Epidemiology of Uterine Cancer in Sarawak, Borneo, A 20-Year Review.

OBJECTIVE: This study aimed to determine the epidemiology of uterine cancer in Sarawak, Malaysia, using data from a population-based cancer registry. METHODS: The study population included all women diagnosed with uterine cancer in Sarawak, Malaysia between January 1996 and December 2015. Data on demographic and clinical characteristics were obtained from the Sarawak Cancer Registry. The crude incidence rate, age-standardized incidence rate (ASR), and incidence risk ratios (IRR) were calculated. Joinpoint regression analyses were performed to assess trends in incidence rates. RESULTS: A total of 811 women were diagnosed with primary uterine cancer during the study period. The overall crude incidence rate for uterine cancer in Sarawak for the period 1996-2015 was 3.7 per 100,000. The ASR was 4.4 per 100,000 with a 95% CI (4.1-4.8). The ASR in 2011-2015 is 1.6 times higher than the ASR of uterine cancer in 1996-2000. Higher incidence rates were observed in women aged 40-59 years and those aged 60 years and above. Chinese women had the highest ASR, followed by Malay and Iban women. Joinpoint regression analyses showed a significant increase in cases of uterine cancer among all ethnic groups and age groups. CONCLUSION: The incidence of primary uterine cancer in Sarawak, Malaysia, has increased over the past 20 years, with higher incidence rates observed in older age groups and among Chinese women. The findings suggest the need for continued efforts to improve the prevention, early detection, and treatment of uterine cancer in Sarawak.

Seroevidence of SARS-CoV-2 spillback to rodents in Sarawak, Malaysian Borneo.

BACKGROUND: SARS-CoV-2 is believed to have originated from a spillover event, where the virus jumped from bats to humans, leading to an epidemic that quickly escalated into a pandemic by early 2020. Despite the implementation of various public health measures, such as lockdowns and widespread vaccination efforts, the virus continues to spread. This is primarily attributed to the rapid emergence of immune escape variants and the inadequacy of protection against reinfection. Spillback events were reported early in animals with frequent contact with humans, especially companion, captive, and farmed animals. Unfortunately, surveillance of spillback events is generally lacking in Malaysia. Therefore, this study aims to address this gap by investigating the presence of SARS-CoV-2 neutralising antibodies in wild rodents in Sarawak, Malaysia. RESULTS: We analysed 208 archived plasma from rodents collected between from 2018 to 2022 to detect neutralising antibodies against SARS-CoV-2 using a surrogate virus neutralisation test, and discovered two seropositive rodents (Sundamys muelleri and Rattus rattus), which were sampled in 2021 and 2022, respectively. CONCLUSION: Our findings suggest that Sundamys muelleri and Rattus rattus may be susceptible to natural SARS-CoV-2 infections. However, there is currently no evidence supporting sustainable rodent-to-rodent transmission.

Molecular epidemiology of dengue in North Kalimantan, a province with the highest incidence rates in Indonesia in 2019.

OBJECTIVES: Dengue is endemic to Indonesia, a country that has largely varied geographical and demographic conditions across different regions. In 2019, dengue epidemic occurred in North Kalimantan province and recorded as the highest incidence rate in Indonesia. This study aims to investigate the molecular epidemiology of dengue during outbreak in the province and compare the epidemiological characteristics between two cities/towns in North Kalimantan, namely Malinau, an inland town surrounded by a dense rainforest, and Tarakan, an island city. METHODS: A cross sectional study was conducted between September 2018 and July 2019. Dengue-like illness patients were recruited in hospitals and tested for dengue NS1 and IgG/IgM. Serological prevalence was measured using IgG ELISA, dengue virus (DENV) serotyping was conducted using RT-PCR and Envelope gene sequencing was performed to infer the virus origins and phylogeny. Clinical, demographical, and diagnostics data were also recorded and analyzed. RESULTS: We recruited 523 patients, 261 from Malinau and 262 from Tarakan. Among them, 349 patients were confirmed dengue. Cases in Malinau had a higher proportion of confirmed dengue (82.0%) compared to those in Tarakan (51.5%). Cases in Malinau were more likely to be dengue hemorrhagic fever with more severe hematological features compared to those in Tarakan. All four DENV serotypes were detected in both cities, the most prevalent serotype being DENV-2. The genetic characteristics of the viruses in the two towns was similar except for DENV-3. No sylvatic DENV was detected as well as alphaviruses and non-dengue flaviviruses during the outbreak. CONCLUSIONS: The molecular epidemiology of dengue in North Kalimantan revealed the similar virological characteristics but different clinical and demographic aspects in Malinau and Tarakan. The distinct dengue dynamics between different regions of Indonesia is prominent and this knowledge will be important for understanding future patterns of DENV transmission in the region.

