Diagnosis Of Severe Malaria Research Articles

The state of malaria in a rural-mission hospital in Nkhoma, Malawi

Introduction: In recent times, malaria has fallen out of the limelight due to an economical migration of populations into medium and higher income settings. Despite this, it remains endemic in 31 countries with 228 million cases per annum. In Malawi, the WHO have reported that all of its citizens are at risk of contracting the disease. In this study we hope to expand on the clinical data available at a rural mission hospital in Malawi, as well as highlight some of the external global health factors in such environments. Methods: An observational retrospective cohort study looking at severe malaria admission in a paediatric population was conducted. The Nkhoma hospital Paediatric department was the centre of the data collection which focused on the diagnosis of severe malaria, as well as the signs and symptoms and treatment regimens of same. Results: Severe malaria accounted for over 40% of all paediatric admissions in the month of May 2019. Patients suffered from anaemia (80%) and cerebral malaria (41%), as well as a host of generalised symptoms such as fever (95%), vomiting (36%), malaise (30%), and diarrhoea (21%). Promisingly, a strict and comprehensive treatment regime for severe malaria was in practice with artesunate, Lumefantrine used in ~100% of cases. Conclusion: Sadly, malaria continues to create horrendous amounts of morbidity and mortality, but our united commitment to eradicating malaria is stronger than ever.

Adherence to severe malaria treatment guidelines in children at a Ugandan regional hospital: a baseline assessment for a malaria treatment quality improvement project

BackgroundMalaria is one of the most common causes of hospital admission and death in children under the age of five. The World Health Organization (WHO) has issued guidelines for the identification and treatment of severe malaria. Evidence has shown that adherence to standardized malaria treatment protocols improves outcomes. As a baseline assessment in preparation for a malaria treatment quality improvement project, this study aimed to determine adherence to the WHO severe malaria treatment guidelines in children at a Ugandan Regional Referral Hospital.MethodsA retrospective review was performed on a convenience sample of children discharged between June 2021 and March 2022 from the Mbale Regional Referral Hospital Paediatrics Ward with a diagnosis of severe malaria. Data were collected using a standardized case report form. Demographics, presenting symptoms, laboratory results, treatments, length of stay, and mortality were extracted. Comparison of treatments received to items recommended in the WHO guidelines was undertaken to determine adherence.Results147 patients were included. The median age was 5 years (IQR 2–7 years), and 55% were male. The most common features of severe malaria were haemoglobinuria (49%), haemoglobin < 5 mg/dL (34%), and altered mentation (24%). Median hospital length of stay was 3 days (IQR 2–4 days), and the mortality rate was 27% (n = 40). Overall adherence to all aspects of the WHO severe malaria guidelines was achieved in 3% (n = 4) of patients. The most common areas of deficiency were not testing to confirm malaria diagnosis (34%) and inadequate administration of artesunate (82%). Fewer than the three recommended doses of artesunate occurred in 22% of patients. Additionally, a delay in the administration of the second dose occurred in 67% (n = 78) and in the third dose in 77% (n = 71) of patients. While the recommended time between doses is 12 h, the median interval between dose one and dose two was 15 h (12–20) and the median interval from dose two to dose three was 17 h (14–25).ConclusionsCurrent adherence to severe malaria treatment guidelines in children at this Ugandan regional referral hospital is poor, but this study has identified target areas for improvement.

Factors influencing severity of recurrent malaria in a conflict-affected state of South Sudan: an unmatched case-control study

