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.     

The origins,isolation, and biological characterization of rodent malaria parasites

Rodent malaria parasites have been widely used in all aspects of malaria research to study parasite development within rodent and insect hosts, drug resistance, disease pathogenesis, host immune response, and vaccine efficacy. Rodent malaria parasites were isolated from African thicket rats and initially characterized by scientists at the University of Edinburgh, UK, particularly by Drs. Richard Carter, David Walliker, and colleagues. Through their efforts and elegant work, many rodent malaria parasite species, subspecies, and strains are now available. Because of the ease of maintaining these parasites in laboratory mice, genetic crosses can be performed to map the parasite and host genes contributing to parasite growth and disease severity. Recombinant DNA technologies are now available to manipulate the parasite genomes and to study gene functions efficiently. In this chapter, we provide a brief history of the isolation and species identification of rodent malaria parasites. We also discuss some recent studies to further characterize the different developing stages of the parasites including parasite genomes and chromosomes. Although there are differences between rodent and human malaria parasite infections, the knowledge gained from studies of rodent malaria parasites has contributed greatly to our understanding of and the fight against human malaria.     

Malaria in India: Challenges and opportunities

India contributes about 70% of malaria in the South East Asian Region of WHO. Although annually India reports about two million cases and 1000 deaths attributable to malaria, there is an increasing trend in the proportion of Plasmodium falciparum as the agent. There exists heterogeneity and variability in the risk of malaria transmission between and within the states of the country as many ecotypes/paradigms of malaria have been recognized. The pattern of clinical presentation of severe malaria has also changed and while multi-organ failure is more frequently observed in falciparum malaria, there are reports of vivax malaria presenting with severe manifestations. The high burden populations are ethnic tribes living in the forested pockets of the states like Orissa, Jharkhand, Madhya Pradesh, Chhattisgarh and the North Eastern states which contribute bulk of morbidity and mortality due to malaria in the country. Drug resistance, insecticide resistance, lack of knowledge of actual disease burden along with new paradigms of malaria pose a challenge for malaria control in the country. Considering the existing gaps in reported and estimated morbidity and mortality, need for estimation of true burden of malaria has been stressed. Administrative, financial, technical and operational challenges faced by the national programme have been elucidated. Approaches and priorities that may be helpful in tackling serious issues confronting malaria programme have been outlined.     

Environmental Management for Malaria Control: Knowledge and Practices in Mvomero,Tanzania

Environmental conditions play an important role in the transmission of malaria; therefore, regulating these conditions can help to reduce disease burden. Environmental management practices for disease control can be implemented at the community level to complement other malaria control methods. This study assesses current knowledge and practices related to mosquito ecology and environmental management for malaria control in a rural, agricultural region of Tanzania. Household surveys were conducted with 408 randomly selected respondents from 10 villages and qualitative data were collected through focus group discussions and in-depth interviews. Results show that respondents are well aware of the links between mosquitoes, the environment, and malaria. Most respondents stated that cleaning the environment around the home, clearing vegetation around the home, or draining stagnant water can reduce mosquito populations, and 63% of respondents reported performing at least one of these techniques to protect themselves from malaria. It is clear that many respondents believe that these environmental management practices are effective malaria control methods, but the actual efficacy of these techniques for controlling populations of vectors or reducing malaria prevalence in the varying ecological habitats in Mvomero is unknown. Further research should be conducted to determine the effects of different environmental management practices on both mosquito populations and malaria transmission in this region, and increased participation in effective techniques should be promoted.     

Plasmodium berghei: the application of cultivation and purification techniques to molecular studies of malaria parasites

Species of malaria parasites that infect rodents provide models for the study of the biology of malaria parasites that infect humans. In this article, Chris Janse and Andy Waters describe some of the recent advances in the cultivation and purification methodology of one of these species, Plasmodium berghei. The improvement of these techniques, and the increasing knowledge about the molecular biology of P. berghei enhance the value of this particular rodent model for the investigation of many aspects of the biology of Plasmodium.     