Prevalence and risk factors associated with alcohol consumption among indigenous people in Sabah Borneo Island.

OBJECTIVES: In this study, we aimed to determine the prevalence and risk factors of alcohol use among a cohort of population in Sabah. DESIGN: This is a prospective, cohort study involving rural community residents. SETTING: Rural community resident at Bingkor, Keningau, Sabah. PARTICIPANTS: 363 individuals aged 13 years old and above. INTERVENTION: Community-based participatory research to determine the prevalence and risk factors associated with alcohol use. MAIN OUTCOME MEASURES: Measurement of alcohol use using Alcohol Use Disorders Identification Test (AUDIT) and assessment of psychiatric morbidity using Mini International Neuropsychiatric Interview (MINI) questionnaires. RESULTS: Most alcohol drinkers aged between 36-45 years old, followed by 26-35 years old and 46-55 years old. Interestingly, there are almost similar female to male ratio. Most were Kadazan-Dusun ethnic, non-Muslims, and married. Although only less than a third of the participants received tertiary education, the majority were working. Based on the findings, being a male, non-Muslim and having an obsessive-compulsive disorder (OCD) (current) posed a significantly higher risk of alcohol consumption. CONCLUSION: A worryingly high prevalence of hazardous alcohol consumption among the locals is reported. There is a need for population-wide intervention towards preventive measures based on the identified risk factors for hazardous alcohol use.

High incidence of asymptomatic cases during an outbreak of Plasmodium malariae in a remote village of Malaysian Borneo.

An outbreak of Plasmodium malariae occurred in Sonsogon Paliu village in the remote area of Ulu Bengkoka sub-district of Kota Marudu, Northern Sabah, Malaysian Borneo from July through August 2019. This was the first outbreak of malaria in this village since 2014. On 11th July 2019 the Kota Kinabalu Public Health Laboratory notified the Kota Marudu District Health Office of a Polymerase Chain Reaction (PCR) positive case of P. malariae. This index case was a male from Sulawesi, Indonesia working for a logging company operating in Sonsogon Paliu. During the resulting outbreak, a total of 14 symptomatic cases were detected. All of these cases were positive by thick and thin blood smear examination, and also by PCR. During the outbreak, a mass blood survey screening was performed by light-microscopy and PCR. A total of 94 asymptomatic villagers 31 (33.0%) were PCR positive but thick and thin blood smear negative for P. malariae. Both symptomatic and asymptomatic cases received treatment at the district hospital. When symptomatic and asymptomatic cases were considered together, males (29/45. 64.5%) were infected more than females (16/45, 35.6%), the male:female ratio being 1.8:1. Adults were the predominant age group infected (22/45, 48.9%) followed by adolescents (19/45, 42.2%) and children under five years of age (4/45, 8.9%). This report illustrates that symptomatic and submicroscopic cases pose a challenge during P. malariae outbreaks and that PCR is a valuable tool for their identification. The rapid identification and control of imported malaria is crucial for the continued control of malaria in Malaysia.

First Report of Lecanicephalidean Tapeworms (Eucestoda) from Freshwater, Including Description of Three New Species of Tetragonocephalum Shipley and Hornell, 1905.

The lecanicephalidean cestodes parasitizing the spiral intestine of the endangered giant freshwater whipray, Urogymnus polylepis (Bleeker), are investigated for the first time. Eight host specimens were collected between 2002 and 2008 at 2 collecting sites off the eastern coast of Borneo: 6 from the Kinabatangan River (Malaysia) and 2 from a fish market in Tarakan (Indonesia). Two of these individuals were found to be infected with a total of 3 new species of TetragonocephalumShipley and Hornell, 1905. Tetragonocephalum georgei n. sp. and Tetragonocephalum opimum n. sp. were recovered from a host specimen from the Kinabatangan River, and Tetragonocephalum levicorpum n. sp. was found parasitizing a host specimen purchased at a fish market in Tarakan. Specimens of each of the new species were prepared for light microscopy; specimens of 2 of the new species were prepared for scanning electron microscopy, and histological sections were prepared for 1 of the new species. The 3 new species are distinct from the 9 valid species of Tetragonocephalum and the 1 species inquirendum based on, for example, total length, number of proglottids and testes, and size of the scolex and acetabula. Tetragonocephalum georgei n. sp. and T. levicorpum n. sp. are unusual among their congeners in that they are euapolytic (i.e., gravid proglottids were not observed) rather than apolytic. They differ from one another in scolex and acetabula size. Tetragonocephalum opimum n. sp. is unusual among its congeners in its possession of vitelline follicles arranged in 2, rather than 3, regions in the proglottid. These new species increase the total number of valid species of Tetragonocephalum to 12 and the total number of known cestodes from U. polylepis to 13 species across 6 genera in 4 orders. This is the first account of lecanicephalideans reported from freshwater. The taxonomic status of each of the 32 nominal taxa historically associated with Tetragonocephalum is re-assessed. Type host identities of all valid species are revised and discussed in light of recent taxonomic efforts in the Dasyatidae Jordan and Gilbert.