BackgroundThe burden of malaria remains the highest in sub-Saharan Africa and South Sudan is not an exception. The country has borne the brunt of years of chronic warfare and remains endemic of malaria, with increasing mortality and morbidity. Limited data still exists on factors influencing the recurrence of severe malaria, especially in emergency contexts such as South Sudan, affected by various conflicts and humanitarian situations. This study therefore aimed to investigate factors influencing severity of occurrence malaria in selected primary healthcare centres in South Sudan. This would assist and guide in malaria prevention, treatment, and eradication efforts.MethodsWe conducted an unmatched case-control study using routinely collected clinic data for individuals aged 1 year and above who received a diagnosis of severe malaria at 3 primary healthcare centres (PHCC); Malual Bab PHCC, Matangai PHCC and Malek PHCC between September 15, 2019 to December 15, 2019 in South Sudan. Patient characteristics were analyzed using simple descriptive statistics. Inferential statistics were also conducted to identify the associated factors influencing recurrence of severe malaria. All analyses were conducted using R Version 3.6.2.ResultsA total of 289 recurrent malaria cases were included in this study. More than half of the participants were female. Overall, the prevalence of severe recurrent malaria was 66.1% (191) while 74.4% (215) did not complete malaria treatment. Among those who did not complete malaria treatment, 76.7% (165) had severe recurrent malaria, while among those who completed malaria treatment 35.1% (26) had severe recurrent malaria (p < 0.001). There is a significant association between marital status (OR 0.33, 95% CI 0.19–0.56, p < 0.001), employment status (OR 0.35, 95% CI 0.14–0.87, p = 0.024), the use of preventive measures (OR 3.82, 95% CI 1.81–8.43, p < 0.001) and nutrition status (OR 0.22, 95% CI 0.13–0.37, p < 0.001). When adjusted for employment, marital status, nutritional and prevention measures in turns using Mantel–Haenszel test of association, this effect remained statistically significant.ConclusionsOur study showed that there is a high prevalence of severe recurrent malaria in South Sudan and that a significant relationship exists between severe recurrent malaria and antimalarial treatment dosage completion influenced by certain personal and social factors such as marital status, employment status, the use of preventive measures and nutrition status. Findings from our study would be useful for effective response to control and prevent malaria in endemic areas of South Sudan.

Assessing Health Workers’ Adherence to the National Guidelines for Diagnosis and Treatment of Severe Malaria in Children (0-5 Years) - A Cross-Sectional Study of Hospitals in Kebbi State, Nigeria

Adherence to treatment guidelines for severe malaria (SM) is a vital component of malaria control strategies. Non-compliance with treatment guidelines has implications on effective SM case management, particularly in children. The study aimed to assess Health workers’ adherence to the National Treatment Guideline for Diagnosis and Treatment of SM in children. A retrospective audit of patients’ records treated for SM from 1st January 2018 to 30th December 2019 was carried out through data abstraction in 5 General hospitals in Kebbi state. Also, questionnaires were distributed to health workers to assess their knowledge of the treatment guideline. Data from the hospitals were analyzed using SPSS version 23.0 and evaluated for HW’s adherence to treatment guidelines in the management of SM cases. A total of 377 cases of severe malaria (SM) were identified. All the cases (100%) were tested for malaria, with RDT being the commonest (60.2%) technique used, while 71 (18.83%) cases received intra-artesunate, 24 (6.36%) received intravenous quinine, and 41 (19.80%) received a follow-up dose of ACT. From the 50 health workers sampled, 38 (76%) of the responders established laboratory confirmation for SM, and all (100%) the responders had received one or more pieces of training on malaria treatment, with 28 (56%) respondents confirming the availability of National Treatment Guidelines for Diagnosis and Treatment of malaria. Findings suggest good compliance with the National Guidelines for Diagnosis and Treatment of severe malaria. However, there is a need to ensure the availability of a copy of the Guidelines in hospitals to sustain the present adherence observed.

Caregivers' perception and determinants of delayed presentation of children with severe malaria in an emergency room in Benin City, Nigeria.