Targeting Human Transmission Biology for Malaria Elimination

Malaria remains one of the leading causes of death worldwide, despite decades of public health efforts. The recent commitment by many endemic countries to eliminate malaria marks a shift away from programs aimed at controlling disease burden towards one that emphasizes reducing transmission of the most virulent human malaria parasite, Plasmodium falciparum. Gametocytes, the only developmental stage of malaria parasites able to infect mosquitoes, have remained understudied, as they occur in low numbers, do not cause disease, and are difficult to detect in vivo by conventional methods. Here, we review the transmission biology of P. falciparum gametocytes, featuring important recent discoveries of genes affecting parasite commitment to gametocyte formation, microvesicles enabling parasites to communicate with each other, and the anatomical site where immature gametocytes develop. We propose potential parasite targets for future intervention and highlight remaining knowledge gaps.     

Barriers to Malaria Control among Marginalized Tribal Communities: A Qualitative Study

Background

Malaria infection accounts for over one million deaths worldwide annually. India has the highest number of malaria deaths outside Africa, with half among Indian tribal communities. Our study sought to identify barriers to malaria control within tribal populations in malaria-endemic Gadchiroli district, Maharashtra.

Methods and Findings

This qualitative study was conducted via focus groups and interviews with 84 participants, and included tribal villagers, traditional healers, community health workers (CHWs), medical officers, and district officials. Questions assessed knowledge about malaria, behavior during early stages of infection, and experiences with prevention among tribal villagers and traditional healers. CHWs, medical officers, and district officials were asked about barriers to treating and preventing malaria among tribal populations. Data were inductively analyzed and assembled into broader explanation linking barriers to geographical, cultural and social factors. Findings indicate lack of knowledge regarding malaria symptoms and transmission. Fever cases initially present to traditional healers or informal providers who have little knowledge of malaria or high-risk groups such as children and pregnant women. Tribal adherence with antimalarial medications is poor. Malaria prevention is inadequate, with low-density and inconsistent use of insecticide-treated nets (ITNs). Malaria educational materials are culturally inappropriate, relying on dominant language literacy. Remote villages and lack of transport complicate surveillance by CHWs. Costs of treating malaria outside the village are high.

Conclusions

Geographic, cultural, and social factors create barriers to malaria control among tribal communities in India. Efforts to decrease malaria burden among these populations must consider such realities. Our results suggest improving community-level knowledge about malaria using culturally-appropriate health education materials; making traditional healers partners in malaria control; promoting within-village rapid diagnosis and treatment; increasing ITN distribution and promoting their use as potential strategies to decrease infection rates in these communities. These insights may be used to shape malaria control programs among marginalized populations.     

DNA-binding antibodies and parasitic diseases

DNA-binding antibodies are produced during the course of many parasitic infections, including malaria, leprosy and schistosomiasis. These antibodies are also present in certain autoimmune diseases, such as systemic lupus erythematosus, and much information is available about their properties and contribution to related disease processes Here, Anne Wozencraft and Norman Staines consider how DNA-binding antibodies might arise during parasitic infection and discuss how an increased knowledge of their properties and functions could lead to a greater understanding of mechanisms of immuno-pathology in these diseases.     

Determining the impact of community awareness-raising activities on the prevention of malaria transmission in Palawan,the Philippines

Palawan has the highest malaria endemicity in the Philippines, and malaria remains a major health burden in the region. In 1999, 344 microscopists were trained in Palawan. This allowed for early diagnosis and prompt treatment throughout the island. To take a significant step toward the elimination of malaria on the island, microscopists implemented community awareness-raising activities aimed at preventing transmission of malaria. The objective of the present study was to determine the impact of these activities on the self-implemented preventive measures against malaria by the ex-patients of the microscopists. Structured interviews were carried out from January to February in 2012, in 20 remote malaria-endemic villages throughout Palawan. In total, 141 ex-patients who had previously been diagnosed malaria-positive by the microscopists, volunteered to participate in the present study. Structural equation modeling was conducted to determine factors associated with self-implemented preventive measures against malaria, which included: (1) place of residence; (2) socio-demographic characteristics; (3) knowledge on malaria; (4) participation in community awareness-raising activities for malaria prevention; and (5) satisfaction with microscopists. Structural equation modeling identified six significant factors independently associated with self-implemented preventive measures against malaria; ethnicity, knowledge on malaria transmission, knowledge on vector species, knowledge on vector's most active time, participation in awareness-raising activities for malaria prevention by microscopists, and satisfaction with microscopists. Tagalog ethnicity (the predominant ethnic group) was positively related to better self-implemented preventive measures. In conclusion, aside from providing early diagnosis and treatment, microscopists played a significant role in self-implemented preventive measures against malaria. The strengthening of awareness-raising activities by microscopists was suggested to be an effective strategy for reducing malaria re-infection in Palawan. These activities should be strengthened to improve preventive measures implemented by ex-patients traveling to mountain areas and to enhance the knowledge on malaria transmission particularly among indigenous residents.     

