Guy Barnish

A large focus of alveolar echinococcosis in central China

Human alveolar echinococcosis (AE) is a rare and highly pathogenic helminthic zoonosis due to infection with the intermediate stage of the small fox tapeworm, Echinococcus multilocularis. Parasite transmission is restricted to northern latitudes, including central and north China, from where few clinical and no detailed community studies have been reported. In August, 1991, 65 (5%) of 1312 people residing in three rural communes of Zhang County, Gansu Province, China were diagnosed as having hepatic AE after mass ultrasound scanning with serological back-up. This represents one of the highest prevalence rates of AE ever recorded. It is also the first time that mass ultrasound scanning and serology have been used together in an AE endemic region. The region was selected one year earlier, when a preliminary serosurvey on 606 unselected people in the same locality resulted in an 8.8% serum antibody positive rate with a 76% rate of confirmation of hepatic AE in 37 individuals who could be followed up in 1991. Seropositivity rates varied for villages between 0 and 20.5%. Overall, females (7.8%) had a significantly greater risk of infection than males (2.5%), especially in the 31-50 age group, a difference which may be related to contact with dogs and dog faeces over many years. Age-specific prevalence of AE increased from 0% in the under 5-year group to 8.2% in those aged 31-50. The youngest case was 11 years and the mean age of diagnosis was 40 years. Adult tapeworms of E multilocularis were identified from the small intestines of 10% of domestic dogs. Sylvatic animal hosts of the parasite have not yet been identified. The high prevalence of human AE in this region of central China is most probably due to semi-domestic transmission of E multilocularis between wild rodents and dogs, together with the poverty and poor hygiene in these rural communities.

Malaria and urbanization in sub-Saharan Africa

There are already 40 cities in Africa with over 1 million inhabitants and the United Nations Environmental Programme estimates that by 2025 over 800 million people will live in urban areas. Recognizing that malaria control can improve the health of the vulnerable and remove a major obstacle to their economic development, the Malaria Knowledge Programme of the Liverpool School of Tropical Medicine and the Systemwide Initiative on Malaria and Agriculture convened a multi-sectoral technical consultation on urban malaria in Pretoria, South Africa from 2nd to 4th December, 2004. The aim of the meeting was to identify strategies for the assessment and control of urban malaria. This commentary reflects the discussions held during the meeting and aims to inform researchers and policy makers of the potential for containing and reversing the emerging problem of urban malaria.

Malaria and anaemia among children in two communities of Kumasi, Ghana: a cross-sectional survey.

BackgroundA survey in Kumasi, Ghana found a marked Plasmodium falciparum prevalence difference between two neighbouring communities (Moshie Zongo and Manhyia). The primary objective of this follow-up study was to determine whether this parasite rate difference was consistent over time. Secondary objectives were to compare prevalences of clinical malaria, anaemia, intestinal parasite infections, and malnutrition between these communities; and to identify potential risk factors for P. falciparum infection and anaemia.MethodsA cross-sectional house-to-house survey of P. falciparum parasitaemia, clinical malaria, anaemia, anthropometric indices, and intestinal helminths was conducted in April-May 2005. Data collection included child and household demographics, mosquito avoidance practices, distance to nearest health facility, childs travel history, symptoms, and anti-malarial use. Risk factors for P. falciparum and anaemia (Hb < 11 g/dl) were identified using generalized linear mixed models.ResultsIn total, 296 children were tested from 184 households. Prevalences of P. falciparum, clinical malaria, anaemia, and stunting were significantly higher in Moshie Zongo (37.8%, 16.9%, 66.2% and 21.1%, respectively) compared to Manhyia (12.8%, 3.4%, 34.5% and 7.4%). Of 197 children tested for helminths, four were positive for Dicrocoelium dendriticum. Population attributable risks (PAR%) of anaemia were 16.5% (P. falciparum) and 7.6% (malnutrition). Risk factors for P. falciparum infection were older age, rural travel, and lower socioeconomic status. Risk factors for anaemia were P. falciparum infection, Moshie Zongo residence, male sex, and younger age.ConclusionHeterogeneities in malariometric indices between neighbouring Kumasi communities are consistent over time. The low helminth prevalence, and the twofold higher PAR% of anaemia attributable to P. falciparum infection compared to malnutrition, indicate the importance of malaria as a cause of anaemia in this urban population.

Integrated Community Case Management of Fever in Children under Five Using Rapid Diagnostic Tests and Respiratory Rate Counting: A Multi-Country Cluster Randomized Trial

Evidence on the impact of using diagnostic tests in community case management of febrile children is limited. This effectiveness trial conducted in Burkina Faso, Ghana, and Uganda, compared a diagnostic and treatment package for malaria and pneumonia with presumptive treatment with anti-malarial drugs; artemisinin combination therapy (ACT). We enrolled 4,216 febrile children between 4 and 59 months of age in 2009–2010. Compliance with the malaria rapid diagnostic test (RDT) results was high in the intervention arm across the three countries, with only 4.9% (17 of 344) of RDT-negative children prescribed an ACT. Antibiotic overuse was more common: 0.9% (4 of 446) in Uganda, 38.5% (114 of 296) in Burkina Faso, and 44.6% (197 of 442) in Ghana. Fever clearance was high in both intervention and control arms at both Day 3 (97.8% versus 96.9%, P = 0.17) and Day 7 (99.2% versus 98.8%, P = 0.17). The use of diagnostic tests limits overuse of ACTs. Its impact on antibiotic overuse and on fever clearance is uncertain.