Severe malaria is a leading cause of mortality due to late presentation to health facilities. Hence, there is a need to identify and mitigate factors promoting delayed presentation with severe malaria. This study aimed to evaluate determinants of delayed presentation of children with severe malaria in a tertiary referral hospital. This study adopted a descriptive, cross-sectional design. The participants were children with a diagnosis of severe malaria, based on WHO diagnostic criteria. Delayed presentation was defined as presentation at the referral centre at >3 days of illness. Inferential analyses were done to identify factors associated with delayed presentation. P < 0.05 was considered statistically significant. A total of 126 children with severe malaria participated in the study; their mean (standard deviation) age was 4.2 (5.3) years. The prevalence of delayed presentation in this study is 37.3%. Socio-economic class (P = 0.003); marital status (P = 0.015) and the number of health facilities visited before admission in the referral centre (P = 0.008) were significantly associated with delayed presentation. Children from upper socio-economic class were thrice more likely to present late, compared to those from lower social class (odds ratio [OR] = 3.728, 95% confidence interval [CI]: 1.694-8.208; P = 0.001). Likewise, the Yorubas were more delayed than the Binis (OR = 0.408, 95% CI: 0.180-0.928; P = 0.033). There was a negative correlation between caregivers' perception of treatment (r = -0.113, P = 0.21) of convulsion in severe malaria and timing of presentation. Delayed presentation is common with multifactorial determinants in the setting. Health education of caregivers on the consequences of delayed presentation in severe malaria is desirable.

Improving statistical power in severe malaria genetic association studies by augmenting phenotypic precision.

Severe falciparum malaria has substantially affected human evolution. Genetic association studies of patients with clinically defined severe malaria and matched population controls have helped characterise human genetic susceptibility to severe malaria, but phenotypic imprecision compromises discovered associations. In areas of high malaria transmission, the diagnosis of severe malaria in young children and, in particular, the distinction from bacterial sepsis are imprecise. We developed a probabilistic diagnostic model of severe malaria using platelet and white count data. Under this model, we re-analysed clinical and genetic data from 2220 Kenyan children with clinically defined severe malaria and 3940 population controls, adjusting for phenotype mis-labelling. Our model, validated by the distribution of sickle trait, estimated that approximately one-third of cases did not have severe malaria. We propose a data-tilting approach for case-control studies with phenotype mis-labelling and show that this reduces false discovery rates and improves statistical power in genome-wide association studies.

Impact of climatic variables on childhood severe malaria in a tertiary health facility in northern Nigeria.

Introduction: Despite the recent progress in the malaria burden, climatic factors are important if the world will achieve the set target of its eradication. Hence, this study determined the impact of climatic conditions on childhood severe malaria in a tertiary health facility in northern Nigeria. Methodology: This was a retrospective descriptive study that involved children with severe malaria managed between July 2016 and August 2017. The diagnosis of severe malaria was according to the World Health Organization 2015 guidelines. We extracted relevant data from case records and obtained the weather information from the Nigerian Meteorological Agency and www.worldweatheronline.com. Data were entered in Microsoft Excel 2013 and analyzed with Statistical Package for the Social Sciences version 20. Results: A total of 483 cases of children with severe malaria were managed. The median age was 4.0 (2.5-8.0) years. Males were 261 (54.0%). In the wet season, 375 (77.6%) cases were recorded, while 108 (22.4%) cases occurred during the dry season. The odds of malaria occurring during the wet season were 2.057 (95% CI, 1.613-2.622). Temperature patterns were not related to malaria cases. Malaria cases showed significant moderate positive cross-correlation at 2- and 3-months lag for the rainfall pattern (best cross-correlation occurred at 3 months lag with a coefficient of 0.598, p = 0.045). Conclusion: This study demonstrated marked seasonality of childhood severe malaria infection with 77% of cases during the wet season. Malaria was associated with only rainfall at a 2 to 3 months lag amongst the climatic variables. We recommend the urgent implementation of seasonal malaria chemoprophylaxis.

Current Aspect of Severe Malaria at the Infectious and Tropical Disease Service in Fann (Dakar)

Background: Severe malaria occupies a significant place in Senegal. It is characterized by a multiple organ failure that is related to a very poor prognosis. The objective of this study was to determine the Current profile of severe malaria in the service of Tropical and Infectious Diseases of Fann Hospital in Dakar. Methods: A retrospective study was conducted regarding patients hospitalized between 2014 and 2016 for whom the diagnosis of severe malaria was established using WHO criteria of severity. Results: The number of cases of severe malaria was 176 cases, ie a hospital prevalence of 6%. The majority of patients were admitted between September and December. The median age averages 33 years [range: 11-86]. Nearly three-quarters of the patients were male (73.9%), a sex ratio of 2.8. Cerebral malaria was the most common (69.9%) and the most frequent signs of gravity were coma (68.2%), followed by jaundice (58.5%) and renal failure (29.6%). Hyperparasitaemia was noted in 13 cases. In all cases Plasmodium falciparum was the responsible parasite. Ninety-nine patients received quinine and 75 artesunate. Almost three quarters of patients (111 cases) had been hospitalized for up to 7 days. Case fatality rate reached 18.8%. Conclusion: Severe malaria is still responsible of multiple organ failure and a life-threatening disease. The most frequent sign of severity is coma but jaundice and renal impairment are increasingly high. Parenteral artesunate’s use is becoming consistent. Patients’ surviving artesunate should be investigated.

