Patient Knowledge on Malaria Symptoms Is a Key to Promoting Universal Access of Patients to Effective Malaria Treatment in Palawan,the Philippines

Introduction

Palawan, where health care facilities are still limited, is one of the most malaria endemic provinces in the Philippines. Since 1999, microscopists (community health workers) have been trained in malaria diagnosis and feasibility of early diagnosis and treatments have been enhanced throughout the province. To accelerate the universal access of malaria patients to diagnostic testing in Palawan, positive health seeking behavior should be encouraged when malaria infection is suspected.

Methods

In this cross-sectional study, structured interviews were carried out with residents (N = 218) of 20 remote malaria-endemic villages throughout Palawan with a history of suspected malaria from January to February in 2012. Structural equation modeling (SEM) was conducted to determine factors associated with appropriate treatment, which included: (1) socio-demographic characteristics; (2) proximity to a health facility; (3) health seeking behavior; (4) knowledge on malaria; (5) participation in community awareness-raising activities.

Results

Three factors independently associated with appropriate treatment were identified by SEM (CMIN = 10.5, df = 11, CFI = 1.000, RMSEA = .000): “living near microscopist” (p < 0.001), “not living near private pharmacy” (p < 0.01), and “having severe symptoms” (p < 0.01). “Severe symptoms” were positively correlated with more “knowledge on malaria symptoms” (p < 0.001). This knowledge was significantly increased by attending “community awareness-raising activities by microscopists” (p < 0.001).

Conclusions

In the resource-limited settings, microscopists played a significant role in providing appropriate treatment to all participants with severe malaria symptoms. However, it was considered that knowledge on malaria symptoms made participants more aware of their symptoms, and further progressed self-triage. Strengthening this recognition sensitivity and making residents aware of nearby microscopists may be the keys to accelerating universal access to effective malaria treatment in Palawan.     

Allelic diversity in the merozoite surface protein 1 gene of Plasmodium falciparum on Palawan Island, the Philippines

Allelic diversity of the Plasmodium falciparum merozoite surface protein 1 gene (msp1) is mainly generated by meiotic recombination at the mosquito stage. We investigated recombination-based allelic diversity of msp1 in a P. falciparum population from Palawan Island, the Philippines, where malaria transmission is moderate. We identified the 5' recombinant types, 3' sequence types and msp1 haplotypes (unique combinations of 5' recombinant type and 3' sequence type), and compared them with those of P. falciparum from the Solomon Islands, where malaria transmission is high. The mean number of 5' recombinant types per patient in Palawan was 1.44, which is comparable to the number for the Solomon Islands (1.41). The Palawan parasite population had 15 msp1 haplotypes, whereas the Solomon Islands population had only 8 haplotypes. The Palawan population showed strong linkage disequilibrium between polymorphic blocks/sites within msp1, which is comparable to the results for the Solomon Islands. These findings support our hypothesis that the extent of allelic diversity of msp1 is determined not only by the transmission intensity but also by the number of msp1 alleles prevalent in the local parasite population and the extent of mixed-allele infections. Contribution of a high prevalence of the chloroquine (CQ)-sensitive allele of P. falciparum CQ resistance transporter (pfcrt) to the relatively high msp1 diversity in the Palawan population is discussed.     

Promoting community knowledge and action for malaria control in rural Cambodia: potential contributions of Village Malaria Workers