Transmission control and drug resistance in malaria: a crucial interaction.

Drug resistance is a major problem affecting progress on malaria control, while many current programmes are seeking to introduce impregnated bednets to reduce transmission and hence child mortality and morbidity. David Molyneux, Katherine Floyd, Guy Barnish and Eric Fèvre propose that more consideration should be given to the interaction between transmission control and the development of drug resistance, and that vector control as a means of reducing disease transmission is involved in reducing the rate of development, and the level, of resistance. Therefore, investment in vector control can have important benefits in reducing the future expenditure on drugs (as well as other costs, such as hospitalization, management of resistant cases and severe disease, drug development and household expenditure on malaria chemotherapy). Modelling the many parameters that impact on this complex relationship will better inform policy makers.

Urban malaria and anaemia in children: a cross-sectional survey in two cities of Ghana.

Objective  To describe the epidemiology of urban malaria, an emerging problem in sub‐Saharan Africa.

Newer drug combinations for malaria

May be impractical unless diagnostic accuracy can be improved Resistance of parasites to cheap, first line malaria drugs is a major obstacle to reducing the more than one million deaths due to malaria each year worldwide. Comparing the number of parasitologically confirmed cases of malaria with those that are presumptively diagnosed reveals shockingly high rates of overdiagnosis at peripheral and community levels where self treatment is routine.1 If more expensive drug treatments are introduced, this degree of misdiagnosis of malaria cannot be condoned or sustained. In sub-Saharan Africa more than 80% of individuals with malaria self treat fevers with antimalarial drugs without seeking help from the formal health sector.2 Sixty per cent of children with fever in Kenya, and 83% in Togo, were treated at home with a malaria drug.3 4 Clinical signs alone are also used at primary healthcare facilities, which lack laboratories for malaria diagnosis. This approach is sensitive but not specific, so that in areas with intermittent malaria transmission it is common for three quarters of febrile patients to be advised to take …

The late biting habit of parous Anopheles mosquitoes and pre-bedtime exposure of humans to infective female mosquitoes

Using the all-night landing catch method (18:00-06:00) we showed, for Anopheles gambiae in Sierra Leone and A. punctulatus in Papua New Guinea, that parous females have a tendency to bite later than nulliparous ones. The biting habit of sporozoite-infected A. punctulatus was also investigated. The sporozoite rates for Plasmodium falciparum and P. vivax were 1.8 and 1.4% respectively, but only one (1.3%) of 76 females infected with P. falciparum was caught between 18:00 and 21:00. A significantly higher proportion (11.6%) of mosquitoes infected with P. vivax was caught in the same period. The late biting habit of mosquitoes infected with P. falciparum is discussed in relation to the differential biting habits of parous and nulliparous females. We conclude with a hypothesis that, in areas where Anopheles mosquitoes have a late-biting cycle and low parous rate, exposure to mosquitoes infected with P. falciparum during the pre-bedtime period (18:00-22:00) is very low. This hypothesis could explain why insecticide-treated bed nets protect children better in areas of seasonal transmission, where nulliparous females tend to predominate, than in areas of perennial transmission, where parous females are usually more numerous. The same hypothesis is compatible with the finding in Papua New Guinea that insecticide-impregnated bed nets are more protective against P. falciparum than against P. vivax malaria.

Household cost of malaria overdiagnosis in rural Mozambique

BackgroundIt is estimated that over 70% of patients with suspected malaria in sub-Saharan Africa, diagnose and manage their illness at home without referral to a formal health clinic. Of those patients who do attend a formal health clinic, malaria overdiagnosis rates are estimated to range between 30–70%.MethodsThis paper details an observational cohort study documenting the number and cost of repeat consultations as a result of malaria overdiagnosis at two health care providers in a rural district of Mozambique. 535 adults and children with a clinical diagnosis of malaria were enrolled and followed over a 21 day period to assess treatment regimen, symptoms, number and cost of repeat visits to health providers in patients misdiagnosed with malaria compared to those with confirmed malaria (determined by positive bloodfilm reading).ResultsDiagnosis based solely on clinical symptoms overdiagnosed 23% of children (<16y) and 31% of adults with malaria. Symptoms persisted (p = 0.023) and new ones developed (p < 0.001) in more adults than children in the three weeks following initial presentation. Adults overdiagnosed with malaria had more repeat visits (67% v 46%, p = 0.01–0.06) compared to those with true malaria. There was no difference in costs between patients correctly or incorrectly diagnosed with malaria. Median costs over three weeks were

Improving access to early treatment of malaria: a trial with primary school teachers as care providers

0.28 for those who had one visit and