An exploratory study of community factors relevant for participatory malaria control on Rusinga Island, western Kenya

Background

Capacity strengthening of rural communities, and the various actors that support them, is needed to enable them to lead their own malaria control programmes. Here the existing capacity of a rural community in western Kenya was evaluated in preparation for a larger intervention.

Methods

Focus group discussions and semi-structured individual interviews were carried out in 1,451 households to determine (1) demographics of respondent and household; (2) socio-economic status of the household; (3) knowledge and beliefs about malaria (symptoms, prevention methods, mosquito life cycle); (4) typical practices used for malaria prevention; (5) the treatment-seeking behaviour and household expenditure for malaria treatment; and (6) the willingness to prepare and implement community-based vector control.

Results

Malaria was considered a major threat to life but relevant knowledge was a chimera of scientific knowledge and traditional beliefs, which combined with socio-economic circumstances, leads to ineffective malaria prevention. The actual malaria prevention behaviour practiced by community members differed significantly from methods known to the respondents. Beside bednet use, the major interventions implemented were bush clearing and various hygienic measures, even though these are ineffective for malaria prevention. Encouragingly, most respondents believed malaria could be controlled and were willing to contribute to a community-based malaria control program but felt they needed outside assistance.

Conclusion

Culturally sensitive but evidence-based education interventions, utilizing participatory tools, are urgently required which consider traditional beliefs and enable understanding of causal connections between mosquito ecology, parasite transmission and the diagnosis, treatment and prevention of disease. Community-based organizations and schools need to be equipped with knowledge through partnerships with national and international research and tertiary education institutions so that evidence-based research can be applied at the grassroots level.     

Cryptic erythrocytic infections in Plasmodium vivax,another challenge to its elimination

Human malaria caused by Plasmodium vivax infection (vivax malaria) is a major global health issue. It is the most geographically widespread form of the disease, accounting for 7 million annual clinical cases, the majority of cases in America and Asia and an estimation of over 2.5 billion people living under risk of infection. The general perception towards vivax malaria has shifted recently, following a series of reports, from being viewed as a benign infection to the recognition of its potential for more severe manifestations including fatal cases. However, the underlying pathogenic mechanisms of vivax malaria remain largely unresolved. Asymptomatic carriers of malaria parasites are a major challenge for malaria elimination. In the case of P. vivax, it has been widely accepted that the only source of cryptic parasites is hypnozoite dormant stages. Here, we will review new evidence indicating that cryptic erythrocytic niches outside the liver, in particular in the spleen and bone marrow, can represent a major source of asymptomatic infections. The origin of such parasites is being controversial and many key gaps in the knowledge of such infections remain unanswered. Yet, as parasites in these niches seem to be sheltered from immune response and antimalarial drugs, research on this area should be reinforced if elimination of malaria is to be achieved. Last, we will glimpse into the role of reticulocyte-derived exosomes, extracellular vesicles of endocytic origin, as intercellular communicators likely involved in the formation of such cryptic erythrocytic infections.     

A systematic classification of Plasmodium falciparum P-loop NTPases: structural and functional correlation

Background

Angola's malaria case-management policy recommends treatment with artemether-lumefantrine (AL). In 2006, AL implementation began in Huambo Province, which involved training health workers (HWs), supervision, delivering AL to health facilities, and improving malaria testing with microscopy and rapid diagnostic tests (RDTs). Implementation was complicated by a policy that was sometimes ambiguous.

