Diagnostic and prognostic utility of an inexpensive rapid on site malaria diagnostic test (ParaHIT f) among ethnic tribal population in areas of high, low and no transmission in central India.

BACKGROUND: Malaria presents a diagnostic challenge in most tropical countries. Rapid detection of the malaria parasite and early treatment of infection still remain the most important goals of disease management. Therefore, performance characteristics of the new indigenous ParaHIT f test (Span diagnostic Ltd, Surat, India) was determined among ethnic tribal population in four districts of different transmission potential in central India to assess whether this rapid diagnostic test (RDT) could be widely applied as a diagnostic tool to control malaria. Beyond diagnosis, the logical utilization of RDTs is to monitor treatment outcome. METHODS: A finger prick blood sample was collected from each clinically suspected case of malaria to prepare blood smear and for testing with the RDT after taking informed consent. The blood smears were read by an experienced technician blinded to the RDT results and clinical status of the subjects. The figures for specificity, sensitivity, accuracy and predictive values were calculated using microscopy as gold standard. RESULTS: The prevalence of malaria infection estimated by RDT in parallel with microscopy provide evidence of the type of high, low or no transmission in the study area. Analysis revealed (pooled data of all four epidemiological settings) that overall sensitivity, specificity and accuracy of the RDT were >90% in areas of different endemicity. While, RDT is useful to confirm the diagnosis of new symptomatic cases of suspected P. falciparum infection, the persistence of parasite antigen leading to false positives even after clearance of asexual parasitaemia has limited its utility as a prognostic tool. CONCLUSION: The study showed that the ParaHIT f test was easy to use, reliable and cheap. Thus this RDT is an appropriate test for the use in the field by paramedical staff when laboratory facilities are not available and thus likely to contribute greatly to an effective control of malaria in resource poor countries.

Short report: Field evaluation of posttreatment sensitivity for monitoring parasite clearance of Plasmodium falciparum malaria by use of the Determine Malaria pf test in central India.

The posttreatment performance of the Plasmodium falciparum histidine-rich protein rapid diagnostic test Determine Malaria pf (Abbott Laboratories, Tokyo, Japan) was assessed in 70 patients in central India with uncomplicated falciparum malaria who were treated with chloroquine, sulfadoxine-pyrimethamine, and arteether. Data were compared with those of microscopy. Results revealed that the sensitivity for predicting recrudescence by means of the Determine test after treatment with chloroquine on Day 14 was 75%, with 50% specificity. However, antigenemia was detected in 16% of patients as late as Day 21 in sulfadoxine-pyrimethamine-treated subjects with a drug-sensitive response. Clearance of parasitemia in thick blood smear and clearance of antigenemia appeared to parallel each other only in arteether-treated subjects. The observed diagnostic trends therefore mean that the potential of the Determine test to detect recrudescent infection is limited.

Forest malaria in Chhindwara, Madhya Pradesh, central India: a case study in a tribal community.

Parasitologic and entomologic cross-sectional surveys were carried out during an outbreak of malaria between December 1998 and August 2000 in forest villages near the Mohkhed Primary Health Center in the Chhindwara District of Madhya Pradesh in central India. In December 1998, surveys showed that more than 70% of the fever cases had malaria, with 87% of the malaria caused by Plasmodium falciparum. The rate of enlarged spleens in children was 74.5%. In November 1999, 58% of the inhabitants were infected with malaria, with 80% of these cases caused by P. falciparum. Chloroquine resistance was seen in 23% of the cases. Anopheles culicifacies was the dominant mosquito species in all surveys (70-85%) and was resistant to DDT. The results indicate that the incidence of malaria in Chhindwara has increased gradually from 0.31 per 1,000 in 1990 to 6.75 per 1,000 in 2000. Improved access to treatment facilities, combination therapy, and vector control using an effective insecticide appear to be the most promising methods for controlling malaria in this region.

Effectiveness of alpha-beta arteether in clearing Plasmodium falciparum parasitemia in central India (Madhya Pradesh).