ABSTRACT: BACKGROUND: Cambodia has been investing in Village Malaria Workers (VMWs) to improve malaria case management in rural areas. This study assessed the quality of the VMWs' services compared to those by a government-run health center from the perspective of community members. We focused on VMWs' contribution to promote their action to control malaria. Methodology A community-based cross-sectional study was conducted in Kampot in 2009. Interviews were conducted at every accessible household in a village with VMWs (n=153) and a village with a health center (n=159), using interviewer administered questionnaire. Preference of the interview was given to female household head. Multiple regression analyses were run to compare knowledge about malaria, preventive measures taken, and time before first malaria treatment between the two villages. FINDINGS: The villagers perceived the VMWs' services equally as good as those provided by the health center. After controlling for confounding factors, the following indicators did not show any statistical significance between two villages: community members' knowledge about malaria transmission (AOR=0.60, 95% CI=0.30-1.22) and government-recommended antimalarial (AOR=0.55, 95% CI=0.25-1.23), preventive measures taken (Beta=-0.191, p=0.315), and time before the first treatment (Beta=0.053, p=0.721). However, knowledge about malaria symptoms was significantly lower in the village with VMWs than the village with a health center (AOR=0.40, 95% CI=0.19-0.83). CONCLUSIONS: VMWs played an equivalent role as the health center in promoting malaria knowledge, action, and effective case management. Although VMWs need to enhance community knowledge about malaria symptoms, the current government policy on VMWs is reasonable and should be expanded to other malaria endemic villages.     

Domestic Larval Control Practices and Malaria Prevalence among Under-Five Children in Burkina Faso

Introduction

Larval source management has contributed to malaria decline over the past years. However, little is known about the impact of larval control practices undertaken at the household level on malaria transmission.

Methods

The study was conducted in Kaya health district after the 2010 mass distribution of insecticide treated-nets and the initiation of malaria awareness campaigns in Burkina Faso. The aim was to (i) estimate the level of domestic larval control practices (cleaning of the house and its surroundings, eradication of larval sources, and elimination of hollow objects that might collect water); (ii) identify key determinants; and (iii) explore the structural relationships between these practices, participation in awareness-raising activities and mothers’ knowledge/attitudes/practices, and malaria prevalence among under-five children.

Results

Overall, 2004 households were surveyed and 1,705 under-five children were examined. Half of the mothers undertook at least one action to control larval proliferation. Mothers who had gone to school had better knowledge about malaria and were more likely to undertake domestic larval control practices. Living in highly exposed rural areas significantly decreased the odds of undertaking larval control actions. Mothers’ participation in malaria information sessions increased the adoption of vector control actions and bednet use. Malaria prevalence was statistically lower among children in households where mothers had undertaken at least one vector control action or used bed-nets. There was a 0.16 standard deviation decrease in malaria prevalence for every standard deviation increase in vector control practices. The effect of bednet use on malaria prevalence was of the same magnitude.

Conclusion

Cleaning the house and its surroundings, eradicating breeding sites, and eliminating hollow objects that might collect water play a substantial role in preventing malaria among under-five. There is a need for national malaria control programs to include or reinforce training activities for community health workers aimed at promoting domestic larval control practices.     

Malaria during pregnancy

Each year approximately 50 million women living in malaria endemic areas become pregnant and are at risk of the adverse health impact of malaria. Approximately half of them live in sub-Saharan Africa and most of them in areas of intense falciparum transmission. The increased susceptibility to malaria of pregnant women has long been recognized. Although some progress has been accomplished in recent years, resulting in the identification of intermittent preventive treatment (IPTp) and insecticide treated nets (ITNs) as key strategies to control malaria in pregnancy in Africa, much work needs to be done to control malaria effectively in this high at risk group. There are still many gaps in knowledge that need to be addressed: from the biological mechanism(s) that explains the increased susceptibility during pregnancy, the most effective control measures in different transmission areas and the best drugs for case management.     

A research agenda for malaria eradication: vaccines

Vaccines could be a crucial component of efforts to eradicate malaria. Current attempts to develop malaria vaccines are primarily focused on Plasmodium falciparum and are directed towards reducing morbidity and mortality. Continued support for these efforts is essential, but if malaria vaccines are to be used as part of a repertoire of tools for elimination or eradication of malaria, they will need to have an impact on malaria transmission. We introduce the concept of "vaccines that interrupt malaria transmission" (VIMT), which includes not only "classical" transmission-blocking vaccines that target the sexual and mosquito stages but also pre-erythrocytic and asexual stage vaccines that have an effect on transmission. VIMT may also include vaccines that target the vector to disrupt parasite development in the mosquito. Importantly, if eradication is to be achieved, malaria vaccine development efforts will need to target other malaria parasite species, especially Plasmodium vivax, where novel therapeutic vaccines against hypnozoites or preventive vaccines with effect against multiple stages could have enormous impact. A target product profile (TPP) for VIMT is proposed and a research agenda to address current knowledge gaps and develop tools necessary for design and development of VIMT is presented.     

