Comprehensive case management of malaria: Operational research informing policy.

In 2013, the Odisha state Vector Borne Disease Control Programme led a five year operational research project, under programmatic conditions, in close collaboration with several partners. This Comprehensive Case Management Project covered a population of 900,000 across paired control and intervention blocks in four districts, each with different transmission intensities. Key gaps in access to malaria services were identified through household surveys and a detailed situation analysis. The interventions included ensuring adequate stocks of rapid diagnostic tests and antimalarial drugs at the village level, the capacity building of health workers and ASHAs, setting up microscopy centres at the primary health care level, and conducting mass screening and treatment in poorly accessible areas. The programme strengthened the routine health system, and improved malaria surveillance as well as the access to and quality of care. Initially, the programme led to increased case reporting due to improved detection, followed by a decline in malaria incidence. Lessons from the project were then scaled up statewide in the form of a new initiative-Durgama Anchalare Malaria Nirakaran (DAMaN).

Village-scale (Phase III) evaluation of the efficacy and residual activity of SumiShield® 50 WG (Clothianidin 50%, w/w) for indoor spraying for the control of pyrethroid-resistant Anopheles culicifacies Giles in Karnataka state, India.

OBJECTIVE: There is an urgent need to test and incorporate new molecules with promising efficacy and novel mode of action to control insecticide-resistant mosquito vectors for disease control. We tested a new compound, clothianidin (SumiShield 50 WG), for its efficacy as an indoor residual spray (IRS) for the control of pyrethroid-resistant Anopheles culicifacies (Diptera: Culicidae) in comparison with pirimiphos methyl (Actellic CS) as a positive control. METHODS: Ten villages were selected, five each for IRS with clothianidin (300 mg AI/m2 ) and pirimiphos methyl (1000 mg AI/m2 ) in Almatti Dam catchment area in Karnataka state, India. Entomological parameters were monitored in these sprayed villages using standard methods. Assessment of quality of spray was performed by analysing the insecticide content in the filter paper samples collected from sprayed houses. Perceptions of spray men and inhabitants were recorded post-spray on safety of these molecules. RESULTS: The mean applied to target ratio of content was 1.7 (n = 29) for clothianidin and 1.8 (n = 50) for pirimiphos methyl on filter paper samples analysed. Residual activity (≥80% mortality in exposed mosquitoes) after 24 h post-exposure of SumiShield WG was 5 months and increased to 6 months when the holding period was extended to 120 h and that of Actellic CS was 3 months at 24-h holding period and extended to 4 months at 120-h extended holding period. The mean densities of An. culicifacies in both arms fell drastically post-spray. In light trap collections, density of mosquitoes collected indoors was lower than outdoors in both arms indicating effectiveness of IRS. SumiShield WG was more efficacious in reducing the per-structure density than Actellic CS. The proportion of nulliparous mosquitoes was higher than that of parous mosquitoes during post-spray collections in both arms. The majority of adverse events reported were transitory and subsided without medication. CONCLUSION: Indoor residual spraying with SumiShield WG was found effective, operationally feasible and safe, and it is effective for up to 6 months.

Small-scale (Phase II) evaluation of the efficacy and residual activity of SumiShield® 50 WG (clothianidin 50%, w/w) for indoor residual spraying in comparison to deltamethrin, bendiocarb and pirimiphos-methyl for malaria vector control in Karnataka state, India.