Methods

Fourteen months after implementation began, a cross-sectional survey was conducted in 33 outpatient facilities in Huambo Province to assess their readiness to manage malaria and the quality of malaria case-management for patients of all ages. Consultations were observed, patients were interviewed and re-examined, and HWs were interviewed.

Results

Ninety-three HWs and 177 consultations were evaluated, although many sampled consultations were missed. All facilities had AL in-stock and at least one HW trained to use AL and RDTs. However, anti-malarial stock-outs in the previous three months were common, clinical supervision was infrequent, and HWs had important knowledge gaps. Except for fever history, clinical assessments were often incomplete. Although testing was recommended for all patients with suspected malaria, only 30.7% of such patients were tested. Correct testing was significantly associated with caseloads < 25 patients/day (odds ratio: 18.4; p < 0.0001) and elevated patient temperature (odds ratio: 2.5 per 1°C increase; p = 0.007). Testing was more common among AL-trained HWs, but the association was borderline significant (p = 0.072). When the malaria test was negative, HWs often diagnosed patients with malaria (57.8%) and prescribed anti-malarials (60.0%). Sixty-six percent of malaria-related diagnoses were correct, 20.1% were minor errors, and 13.9% were major (potentially life-threatening) errors. Only 49.0% of malaria treatments were correct, 5.4% were minor errors, and 45.6% were major errors. HWs almost always dosed AL correctly and gave accurate dosing instructions to patients; however, other aspects of counseling needed improvement.

Conclusion

By late-2007, substantial progress had been made to implement the malaria case-management policy in a setting with weak infrastructure. However, policy ambiguities, under-use of malaria testing, and distrust of negative test results led to many incorrect malaria diagnoses and treatments. In 2009, Angola published a policy that clarified many issues. As problems identified in this survey are not unique to Angola, better strategies for improving HW performance are urgently needed.     

Knowledge,Attitudes and Perceptions Regarding Endemic Vivax Malaria in Inhabitants and Patients in Two Cities of Northern Gyeonggi-do,Korea, 2020

An understanding of the knowledges, attitudes and perceptions of different populations is key for public health policy makers. Here, a survey was performed on knowledge, attitudes, and perceptions about malaria diagnosis, prevention, control, and treatment. The 407 survey participants included both uninfected inhabitants and patients from 2 cities (Gimpo- and Paju-si) of Northern Gyeonggi-do, known as high-risk areas for vivax malaria. We used community-based study design and non-probability sampling method using the primary data. Association between variables were tested using χ²-tests. In general, the information on malaria reported by the participants in this study was unsystematic and included inaccurate details. The knowledge of malaria symptoms, identified as headache, chills and fever, was high, but the surveyed community lacks knowledge of the specific medications used for malaria treatment, with a large number of respondents having no knowledge of any form of medication. Survey questions with high correct answer rates included questions about easy treatment of malaria in Korea, the high daytime activity of malaria-borne mosquitoes, and the infection risk posed by outdoor activities. However, a large portion of the respondents was unable to provide simple medical and biological information about the disease. This study aimed to comprehensively evaluate the knowledge, attitude, and practical behavior of the surveyed community with respect to malaria and the implications reported here could be applicable to other malaria endemic areas in Korea.     

A simulation model of African Anopheles ecology and population dynamics for the analysis of malaria transmission

Background

Malaria is one of the oldest and deadliest infectious diseases in humans. Many mathematical models of malaria have been developed during the past century, and applied to potential interventions. However, malaria remains uncontrolled and is increasing in many areas, as are vector and parasite resistance to insecticides and drugs.

Methods

This study presents a simulation model of African malaria vectors. This individual-based model incorporates current knowledge of the mechanisms underlying Anopheles population dynamics and their relations to the environment. One of its main strengths is that it is based on both biological and environmental variables.

Results

The model made it possible to structure existing knowledge, assembled in a comprehensive review of the literature, and also pointed out important aspects of basic Anopheles biology about which knowledge is lacking. One simulation showed several patterns similar to those seen in the field, and made it possible to examine different analyses and hypotheses for these patterns; sensitivity analyses on temperature, moisture, predation and preliminary investigations of nutrient competition were also conducted.

