Journal of Tropical Medicine The latest articles from Hindawi Publishing Corporation © 2014 , Hindawi Publishing Corporation . All rights reserved. Evidence of HLA-DQB1 Contribution to Susceptibility of Dengue Serotype 3 in Dengue Patients in Southern Brazil Thu, 10 Apr 2014 12:54:55 +0000 Dengue infection (DI) transmitted by arthropod vectors is the viral disease with the highest incidence throughout the world, an estimated 300 million cases per year. In addition to environmental factors, genetic factors may also influence the manifestation of the disease; as even in endemic areas, only a small proportion of people develop the most serious form. Immune-response gene polymorphisms may be associated with the development of cases of DI. The aim of this study was to determine allele frequencies in the HLA-A, B, C, DRB1, DQA1, and DQB1 loci in a Southern Brazil population with dengue virus serotype 3, confirmed by the ELISA serological method, and a control group. The identification of the HLA alleles was carried out using the SSO genotyping PCR program (One Lambda), based on Luminex technology. In conclusion, this study suggests that DQB106:11 allele could act as susceptible factors to dengue virus serotype 3, while HLA-DRB111 and DQA105:01 could act as resistance factors. Daniela Maria Cardozo, Ricardo Alberto Moliterno, Ana Maria Sell, Gláucia Andréia Soares Guelsin, Leticia Maria Beltrame, Samaia Laface Clementino, Pamela Guimarães Reis, Hugo Vicentin Alves, Priscila Saamara Mazini, and Jeane Eliete Laguila Visentainer Copyright © 2014 Daniela Maria Cardozo et al. All rights reserved. Effect of Environmental Disturbance onthe Population of Sandflies and Leishmania Transmission inan Endemic Area of Venezuela Mon, 07 Apr 2014 14:03:22 +0000 The exploitation of new wilderness areas with crops is increasing and traditional crop substitution has been modified by new more productive crops. The results show the anthropogenic disturbance effect on the sandflies population and Leishmania transmission in endemic areas of Venezuela. Three agroecosystems with variable degrees of ecological disturbance, forest (conserved), cacao (fragmented), and orangery (disturbed), were selected. Four methods to sandfly capture were used; the specimens were identified and infected with Leishmania. Diversity, population structure, ANOVA, Tukey test, and simple correlation analysis were carried out. Shannon traps were able to capture 94.7% of the total sandflies, while CDC light traps, Sticky traps, and direct suction just captured 2.2%, 1.2%, and 0.9%, respectively. The results showed the effect of ecological disturbance degree on the composition of sandflies and population structure, revealing a dominance level increased but decreased on the diversity and richness of sandflies species in the greatest ecological disturbance area in relation to areas with less organic disturbance. Environments more disturbed cause adaptability of certain species such as Lutzomyia gomezi and Lutzomyia walkeri. These changes on the composition of sandflies population and structure emerging species could cause increasing of leishmaniasis transmission. Elsa Nieves, Luzmary Oraá, Yorfer Rondón, Mireya Sánchez, Yetsenia Sánchez, Masyelly Rojas, Maritza Rondón, Maria Rujano, Nestor González, and Dalmiro Cazorla Copyright © 2014 Elsa Nieves et al. All rights reserved. Role of Clinical Presentations and Routine CSF Analysis in the Rapid Diagnosis of Acute Bacterial Meningitis in Cases of Negative Gram Stained Smears Thu, 03 Apr 2014 09:30:25 +0000 Background and Aim. Bacterial meningitis is a lethal, disabling endemic disease needing prompt antibiotic management. Gram stained smears is rapid accurate method for diagnosis of bacterial meningitis. In cases of negative gram stained smears diagnosis is delayed till culture results. We aim to assess the role of clinical presentations and routine CSF analysis in the cost-effective rapid diagnosis of negative gram stained smears bacterial meningitis. Methods. Cross sectional study including 623 acute meningitis patients divided into two groups: bacterial meningitis and nonbacterial meningitis groups. The clinical presentations, systemic inflammatory parameters, and CSF analysis were evaluated and compared in both groups. Results. Altered conscious level, localizing neurological signs, Kernig’s and Brudzinski’s signs together with peripheral leucocytosis (>10.000/mm3), high CRP (>6) together with high CSF protein (>50 gl/dL), CSF neutrophilic count (≥50% of total CSF leucocytic count), and low CSF glucose level (<45 gm/dL) and CSF/serum glucose ≤0.6 were significantly diagnostic in bacterial meningitis patients. From the significant CSF analysis variables CSF protein carried the higher accuracy of diagnosis 78% with