BACKGROUND & OBJECTIVES: There is an urgent need of introducing new insecticide molecules with novel modes of action to counter the ever growing insecticide-resistance in mosquito vectors. In the present study, a new insecticide molecule, SumiShield 50 WG (clothianidin 50%, w/w) was investigated for its efficacy as an indoor residual spray along with its residual action in comparison to deltamethrin, pirimiphos-methyl and bendiocarb. METHODS: The study area included three villages in Almatti Dam catchment area in Bagalkot district, Karnataka, India. Spraying was done using Hudson sprayers with the following dosages-Clothianidin, 300 mg AI/m2; deltamethrin, 25 mg AI/m2; bendiocarb, 400 mg AI/m2; and pirimiphos-methyl, 1 g AI/m2. Cone bioassays were conducted on cement and mud plastered surfaces at fortnightly intervals to assess the bioefficacy and residual activity. Mosquito densities in the sprayed houses were recorded at regular intervals for assessment of the insecticidal efficacy. Filter paper samples collected from the sprayed houses were analyzed for insecticide content sprayed on different wall surfaces at the Walloon Agricultural Research Institute, Gembloux, Belgium. RESULTS: Chemical content analysis of filter paper samples revealed that the applied to target ratios were in the acceptable range (1 + 0.5) for all the treatment types. Duration of persistence of effectiveness of bendiocarb (≥80% mortality in cone bioassays) was 19 to 21 wk on cement plastered surfaces and 15 to 19 wk on mud plastered surfaces. Duration of persistence of effectiveness of deltamethrin was 17 to 21 wk on both mud and cement plastered surfaces and that of pirimiphos-methyl was 15 to 19 wk. For SumiShield, it was 17 to 25 wk on both types of surfaces, indicating slow action of SumiShield. The densities of Anopheles culicifacies were lower in bendiocarb sprayed houses throughout the observation period, followed by pirimiphos methyl, deltamethrin and clothianidin sprayed houses. In case of other mosquitoes also, similar trend was observed. INTERPRETATION & CONCLUSION: Considering the persistence of effectiveness of SumiShield on sprayed surfaces, effectiveness in reducing the density of mosquitoes, operational feasibility, safety and community acceptance, the formulation of clothianidin is a better option for IRS for the control of insecticide-resistant mosquito vectors.

Burden of asymptomatic malaria among a tribal population in a forested village of central India: a hidden challenge for malaria control in India.

OBJECTIVE: Chhattisgarh in India is a malaria-endemic state with seven southern districts that contributes approximately 50-60% of the reported malaria cases in the state every year. The problem is further complicated due to asymptomatic malaria cases which are largely responsible for persistent transmission. This study was undertaken in one of the forested villages of the Keshkal subdistrict in Kondagaon district to ascertain the proportion of the population harbouring subclinical malarial infections. STUDY DESIGN: Community-based cross-sectional study. METHODS: Mass blood surveys were undertaken of the entire population of the village in the post-monsoon seasons of 2013 and 2014. Fingerprick blood smears were prepared from individuals of all ages to detect malaria infections in their blood. Individuals with fever at the time of the survey were tested with rapid diagnostic tests, and parasitaemia in thick blood smears was confirmed by microscopy. Malaria-positive cases were treated with anti-malarials in accordance with the national drug policy. RESULTS: Peripheral blood smears of 134 and 159 individuals, including children, were screened for malaria infection in 2013 and 2014, respectively. Overall, the malaria slide positivity rates were 27.6% and 27.7% in 2013 and 2014, respectively, and the prevalence rates of asymptomatic malaria were 20% and 22.8%. This study showed that, for two consecutive years, the prevalence of asymptomatic malaria infection was significantly higher among children aged ≤14 years (34.4% and 34.1% for 2013 and 2014, respectively) compared with adults (15.2% and 18.2% for 2013 and 2014, respectively; P = 0.023 and 0.04, respectively). CONCLUSION: The number of asymptomatic malaria cases, especially Plasmodium falciparum, is significant, reinforcing the underlying challenge facing the malaria elimination programme in India.

Comparison of three PCR-based assays for the non-invasive diagnosis of malaria: detection of Plasmodium parasites in blood and saliva.

The conventional molecular diagnosis of malaria uses 18S rRNA-based PCR assay employing blood samples. This assay presents limitation in terms of long turnaround time and increased chances of false-positive results. Here, we evaluated one-step singleplex or multiplex PCR assay based on high copy species-specific consensus repeat sequences (CRS) along with standard 18S rRNA nested PCR (18S n-PCR) assay to detect P. falciparum and P. vivax infection using blood and saliva samples from Indian febrile patients. Out of 327 patients, 187 were found to be positive for malaria parasites by microscopic examination of peripheral blood smears. Among these 130 were P. vivax and 57 were P. falciparum cases. The 18S n-PCR assay and CRS PCR assay identified 186 out of 187 cases (99.4 %). Multiplex CRS PCR assay detected Plasmodium in 176 out of 187 cases (94.1 %). Both singleplex and multiplex CRS PCR assay identified 6 mixed infection cases, while 18S n-PCR assay detected 10 mixed infection cases of P. vivax and P. falciparum, which were not recognized by microscopy. Non-invasive Plasmodium detection rate with DNA derived from saliva samples was highest for 18S n-PCR (87.36 %), followed by singleplex CRS (81 %) and multiplex CRS PCR assay (70.5 %). Specificity for P. vivax and P. falciparum detection for all assays was 98.48 % and 100 % respectively. Detection rate for P. vivax in saliva correlated with parasite density for CRS target-based assays. The species-specific CRS PCR, either as a singleplex or multiplex assay, can have an impact on diagnosis and epidemiological studies in malaria.

