Malaria In Sudan Research Articles

Descriptive study on the efficacy of artemether-lumefantrine in the treatment of uncomplicated Plasmodium falciparum malaria in Sudan

The aim of this study was to investigate the efficacy of artemether-lumefantrine in treating uncomplicated Plasmodium falciparum malaria in four sentinel areas in Sudan with different malaria transmission (Damazin, Sinnar, and Kosti in the north, and Juba in the south). World Health Organization protocol for assessing antimalarial drug efficacy in treating uncomplicated P. falciparum malaria was employed. A total of 2,139 patients were screened, and 771 had P. falciparum monoinfection. Only 291 met the enrollment criteria and gave written consent to be recruited in the study. Patients were treated with artemether-lumefantrine tablets in a six-dose regimen calculated according to body weight. Tablets were given at 0, 8, 24, 36, 48, and 60 h. Patients were followed up for 28 days. A total of 291 patients were recruited to the study, of whom ten [3.4; 95% confidence interval (CI):1.8-6.4%] patients showed early treatment failure (ETF) or late clinical failure (LCF) and were excluded from further follow-up. Of the remaining 281 patients, 276 (98.2%; 95% CI: 95.7-99.3%) completed the 28-day follow-up. Of these, 274 (99.3%; 95% CI: 97.1-99.9%) had adequate clinical and parasitological response (ACPR), and two (0.7%; 95% CI: 0.13-2.9%) showed late parasitological failure (LPF) at days 21 and 28. The overall mean +/- standard deviation (SD) of parasitemia and fever clearance times were 36.4 (23.7) h and 34.6 (19.2) h, respectively. Mild and reversible adverse effects were reported by 11 patients (3.8%; CI: 2.0- 7.0%) and were relieved without the need for termination of drug therapy or supportive treatment. Our findings showed that artemether-lumefantrine was an effective and safe drug for treating uncomplicated P. falciparum malaria in northern and southern Sudan.

Malaria preventive measures, health care seeking behaviour and malaria burden in different epidemiological settings in Sudan

To provide information about preventive measures and treatment seeking behaviour as well as an estimate of the malaria burden in different epidemiological settings for effective monitoring and evaluation of the ongoing efforts. Cross-sectional survey carried out in four areas representing different levels of transmission to explore the use of preventive measures, care-seeking behaviour and accessibility in addition to point prevalence was followed by a follow-up phase in which the health workers registered and reported all fever cases including malaria. The relation between the reported malaria incidence, the product of symptomatic/asymptomatic ratio and the prevalence of confirmed malaria cases was used to develop the equation that could predict the true malaria incidence. Thousand households and 3628 individuals were surveyed. The presence of any net varied between 6.6% and 40%; the percentage of people who reportedly slept under mosquito nets in the previous night varied between 35 and 80. Prompt use of medications ranged between 14 and 48% with a delay of more than 24 h noticed in different areas. The mean number of individuals per household who reported use of anti-malarial drugs in the last 2 weeks ranged between 0.6 (SD = 0.92) and 1.2 (SD = 1.1), with variable cost per treatment and affordability. The prevalence of asymptomatic parasitaemia, fever and confirmed malaria at time of the survey differed by area. The incidence of malaria during the follow-up period was estimated to be 8.5, 178.6, 23.7 and 10.3 episodes per 1000 population in Malakal, Elrank, Elhosh and El Matama, respectively. Based on this, a prediction equation was developed. We found suboptimal health care seeking behaviour, coverage and use of preventive measures with a high malaria burden. We developed a model for future estimation of malaria episodes.