Forty-six patients (25 Females + 21 Males) of uncomplicated Plasmodium falciparum in districts Jabalpur and Mandla of central India (Madhya Pradesh) were administered alpha-beta arteether (an ethyl derivative of qinghaosu), intramuscularly for 3 consecutive days (150 mg once a day). The results revealed that there was rapid control of fever in all the patients without administration of any antipyretic drug. The mean parasite clearance time was 30.78 +/- 10.92 hours and recrudescence/reinfection rate was 6.7% within 28 days. Study indicates that arteether, besides being a potent and fast acting schizontocidal drug, also exhibited gametocytocidal action on P. falciparum.

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.

Malaria control using indoor residual spraying and larvivorous fish: a case study in Betul, central India.

OBJECTIVES: To assess the impact of intensified malaria control interventions in an ethnic minority community in Betul using existing tools. METHODS: Two rounds of indoor residual spraying with synthetic pyrethroid insecticide were applied and larvivorous fish introduced, followed by intensive surveillance for early detection of Plasmodium falciparum with rapid diagnostic tests and prompt treatment with sulphadoxine pyrimethamine. RESULTS: Pre-intervention surveys revealed a very high fever rate in the community in all age groups with a slide positivity rate of >50% with >90%P. falciparum. The post-intervention phase showed a sharp steady decline in number of malaria cases (beta 0.972; P < 0.0001, 95% CI 0.35-0.47). Monitoring of entomological results revealed a significant decline in both Anopheles species and An. culicifacies (P < 0.0001). CONCLUSION: A combination of indoor residual spraying and early detection and prompt treatment complemented by rapid diagnostic tests and larvivorous fishes successfully brought malaria under control. These approaches could be applied in other regions of different endemicity to control malaria in India.

Response of Plasmodium falciparum to chloroquine in a tribal area of Madhya Pradesh.

In vivo tests for chloroquine sensitivity of P. falciparum malaria parasites were carried out on a sample of 130 patients (mean age, 21 years) from two PHCs during October-November 1988. During this period 20 cases (5.2%) were found positive for all seven days suggesting the presence of RII/RIII chloroquine resistance. All the resistant cases were treated with metakelfin successfully without any recrudescence.

Epidemiology of malaria in pregnancy in central India.

Analysis of three years of data from a malaria clinic operated by the Indian Council of Medical Research (ICMR) in the Government Medical College Hospital in Jabalpur, central India, showed a high malaria prevalence among pregnant women, which was statistically highly significant (P < 0.0001) compared with the situation among nonpregnant women. Cerebral malaria was a common complication of severe Plasmodium falciparum infection, with a high mortality during pregnancy, requiring immediate attention. The study also showed that malaria infection was more frequent in primigravidae, falling progressively with increasing parity. Mean parasite densities were significantly higher in pregnant women compared with nonpregnant women for both P. falciparum (P < 0.001; df = 137) and P. vivax (P < 0.05; df = 72) infection. Pregnant women with falciparum or vivax malaria were significantly more anaemic than noninfected pregnant women or infected nonpregnant women. The average weight of 155 neonates from infected mothers was 350 g less than that of 175 neonates from noninfected mothers. This difference in birth weight was statistically significant for both P. falciparum (P < 0.0001; df = 278) and P. vivax (P < 0.0001; df = 223) infection. Congenital malaria was not recorded. We conclude that pregnant women from this geographical area require systematic intervention owing to their high susceptibility to malaria during pregnancy and the puerperium.

PIP: A 3-year study on malarial epidemiology was conducted among 2127 pregnant women from 12 weeks' gestation up to 40 days after delivery at the Obstetrics and Gynecology Department of Government Medical College in Central India. The women either had fever or a history of fever, belonged to the lower socioeconomic groups, and worked in their homes and in the fields. Personal and reproductive histories as well as antimalarial drug intake during pregnancy were considered. Comparisons in rates of anemia and low birth weight were investigated between the two groups, which were composed, respectively, of nonpregnant women of reproductive age assessed for the prevalence of vivax/falciparum malaria and parasite density (the control group) and pregnant women from the study group who had fever, but no malarial infection. Blood smears from all neonates whose mothers were enrolled in the study were also prepared. Results showed statistically higher malaria prevalence in primigravidae, decreasing progressively with increasing parity. 33 pregnant women were infected with P. vivax, while 67% were infected with P. falciparum; 17 of these were cerebral malaria cases. Women with falciparum or vivax malaria were significantly more anemic than noninfected pregnant women or infected nonpregnant women. The average weight of 155 neonates from infected mothers was 350 g less than that of 174 neonates from noninfected mothers. These findings suggest that the high susceptibility of pregnant women to malaria requires systemic intervention.