Allelic polymorphism in the Plasmodium vivax dihydrofolate reductase gene among Indian field isolates.

In total, 129 Plasmodium vivax isolates from different geographical areas in India were analysed for point mutations in the P. vivax dihydrofolate reductase gene that were associated with pyrimethamine resistance. A gradual increase in the frequency of mutant genotypes was observed from north to south (p <0.0001). In the northern region (Delhi, Panna and Nadiad), the wild-type genotype was most prevalent, while the mutant genotype predominated in the coastal regions of southern India (Navi Mumbai, Goa and Chennai). Isolates from the Car-Nicobar islands showed only mutant genotypes. The differential geographical pattern of mutations may be associated with the transmission pattern.

Therapeutic efficacy of antimalarial drugs along the eastern Indo-Nepal border: a cross-border collaborative study.

This collaborative cross-border study was performed to determine the therapeutic efficacy of antimalarial drugs used by the National Programmes for falciparum malaria along the eastern Indo-Nepal border where there is unregulated population movement across the border. The study was conducted at sites in Jhapa District, Nepal and Darjeeling District, India. The study was conducted from August 2003 to February 2004, following the WHO 28 day treatment protocol. The efficacy of chloroquine was tested in India among 91 subjects and of sulfadoxine-pyrimethamine in Nepal among 107 subjects with laboratory-confirmed Plasmodium falciparum malaria. Of the 102 subjects who completed the study in Nepal, there were 21 (20.6%) treatment failures comprising 7 (6.9%) early treatment failures (ETF) and 14 (14.7%) late treatment failures (LTF) (5 late clinical failures [LCF] and 9 late parasitological failures [LPF]). Of the 89 subjects who completed the study in India, there were 46 (51.7%) treatment failures comprising 7 (7.9%) ETFs and 39 (43.8%) LTFs (13 LCFs and 26 LPFs). Based on WHO guidelines both countries need to review their drug policy urgently and make appropriate changes, taking into account aspects of cross-border collaboration in the control of drug-resistant malaria.

A rapid immunochromatographic test (ICT) for diagnosis of Plasmodium falciparum.

A field study was conducted to assess the sensitivity and specificity of rapid immunodiagnostic test based on detection of Plasmodium falciparum histidine-rich protein-2 (PfHRP-2) in peripheral blood for diagnosis of P. falciparum infection. Evaluation in 173 patients showed that the assay was 98.59% sensitive and 97.1% specific. There was no cross-reactivity with P. vivax. The test was positive in few patients who were found to be negative by microscopy showing the presence of antigen after curative chemotherapy. The test is a valuable diagnostic tool for falciparum malaria, especially in emergency/field situations requiring rapid diagnosis.

Malaria diagnosis by field workers using an immunochromatographic test.

A rapid immunodiagnostic test (ICT Malaria PfTest) has been developed by ICT Diagnostics (Sydney, Australia) for the diagnosis of Plasmodium falciparum infection. The test is an antigen capture assay based on the detection of P. falciparum histidine-rich protein 2 in peripheral blood. This study was undertaken to assess the performance and usefulness of the test as a diagnostic method in highly malarious, inaccessible forested villages of Mandla district, central India. In all, 353 patients with fever were scanned by the test in parallel with thick blood film examination. The sensitivity and specificity were 100% and 84.5%, respectively. The whole test took about 5 min. The test results became negative in most cases (70%) within 7 d after initiation of curative chemotherapy. The test is simple, easy to learn and accurate, and may prove to be an important tool in the battle against falciparum malaria.

Single dose pharmacokinetics of lithium and prediction of maintenance dose in manic depressive patients.

