The neglected role of relative humidity in the interannual variability of urban malaria in Indian cities.

The rapid pace of urbanization makes it imperative that we better understand the influence of climate forcing on urban malaria transmission. Despite extensive study of temperature effects in vector-borne infections in general, consideration of relative humidity remains limited. With process-based dynamical models informed by almost two decades of monthly surveillance data, we address the role of relative humidity in the interannual variability of epidemic malaria in two semi-arid cities of India. We show a strong and significant effect of humidity during the pre-transmission season on malaria burden in coastal Surat and more arid inland Ahmedabad. Simulations of the climate-driven transmission model with the MLE (Maximum Likelihood Estimates) of the parameters retrospectively capture the observed variability of disease incidence, and also prospectively predict that of 'out-of-fit' cases in more recent years, with high accuracy. Our findings indicate that relative humidity is a critical factor in the spread of urban malaria and potentially other vector-borne epidemics, and that climate change and lack of hydrological planning in cities might jeopardize malaria elimination efforts.

El Niño-based malaria epidemic warning for Oromia, Ethiopia, from August 2016 to July 2017.

OBJECTIVE: Tropical highland malaria intensifies and shifts to higher altitudes during exceptionally warm years. Above-normal temperatures associated with El Niño during boreal winter months (December-March) may intensify malaria in East African highlands. We assessed the malaria risk for Oromia, the largest region of Ethiopia with around 30 million inhabitants. METHODS: Simple linear regression and spatial analyses were used to associate sea surface temperatures (SST) in the Pacific and surface temperatures in Ethiopia with annual malaria risk in Oromia, based on confirmed cases of malaria between 1982 and 2005. RESULTS: A strong association (R2 = 0.6, P < 0.001) was identified between malaria and sea surface temperatures in the Pacific, anticipating a 70% increase in malaria risk for the period from August 2016 to July 2017. This forecast was quantitatively supported by elevated land surface temperatures (+1.6 °C) in December 2015. When more station data become available and mean March 2016 temperatures from meteorological stations can be taken into account, a more robust prediction can be issued. CONCLUSION: An epidemic warning is issued for Oromia, Ethiopia, between August 2016 and July 2017 and may include the pre-July short malaria season. Similar relationships reported for Madagascar point to an epidemic risk for all East African highlands with around 150 million people. Preparedness for this high risk period would include pre-emptive intradomestic spraying with insecticides, adequate stocking of antimalarials, and spatial extension of diagnostic capacity and more frequent reporting to enable a rapid public health response when and where required.

Altitudinal changes in malaria incidence in highlands of Ethiopia and Colombia.

The impact of global warming on insect-borne diseases and on highland malaria in particular remains controversial. Temperature is known to influence transmission intensity through its effects on the population growth of the mosquito vector and on pathogen development within the vector. Spatiotemporal data at a regional scale in highlands of Colombia and Ethiopia supplied an opportunity to examine how the spatial distribution of the disease changes with the interannual variability of temperature. We provide evidence for an increase in the altitude of malaria distribution in warmer years, which implies that climate change will, without mitigation, result in an increase of the malaria burden in the densely populated highlands of Africa and South America.

Shifting patterns: malaria dynamics and rainfall variability in an African highland.

The long-term patterns of malaria in the East African highlands typically involve not only a general upward trend in cases but also a dramatic increase in the size of epidemic outbreaks. The role of climate variability in driving epidemic cycles at interannual time scales remains controversial, in part because it has been seen as conflicting with the alternative explanation of purely endogenous cycles exclusively generated by the nonlinear dynamics of the disease. We analyse a long temporal record of monthly cases from 1970 to 2003 in a highland of western Kenya with both a time-series epidemiological model (time-series susceptible-infected-recovered) and a statistical approach specifically developed for non-stationary patterns. Results show that multiyear cycles of malaria outbreaks appear in the 1980s, concomitant with the timing of a regime shift in the dynamics of cases; the cycles become more pronounced in the 1990s, when the coupling between disease and rainfall is also stronger as the variance of rainfall increased at the frequencies of coupling. Disease dynamics and climate forcing play complementary and interacting roles at different temporal scales. Thus, these mechanisms should not be viewed as alternative and their interaction needs to be integrated in the development of future predictive models.

Cholera dynamics and El Niño-Southern Oscillation.