Taxonomic Boundaries and Craniometric Variation in the Treeshrews (Scandentia,Tupaiidae) from the Palawan Faunal Region

The taxonomy of treeshrews (Order Scandentia) has long been complicated by ambiguous morphological species boundaries, and the treeshrews of the Palawan faunal region of the Philippines are no exception. Four named forms in the genus Tupaia Raffles, 1821, have been described from four island groups based on subtle qualitative morphological characters, and as many as three distinct species have been recognized. A recent molecular phylogenetic study of relationships among Tupaia species suggests that the two currently-recognized treeshrew species from the Palawan faunal region diverged very recently relative to other sister-species divergences within the genus and may not represent species-level taxonomic entities. Here we review the taxonomic and biogeographic histories of the Tupaia taxa from this region. We also collected craniodental data from 133 skulls of all four named forms, representing five island populations, and conducted univariate and multivariate analyses on these data. Our morphometric results are consistent with molecular results, further suggesting that there is insufficient evidence to recognize T. moellendorffi Matschie, 1898, as a separate species from T. palawanensis Thomas, 1894. Our analyses also revealed a craniodentally divergent population from the island of Balabac, which has never been considered a distinct subspecies (or species) from the population on Palawan. These results have conservation implications for the island populations in our analyses, but additional surveys and molecular evidence will be required to fully assess conservation priorities for the treeshrews of the Palawan faunal region.     

A systematic review and meta-analysis of the efficacy and safety of intermittent preventive treatment of malaria in children (IPTc)

Background

Intermittent preventive treatment of malaria in children less than five years of age (IPTc) has been investigated as a measure to control the burden of malaria in the Sahel and sub-Sahelian areas of Africa where malaria transmission is markedly seasonal.

Methods and Findings

IPTc studies were identified using a systematic literature search. Meta-analysis was used to assess the protective efficacy of IPTc against clinical episodes of falciparum malaria. The impact of IPTc on all-cause mortality, hospital admissions, severe malaria and the prevalence of parasitaemia and anaemia was investigated. Three aspects of safety were also assessed: adverse reactions to study drugs, development of drug resistance and loss of immunity to malaria. Twelve IPTc studies were identified: seven controlled and five non-controlled trials. Controlled studies demonstrated protective efficacies against clinical malaria of between 31% and 93% and meta-analysis gave an overall protective efficacy of monthly administered IPTc of 82% (95%CI 75%–87%) during the malaria transmission season. Pooling results from twelve studies demonstrated a protective effect of IPTc against all-cause mortality of 57% (95%CI 24%–76%) during the malaria transmission season. No serious adverse events attributable to the drugs used for IPTc were observed in any of the studies. Data from three studies that followed children during the malaria transmission season in the year following IPTc administration showed evidence of a slight increase in the incidence of clinical malaria compared to children who had not received IPTc.

Conclusions

IPTc is a safe method of malaria control that has the potential to avert a significant proportion of clinical malaria episodes in areas with markedly seasonal malaria transmission and also appears to have a substantial protective effect against all-cause mortality. These findings indicate that IPTc is a potentially valuable tool that can contribute to the control of malaria in areas with markedly seasonal transmission.     