Malaria overdiagnosis and burden of malaria misdiagnosis in the suburbs of central Sudan: special emphasis on artemisinin-based combination therapy era

Accuracy of diagnosis is central for malaria control. Although microscopy is gold standard in malaria diagnosis, its reliability is largely dependent on user skill. In this study, we evaluated practitioners' clinical and microscopists' technical skills in diagnosis of malaria in central Sudan. In a retrospective study, 3203 blood smears from 95 peripheral health facilities (each represented by a general practitioner [GP] and general microscopist [GM]) were reexamined by expert microscopist. Furthermore, in a prospective study, 410 patients had their malaria diagnosis rechecked by rapid diagnostic test for validation of the microscopic diagnosis. Results showed that the rate of false-positive diagnosis of malaria was 75.6% and false-negative diagnosis was 0.01%. The study disclosed poor skills of the GPs and GMs in malaria diagnosis because 43% of the GPs and 44% of the GMs failed to make a single true-positive malaria diagnosis. The false-positive malaria diagnosis showed bias toward adult females. Economically, the calculated cost of diagnosis and treatment of malaria in Sudan in year 2000 is US$100 million, whereas the calculated cost of true malaria is approximately US$14 million. In conclusion, malaria overdiagnosis was widely recognized in central Sudan, with high economic burden during the era of artemisinin-based combination therapy. Finally, different scenarios were suggested for improvement of malaria diagnosis.

Point Mutations in Pfcrt (K76t) and Pfmdr (N86y) Genes of P. falciparum and in vivo Responses of Chloroquine Among Malaria Patients Sennar, Sudan

Chloroquine resistance in P. falciparum has been associated with specific mutations in the Pfcrt and Pfmdr-1 genes. In this study, 66 patients aged (1—65 years) with uncomplicated falciparum malaria in Sudan, were examined to assess the association between the mutations and clinical outcome. In vivo method was used according to WHO (1996) protocol and PCR-RFLP was used to detect point of mutations. The results showed that 48 (72.7%) were sensitive to Chloroquine and successfully treated, failure was observed in 18 (27.3%). R1, R11 & R111 levels of resistance were detected, while PCR-RFLP analysis revealed the presence of mutant T76 allele in 42 (63.6%) isolates. The remaining 24 (36.4%) isolates carried the wild type (K76) allele and no mixed alleles were found. The Pfmdr1 (Tyr-86) was found in 33 (50%) isolates, while 26 (39.4%) isolates carried (Asn-86) wild type, and 7 (10.6%) isolates had mixed infection (Tyr-86 plus Asn-86). The data showed that the allele of the Pfcrt gene with K76T is strongly associated with chloroquine resistance, while there is no association between Pfmdr -1 gene and chloroquine in vivo test, further studies are needed to assess the drug resistance in other regions of intense transmission.

The burden of malaria in Sudan: incidence, mortality and disability – adjusted life – years

BackgroundEstimating the burden of malaria in Sudan is important for evidence-based planning of malaria control. Estimates of malaria burden in terms of DALYs (Disability Adjusted Life Years) were not developed locally. This study synthesized information from different sources to calculate malaria incidence, mortality and DALYs lost in Sudan in 2002.MethodsA search for local studies and reports providing epidemiological data on malaria in Sudan was conducted. Preliminary estimates of incidence rate, case fatality rate and mortality rate were developed from the data found. The preliminary estimates were processed in the disease modelling computer software, DisMod II, to produce internally consistent mortality and incidence rates, which were used to calculate DALYs lost due to malaria.ResultsMalaria incidence in Sudan was estimated to be about 9 million episodes in 2002 and the number of deaths due to malaria was about 44,000. 2,877,000 DALYs were lost in Sudan in 2002 due to malaria mortality, episodes, anaemia and neurological sequelae. Children under five years of age had the highest burden. Males had the highest incidence and mortality, but females lost more DALYs.ConclusionFormal health system data underestimated malaria burden. The burden estimates can be useful in informing decision making, although uncertainty around them needs to be quantified. Epidemiological research is needed to fill data gaps and update the estimates.