Copro-molecular identification of intestinal nematode infections in a rural community in East Malaysia.

Soil-transmitted helminth (STH) infections are the most common intestinal parasitic infections of medical importance in humans. The infections are widely distributed throughout tropical and subtropical countries, particularly among disadvantaged and underprivileged communities. In Malaysia, STH infections is highly prevalent, especially among the indigenous groups. However, species identification through molecular studies is still lacking. Using molecular techniques, this study was conducted to identify STH species that infect humans. Faecal samples were collected from three Iban tribal longhouses in the rural area of Sarikei Division, Sarawak. Positive faecal samples by microscopy were subjected to PCR and sequenced for species identification. Based on the microscopy examination, the most prevalent STH infection was Ascaris, followed by hookworm and Trichuris. All microscopy-positive samples were then PCR-amplified. The amplicons were sequenced, aligned, and compared with other sequences in the GenBank database. The results showed that Ascaris lumbricoides was the predominant STH species, followed by Trichuris trichiura, Ancylostoma duodenale, and Necator americanus. Our findings were contradictory to past studies, as we showed that A. duodenale was more abundant than N. americanus. Socioeconomic improvement and health education programs should be included in the management and prevention of public health strategies against STH.

High incidence of asymptomatic leptospirosis among urban sanitation workers from Kota Kinabalu, Sabah, Malaysian Borneo.

Leptospirosis is a public health challenge in Sabah State of Malaysian Borneo. Rapid urbanization, rural-to-urban migration, and undocumented immigration in Sabah have increased the pressure on the urban garbage disposal system. Rodents and other small animals thrive under these conditions. We hypothesized that urban sanitation workers would be at risk of developing leptospirosis. In total, 303 urban sanitation workers with a mean age of 42.6 years were enrolled in this study. The serum samples collected from these workers were subjected to the microscopic agglutination test (MAT), PCR and nucleotide sequencing of the amplicons to confirm the presence of Leptospira. The phylogenetic analysis using the neighbor joining method was performed to assess whether they were pathogenic. In this study 43.8% (133/303) of the samples were MAT-seropositive and among them, 29 (21.8%) were positive by PCR. Nucleotide sequencing of the amplicons confirmed the presence of Leptospira. Phylogenetic analysis showed that our strains belonged to the pathogenic group of Leptospira. A high proportion of urban sanitation workers were seropositive for leptospirosis, and a considerable number were PCR positive for Leptospira, thereby indicating asymptomatic infections. Further research is needed to confirm whether this is a transient phenomenon or antibiotic therapy is required.

Malaria distribution and performance of malaria diagnostic methods in Malaysia (1980-2019): a systematic review.

BACKGROUND: Malaysia has already achieved remarkable accomplishments in reaching zero indigenous human malaria cases in 2018. Prompt malaria diagnosis, surveillance and treatment played a key role in the country's elimination success. Looking at the dynamics of malaria distribution during the last decades might provide important information regarding the potential challenges of such an elimination strategy. This study was performed to gather all data available in term of prevalence or incidence on Plasmodium infections in Malaysia over the last four decades. METHODS: A systematic review of the published English literature was conducted to identify malaria distribution from 1980 to June 2019 in Malaysia. Two investigators independently extracted data from PubMed, Scopus, Web of Science and Elsevier databases for original papers. RESULTS: The review identified 46 epidemiological studies in Malaysia over the 39-year study period, on which sufficient information was available. The majority of studies were conducted in Malaysia Borneo (31/46; 67.4%), followed by Peninsular Malaysia (13/46; 28.3%) and in both areas (2/46; 4.3%). More than half of all studies (28/46; 60.9%) were assessed by both microscopy and PCR. Furthermore, there was a clear trend of decreases of all human malaria species with increasing Plasmodium knowlesi incidence rate throughout the year of sampling period. The summary estimates of sensitivity were higher for P. knowlesi than other Plasmodium species for both microscopy and PCR. Nevertheless, the specificities of summary estimates were similar for microscopy (40-43%), but varied for PCR (2-34%). CONCLUSIONS: This study outlined the epidemiological changes in Plasmodium species distribution in Malaysia. Malaria cases shifted from predominantly caused by human malaria parasites to simian malaria parasites, which accounted for the majority of indigenous cases particularly in Malaysia Borneo. Therefore, malaria case notification and prompt malaria diagnosis in regions where health services are limited in Malaysia should be strengthened and reinforced to achieving the final goal of malaria elimination in the country.