Population structure of an island malaria vector

The impact of islands on the population structure of Anopheles flavirostris (Ludlow) (Diptera: Culicidae), the primary malaria vector in the Philippines, was assessed. A phylogenetic analysis of 16 cytochrome oxidase subunit 1 (CO1) haplotypes revealed three clades: one basal clade containing genetically disparate haplotypes from Mindanao, and two derived clades, one of which was largely confined to the largest island, Luzon, and one that was widespread except for Luzon. For the Luzon clade, nested clade analysis revealed an isolation-by-distance effect, and a mismatch distribution analysis diagnosed a recent demographic expansion (sum of squared deviation, SDD = 0.0093, P= 0.075), which mirrors demographic attributes found in mainland primary malaria vectors and could inflate estimates of gene flow from F(ST). For the widespread clade, evidence of range expansion and past fragmentation and/or long distance colonization from the Visayas or Mindanao to Palawan is suggested. A south-to-north range expansion of An. flavirostris is suggested; estimates of coalescence for the Luzon clade was 214 000 years ago (ya) (95% confidence interval 35 600-298 000 ya), i.e. late Pleistocene. Present day rather than Pleistocene island association and some, but not all, sea barriers appeared to be important for An. flavirostris population structure. Our results suggest that endemic island malaria vector species need to be considered before any generalizations are made about the population structure of primary and secondary vectors.     

Performance of local light microscopy and the ParaScreen Pan/Pf rapid diagnostic test to detect malaria in health centers in Northwest Ethiopia

Background

Diagnostic tests are recommended for suspected malaria cases before treatment, but comparative performance of microscopy and rapid diagnostic tests (RDTs) at rural health centers has rarely been studied compared to independent expert microscopy.

Methods

Participants (N = 1997) with presumptive malaria were recruited from ten health centers with a range of transmission intensities in Amhara Regional State, Northwest Ethiopia during October to December 2007. Microscopy and ParaScreen Pan/Pf® RDT were done immediately by health center technicians. Blood slides were re-examined later at a central laboratory by independent expert microscopists.

Results

Of 1,997 febrile patients, 475 (23.8%) were positive by expert microscopists, with 57.7% P.falciparum, 24.6% P.vivax and 17.7% mixed infections. Sensitivity of health center microscopists for any malaria species was >90% in five health centers (four of which had the highest prevalence), >70% in nine centers and 44% in one site with lowest prevalence. Specificity for health center microscopy was very good (>95%) in all centers. For ParaScreen RDT, sensitivity was ≥90% in three centers, ≥70% in six and <60% in four centers. Specificity was ≥90% in all centers except one where it was 85%.

Conclusions

Health center microscopists performed well in nine of the ten health centers; while for ParaScreen RDT they performed well in only six centers. Overall the accuracy of local microscopy exceeded that of RDT for all outcomes. This study supports the introduction of RDTs only if accompanied by appropriate training, frequent supervision and quality control at all levels. Deficiencies in RDT use at some health centers must be rectified before universal replacement of good routine microscopy with RDTs. Maintenance and strengthening of good quality microscopy remains a priority at health center level.     

Malaria prevalence in Mangaluru city area in the southwestern coastal region of India

Background

Malaria is highly prevalent in many parts of India and the Indian subcontinent. Mangaluru, a city in the southwest coastal region of Karnataka state in India, and surrounding areas are malaria endemic with 10–12 annual parasite index. Despite high endemicity, to-date, very little has been reported on the epidemiology and burden of malaria in this area.

Methods

A cross-sectional surveillance of malaria cases was performed among 900 febrile symptomatic native people (long-time residents) and immigrant labourers (temporary residents) living in Mangaluru city area. During each of dry, rainy, and end of rainy season, blood samples from a group of 300 randomly selected symptomatic people were screened for malaria infection. Data on socio-demographic, literacy, knowledge of malaria, and treatment-seeking behaviour were collected to understand the socio-demographic contributions to malaria menace in this region.

Results

Malaria is prevalent in Mangaluru region throughout the year and Plasmodium vivax is predominant species compared to Plasmodium falciparum. The infection frequency was found to be high during rainy season. Infections were markedly higher in males than females, and in adults aged 16–45 years than both younger and older age groups. Also, malaria incidence was high among immigrants compared to native population. In both groups, infection rate was directly correlated with their literacy level, knowledge on malaria, dwelling environment, and protective measures used. There was also a significant difference in treatment-seeking behaviour between these two groups.