Pharmacokinetics of lithium was studied in 60 manic-depressive patients after an initial dose of 900 mg, in serial blood samples for 24 h. The values (mean +/- SD) obtained were peak serum Li concentration 0.81 +/- 0.18 mEq/l; time to peak 2.57 +/- 0.87 h; total Li clearance 33.2 +/- 15.5 ml/min; volume of distribution 0.62 +/- 0.26 l/kg; elimination rate constant 0.0514 +/- 0.02 h; area under serum concentration-time curve 16.41 +/- 11.41 mEq/1 h; serum half life 15.34 +/- 6.06 h. Thereafter, the applicability of various dose prediction methods was evaluated vis-a-vis the actual doses needed to attain steady state serum lithium concentration of 0.6-1.2 mEq/l in 46 patients. The method based on body weight was not found suitable. A nomographic method predicted higher doses in 27 patients, while Zetin's mathematical model predicted dose was in the range of +/- 150 mg of the actual dose in 21 patients. A method for predicting maintenance dose based on 24 h serum lithium level and body weight is suggested.

Curative efficacy of norfloxacin in falciparum malaria.

Fifteen patients of uncomplicated falciparum malaria from Delhi were treated with norfloxacin (10 with 400 mg, 5 with 800 mg, both twice daily) for 3 days and the response was measured according to the WHO extended in vivo test criteria. The lower dose produced S response in two, RII response in five and RIII response in three patients, while the higher dose produced S response in four and RI response in one patient. In patients with S or RI response, the parasite clearance time was 68.6 +/- 9.1 h the defervescence time being 48 h. Thus, norfloxacin did reveal in vivo activity in falciparum malaria, but a dose of 400 mg twice daily proved to be curative only in a small percentage of cases and not consistently. Nausea and bitter taste were the only side effects noted in two patients.

Anti-malarial activity of some xanthones isolated from the roots of Andrographis paniculata.

Four xanthones were isolated from the roots of Andrographis paniculata using a combination of column and thin-layer chromatographic methods. They were characterized as (i) 1,8-di-hydroxy-3,7-dimethoxy-xanthone, (ii) 4,8-dihydroxy-2,7-dimethoxy-xanthone, (iii) 1,2-dihydroxy-6,8-dimethoxy-xanthone and (iv) 3,7,8-trimethoxy-1-hydroxy xanthone by IR, MS and NMR spectroscopic methods. In vitro study revealed that compound 1,2-dihydroxy-6,8-dimethoxy-xanthone possessed substantial anti-plasmodial activity against Plasmodium falciparum with its IC(50) value of 4 microg ml(-1). Xanthones bearing hydroxyl group at 2 position demonstrated most potent activity while xanthones with hydroxyl group at 1,4 or 8 position possessed very low activity. In vivo anti-malarial sensitivity test of this compound on Swiss Albino mice with Plasmodium berghei infection using Peters' 4-day test gave substantial reduction (62%) in parasitaemia after treating the mice with 30 mg kg(-1) dose. In vitro cytotoxicity against mammalian cells revealed that 1,2-dihydroxy-6,8-dimethoxy-xanthone is non-cytotoxic with its IC(50) > 32 microg ml(-1).

Efficacy of alpha,beta-arteether in acute uncomplicated P. falciparum malaria.

A phase-III clinical trial was conducted in 50 patients (42M + 8F) with acute uncomplicated falciparum malaria from Delhi during the period of September to November 1995. Their mean age was 27.2 years, and the mean parasitaemia on day 0 was 0.65%. Patients were hospitalized and treated with a new ethyl derivative of artemisinin developed at CDRI called alpha, beta-arteether, at the dosage of 150 mg l/M for three consecutive days. Peripheral smears were examined every day for 4 days and then weekly up to 28 days. The results of the study showed that the mean parasite and fever clearance times were respectively 19.94 +/- 6.87 and 37.81 +/- 21.67 hours. Within 48 h, 70% of the cases became afebrile and the peripheral smear was negative in 100% of the cases. The drug was well tolerated. Three cases (6%) had recrudescence within 28 days. It is concluded that alpha, beta-arteether is a safe, effective and rapidly acting antimalarial.

Studies on malaria during pregnancy in a tribal area of central India (Madhya Pradesh).

In tribal villages of central India where malaria is highly prevalent (mesoendemic), this preliminary study was undertaken to determine the effects of malaria infection in a group of 456 pregnant women with or without fever. Only 96 women were found infected with malaria, of which Plasmodium falciparum accounted for 64% of the detected parasites, while P. vivax for the remaining 36%. There were no instances of cerebral malaria or death however, one abortion and four still births were recorded among 38 primigravid women. Only one neonate was found infected with P. falciparum on day 21 though parasitemia was not high. Anemia was commonly present in most of the women (80%). Failure to clear P. falciparum parasitemia after a chloroquine regimen (25 mg/kg of body weight) was commonly observed. Persistent P. falciparum parasitemia was recorded in 8% cases. Poor response to chloroquine suggests the need to change the drug policy.