Neurosurgical Services in the Northern Zone of Sarawak in Malaysia: The Way Forward Amid the COVID-19 Pandemic.

BACKGROUND: The novel coronavirus disease 2019 (COVID-19) pandemic has set a huge challenge to the delivery of neurosurgical services, including the transfer of patients. We aimed to share our strategy in handling neurosurgical emergencies at a remote center in Borneo island. Our objectives included discussing the logistic and geographic challenges faced during the COVID-19 pandemic. METHODS: Miri General Hospital is a remote center in Sarawak, Malaysia, serving a population with difficult access to neurosurgical services. Two neurosurgeons were stationed here on a rotational basis every fortnight during the pandemic to handle neurosurgical cases. Patients were triaged depending on their urgent needs for surgery or transfer to a neurosurgical center and managed accordingly. All patients were screened for potential risk of contracting COVID-19 prior to the surgery. Based on this, the level of personal protective equipment required for the health care workers involved was determined. RESULTS: During the initial 6 weeks of the Movement Control Order in Malaysia, there were 50 urgent neurosurgical consultations. Twenty patients (40%) required emergency surgery or intervention. There were 9 vascular (45%), 5 trauma (25%), 4 tumor (20%), and 2 hydrocephalus cases (10%). Eighteen patients were operated at Miri General Hospital, among whom 17 (94.4%) survived. Ninety percent of anticipated transfers were avoided. None of the medical staff acquired COVID-19. CONCLUSIONS: This framework allowed timely intervention for neurosurgical emergencies (within a safe limit), minimized transfer, and enabled uninterrupted neurosurgical services at a remote center with difficult access to neurosurgical care during a pandemic.

Human exposure to zoonotic malaria vectors in village, farm and forest habitats in Sabah, Malaysian Borneo.

The zoonotic malaria parasite, Plasmodium knowlesi, is now a substantial public health problem in Malaysian Borneo. Current understanding of P. knowlesi vector bionomics and ecology in Sabah comes from a few studies near the epicentre of human cases in one district, Kudat. These have incriminated Anopheles balabacensis as the primary vector, and suggest that human exposure to vector biting is peri-domestic as well as in forest environments. To address the limited understanding of vector ecology and human exposure risk outside of Kudat, we performed wider scale surveillance across four districts in Sabah with confirmed transmission to investigate spatial heterogeneity in vector abundance, diversity and infection rate. Entomological surveillance was carried out six months after a cross-sectional survey of P. knowlesi prevalence in humans throughout the study area; providing an opportunity to investigate associations between entomological indicators and infection. Human-landing catches were performed in peri-domestic, farm and forest sites in 11 villages (3-4 per district) and paired with estimates of human P. knowlesi exposure based on sero-prevalence. Anopheles balabacensis was present in all districts but only 6/11 villages. The mean density of An. balabacensis was relatively low, but significantly higher in farm (0.094/night) and forest (0.082/night) than peri-domestic areas (0.007/night). Only one An. balabacensis (n = 32) was infected with P. knowlesi. Plasmodium knowlesi sero-positivity in people was not associated with An. balabacensis density at the village-level however post hoc analyses indicated the study had limited power to detect a statistical association due low vector density. Wider scale sampling revealed substantial heterogeneity in vector density and distribution between villages and districts. Vector-habitat associations predicted from this larger-scale surveillance differed from those inferred from smaller-scale studies in Kudat; highlighting the importance of local ecological context. Findings highlight potential trade-offs between maximizing temporal versus spatial breadth when designing entomological surveillance; and provide baseline entomological and epidemiological data to inform future studies of entomological risk factors for human P. knowlesi infection.