Effectiveness of Seasonal Malaria Chemoprevention in Children under Ten Years of Age in Senegal: A Stepped-Wedge Cluster-Randomised Trial.

BackgroundSeasonal Malaria Chemoprevention (SMC) with sulfadoxine-pyrimethamine (SP) plus amodiaquine (AQ), given each month during the transmission season, is recommended for children living in areas of the Sahel where malaria transmission is highly seasonal. The recommendation for SMC is currently limited to children under five years of age, but, in many areas of seasonal transmission, the burden in older children may justify extending this age limit. This study was done to determine the effectiveness of SMC in Senegalese children up to ten years of age.Methods and FindingsSMC was introduced into three districts over three years in central Senegal using a stepped-wedge cluster-randomised design. A census of the population was undertaken and a surveillance system was established to record all deaths and to record all cases of malaria seen at health facilities. A pharmacovigilance system was put in place to detect adverse drug reactions. Fifty-four health posts were randomised. Nine started implementation of SMC in 2008, 18 in 2009, and a further 18 in 2010, with 9 remaining as controls. In the first year of implementation, SMC was delivered to children aged 3–59 months; the age range was then extended for the latter two years of the study to include children up to 10 years of age. Cluster sample surveys at the end of each transmission season were done to measure coverage of SMC and the prevalence of parasitaemia and anaemia, to monitor molecular markers of drug resistance, and to measure insecticide-treated net (ITN) use. Entomological monitoring and assessment of costs of delivery in each health post and of community attitudes to SMC were also undertaken. About 780,000 treatments were administered over three years. Coverage exceeded 80% each month. Mortality, the primary endpoint, was similar in SMC and control areas (4.6 and 4.5 per 1000 respectively in children under 5 years and 1.3 and 1.2 per 1000 in children 5-9 years of age; the overall mortality rate ratio [SMC: no SMC] was 0.90, 95% CI 0.68–1.2, p = 0.496). A reduction of 60% (95% CI 54%–64%, p < 0.001) in the incidence of malaria cases confirmed by a rapid diagnostic test (RDT) and a reduction of 69% (95% CI 65%–72%, p < 0.001) in the number of treatments for malaria (confirmed and unconfirmed) was observed in children. In areas where SMC was implemented, incidence of confirmed malaria in adults and in children too old to receive SMC was reduced by 26% (95% CI 18%–33%, p < 0.001) and the total number of treatments for malaria (confirmed and unconfirmed) in these older age groups was reduced by 29% (95% CI 21%–35%, p < 0.001). One hundred and twenty-three children were admitted to hospital with a diagnosis of severe malaria, with 64 in control areas and 59 in SMC areas, showing a reduction in the incidence rate of severe disease of 45% (95% CI 5%–68%, p = 0.031). Estimates of the reduction in the prevalence of parasitaemia at the end of the transmission season in SMC areas were 68% (95% CI 35%–85%) p = 0.002 in 2008, 84% (95% CI 58%–94%, p < 0.001) in 2009, and 30% (95% CI -130%–79%, p = 0.56) in 2010. SMC was well tolerated with no serious adverse reactions attributable to SMC drugs. Vomiting was the most commonly reported mild adverse event but was reported in less than 1% of treatments. The average cost of delivery was US$0.50 per child per month, but varied widely depending on the size of the health post. Limitations included the low rate of mortality, which limited our ability to detect an effect on this endpoint.ConclusionsSMC substantially reduced the incidence of outpatient cases of malaria and of severe malaria in children, but no difference in all-cause mortality was observed. Introduction of SMC was associated with an overall reduction in malaria incidence in untreated age groups. In many areas of Africa with seasonal malaria, there is a substantial burden in older children that could be prevented by SMC. SMC in older children is well tolerated and effective and can contribute to reducing malaria transmission.Trial RegistrationClinicalTrials.gov NCT00712374

Adherence to national guidelines for the diagnosis and management of severe malaria: a nationwide, cross-sectional survey in Malawi, 2012.

