <7 g/dL; odds ratio [OR], 2.8; 95% confidence interval [95% CI], 2.0-4.0) and a 192 g (95% CI, 119-265) reduction in mean birth weight (P<.001). P. vivax infection was associated with an increased risk of moderate anemia (hemoglobin concentration, 7-11 g/dL; OR, 1.8; 95% CI, 1.2-2.9; P=.01) and a 108 g (95% CI, 17.5-199) reduction in mean birth weight (P<.019). Parasitemia was associated with preterm delivery (OR, 1.5; 95% CI, 1.1-2.0; P=.02) and stillbirth (OR, 2.3; 95% CI, 1.3-4.1; P=.007) but was not associated with these outcomes after controlling for the presence of fever and severe anemia, suggesting that malaria increases the risk of preterm delivery and stillbirth through fever and contribution to severe anemia rather than through parasitemia per se. CONCLUSIONS These observations highlight the need for novel, safe, and effective treatment and prevention strategies against both multidrug-resistant P. falciparum and multidrug-resistant P. vivax infections in pregnant women in areas of mixed endemicity.
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Affiliation(s)
- Jeanne Rini Poespoprodjo
- District Health Authority, School of Health Research-National Institute of Health Research and Development Malaria Research Program, Indonesia
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