Analysis of a monthly 18-year cholera time series from Bangladesh shows that the temporal variability of cholera exhibits an interannual component at the dominant frequency of El Niño-Southern Oscillation (ENSO). Results from nonlinear time series analysis support a role for both ENSO and previous disease levels in the dynamics of cholera. Cholera patterns are linked to the previously described changes in the atmospheric circulation of south Asia and, consistent with these changes, to regional temperature anomalies.

Activity of disulfiram (bis(diethylthiocarbamoyl)disulphide) and ditiocarb (diethyldithiocarbamate) against metronidazole-sensitive and -resistant Trichomonas vaginalis and Tritrichomonas foetus.

Clinical resistance of Trichomonas vaginalis to metronidazole is best correlated with MIC values measured under aerobic conditions. Under these conditions both disulfiram (bis(diethylthiocarbamoyl)disulphide), and its first mammalian metabolite, ditiocarb (diethyldithiocarbamate), showed high levels of activity against metronidazole-sensitive (disulfiram MIC, 0.1-0.7 microM; ditiocarb MIC, 0.3-9 microM) and -resistant (MICs 0.2-1.3 microM and 1.2-9 microM respectively) isolates. Tritrichomonas foetus was also sensitive-the MICs for seven metronidazole-sensitive isolates were 0.1-1.0 microM for disulfiram and 1.0-6.9 microM for ditiocarb; those for two highly metronidazole-resistant strains were 0.3-1.3 microM and 0.6-6 microM respectively. Under anerobic conditions most strains became highly resistant to both compounds. Surprisingly, disulfiram was consistently more active than ditiocarb.

Cycles of malaria associated with El Niño in Venezuela.

CONTEXT: Malaria has been increasing globally, and epidemics tend to occur when weather conditions favor this vector-borne disease. Long-term meteorologic forecasting using El Niño Southern Oscillation (ENSO) may assist in anticipating epidemics and targeting scarce resources. OBJECTIVE: To determine whether malaria epidemics in Venezuela are related to ENSO and rainfall and to determine whether such a relationship could be used to predict outbreaks. DESIGN: Retrospective analysis of national malaria morbidity (1975-1995) and mortality (1910-1935) data in the coastal zone and interior of Venezuela in relation to El Niño events and rainfall. MAIN OUTCOME MEASURE: Correlation between malaria mortality and morbidity and sea surface temperatures (SSTs) in the Eastern Tropical Pacific, a parameter of ENSO. RESULTS: Malaria mortality and morbidity have increased by an average of 36.5% (95% confidence interval, 3.7%-69.3%; P=.004) in years following recognized El Niño events. A moderate correlation was found between Pacific tropical SST during a Niño event and malaria 1 year later (r=0.50, P<.001). Malaria mortality is more strongly related to drought in the year preceding outbreaks than to rainfall during epidemic years. CONCLUSIONS: Historic and recent data from Venezuela demonstrate that malaria increases by an average of about one third in the year following a Nino event; change in malaria risk can be predicted from Pacific SSTs in the previous year. Therefore, the occurrence of an El Niño event may help predict malaria epidemics in this part of South America.

Global assessment of El Niño's disaster burden.

BACKGROUND: Natural disasters have profound effects on health and require medical intervention as part of relief operations. The world's populations are becoming increasingly vulnerable to extreme weather events, which are responsible for most natural disasters. The El Niño Southern Oscillation (ENSO) is the most prominent global climate system associated with year-to-year weather variability and extreme events. We have estimated the burden on human health of natural disasters associated with ENSO. METHODS: We used time-series regression analysis of the relation between El Niño years and the annual rates of persons affected by natural disasters per 1000 population during 1964-93, globally and also by region and disaster type. Correlations between sea-surface temperature (SST) anomalies (index of ENSO) and the rates of persons affected by natural disasters per 1000 population were determined globally, by region and by disaster type. FINDINGS: The rate of persons affected by natural disasters worldwide is strongly associated with ENSO; rates are greater during the first El Niño year (p = 0.05) and the following year (p = 0.01) than in the pre-Niño year. The correlation between rates of persons affected by natural disasters and SST anomalies in the Eastern Pacific (a key ENSO indicator) is highest in the last quarter of the previous year (r = 0.53, p < 0.01). These associations are strongest in South Asia, the region where more than 50% of all disaster victims live. Worldwide, rates of persons affected by drought/famine (half of all disaster victims) and by volcanic eruptions show significant associations with the ENSO cycle, being highest in the post-Niño year and El Niño year, respectively, and being significantly associated with SST anomalies. INTERPRETATION: The strong relation between ENSO and populations affected by natural disasters can be described as a "natural disaster cycle". Determining the phase in this cycle, using SST from the Eastern Equatorial Pacific, could benefit disaster preparedness on a global scale, for South Asia in particular, and for all populations affected by drought/famine and volcanic disasters.