BackgroundSevere malaria has a case fatality rate of 10-20 %; however, few studies have addressed the quality of severe malaria case management. This study evaluated the diagnostic and treatment practices of malaria patients admitted to inpatient health facilities (HF) in Malawi.MethodsIn July–August 2012, a nationwide, cross-sectional survey of severe malaria management was conducted in 36 HFs selected with equal probability from all eligible public sector HFs in Malawi. Patient records from all admissions during October 2011 and April 2012 (low and high season, respectively) were screened for an admission diagnosis of malaria or prescription of any anti-malarial. Eligible records were stratified by age (< 5 or ≥ 5 years). A maximum of eight records was randomly selected within each age and month stratum. Severe malaria was defined by admission diagnosis or documentation of at least one sign or symptom of severe malaria. Treatment with intravenous (IV) quinine or artesunate was considered correct. Patients without documentation of severe malaria were analysed as uncomplicated malaria patients; treatment with an artemisinin-based combination therapy (ACT) or oral quinine based on malaria test results was considered correct. All analyses accounted for HF level clustering and sampling weights.ResultsThe analysis included 906 records from 35 HFs. Among these, 42 % (95 % confidence interval [CI] 35–49) had a severe malaria admission diagnosis and 50 % (95 % CI 44–57) had at least one severe malaria sign or symptom documented. Severe malaria patients defined by admission diagnosis (93, 95 % CI 86–99) were more likely to be treated correctly compared to patients defined by a severe sign (82, 95 % CI 75–89) (p < 0.0001). Among uncomplicated malaria patients, 26 % (95 % CI 18–35) were correctly treated and 53 % (95 % CI 42–64) were adequately treated with IV quinine alone or in combination with an ACT or oral quinine.ConclusionsA majority of patients diagnosed with severe malaria received the recommended IV therapy in accordance with national treatment guidelines. However, the inconsistencies between diagnosis of severe malaria and documentation of severe signs and symptoms highlight the need to improve healthcare worker recognition and documentation of severe signs and symptoms.Electronic supplementary materialThe online version of this article (doi:10.1186/s12936-016-1423-2) contains supplementary material, which is available to authorized users.

Severe malaria in Battambang Referral Hospital, an area of multidrug resistance in Western-Cambodia: a retrospective analysis of cases from 2006-2009.

BackgroundDespite recent malaria containment and control efforts leading to reduced incidence, Cambodia remains endemic for both Plasmodium vivax and multidrug-resistant Plasmodium falciparum malaria. Little has been reported in the peer-reviewed literature regarding the burden of severe malaria (SM) in Cambodia.MethodsMedical records for all patients admitted to the Battambang Referral Hospital (BRH) with an admitting or discharge diagnosis of SM from 2006 to 2009 (suspected SM cases) were reviewed. Those meeting the case definition of SM according to retrospective chart review and investigator assessment of probable cases, based on published national guidelines available at the time, were analysed for trends in demographics, mortality and referral patterns.ResultsOf the 537 suspected SM cases at BRH during the study period, 393 (73%) met published WHO criteria for SM infection. Despite limited diagnostic and treatment facilities, overall mortality was 14%, with 7% mortality in children 14 and under, but 19% in adults (60% of cases). Cerebral malaria with coma was relatively rare (17%), but mortality was disproportionately high at 35%. Mean time to hospital presentation was five days (range one to 30 days) after onset of symptoms. While patients with delays in presentation had worse outcomes, there was no excess mortality based on treatment referral times, distance travelled or residence in artemisinin-resistance containment (ARC) Zone 1 compared to Zone 2.ConclusionsDespite limitations in diagnosis and treatment, and multiple confounding co-morbidities, mortality rates at BRH were similar to reports from other countries in the region. Interventions to improve access to early diagnosis and effective treatment, combined with modest improvements in intensive care, are likely to reduce mortality further. Patients referred from Zone 1 did not have excess mortality compared to Zone 2 ARC areas. A steep decrease in SM cases and deaths observed in the first half of 2009 has since continued, indicating some success from containment efforts despite the emergence of artemisinin resistance in this area.