Early Detection of Undiagnosed Abdominal Aortic Aneurysm and Sub-Aneurysmal Aortic Dilatations in Patients with High-Risk Coronary Artery Disease: The Value of Targetted Screening Programme.

INTRODUCTION: Abdominal aortic aneurysm (AAA) and coronary artery disease (CAD) share common risk factors. The objective of this study was to determine the prevalence of undiagnosed AAA in patients with angiographically diagnosed significant CAD. PATIENTS AND METHODS: Male patients aged 50 years and above (including indigenous people) with angiographically diagnosed significant CAD in the recent one year were screened for AAA. Standard definition of abdominal aortic aneurysm and CAD was used. All new patients were followed up for six months for AAA events (ruptured AAA and AAA-related mortality). RESULTS: A total of 277 male patients were recruited into this study. The total prevalence of undiagnosed AAA in this study population was 1.1% (95% CI 0.2-3.1). In patients with high-risk CAD, the prevalence of undiagnosed AAA was 1.7% (95% CI 0.3-4.8). The detected aneurysms ranged in size from 35.0mm to 63.8mm. Obesity was a common factor in these patients. There were no AAA-related mortality or morbidity during the follow-up. Although the total prevalence of undiagnosed AAA is low in the studied population, the prevalence of sub-aneurysmal aortic dilatation in patients with significant CAD was high at 6.6% (95% CI 3.9-10.2), in which majority were within the younger age group than 65 years old. CONCLUSION: This was the first study on the prevalence of undiagnosed AAA in a significant CAD population involving indigenous people in the island of Borneo. Targeted screening of patients with high-risk CAD even though they are younger than 65 years old effectively discover potentially harmful asymptomatic AAA and sub-aneurysmal aortic dilatations.

Nineteen Years of Japanese Encephalitis Surveillance in Sabah, Malaysian Borneo.

Japanese encephalitis (JE) is endemic in Malaysia. Although JE vaccination is practiced in the neighboring state of Sarawak for a long time, little is known about JE in Sabah state in Borneo. As a result, informed policy formulation for JE in Sabah has not been accomplished. In the present study, we have analyzed JE cases that have been reported to the Sabah State Health Department from 2000 to 2018. A total of 92 JE cases were reported during 19 years, and three-fourths of the cases were attributed to children. The estimated mean incidence for JE cases is 0.161/100,000 population. Japanese encephalitis was predominant in Sabah during June, July, and August, peaking in July. In most cases, pigs were absent within a 400-m radius of the place of residence. We could not establish any relationship between the mapping of JE cases and the number of piggeries in each district. We could not establish a relationship between average rainfall and JE cases, either. We propose the cases reported are possibly showing the tip of an iceberg and continuous surveillance is needed, as JE is a public health challenge in Sabah.

Entamoeba histolytica infections in wild and semi-wild orangutans in Sumatra and Kalimantan.

Key to the success of orangutan conservation management practices is the prevention of the introduction of infectious diseases to the remaining populations. Previous reports of Entamoeba spp. positive orangutans are of concern as Entamoeba spp. infection has been linked to morbidity and mortality in primates. It remains to be determined if the Entamoeba species infecting orangutans is the pathogenic Entamoeba histolytica. Orangutan fecal samples have been collected from orangutans from sites in Sumatra (Bukit Lawang, Ketambe, and Suaq, 241 samples from 64 individuals), and two sites in Kalimantan (Sebangau and Tuanan, 129 samples from 39 individuals). All samples were from wild orangutans except for a proportion from Sumatra which were from semi-wild (108 samples, 10 individuals). E. histolytica-specific nested PCR assays were carried out on the fecal samples. A total of 36 samples from 17 individuals tested positive for E. histolytica. When compared with published sequences using NCBI BLAST the E. histolytica positive samples showed a 98-99% concordance. The majority (76%, n = 36) of the positive isolates came from semi-wild orangutans in Bukit Lawang. This study supports the growing body of evidence that contact with humans is an important risk factor for infection of wild primates with E. histolytica.

Helminth parasites occurrence in wild proboscis monkeys (Nasalis larvatus), endemic primates to Borneo Island.

BACKGROUND: Nasalis larvatus are well-known attraction for tourists in the mangrove forest of Bako National Park (BNP). Little is known regarding the infestation of helminth parasites in proboscis monkeys. Therefore, the objectives of this study are to determine the prevalence species of major helminth parasites of public health importance in proboscis monkeys in BNP. METHODS: A total of 65 faecal samples screened for helminth parasites via sodium nitrate floatation and faecal sedimentation techniques. RESULTS: A total of 14 helminth parasite species comprising of eight genera of nematodes, two species of cestodes and two trematodes were identified. Eggs of Trichuris trichiura were the most frequently encountered in proboscis monkeys. CONCLUSION: This is the first survey on the fauna of helminth parasites of proboscis monkeys living in mangrove forests, and therefore, it implies the important baseline information that increases our current knowledge for future research regarding parasite-host ecology in primates.