Comparative bioequivalence study of different brands of acetyl salicylic acid in human volunteers.

A double blind cross over randomized study was conducted in 7 normal healthy volunteers. Single dose (700 mg) of buffered aspirin or aspirin with calcium carbonate or aspirin with caffeine was administered orally, at least 3 days apart. Blood samples were drawn at different time intervals after administration of drug for estimation of salicylate levels. The values of different pharmacokinetic parameters (AUC0-infinity, Cmax and tmax) did not show any significant difference, suggesting that these three brands of aspirin are biologically equivalent.

Bromo-deoxyuridine based assay for detection of parasite and drug sensitivity in Plasmodium falciparum in vitro.

A non-radioactive, thymidine analogue-bromodeoxyuridine (Brdu), derivative of uridine has been used for incorporation in DNA in culture of P. falciparum at various dosages and at different time period. Parasite growth rate and effect of chloroquine in culture were monitored by microscopic observation of stained smears and incorporation of Brdu molecules were visualized by immunofluorescence and measured by enzyme immuno assay using anti-Brdu. Uptaking of Brdu in parasite is slower unlike tumour cells. A positive correlation between parasite growth and Brdu uptake measurement by ELISA has been observed.

In vitro antimalarial activity of monoterpenic fragment analogues of aplasmomycin.

Synthetic analogues of a monoterpenic fragment of aplasmomycin were tested for their antimalarial activity in Plasmodium falciparum culture in vitro. The antimalarial activities of these agents were evaluated in chloroquine sensitive strains. Parasite growth was inhibited in a dose dependent manner in the presence of the synthetic compounds (3-9).

A multicentric study with arteether in patients of uncomplicated falciparum malaria.

Two hundred and sixty seven patients of uncomplicated P. falciparum malaria completed study in a multicentric phase III clinical trial of Arteether. Arteether was given intramuscularly in a dose of 150 mg daily for three consecutive days. Each patient was followed upto 28 days of alpha, beta arteether therapy. The cure rate was 97% with fever clearance time between 1-7 days (24-168 hours) and parasite clearance time between 1-3 days (24-72 hours). Parasite reappearance rate was found to be 3% and reported at only three of the centres. Following the treatment no adverse effect was observed on haematological, biochemical and vital clinical parameters.

Influence of clonidine, methyldopa and propranolol on acute toxicity of fenitrothion in mice.

The effect of pretreatment with clonidine, methyldopa and propranolol, and of atropine was studied in mice on acute toxicity of fenitrothion, the active ingredient of TIK-20. Atropine significantly decreased and propranolol somewhat decreased the fenitrothion induced death in mice. Clonidine and methyldopa somewhat increased the percentage mortality due to fenitrothion.

Genetic diversity of Plasmodium falciparum field isolates from south western Nigeria.

BACKGROUND: Plasmodium falciparum the main causative agent of malaria is an important public health vector. With the use of PCR, its genetic diversity has been extensively studied with dearth information from Nigeria. METHODS: In this study, 100 P. falciparum strains merozoite surface protein 1(msp-1), merozoite surface protein 2 (msp-2) and Glutamate rich protein (Glurp) from Ogun State General Hospitals were characterized. The genetic diversity of P. falciparum isolates was analyzed by restriction fragment length polymorphism following gel electrophoresis of DNA products from nested polymerase chain reactions (PCR) of their respective allelic families KI, MAD 20, RO33 (MSP-1);FC27, 3D7 (MSP-2) and Glutamate rich protein respectively. RESULTS: Majority of the patients showed monoclonal infections while multiplicity of the infection for msp-1 and msp-2 were 1.1 and 1.2 respectively. The estimated number of genotypes was 8 msp-1 (4 KI; 3 MAD; 1 RO33) and 6 msp-2 (3 FC27; 3 3D7). 80% of the isolates coded for Glurp with allelic size ranged between 700 and 900 bp. CONCLUSION: The allelic distributions however were similar to those previously reported in other endemic malaria countries. Future studies will be designed to include other malaria endemic regions of Nigeria such as the oil exploration regions.