Malaria Transmission Under an Unusual Circumstance Causing Death in Two Siblings.

Two school-going siblings from a family residing in a presumed malaria non-endemic locality ∼90 km from Mangalore city in southwestern India contracted Plasmodium falciparum infection. In both cases, misunderstanding of initial clinical symptoms as due to viral hepatitis resulted in progression to severe malaria before malaria treatment was initiated. Despite treatment at a tertiary hospital, the children died of cerebral malaria and multi-organ dysfunction. Active case detection in the affected locality suggested that the infection was transmitted from infected individuals who worked in nearby malaria-endemic areas and periodically visited their families. A lesson from this study is that lethal falciparum malaria can be transmitted in regions of India, believed to be non-endemic for the disease, resulting in fatal outcomes if diagnosis is missed or delayed. Implementation of effective surveillance and control measures as well as preparedness for malaria detection and diagnosis are necessary in areas that are potentially disposed to malaria transmission even though they are presumed to be non-endemic.

Anopheles stephensi saliva enhances progression of cerebral malaria in a murine model.

Malaria accounts for the greatest morbidity and mortality of any arthropod-borne disease globally. Recently, it was determined that the protective antisporozoite CD8+ T-cell response originates predominantly from cutaneous lymph nodes draining the site of parasite inoculation by an Anopheles mosquito. The female mosquito inoculates sporozoites along with an assortment of salivary proteins into the skin of its mammalian host. Mosquito saliva has demonstrable antihemostatic as well as various immunomodulatory activities, and studies with mosquito-borne viruses support a role for mosquito saliva in enhancement of transmission and exacerbation of disease. Early differences in immune response can be detected, which discriminate between mice that are resistant and susceptible to neurological pathology. This supports the idea that early divergence in the immune response may influence the likelihood of progression to the more severe forms of malaria. To evaluate the effect of mosquito feeding on the pathogenesis and immune response to malaria, we injected washed Plasmodium berghei sporozoites intradermally in the presence or absence of mosquito feeding. We observed that mice exposed to mosquito feeding in tandem with the inoculation of sporozoites had higher parasitemias and an elevated progression to cerebral malaria. This was associated with, in particular, elevated levels of interleukin-4 and interleukin-10, suppression of overall transcription in response to infection, and decreased extravasation of dendritic cells and monocytes. This study enhances to our understanding of the complexity of the interactions between the malaria parasite, its host, and the mosquito vector.

Bimodal transmission of cerebral malaria and severe malarial anemia and reciprocal co-existence of sexual and asexual parasitemia in an area of seasonal malaria transmission.

The parasite dynamics in severe malaria (SM) varies with malaria endemicity. This study was conducted in eastern Sudan, an area of seasonal and unstable malaria transmission. From the beginning of October to the end of December (malaria season) in the years 2000, 2001, and 2003, 99 patients with severe malarial anemia (SMA) and 54 patients with cerebral malaria (CM) were identified. There was marked variation in the incidence of SMA and CM (up to six folds) and in the CM/SMA incidence ratio, over 3 years. In the heavy season of 2003, CM peaked at the beginning of the season and declined within a month at a time that the SMA reached the peak. At diagnosis, the rate of gametocytemia had inclined from approximately 10% to 100% from the beginning to the end of the season. During follow-up, gametocytemia was more associated with SMA than with CM. Paradoxically, the late occurring SMA was associated with early gametocytemia (day 7) and the opposite was true in CM. In conclusion, within the season the transmission of CM and SMA was bimodal, the prevalence of the asexual and sexual parasitemia was reciprocal, and the peaks of transmission and gametocytemia were paradoxical.

Acquired immunity and postnatal clinical protection in childhood cerebral malaria.

By analysing data on the age distribution of cerebral malaria among sites of different transmission intensities, we conclude that the most plausible explanation for the epidemiological patterns seen is that (i) cerebral malaria is caused by a distinct set of Plasmodium falciparum antigenic types; (ii) these antigenic types or 'CM strains' are very common and induce strong strain-specific immunity; and (iii) the postnatal period of protection against cerebral malaria is much longer than the period of protection against other forms of severe disease. The alternative hypothesis that cerebral malaria may be caused by any 'strain' of P. falciparum is compatible with the data only if a single exposure is sufficient to protect against further episodes. This is not consistent with observations on the history of exposure of patients with cerebral malaria. Finally, it is clear that although the delayed peak in incidence of cerebral malaria (with age) can be generated by assuming that subsequent exposures carry a higher risk of disease, such an explanation is not compatible with the observation that severe disease rates are low among infants and young children in areas of high transmissibility.

Relation between severe malaria morbidity in children and level of Plasmodium falciparum transmission in Africa.

BACKGROUND: Malaria remains a major cause of mortality and morbidity in Africa. Many approaches to malaria control involve reducing the chances of infection but little is known of the relations between parasite exposure and the development of effective clinical immunity so the long-term effect of such approaches to control on the pattern and frequency of malaria cannot be predicted. METHODS: We have prospectively recorded paediatric admissions with severe malaria over three to five years from five discrete communities in The Gambia and Kenya. Demographic analysis of the communities exposed to disease risk allowed the estimation of age-specific rates for severe malaria. Within each community the exposure to Plasmodium falciparum infection was determined through repeated parasitological and serological surveys among children and infants. We used acute respiratory-tract infections (ARI) as a comparison. FINDINGS: 3556 malaria admissions were recorded for the five sites. Marked differences were observed in age, clinical spectrum and rates of severe malaria between the five sites. Paradoxically, the risks of severe disease in childhood were lowest among populations with the highest transmission intensities, and the highest disease risks were observed among populations exposed to low-to-moderate intensities of transmission. For severe malaria, for example, admission rates (per 1000 per year) for children up to their 10th birthday were estimated as 3.9, 25.8, 25.9, 16.7, and 18.0 in the five communities; the forces of infection estimated for those communities (new infections per infant per month) were 0.001, 0.034, 0.050, 0.093, and 0.176, respectively. Similar trends were noted for cerebral malaria and for severe malaria anaemia but not for ARI. Mean age of disease decreased with increasing transmission intensity. INTERPRETATION: We propose that a critical determinant of life-time disease risk is the ability to develop clinical immunity early in life during a period when other protective mechanisms may operate. In highly endemic areas measures which reduce parasite transmission, and thus immunity, may lead to a change in both the clinical spectrum of severe disease and the overall burden of severe malaria morbidity.

PIP: 3556 pediatric admissions with severe malaria over 3-5 years from five discrete communities in the Gambia and Kenya were recorded prospectively in a study of the relationship between parasite exposure and the development of effective clinical immunity against malaria. The exposure to Plasmodium falciparum infection in each community was determined through repeated parasitological and serological surveys among children and infants, while acute respiratory tract infections (ARI) were used as a comparison. Clear differences were observed in age, clinical spectrum, and rates of severe malaria between the five sites. The risks of severe disease in childhood were lowest in populations with the highest transmission intensities, while the highest disease risks were observed among populations exposed to low-to-moderate intensities of transmission. Similar trends were observed for cerebral malaria and severe malaria anemia, but not for ARI. The mean age of disease decreased with increasing transmission intensity.