Conclusions

Malaria incidences in Mangaluru region are predominantly localized to certain hotspot areas within the city, where socioeconomically underprivileged and immigrant labourers are densely populated. These areas have inadequate sanitation and constant water stagnation, harbouring high vector density and contributing to high infection incidences. Additionally, people in these areas seldom practice preventive measures such as using bed nets. The high incidences of malaria in adults are due to minimal cloth wearing, and long working hours stretching to late evenings in places with high vector density. Instituting heightened preventive public measures by governments and creating awareness on using preventive protective and environmental hygienic measures through educational programmes may substantially reduce the risk of contracting infections in these areas and spreading to other areas.

     

Modelling the epidemiological impact of intermittent preventive treatment against malaria in infants

Background

Trials of intermittent preventive treatment against malaria in infants (IPTi) using sulphadoxine-pyrimethamine (SP) have shown a positive, albeit variable, protective efficacy against clinical malaria episodes. The impact of IPTi in different epidemiological settings and over time is unknown and predictions are hampered by the lack of knowledge about how IPTi works. We investigated mechanisms proposed for the action of IPTi and made predictions of the likely impact on morbidity and mortality.

Methods/Principal Findings

We used a comprehensive, individual-based, stochastic model of malaria epidemiology to simulate recently published trials of IPTi using SP with site-specific characteristics as inputs. This baseline model was then modified to represent hypotheses concerning the duration of action of SP, the temporal pattern of fevers caused by individual infections, potential benefits of avoiding fevers on immunity and the effect of sub-therapeutic levels of SP on parasite dynamics. The baseline model reproduced the pattern of results reasonably well. None of the models based on alternative hypotheses improved the fit between the model predictions and observed data. Predictions suggest that IPTi would have a beneficial effect across a range of transmission intensities. IPTi was predicted to avert a greater number of episodes where IPTi coverage was higher, the health system treatment coverage lower, and for drugs which were more efficacious and had longer prophylactic periods. The predicted cumulative benefits were proportionately slightly greater for severe malaria episodes and malaria-attributable mortality than for acute episodes in the settings modelled. Modest increased susceptibility was predicted between doses and following the last dose, but these were outweighed by the cumulative benefits. The impact on transmission intensity was negligible.

Conclusions

The pattern of trial results can be accounted for by differences between the trial sites together with known features of malaria epidemiology and the action of SP. Predictions suggest that IPTi would have a beneficial impact across a variety of epidemiological settings.     

Forty years of malaria eradication in Sardinia. A new appraisal of a great enterprise

The campaign against malaria in Sardinia carried out by the Ente Regionale per la Lotta Anti-Anofelica in Sardegna (ERLAAS), appears today as one of the greatest efforts against malaria since the discovery of its aetiology and mode of transmission. The disease was eradicated without achieving the eradication of the vector, Anopheles labranchiae, the main objective of the campaign. This species eradication failure had been at first attributed to the indigenous character of A. labranchiae and its long standing in the island. A more recent analysis, based on paleoclimatological information, makes virtually impossible the presence of A. labranchiae during the last (Würm) glacial period and indicates a comparatively recent introduction of the species in the island. It was the absence of A. atroparvus, with which it has usually to compete in Southern Europe, what permitted the wide distribution of A. labrianchiae in the island. Four decades after the events the concept of species eradication as an anti-malaria weapon appears as basically wrong, the results of Sardinia as well as those obtained in the Italian mainland having demonstrated that the eradication of the vector was not required for the successful eradication of the disease.     

Duration of protection against malaria and anaemia provided by intermittent preventive treatment in infants in Navrongo, Ghana

Background

Intermittent preventive treatment for malaria in Infants (IPTi) has been shown to give effective and safe protection against malaria. It has been suggested that IPTi might have long-lasting beneficial effects but, in most settings, the protection provided by IPTi appears to be short-lived. Knowledge of the duration of protection given by IPTi would help interpret the results of existing trials and suggest optimal delivery schedules for IPTi. This study investigated how the protective efficacy of IPTi against malaria and anaemia changes over time.