Clinical spectrum and treatment outcome of severe malaria caused by Plasmodium vivax in 18 children from northern India

Objective: The study was intended to document the clinical profile and treatment outcome of severe malaria caused by Plasmodium vivax (P.vivax) in children hospitalized in a tertiary care centre of northern India.Methods: This prospective observational study was performed among children admitted with severe malaria at a tertiary care referral hospital of northern India from January 2012 to December 2012. Information was recorded pertaining to clinical symptoms at presentation, examination findings, biochemical and hematological investigation, and treatment outcome. Presence of malarial parasite on thick and thin smears and/or positive parasite lactate dehydrogenase (p-LDH) based rapid malaria antigen test was considered diagnostic of ‘malaria’. Based on the etiology, children were categorized into three groups: P.vivax, Plasmodium falciparum (P. falciparum) and mixed infection. Children diagnosed with ‘severe malaria’ (World Health Organization, 2000), were started on intravenous artesunate followed by artemether-lumefantrine combination.Results: Thirty-five children with a diagnosis of severe malaria were enrolled [18 (51·4%) P. vivax, nine (25·7%) mixed infection, eight (22·8%) P. falciparum]. Clinical features of severe vivax malaria (n = 18) were abnormal sensorium [9 (50%)], multiple seizures [8 (44·4%)], jaundice [5 (27·8%)], severe anaemia [5 (27·8%)], and shock [3 (16·7%)]. Two children [2/18 (11·1%)] infected with P. vivax had died of cerebral malaria, acute respiratory distress syndrome, shock, and metabolic acidosis. The clinical presentation and outcome of severe vivax malaria was found to be similar to severe malaria caused by P. falciparum and mixed infection, except for higher chances of severe anaemia among the children infected with P. falciparum (P = 0·04).Conclusion: The present study highlights P. vivax as an increasingly recognized causative agent for severe malaria in children from Rohtak, with similar clinical presentation and outcome to that caused by P. falciparum.

Serum Procalcitonin: as a Triage Tool for Severe Plasmodium falciparum Malaria

Objective: Patients of severe falciparum malaria may present with multi organ failure requiring critical care management. Procalcitonin (PCT) can be used as a triage tool to discriminate such patients. Methods: We determined serum PCT semi-quantitatively by immunochromatographic test in 41 patients of severe and in 19 cases of uncomplicated falciparum malaria. The diagnosis of malaria was made with detection of the parasite from peripheral blood smear. All patients were subjected to detail clinical, biochemical, and haematological work up. The diagnosis of severe malaria was done according to WHO criteria and the severity of organ dysfunction was assessed with Malaria Severity Score (MSS) in all patients by taking different physiological parameters into consideration. The risk stratification of severe malaria was determined with MSS and it is compared with PCT level. Results: Out of 41 patients of severe falciparum malaria 39 (95.1%) patients had multiple complications and 2 (4.9%) had single complication. The mean MSS was 8.39 ± 4.35. According to MSS, patients were categorized in to low, intermediate, and high risk group in 4 (9.7%), 9 (21.9%), and 28 (68.3%) patients respectively. Estimation of PCT showed that 13 (31.7%) patients of severe malaria had PCT value within 2-10 ng/ml (moderately raised) and 28 (68.3%) patients had ≥ 10.0 ng/ml (highly raised). High risk patients according to MSS were categorized as critical malaria. PCT could able to diagnose such cases with excellent sensitivity and specificity. Conclusion: S. PCT ≥ 10.0 could able to define critical malaria and can be conveniently used as a triage tool for management of severe falciparum malaria. Instead of MSS, PCT enhanced triage will save time and decrease the overall costs while achieving similar result.