Artesunate plus sulfadoxine-pyrimethamine for treatment of uncomplicated Plasmodium falciparum malaria in Sudan

BackgroundEarly diagnosis and effective treatment with an appropriate drug form the main components of the World Health Organization's strategy to reduce malaria related mortality. The few available drugs might be safeguarded if combined with artesunate. The addition of artesunate to a standard antimalarial treatment substantially reduces treatment failure, recrudescence and gametocyte carriage.MethodsDuring late 2004, the efficacy of artesunate (4 mg/kg. day, on days 0–2) plus sulfadoxine-pyrimethamine (25 mg/kg, on day 0) for the treatment of uncomplicated Plasmodium falciparum malaria was investigated in four sentinel areas in Sudan, with different malaria transmission (Damazin, Kassala, Kosti, and Malakal).ResultsTwo hundreds and sixty-nine patients completed the 28-day follow-up. On day one, 60 (22.3%) patients were febrile and 15 (5.5%) patients were parasitaemic. On day three, all the patients were afebrile and aparasitaemic. While two patients (0.7%, Kassala) showed late Clinical and Parasitological Failures, the rest (99.3%) of the patients demonstrated Adequate Clinical and Parasitological Response. A gametocytaemia were detected during the follow-up in one patient (0.37%, Kassala). Adverse drug effects were detected in 32 (11.9%) patientsConclusionThe study showed that AS plus SP is an effective, safe drug in the treatment of uncomplicated P. falciparum malaria in Sudan.

Efficacy of two artemisinin combination therapies for uncomplicated falciparum malaria in children under 5 years, Malakal, Upper Nile, Sudan

BackgroundThe treatment for Plasmodium falciparum malaria in Sudan has been in process of change since 2003. Preceding the change, this study aimed to determine which artemisinin-based combination therapies is more effective to treat uncomplicated malaria in Malakal, Upper Nile, Sudan.MethodsClinical trial to assess the efficacy of 2 antimalarial therapies to treat P. falciparum infections in children aged 6–59 months, in a period of 42 days after treatment.ResultsA total of 269 children were followed up to 42 days. Artesunate plus Sulfadoxine/Pyrimethamine (AS+SP) and Artesunate plus Amodiaquine (AS+AQ) were both found to be efficacious in curing malaria infections by rapid elimination of parasites and clearance of fever, in preventing recrudescence and suppressing gametocytaemia. The combination of AS+SP appeared slightly more efficacious than AS+AQ, with 4.4% (4/116) versus 15% (17/113) of patients returning with malaria during the 6-week period after treatment (RR = 0.9, 95% CI 0.81–0.96). PCR analysis identified only one recrudescence which, together with one other early treatment failure, gave efficacy rates of 99.0% for AS+AQ (96/97) and 99.1% for AS+SP (112/113). However, PCR results were incomplete and assuming part of the indeterminate samples were recrudescent infections leads to an estimated efficacy ranging 97–98% for AS+SP and 88–95% for AS+AQ.ConclusionThese results lead to the recommendation of ACT, and specifically AS+SP, for the treatment of uncomplicated falciparum malaria in this area of Sudan. When implemented, ACT efficacy should be monitored in sentinel sites representing different areas of the country.

Screening blood donors for malaria parasite in Sudan

Abstract Background: In countries where malaria is endemic, its transmission is a hazard of blood transfusion and could lead to serious if not fatal complications. To assess the likely importance of transfusion induced malaria in Sudan; a descriptive cross sectional facility based study was carried out. Material and Methods: A total number of 1564 blood donors were screened for malaria parasite by thick and thin blood film using Geimsa’ staining technique. All the 397 transfused patients who received the donors’ blood during the study period were investigated for malaria before transfusion by the same technique, followed up for four days after transfusion and reinvestigated, if any signs of malaria were present. Results: Results showed that the prevalence of infected donors was 6.5%, the majority of them were between 20 and 40 years old; the required age for donation. The recognized species were predominantly (98.1%) Plasmodium falciparum and secondly Plasmodium vivax (1.9%). Mainly ring (50.5%) and trophozoite (40.2%) stages were detected, and most of the positive blood films (96.9%) showed densities less than 1000 parasites/µl. Post transfusion malaria (PTM) was observed in 2.9% of the single transfused and in 4.9% of the multiple transfused patients. Conclusion: It was concluded that the infectivity of asymptomatic donors is considerable. Moreover, the exclusion of this percentage minimizes the risk of transfusion-induced malaria and does not affect donation flow. [Ethiop.J.Health Dev. 2004;18(2)70-74]