Methods and Findings

A secondary analysis of data from a cluster-randomised, placebo-controlled trial of IPTi using sulfadoxine-pyrimethamine (SP) in Ghana was conducted. In this trial IPTi was given to 2485 infants at 3, 4, 9 and 12 months of age; children remained in follow-up until two years of age. Poisson regression with a random effect to adjust for the cluster-randomised design was used to determine protective efficacy of IPTi against clinical malaria and anaemia in defined time strata following administration of IPTi. Analysis of first-or-only clinical malaria episode following the individual IPTi doses showed that some protection against malaria lasted between 4 to 6 weeks. A similar pattern was seen when the incidence of all malaria episodes up to 2 years of age was analysed in relation to the most recent IPT, by pooling the incidence of malaria after the individual IPTi doses. Protective efficacy within four weeks of IPTi was 75.2% (95% CI: 66–82) against malaria, 78.9% (95% CI: 69–86) against high parasite density malaria, and 93.8% (95% CI: 73–99) against anaemia. Protection against these outcomes was short-lived, with evidence of any effect lasting for only 6, 6 and 4 weeks respectively. Protection in children who were parasitaemic when receiving IPTi appeared to be of shorter duration than in uninfected children. There was no evidence of any benefit of IPTi after the immediate period following the IPTi doses.

Conclusions

Intermittent preventive treatment provides considerable protection against malaria and anaemia for short periods, even in an area of intense seasonal transmission. Due to the relatively short duration of protection provided by each dose of IPTi, this treatment will be of most benefit when delivered at the time of peak malaria incidence.     

Modelling the protective efficacy of alternative delivery schedules for intermittent preventive treatment of malaria in infants and children

Background

Intermittent preventive treatment in infants (IPTi) with sulfadoxine-pyrimethamine (SP) is recommended by WHO where malaria incidence in infancy is high and SP resistance is low. The current delivery strategy is via routine Expanded Program on Immunisation contacts during infancy (EPI-IPTi). However, improvements to this approach may be possible where malaria transmission is seasonal, or where the malaria burden lies mainly outside infancy.

Methods and Findings

A mathematical model was developed to estimate the protective efficacy (PE) of IPT against clinical malaria in children aged 2-24 months, using entomological and epidemiological data from an EPI-IPTi trial in Navrongo, Ghana to parameterise the model. The protection achieved by seasonally-targeted IPT in infants (sIPTi), seasonal IPT in children (sIPTc), and by case-management with long-acting artemisinin combination therapies (LA-ACTs) was predicted for Navrongo and for sites with different transmission intensity and seasonality. In Navrongo, the predicted PE of sIPTi was 26% by 24 months of age, compared to 16% with EPI-IPTi. sIPTc given to all children under 2 years would provide PE of 52% by 24 months of age. Seasonally-targeted IPT retained its advantages in a range of transmission patterns. Under certain circumstances, LA-ACTs for case-management may provide similar protection to EPI-IPTi. However, EPI-IPTi or sIPT combined with LA-ACTs would be substantially more protective than either strategy used alone.

Conclusion

Delivery of IPT to infants via the EPI is sub-optimal because individuals are not protected by IPT at the time of highest malaria risk, and because older children are not protected. Alternative delivery strategies to the EPI are needed where transmission varies seasonally or the malaria burden extends beyond infancy. Long-acting ACTs may also make important reductions in malaria incidence. However, delivery systems must be developed to ensure that both forms of chemoprevention reach the individuals who are most exposed to malaria.     