Colecistite aguda alitiásica num doente com malária grave.

The authors present a clinical case of a 53 years old male admited in an ICU - DI (Intensive care Unit of Infectious Disease) with the diagnosis of severe malaria. He was treated with IV quinine di-hydrochloride and doxycycline and developed on the sixth day an acute alithiasic cholecystitis. Transhepatic percutaneous drainage was performed and the patient had good clinical outcome.

Assessment of severe malaria in a multicenter, phase III, RTS, S/AS01 malaria candidate vaccine trial: case definition, standardization of data collection and patient care

BackgroundAn effective malaria vaccine, deployed in conjunction with other malaria interventions, is likely to substantially reduce the malaria burden. Efficacy against severe malaria will be a key driver for decisions on implementation. An initial study of an RTS, S vaccine candidate showed promising efficacy against severe malaria in children in Mozambique. Further evidence of its protective efficacy will be gained in a pivotal, multi-centre, phase III study. This paper describes the case definitions of severe malaria used in this study and the programme for standardized assessment of severe malaria according to the case definition.MethodsCase definitions of severe malaria were developed from a literature review and a consensus meeting of expert consultants and the RTS, S Clinical Trial Partnership Committee, in collaboration with the World Health Organization and the Malaria Clinical Trials Alliance. The same groups, with input from an Independent Data Monitoring Committee, developed and implemented a programme for standardized data collection.The case definitions developed reflect the typical presentations of severe malaria in African hospitals. Markers of disease severity were chosen on the basis of their association with poor outcome, occurrence in a significant proportion of cases and on an ability to standardize their measurement across research centres. For the primary case definition, one or more clinical and/or laboratory markers of disease severity have to be present, four major co-morbidities (pneumonia, meningitis, bacteraemia or gastroenteritis with severe dehydration) are excluded, and a Plasmodium falciparum parasite density threshold is introduced, in order to maximize the specificity of the case definition. Secondary case definitions allow inclusion of co-morbidities and/or allow for the presence of parasitaemia at any density. The programmatic implementation of standardized case assessment included a clinical algorithm for evaluating seriously sick children, improvements to care delivery and a robust training and evaluation programme for clinicians.ConclusionsThe case definition developed for the pivotal phase III RTS, S vaccine study is consistent with WHO recommendations, is locally applicable and appropriately balances sensitivity and specificity in the diagnosis of severe malaria. Processes set up to standardize severe malaria data collection will allow robust assessment of the efficacy of the RTS, S vaccine against severe malaria, strengthen local capacity and benefit patient care for subjects in the trial.Trial registrationClinicaltrials.gov NCT00866619

Diagnostic et prise en charge du paludisme grave chez l’adulte : observance des directives nationales au Burkina Faso

The purpose of this study was to assess the application of national guidelines on the diagnosis and treatment of severe malaria in adults in Burkina Faso. We conducted a retrospective study of medical records of the patients admitted for severe malaria in the emergency service of the regional hospital of Fada N'Gourma in the east of Burkina Faso in the year 2008; 165 records were chosen by simple random sampling. We reported all the severe clinical and biological signs of malaria and its treatment. We compared them with the criteria of severe malaria diagnosis and its treatment according to the national guidelines. The mean age of patients was 38 ± 16.2 and male to female ratio was 0.96. The most frequent period of admissions was between July and October. Fever or recent past of fever was reported in 142 cases (86.1%). According to the two criteria for severe malaria (means existing of at least one of the severe signs associated and positive parasitemia with Falciparum plasmodium), we noted that only 74 cases had at least one of the severe signs (44.8%) which were: anemia (51.3%), cardiovascular collapse (7.9%), jaundice (7.3%), dyspnea (6.7%), impairment of consciousness (5.5%), prostration (5.5%), renal failure (4.8%), hypoglycemia (2.4%), hemorrhage (1.8%) and seizures (1.2%). The biological signs were not systematically searched. Parasitological exam was conducted in 91 cases (55.1%). Only 18 were positive (19.8%). In total, only 18 cases (10.9%) met the guidelines' criteria of severe malaria. The other cases were over-diagnosed; note that the investigation was not complete for 74 of these cases (50.3%). Among the 165 cases, the treatment was appropriate in 146 (88.5%) and 19 cases (11.5%) didn't receive treatment for malaria.So much we observed an over diagnosis of severe malaria in adults that we can suggest an under diagnosis of the disease due to the lack of biological investigations.