Invasive Salmonella infections among children in Bintulu, Sarawak, Malaysian Borneo: a 6-year retrospective review.

BACKGROUND: Invasive Salmonella infections result in significant morbidity and mortality in developing countries. In Asia, typhoid and paratyphoid fever are reported to be the major invasive Salmonella infections, while invasive non-typhoidal Salmonella (iNTS) infections are believed to be uncommon. Data from Sarawak, in Malaysian Borneo, are limited. METHODS: A retrospective study identifying all children aged < 15 years with invasive Salmonella infections from 2011 to 2016 was conducted in Bintulu Hospital in Sarawak. Population incidences, clinical and bacterial characteristics were examined. RESULTS: Forty-four patients were identified during the 6-year study period: 43 had iNTS infection and 1 had typhoid fever. The average annual iNTS incidence was 32.4 per 100,000 children aged < 5 years. None of the children had malaria or HIV infection, and only 7% were severely malnourished. Salmonella Enteritidis and Salmonella Java were the commonest NTS serovars identified. Pneumonia was the most common manifestation of iNTS disease, present in 20 (47%) children. Other manifestations included gastroenteritis, fever without a source, septic arthritis and meningitis. Salmonella Enteritidis was identified in 76% of those with pneumonia, significantly more frequently than in children with other manifestations. Over 25% of children with iNTS developed severe disease and nearly 10% suffered long term morbidity or mortality. While 78% of Salmonella Java isolates were multi-drug resistant, nearly all other isolates were susceptible to most antimicrobials, including ampicillin. CONCLUSIONS: Bintulu Division in Sarawak observed a very high incidence of childhood iNTS infections. Enteric fever was uncommon. The epidemiology of invasive Salmonella infections in Malaysian Borneo differs considerably from that of neighbouring countries in Asia.

Cholera outbreak by Sea Gypsies in Sabah, Malaysia: A challenge in North Borneo.

OBJECTIVES: In this study we investigated an outbreak of Vibrio cholera O1 Ogawa serotype, occurred during December 2014 in Kudat district, situated in Sabah state of the Malaysian part of Borneo. METHODS: Active case detection and contact tracing were done at respective localities by house to house survey. Passive case detection was done among acute gastroenteritis patients attended at various health facilities. To determine the source, samples from food, water and environment were taken. A case control study was also done to determine the risk factors. RESULTS: A total of 44 symptomatic and 34 asymptomatic cases from 19 localities were investigated. 39 cases were detected through passive case detection. Median age of cases was 23 years. All cases belonged to serogroup O1 and Ogawa serotype. The epidemiological investigation of time, place, and person identified that V. cholerae cross-transmission might have occurred in two fish markets and the fish-loading port. Circumstantial evidences indicated that cholera was possibly transmitted through contaminated sea foods. CONCLUSIONS: We concluded that the life-style of Sea Gypsies is a challenge in cholera control; therefore vaccination might be an effective way to mitigate cholera in an outbreak prone area like Kudat.

Defining the ecological and evolutionary drivers of Plasmodium knowlesi transmission within a multi-scale framework.

Plasmodium knowlesi is a zoonotic malaria parasite normally residing in long-tailed and pig-tailed macaques (Macaca fascicularis and Macaca nemestrina, respectively) found throughout Southeast Asia. Recently, knowlesi malaria has become the predominant malaria affecting humans in Malaysian Borneo, being responsible for approximately 70% of reported cases. Largely as a result of anthropogenic land use changes in Borneo, vectors which transmit the parasite, along with macaque hosts, are both now frequently found in disturbed forest habitats, or at the forest fringes, thus having more frequent contact with humans. Having access to human hosts provides the parasite with the opportunity to further its adaption to the human immune system. The ecological drivers of the transmission and spread of P. knowlesi are operating over many different spatial (and, therefore, temporal) scales, from the molecular to the continental. Strategies to prevent and manage zoonoses, such as P. knowlesi malaria require interdisciplinary research exploring the impact of land use change and biodiversity loss on the evolving relationship between parasite, reservoir hosts, vectors, and humans over multiple spatial scales.