Predicting high-risk years for malaria in Colombia using parameters of El Niño Southern Oscillation.

The interannual variation in malaria cases in Colombia between 1960 and 1992 shows a close association with a periodic climatic phenomenon known as El Niño Southern Oscillation (ENSO). Compared with other years, malaria cases increased by 17.3% during a Niño year and by 35.1% in the post-Niño year. The annual total number of malaria cases is also strongly correlated (r = 0.62, P < 0.001) with sea surface temperature (SST) anomalies in the eastern equatorial Pacific, a principal parameter of ENSO. The strong relation between malaria and ENSO in Colombia can be used to predict high and low-risk years for malaria with sufficient time to mobilize resources to reduce the impact of epidemics. In view of the current El Niño conditions, we anticipate an increase in malaria cases in Colombia in 1998. Further studies to elucidate the mechanisms which underlie the association are required. As Colombia has a wide range of climatic conditions, regional studies relating climate and vector ecology to malaria incidence may further improve an ENSO-based early warning system. Predicting malaria risk associated with ENSO and related climate variables may also serve as a short-term analogue for predicting longer-term effects posed by global climate change.

Falciparum malaria and climate change in the northwest frontier province of Pakistan.

Following a striking increase in the severity of autumnal outbreaks of Plasmodium falciparum during the last decade in the Northwest Frontier Province (NWFP) of Pakistan, the role of climatologic variables was investigated. A multivariate analysis showed that during the transmission season of P. falciparum, the amount of rainfall in September and October, the temperature in November and December, and the humidity in December were all correlated (r2 = 0.82) with two measures of P. falciparum, the falciparum rate (percent of slides examined positive for P. falciparum) since 1981 and the annual P. falciparum proportion (percent of all malaria infections diagnosed as P. falciparum) since 1978. Climatologic records since 1876 show an increase in mean November and December temperatures by 2 degrees C and 1.5 degrees C, respectively, and in October rainfall. Mean humidity in December has also been increasing since 1950. These climatologic changes in the area appear to have made conditions for transmission of P. falciparum more favorable, and may account for the increase in incidence observed in the NWFP in recent years.

Rapid decomposition of permethrin in the outer fly of an experimental tent in Pakistan.

The residual activity of permethrin on the canvas of an experimental tent, used by nomadic refugees in a malarious area in northern Pakistan, was assessed. A permethrin emulsion sprayed on the inner sheet of a pitched double-fly tent (0.5 g/m2) had an effective residue for at least 6 months in bioassays using the local malaria vectors, Anopheles stephensi and Anopheles culcifacies. However, a high concentration of permethrin (2 g/m2) sprayed on the inner surface of the outer tent, simulating single-fly tents, decomposed within 2 months. These findings were confirmed with chromatographic analysis. Under the conditions found in the study area, the shortened residual effect most likely resulted from photodecomposition, not previously reported to affect operational performance of this insecticide.

The El Niño Southern Oscillation and the historic malaria epidemics on the Indian subcontinent and Sri Lanka: an early warning system for future epidemics?

The recurrent great malaria epidemics which occurred in the Punjab province of former British India and Ceylon before the introduction of residual insecticides have been related to excessive and failing monsoon rains respectively. In the arid Punjab, rainfall facilitated breeding and increased the lifespan of the mosquito vector and, in the wet part of Ceylon, failing monsoon rains caused rivers to pool, creating more favourable breeding conditions. The periodic fluctuations in monsoon rainfall and epidemic malaria are here explained in relation to the El Niño Southern Oscillation. In the Punjab, epidemic malaria between 1868 and 1943 correlates significantly (r = 0.34, P < 0.005) with the sea surface temperature anomalies in the Eastern Equatorial Pacific, a parameter of the oscillation, and epidemics were significantly more prevalent in a year with a wet monsoon following a dry El Niño year than in other years. In Ceylon, epidemics were significantly more prevalent during El Niño years, when the same south-west monsoon tends to fail. With the reduced reliance on residual insecticides and the recurrence of epidemic malaria on the Indian subcontinent, advances made in predicting El Niño events may be used to forecast high and low risk years for future malaria epidemics.