Clinical pattern of severe Plasmodium falciparum malaria in Sudan in an area characterized by seasonal and unstable malaria transmission

A hospital-based study was carried out in Gedarif town, eastern Sudan, an area of markedly unstable malaria transmission. Among the 2488 diagnosed malaria patients, 4.4% fulfilled the WHO criteria for severe malaria, and seven died of cerebral malaria. The predominant complication was severe malarial anemia (45.4%), followed by convulsions (21%), cerebral malaria (16. 4%) and hypotension (11.8%). Severe malaria was recognized in all age groups, but 44.5% of patients were aged 2 to 4 years. The mean ages of patients with severe anemia (5.6 years) and convulsions (5.9 years) were significantly lower than the mean ages of patients with cerebral malaria (14.1 years) or hypotension (35.2 years). Patients with convulsions and cerebral malaria had significantly higher mean parasite count (69972 and 56110 parasites/microL, respectively) than patients with severe anemia (24637 parasites/microL) or hypotension (13667 parasites/microL). The mean blood glucose level was higher in patients with cerebral malaria than in patients with anemia, and higher in patients who died than in patients who survived. In this setting, the clinico-epidemiological pattern of severe malaria varies considerably from that of hyperendemic regions in sub-Saharan Africa, and there is considerable variation between the individual complications of severe malaria.

The impact of user fee exemption on service utilization and treatment seeking behaviour: the case of malaria in Sudan

This experimental study was undertaken to assess the effect of different levels of exemption, 25%, 50% and 75%, from health centre user fees on health service utilization and treatment seeking behaviour for malaria by a high risk group of pregnant women and children under 5 years. These are groups in need of special medical attention to prevent progression of the disease into complicated or severe malaria. Sinnar State, one of Sudan's highly endemic malaria regions, was selected to be the experimental area. Exemptions were introduced for one year in six health centres. Two centres for each exemption level, and a further two health centres without exemptions were studied. At the beginning and the end of the trial year, households surveys were conducted in the catchment areas of the health centres, and focus group discussions with pregnant women and mothers of children under 5 years were conducted. Routine data were reviewed for malaria cases in the health centres and six studies on malaria cases were done upon exit from the health centres. In-depth interviews with health staff of the health centres were conducted. Exemption from user fees increased health services utilization, improved treatment-seeking behaviour and promoted early diagnosis. The changes during the experimental year were the largest in the centres with the largest exemption. Therefore, policy changes towards exemptions are necessary to facilitate early diagnosis and treatment of malaria.

High Proportion of Subclinical Plasmodium falciparum Infections in an Area of Seasonal and Unstable Malaria in Sudan

In the present longitudinal study, a cohort (n = 98) of children and adults 5-30 years of age living in an area of highly seasonal and unstable malaria transmission were followed for malaria morbidity during several successive transmission seasons. Based on morbidity surveillance during 1993 and measurements of antibody titers to the Plasmodium falciparum ring-infected erythrocyte surface antigen (Pf155/RESA), the cohort was divided into three groups: those who had at least one episode of clinical malaria (Group 1, n = 31), those who did not suffer from clinical malaria but had (Group 2, n = 63) or had not (Group 3, n = 4) a significant increase in antibody titers against the Pf155/RESA antigen. This increase was defined as equal to or greater than a four-fold increase in antibody titer in samples from same individuals taken at the beginning and the end of the malaria transmission season. Such increases in specific antibody levels suggested that the donors had been exposed to a P. falciparum blood-stage infection. Measurements of antibody titers to a peptide derived from the glutamate-rich protein exoantigen gave data parallel to those for Pf155/RESA. A surprisingly high fraction of individuals in the study cohort (approximately 66%) showed evidence of infection without ensuing clinical disease (Group 2).

