Plasmodium knowlesi transmission: integrating quantitative approaches from epidemiology and ecology to understand malaria as a zoonosis.

The public health threat posed by zoonotic Plasmodium knowlesi appears to be growing: it is increasingly reported across South East Asia, and is the leading cause of malaria in Malaysian Borneo. Plasmodium knowlesi threatens progress towards malaria elimination as aspects of its transmission, such as spillover from wildlife reservoirs and reliance on outdoor-biting vectors, may limit the effectiveness of conventional methods of malaria control. The development of new quantitative approaches that address the ecological complexity of P. knowlesi, particularly through a focus on its primary reservoir hosts, will be required to control it. Here, we review what is known about P. knowlesi transmission, identify key knowledge gaps in the context of current approaches to transmission modelling, and discuss the integration of these approaches with clinical parasitology and geostatistical analysis. We highlight the need to incorporate the influences of fine-scale spatial variation, rapid changes to the landscape, and reservoir population and transmission dynamics. The proposed integrated approach would address the unique challenges posed by malaria as a zoonosis, aid the identification of transmission hotspots, provide insight into the mechanistic links between incidence and land use change and support the design of appropriate interventions.

Factors that are associated with the risk of acquiring Plasmodium knowlesi malaria in Sabah, Malaysia: a case-control study protocol.

INTRODUCTION: Plasmodium knowlesi has long been present in Malaysia, and is now an emerging cause of zoonotic human malaria. Cases have been confirmed throughout South-East Asia where the ranges of its natural macaque hosts and Anopheles leucosphyrus group vectors overlap. The majority of cases are from Eastern Malaysia, with increasing total public health notifications despite a concurrent reduction in Plasmodium falciparum and P. vivax malaria. The public health implications are concerning given P. knowlesi has the highest risk of severe and fatal disease of all Plasmodium spp in Malaysia. Current patterns of risk and disease vary based on vector type and competence, with individual exposure risks related to forest and forest-edge activities still poorly defined. Clustering of cases has not yet been systematically evaluated despite reports of peri-domestic transmission and known vector competence for human-to-human transmission. METHODS AND ANALYSIS: A population-based case-control study will be conducted over a 2-year period at two adjacent districts in north-west Sabah, Malaysia. Confirmed malaria cases presenting to the district hospital sites meeting relevant inclusion criteria will be requested to enrol. Three community controls matched to the same village as the case will be selected randomly. Study procedures will include blood sampling and administration of household and individual questionnaires to evaluate potential exposure risks associated with acquisition of P. knowlesi malaria. Secondary outcomes will include differences in exposure variables between P. knowlesi and other Plasmodium spp, risk of severe P. knowlesi malaria, and evaluation of P. knowlesi case clustering. Primary analysis will be per protocol, with adjusted ORs for exposure risks between cases and controls calculated using conditional multiple logistic regression models. ETHICS: This study has been approved by the human research ethics committees of Malaysia, the Menzies School of Health Research, Australia, and the London School of Hygiene and Tropical Medicine, UK.

Measuring the exposure of infants and children to indoor air pollution from biomass fuels in The Gambia.

UNLABELLED: Indoor air pollution (IAP) from biomass fuels contains high concentrations of health damaging pollutants and is associated with an increased risk of childhood pneumonia. We aimed to design an exposure measurement component for a matched case-control study of IAP as a risk factor for pneumonia and severe pneumonia in infants and children in The Gambia. We conducted co-located simultaneous area measurement of carbon monoxide (CO) and particles with aerodynamic diameter <2.5 microm (PM(2.5)) in 13 households for 48 h each. CO was measured using a passive integrated monitor and PM(2.5) using a continuous monitor. In three of the 13 households, we also measured continuous PM(2.5) concentration for 2 weeks in the cooking, sleeping, and playing areas. We used gravimetric PM(2.5) samples as the reference to correct the continuous PM(2.5) for instrument measurement error. Forty-eight hour CO and PM(2.5) concentrations in the cooking area had a correlation coefficient of 0.80. Average 48-h CO and PM(2.5) concentrations in the cooking area were 3.8 +/- 3.9 ppm and 361 +/- 312 microg/m3, respectively. The average 48-h CO exposure was 1.5 +/- 1.6 ppm for children and 2.4 +/- 1.9 ppm for mothers. PM(2.5) exposure was an estimated 219 microg/m3 for children and 275 microg/m3 for their mothers. The continuous PM(2.5) concentration had peaks in all households representing the morning, midday, and evening cooking periods, with the largest peak corresponding to midday. The results are used to provide specific recommendations for measuring the exposure of infants and children in an epidemiological study. PRACTICAL IMPLICATIONS: Measuring personal particulate matter (PM) exposure of young children in epidemiological studies is hindered by the absence of small personal monitors. Simultaneous measurement of PM and carbon monoxide suggests that a combination of methods may be needed for measuring children's PM exposure in areas where household biomass combustion is the primary source of indoor air pollution. Children's PM exposure in biomass burning homes in The Gambia is substantially higher than concentrations in the world's most polluted cities.