Malaria control using permethrin applied to tents of nomadic Afghan refugees in northern Pakistan.

Malaria control among nomadic populations has, in the past, posed serious logistic difficulties. Presented in this article are the results of a pilot study in which permethrin was sprayed on the tents of over 26000 nomadic Afghan refugees in an area of Pakistan where seasonal malaria outbreaks occur. In this area Anopheles culicifacies and A. stephensi are the malaria vectors. Population surveys in the year of the study, before and at the end of the transmission season, showed that the increase in the Plasmodium falciparum prevalence among the Afghan nomads was on average significantly less (increase from 6.4% to 15.3%) than that among the resident Pakistani population (from 3.2% to 45.6%). Surveys at the end of the transmission season among primary schoolchildren the year before and the year of the permethrin trial showed that the P. falciparum prevalence among nomadic children decreased significantly (from 46.9% to 16.3%), whereas an increase was observed among the local Pakistani children. The results show that spraying tents with permethrin was a safe and culturally acceptable intervention for the Afghan refugees and that the findings warrant further investigation.

PIP: During 1989-90, in the North-West Frontier Province of Pakistan, a pilot study was conducted in the remote and politically unstable area of South Waziristan Agency (altitude, 1300-1750 m) to determine the feasibility of spraying about 5600 tents (used by more than 26,000 nomadic Afghan refugees) with permethrin and its effect on malaria prevalence. The researchers compared baseline data on the refugees and data from Pakistani schoolchildren with follow-up data on the nomadic Afghan refugees. The mosquito species harboring malaria parasites in the area were Anopheles culicifacies and A. stephensi. An effective permethrin residue persisted for at least 6 months after spraying. Between seasons, the prevalence of Plasmodium falciparum increased at a significantly lower rate among the Afghan nomads (6.4-15.3%) than the resident Pakistan population (3.2-45.6%). Prevalence decreased significantly among nomadic Afghan children after the permethrin intervention (46.9-16.3%; p 0.002). On the other hand, it increased significantly among the local Pakistani children (11.6-40.7%; p 0.001). There were no reports of adverse effects from permethrin spraying operations. The absence of toxic effects, the immediate impact on flies, and the lack of smell or color of the permethrin emulsion made the spraying operation acceptable among the nomads. These findings suggest that spraying tents with permethrin was a safe and culturally acceptable intervention.

Prevalence and clinical presentation of glucose-6-phosphate dehydrogenase deficiency in Pakistani Pathan and Afghan refugee communities in Pakistan; implications for the use of primaquine in regional malaria control programmes.

Glucose-6-phosphate dehydrogenase (G-6-PD) deficiency surveys in Afghan refugees and a local community in the North-West Frontier Province, Pakistan, showed that this trait was most common among Pathan and Uzbak refugees (15.8% and 9.1% respectively). The prevalence among Pakistani Pathans was 7.0%, and that in Tajik and Turkoman refugees was 2.9% and 2.1% respectively. Hospital studies showed that the type of G-6-PD deficiency in Pathans could cause severe haemolytic crises. The potentially fatal side effects of primaquine treatment in the Pathan communities, and the high risk of re-infection, render the anti-relapse treatment policy for Plasmodium vivax obsolete. However, epidemic conditions of P. falciparum malaria may justify the use of primaquine as a gametocidal drug, administered as a single dose, during the transmission season. These findings necessitate revision of the recommendations for the use of primaquine in the area.

Fenitrothion intoxication during spraying operations in the malaria programme for Afghan refugees in North West Frontier Province of Pakistan.

During the experimental use of fenitrothion to replace malathion for the control of malaria in North West Frontier Province of Pakistan, serious intoxication of Afghan refugee spraymen occurred. A few weeks after commencement of the spraying operations, cholinesterase levels had fallen to 43.8% in personnel mixing the insecticide, and to 60.7% in spraymen, as measured by tintometry. Most of the personnel reported symptoms of overexposure and the spraying operations had to be discontinued. Intoxication of personnel resulted in poor coverage of the target area. High ambient temperatures during Pakistan's spray season discourage the use of full-protective clothing. Fenitrothion intoxication observed in the Afghan refugee programme, and similar experiences in Pakistan in the past, suggest that this insecticide is too toxic for routine use, when the compliance with safety precautions cannot be effectively supervised.