Clinical and Molecular Characterization of a Near Fatal Case of Human Babesiosis in Austria

A previously healthy febrile patient with travel history to Nicaragua showed rapid clinical deterioration with hemodynamic shock and anuria. Diagnosis of severe malaria was established based on intra-erythrocytic parasites and antimalarial treatment was initiated. However, upon reevaluation Babesia microti infection was suspected and molecular characterization by polymerase chain reaction and sequence analysis was performed.

Accuracy of Clinical Diagnosis of Malaria in Children under Five in Lagos

Background: Malaria diagnosis is confirmed by finding asexual parasites in peripheral blood firm. Due to the absence of microscopy at most health centers, clinical judgment is often used to make the diagnosis. Studies on clinical accuracy have been done but none from Lagos . Objective: To document the accuracy of clinical diagnosis of malaria among children under five years . Methods: A prospective study on children under five years presenting with fever presenting to the children\'s Emergency Room, LUTH. The study was done between January and October 2001. Result: A total of 184/323 children had a clinical diagnosis of malaria. The diagnosis was confirmed in 57 (31%) of them . Those with a clinical diagnosis of severe malaria had a higher chance of it actually being malaria compared with those with a clinical diagnosis of acute malaria (p NQJHM Vol. 14 (1) 2004: pp. 101-103

Biomass Smoke: Does It Offer Protection Against Severe Malaria?

ISEE-614 Objective: To assess whether biomass smoke offers protection against severe malaria by creating environments that are less hospitable for mosquitoes. To evaluate PM2.5 and CO concentrations in the households of participants with and without a diagnosis of severe malaria. Materials and Methods: This retrospective case-control study examined differences in biomass smoke concentrations in households with women (15–45 years) and/or children (≤9 years) in conjunction with severe malaria incidence in Nouna, Burkina Faso. A household survey was conducted as well as measurements of area PM2.5 concentrations in the kitchen and bedrooms of the participating households. Twenty-four hour personal carbon monoxide (CO) concentrations were also measured. Results: Mean area PM2.5 concentration for cases was 2069 μg/m3 and 2387 μg/m3 for controls. Mean personal CO concentrations for cases and controls were 2.89 ppm and 3.65 ppm, respectively. The mean difference between matched cases and controls for area PM2.5 concentrations was −80.05 μg/m3. The mean difference for CO was −0.54 ppm. For women and children with severe malaria exposed to PM2.5, the odds ratio was 1.18 (95% CI: 0.532 to 1.346), a non-significant result (P=0.4808). Similar result were also obtained for personal exposure to CO (OR=1.10, 95% CI: 0.460 to 1.791, P=0.7793). Conclusions: These initial results suggest that biomass smoke may be protective among factors that could affect the incidence of severe malaria; however, the statistical evidence is not strong and the sample size is small. Further analyses may further elucidate these results and provide a clearer picture of the nature of this relationship.

Diagnosis and management of malaria by rural community health providers in the Lao People's Democratic Republic (Laos)

We assessed the knowledge of malaria diagnosis and management by community health providers in rural Vientiane and Savannakhet Provinces, Lao PDR. Sixty health providers (17 pharmacy owners/drug sellers and 43 village health volunteers) were interviewed. All diagnosed malaria using symptoms and signs only; 14% were aware of >2 criteria for the diagnosis of severe malaria. Although chloroquine and quinine, the then recommended Lao national policy for uncomplicated malaria treatment, were the most common antimalarials prescribed - 65% gave incorrect doses and 70% did not know the side effects. Although not recommended by the then national policy, 27% of the health providers used combinations of antimalarials as they considered monotherapy ineffective. This study strongly suggests that further training of Lao rural health providers in malaria diagnosis and management is needed to improve the quality of health services in areas remote from district hospitals.