Malaria parasite density in pregnant women of district Jabalpur, Madhya Pradesh.

Twenty-two cases (nineteen Plasmodium falciparum and three P. vivax) of severe malaria among 200 pregnant women from District Jabalpur, M.P. were studied for malaria parasite density. Almost all of them were found anaemic. The patients were treated with quinine/chloroquine intravenously but seventeen Pf cases died within 96 h of admission in hospital. Out of twenty-two, thirteen were primigravidae.

Prevalence of malaria among pregnant and non-pregnant women of district Jabalpur, Madhya Pradesh.

In the study period of two years 145 pregnant and 79 non-pregnant women with malarial infection were recorded. Plasmodium falciparum was the most prevalent species accounting for 72% of the total malaria infection in pregnant women while, in non-pregnant women it accounted for 58%. Results were analysed according to the species to which the parasite belonged, period of gestation and parity. While cerebral malaria, abortions, intrauterine foetal death, maternal anaemia were common in pregnant patients, only one neonatal death was recorded. Malaria parasites were not found in infants born to mothers with very heavy parasitaemia at the time of delivery. Even though pregnant women of all age groups and parity remain highly susceptible to malaria throughout pregnancy and puerperium from this area, some striking differences like malaria infection more prevalent in primigravidas than multigravidas and in second trimester than in third trimester were noticed in comparison to northern India. Results emphasize the need to target malaria control for this group of women. Failure to clear parasitaemia after chloroquine administration in P. falciparum was common in both pregnant and non-pregnant women. This is an area, where there is a great need to introduce effective malaria interventions. As chloroquine resistant parasites spread a better understanding of the problem is needed leading to a few chemotherapeutic options for pregnant women.

ABO blood groups among malaria cases from district Mandla, Madhya Pradesh.

A total of 2095 patients with fever were tested for malaria and classified according to ABO blood groups. Only 696 cases were malaria positive. While blood group A, B and O were equally susceptible to malaria infection, AB blood group had less number of persons with malaria parasites. A significantly lower frequency of Plasmodium falciparum was observed among individuals with blood groups A and O. In other two blood groups B and AB, no difference in P. vivax and P. falciparum proportions were observed. A two-year study showed that the frequency of repeated attacks between all blood groups was similar.

A focus of high degree chloroquine resistant P. falciparum in Mandla district (M.P.).

A study on the bioenvironmental control of malaria was launched in Bizadandi block (Mandla district, M.P.) in May 1986. Besides intervention, using environmental management methods and larvivorous fishes, weekly surveillance and chloroquine administration at 25 mg/kg body weight was practiced. Studies during 1987 revealed that a large number of P. falciparum cases did not respond to the standard anti-malarial treatment. Therefore, systematic 28 day in vivo studies were taken up on the follow-up of P. falciparum cases after administration of 3 day course of 25 mg/kg body weight as per the WHO procedure. Results revealed a high proportion of drug resistant cases belonging to RI (237), RII and RIII (182) category. In vivo studies on the sensitivity to metakelfin showed that some cases were resistant to this drug. There is an urgent need to eradicate this focus before it starts spreading to other areas.

Cerebral malaria in Jabalpur, India.

A total of 1783 patients were admitted in Govt. Medical College Hospital, Jabalpur with fever in 1993. Out of these 152 (8.5%) patients had cerebral malaria, of which 39 (25.6%) patients died. Age and sex-wise break-up indicated that males suffered more (p < 0.01) from malaria and majority of patients belonged to 16-40 yrs age-group. Mortality was significantly higher in patients with hyperparasitaemia, hypoglycaemia and delayed diagnosis and treatment. Comatose condition was the main determinant of death.