Spatially explicit burden estimates of malaria in Tanzania: bayesian geostatistical modeling of the malaria indicator survey data

A national HIV/AIDS and malaria parasitological survey was carried out in Tanzania in 2007-2008. In this study the parasitological data were analyzed: i) to identify climatic/environmental, socio-economic and interventions factors associated with child malaria risk and ii) to produce a contemporary, high spatial resolution parasitaemia risk map of the country. Bayesian geostatistical models were fitted to assess the association between parasitaemia risk and its determinants. bayesian kriging was employed to predict malaria risk at unsampled locations across Tanzania and to obtain the uncertainty associated with the predictions. Markov chain Monte Carlo (MCMC) simulation methods were employed for model fit and prediction. Parasitaemia risk estimates were linked to population data and the number of infected children at province level was calculated. Model validation indicated a high predictive ability of the geostatistical model, with 60.00% of the test locations within the 95% credible interval. The results indicate that older children are significantly more likely to test positive for malaria compared with younger children and living in urban areas and better-off households reduces the risk of infection. However, none of the environmental and climatic proxies or the intervention measures were significantly associated with the risk of parasitaemia. Low levels of malaria prevalence were estimated for Zanzibar island. The population-adjusted prevalence ranges from 0.29% in Kaskazini province (Zanzibar island) to 18.65% in Mtwara region. The pattern of predicted malaria risk is similar with the previous maps based on historical data, although the estimates are lower. The predicted maps could be used by decision-makers to allocate resources and target interventions in the regions with highest burden of malaria in order to reduce the disease transmission in the country.     

Integrating phylogenetic and taxonomic evidence illuminates complex biogeographic patterns along Huxley’s modification of Wallace’s Line

Aim Nearly 150 years ago, T. H. Huxley modified Wallace’s Line, including the island of Palawan as a component of the Asian biogeographic realm and separating it from the oceanic Philippines. Although Huxley recognized some characteristics of a transition between the regions, Palawan has since been regarded primarily as a peripheral component of the Sunda Shelf. However, several recent phylogenetic studies of Southeast Asian lineages document populations on Palawan to be closely related to taxa from the oceanic Philippines, apparently contradicting the biogeographic association of Palawan with the Sunda Shelf. In the light of recent evidence, we evaluate taxonomic and phylogenetic data in an attempt to identify the origin(s) of Palawan’s terrestrial vertebrate fauna. Location The Sunda Shelf and the Philippines. Methods We review distributional and phylogenetic data for populations of terrestrial vertebrates from Palawan. Using taxonomic data, we compare the number of Palawan taxa (species and genera) shared with the Sunda Shelf and oceanic Philippines. Among widespread lineages, we use phylogenetic data to identify the number of Palawan taxa with sister relationships to populations or species from the Sunda Shelf or oceanic Philippines. Results Although many terrestrial vertebrate taxa are shared between Palawan and the Sunda Shelf, an increasing number of species and populations are now recognized as close relatives of lineages from the oceanic Philippines. Among the 39 putative lineages included in molecular phylogenetic studies with sampling from the Sunda Shelf, Palawan and the oceanic Philippines, 17 of them reveal sister relationships between lineages from Palawan and the oceanic Philippines. Main conclusions Rather than a simple nested subset of Sunda Shelf populations, Palawan is best viewed as having played multiple biogeographic roles, including a young and old extension of the Sunda Shelf, a springboard to diversification in the oceanic Philippines, and a biogeographic component of the Philippine archipelago. Palawan has a long, complex geological history, which may explain this variation in pattern. Huxley originally noted transitional elements in Palawan’s fauna; we therefore suggest that his modification of Wallace’s Line should be recognized as a filter zone, reflecting both his original intent and available taxonomic and molecular evidence.     

Seasonal malaria chemoprevention: successes and missed opportunities

Seasonal malaria chemoprevention (SMC) was recommended in 2012 for young children in the Sahel during the peak malaria transmission season. Children are given a single dose of sulfadoxine/pyrimethamine combined with a 3-day course of amodiaquine, once a month for up to 4 months. Roll-out and scale-up of SMC has been impressive, with 12 million children receiving the intervention in 2016. There is evidence of its overall benefit in routine implementation settings, and a meta-analysis of clinical trial data showed a 75% decrease in clinical malaria compared to placebo. SMC is not free of shortcomings. Its target zone includes many hard-to-reach areas, both because of poor infrastructure and because of political instability. Treatment adherence to a 3-day course of preventive treatment has not been fully documented, and could prove challenging. As SMC is scaled up, integration into a broader, community-based paradigm which includes other preventive and curative activities may prove beneficial, both for health systems and for recipients.     