The efficacy of artemether in the treatment of Plasmodium falciparum malaria in Sudan

The efficacy of artemether (a qinghaosu derivative) administered intramuscularly for the treatment of Plasmodium falciparum malaria was compared to quinine in an open randomized trial including 54 patients in eastern Sudan, where chloroquine resistance is common. The artemether treatment (5 d intramuscular regimen) was effective and the drug was well tolerated. All patients had cleared the parasitaemia and were free of symptoms 48 h after initiation of treatment. The parasite clearance time was comparable in patients receiving artemether and quinine. No side effect was reported by patients receiving artemether. No recrudescence was seen in 21 patients treated with artemether who completed 28 d follow-up. In the quinine group 3 of 18 patients had recrudescences, or possibly reinfections, on days 14, 21 and 28.

Clindamycin for the treatment of falciparum malaria in Sudan.

Clindamycin, 5 mg/kg twice a day for 5 days, was used to treat falciparum malaria after clinical and parasitological diagnosis at a health station in Faki Hashim, a suburb of Khartoum, Sudan. Twenty out of twenty-six patients enrolled completed the study. Giemsa-stained thick blood films were negative for asexual parasites by day 7 in 17 patients and by day 8 in the remaining 3. All were examined on days 14 or 28; 2 who had initially been cleared by day 6 had asymptomatic low density asexual parasitemia on day 14, which disappeared without treatment by day 28, and 2 others initially cleared by day 5 were similarly positive at day 28. Reinfection in these patients cannot be ruled out. Of the 6 patients withdrawn from the study, 2 took chloroquine independently, 1 developed vomiting, 1 developed diarrhea, 1 acquired a circumoral maculopapular rash, and 1 had an increasing parasitemia on day 3 and was switched to chloroquine. Generally, the treatment was without toxicity and was well received. Clindamycin proved satisfactory for the treatment of simple cases of falciparum malaria in the field in Africa.

Comparison of immunity to malaria in Sudan and Indonesia: crisis-form versus merozoite-invasion inhibition.

Immunity to falciparum malaria was compared in two populations from malarious areas of southern Sudan and Flores, Indonesia. In Sudan, splenomegaly in adults was rare and anti-plasmodium indirect fluorescent antibody (IFA) titers were low to moderate, 1:1,280 being the modal titer. Sudanese serum was profoundly inhibitory to cultured Plasmodium falciparum, reducing incorporation of radiolabeled hypoxanthine by 63-93% and severely retarding intraerythrocytic parasite development, resulting in moribund crisis-form parasites and virtually no healthy schizonts. In Flores, 64% of the serum donors had splenomegaly greater than or equal to Hackett spleen grade 4 or 5, and the modal IFA titer was 1:10,240. Sera from Indonesia did not retard intraerythrocytic parasite development, but inhibited merozoite erythrocyte invasion 22-87%. Anti-merozoite activity did not correlate with IFA titers. The differences in principal modes of anti-parasitic activity suggest that immunity to malaria in Sudan is based on cell-mediated immune mechanisms associated with crisis forms, merozoite neutralization being of secondary importance. In contrast, malaria immunity in Flores appears to be principally based on anti-merozoite antibody, which does not cause crisis forms and allows for development of reduced numbers of healthy schizonts. This less efficient mechanism may lead to a continuous low-grade parasitemia, which could explain the high specific malaria antibody titers and adult splenomegaly in Flores as compared to Sudan. This latter approach to immunity, being less efficient than the former, apparently results in chronic malaria infections with associated high Ig titers and splenomegaly.