Conclusions

Although based on some mathematical formulae and parameters, this new tool has been developed in order to be as explicit as possible, transparent in use, close to reality and amenable to direct use by field workers. It allows a better understanding of the mechanisms underlying Anopheles population dynamics in general and also a better understanding of the dynamics in specific local geographic environments. It points out many important areas for new investigations that will be critical to effective, efficient, sustainable interventions.     

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.     

Diversity of malaria in rice growing areas of the Afrotropical region

It is well known that 'in many instances the rice agrosystem perfectly fits the ecological requirements of pathogens or vectors' and in fact 'malaria, schistosomiasis and Japanese encephalitis are important vector-borne diseases associated with rice production in developing countries' (IRRI, 1987). In spite of these fears, rice cultivation has been on the increase in the African region in response to demographic and economic pressures. However, although rice fields provide suitable breeding places for Anopheles mosquitoes and rice cultivation leads to an increase in the biting rates, the species which are adapted to these sites are not the same in all parts of Africa. Several examples illustrate this phenomenon: An. funestus in the rice fields of Madagascar, An. pharoensis in saline water rice fields in the delta of the Senegal river, An. arabiensis in northern Cameroon and Burundi, An. gambiae Mopti form in the Kou Valley (Burkina Faso) and An. gambiae Savanna form in the rice fields of Kafine near Bouaké (C?te d'Ivoire). The vectorial capacities of these species are not the same and malaria inoculation rates are not necessarily increased in the riceland agroecosystem. The consequences for malaria of introducing rice cultivation depend on the situation before its introduction: it could be worsened in unstable malaria areas but not in stable malaria areas. Therefore, sound epidemiological and entomological knowledge are needed before causing any environmental modifications for agricultural purposes and there should be regular monitoring to avoid any outbreak.     

HIV and malaria: a lesson in immunology?

HIV is now common in many areas of Africa that are also highly endemic for malaria. In this article, Geoff Butcher summarizes the available data on the possible interaction o f HIV and malaria, and shows that the course of falciparum malaria is virtually unaffected by the presence of HIV. This raises significant questions for our understanding of immunity to the asexual blood stages of human malaria and the use of animal models in malaria research.     

Challenges of the medical entomology for the surveillance in public health in Colombia: reflections on the state of malaria

The relevance of the medical entomology was considered with respect to current framework of malaria control programs in Colombia. A responsibility is indicated for balancing control efforts along with providing information on the malaria vectors. This knowledge must be acquired in order to focus the related activities that are required. The malaria control program must be based on results of local entomological surveillance, and the data must be in a form to give practical answers to questions regarding the control program. Difficulties in undertaking the required studies are described, particularly regarding the taxonomic identification of Colombian Anopheles in Colombia and which of these can be incriminated as malaria vectors.     

TNF family members and malaria: Old observations, new insights and future directions

Tumor necrosis factor (TNF) has long been recognized to promote malaria parasite killing, but also to contribute to the development of severe malaria disease. The precise molecular mechanisms that influence these different outcomes in malaria patients are not well understood, but the virulence and drug-resistance phenotype of malaria parasites and the genetic background and age of patients are likely to be important determinants. In the past few years, important roles for other TNF family members in host immune responses to malaria parasites and the induction of disease pathology have been discovered. In this review, we will summarize these more recent findings and highlight major gaps in our current knowledge. We will also discuss future research strategies that may allow us to better understand the sometimes subtle and intricate effects of TNF family molecules during malaria infection.     

Host–parasite interactions in vector-borne protozoan infections

Protists embrace many species, some of which may be either occasional or permanent parasites of vertebrate animals. Between the parasite species, several of medical and veterinary importance are vector-transmitted. The ecology and epidemiology of vector-borne parasitoses, including babesiosis, leishmaniasis and malaria, are particularly complex, as they are influenced by many factors, such as vector reproductive efficiency and geographical spread, vectorial capacity, host immunity, travel and human behaviour and climatic factors. Transmission dynamics are determined by the interactions between pathogen, vector, host and environmental factors and, given their complexity, many different types of mathematical models have been developed to understand them. A good basic knowledge of vector-pathogen relationships and transmission dynamics is thus essential for disease surveillance and control interventions and may help in understanding the spread of epidemics and be useful for public health planning.