Effect of transmission setting and mixed species infections on clinical measures of malaria in Malawi

Background

In malaria endemic regions people are commonly infected with multiple species of malaria parasites but the clinical impact of these Plasmodium co-infections is unclear. Differences in transmission seasonality and transmission intensity between endemic regions have been suggested as important factors in determining the effect of multiple species co-infections.

Principal Findings

In order to investigate the impact of multiple-species infections on clinical measures of malaria we carried out a cross-sectional community survey in Malawi, in 2002. We collected clinical and parasitological data from 2918 participants aged >6 months, and applied a questionnaire to measure malaria morbidity. We examined the effect of transmission seasonality and intensity on fever, history of fever, haemoglobin concentration ([Hb]) and parasite density, by comparing three regions: perennial transmission (PT), high intensity seasonal transmission (HIST) and low intensity seasonal transmission (LIST). These regions were defined using multi-level modelling of PCR prevalence data and spatial and geo-climatic measures. The three Plasmodium species (P. falciparum, P. malariae and P. ovale) were randomly distributed amongst all children but not adults in the LIST and PT regions. Mean parasite density in children was lower in the HIST compared with the other two regions. Mixed species infections had lower mean parasite density compared with single species infections in the PT region. Fever rates were similar between transmission regions and were unaffected by mixed species infections. A history of fever was associated with single species infections but only in the HIST region. Reduced mean [Hb] and increased anaemia was associated with perennial transmission compared to seasonal transmission. Children with mixed species infections had higher [Hb] in the HIST region.

Conclusions

Our study suggests that the interaction of Plasmodium co-infecting species can have protective effects against some clinical outcomes of malaria but that this is dependent on the seasonality and intensity of malaria transmission.     

Is the Mbita trap a reliable tool for evaluating the density of anopheline vectors in the highlands of Madagascar?

Background

Malaria can be eradicated from islands. To assess the prospects for eradication of malaria from the island of Príncipe in the Gulf of Guinea, we fitted a mathematical model to age-prevalence curves and thus obtained estimates of the vectorial capacity and of the basic reproductive number (R ₀) for malaria.

Methods

A cross-sectional malariological survey was carried out, in mid-1999, in six communities, comprising circa 17% of the total 6,000 population of the island. All houses in these communities were registered and their mode of construction recorded. Thick and thin blood films were prepared from all consenting individuals. Each individual was asked whether they possessed a mosquito net, whether they had slept under a mosquito net the previous night, whether they were allergic to chloroquine, and whether they had visited the main island of São Tomé since the beginning of the year. Outpatient records from March 1999 until the end of December 2000 were also examined and the age and place of residence of diagnosed cases noted.

Results

203 (19.8%) of the 1,026 individuals examined were found to be infected with Plasmodium falciparum. By fitting the mathematical model of the Garki project to the age-prevalence curve we estimate that the basic reproductive number, R ₀, on the island is approximately 1.6. Over a period of one year, a total of 1,792 P. falciparum cases reported to an outpatient facility at the island's hospital. Overall, 54% of the people interviewed slept under mosquito nets and were at reduced risk of infection. Conversely, people living in houses with openings between the top of the wall and the roof had higher risk of infection.

Conclusion

This high incidence suggests that most of the malaria cases on the island attend the hospital and that treatment of these cases is an important factor reducing the effective rate of transmission. Providing that clinical cases are effectively treated, endemic malaria can probably be eliminated from the island mainly by reducing exposure to the vector with simple measures such as insecticide-treated nets and mosquito-proofing of dwellings. In contrast to traditional malaria eradication strategies, this would avoid the risk of malaria epidemics because the reduction in R ₀ should be sustainable.