sensitivity 88% and specificity 72%. Conclusions. High CSF protein (>50 mg/dL) together with plasma inflammatory markers and CSF cytochemical parameters can diagnose bacterial meningitis in gram stain negative smear till culture results. Rabab Fouad, Marwa Khairy, Waleed Fathalah, Taha Gad, Badawy El-Kholy, and Ayman Yosry Copyright © 2014 Rabab Fouad et al. All rights reserved. Incidence of Tuberculosis and Amyloidosis among Sudanese Patients Presented with Enlarged Nodes Sun, 30 Mar 2014 11:40:47 +0000 Objectives. To determine the incidence of tuberculous lymphadenitis and amyloidosis in enlarged lymph nodes (LN). Methodology. A retrospective study was carried out in the department of pathology at the Faculty of Medicine, University of Kordofan, during one-year period. The study included a group of 103 patients with lymphadenopathy. Results. Of the 103 cases with enlarged neck nodes, 35 (34%) had tuberculous lymphadenitis. Sixteen (46%) cases were males and 19 (54%) cases were females. Out of the 103 patients, amyloidosis was diagnosed in 9/103 (8.7%). Out of the 9 positive cases, 2/9 (22.2%) were males and 7/9 (77.8%) were females. Conclusion. There is high incidence of tuberculous lymphadenitis in patients with enlarged LN in developing countries like North Sudan. Amyloidosis should not be ignored when investigating enlarged LN. Ahmed Abdalla Agab Eldour, Entisar Najeeb Mohmed Salih, and Hussain Gadelkarim Ahmed Copyright © 2014 Ahmed Abdalla Agab Eldour et al. All rights reserved. Viral Aetiology of Acute Flaccid Paralysis Surveillance Cases, before and after Vaccine Policy Change from Oral Polio Vaccine to Inactivated Polio Vaccine Wed, 19 Mar 2014 09:53:16 +0000 Since 1992, surveillance for acute flaccid paralysis (AFP) cases was introduced in Malaysia along with the establishment of the National Poliovirus Laboratory at the Institute for Medical Research. In 2008, the Ministry of Health, Malaysia, approved a vaccine policy change from oral polio vaccine to inactivated polio vaccine (IPV). Eight states started using IPV in the Expanded Immunization Programme, followed by the remaining states in January 2010. The objective of this study was to determine the viral aetiology of AFP cases below 15 years of age, before and after vaccine policy change from oral polio vaccine to inactivated polio vaccine. One hundred and seventy-nine enteroviruses were isolated from the 3394 stool specimens investigated between 1992 and December 2012. Fifty-six out of 107 virus isolates were polioviruses and the remaining were non-polio enteroviruses. Since 2009 after the sequential introduction of IPV in the childhood immunization programme, no Sabin polioviruses were isolated from AFP cases. In 2012, the laboratory AFP surveillance was supplemented with environmental surveillance with sewage sampling. Thirteen Sabin polioviruses were also isolated from sewage in the same year, but no vaccine-derived poliovirus was detected during this period. T. S. Saraswathy Subramaniam, Mohd Apandi Apandi, Rohani Jahis, Mohd Samsul Samsudin, and Zainah Saat Copyright © 2014 T. S. Saraswathy Subramaniam et al. All rights reserved. Concomitant Infection with Leishmania donovani and L. major in Single Ulcers of Cutaneous Leishmaniasis Patients from Sudan Wed, 12 Mar 2014 06:36:11 +0000 In Sudan human leishmaniasis occurs in different clinical forms, that is, visceral (VL), cutaneous (CL), mucocutaneous (ML), and post-kala-azar dermal leishmaniasis (PKDL). Clinical samples from 69 Sudanese patients with different clinical manifestations were subjected to a PCR targeting the cytochrome oxidase II (COII) gene for Leishmania species identification. Mixed infections were suspected due to multiple overlapping peaks presented in some sequences of the COII amplicons. Cloning these amplicons and alignment of sequences from randomly selected clones confirmed the presence of two different Leishmania species, L. donovani and L. major, in three out of five CL patients. Findings were further confirmed by cloning the ITS gene. Regarding other samples no significant genetic variations were found in patients with VL (62 patients), PKDL (one patient), or ML (one patient). The sequences clustered in a single homogeneous group within L. donovani genetic group, with the exception of one sequence clustering with L. infantum genetic group. Findings of this study open discussion on the synergetic/antagonistic interaction between divergent Leishmania species both in mammalian and vector hosts, their clinical implications with respect to parasite fitness and response to treatment, and the route of transmission with respect to vector distribution and or adaptation. A. M. Babiker, S. Ravagnan, A. Fusaro, M. M. Hassan, S. M. Bakheit, M. M. Mukhtar, G. Cattoli, and G. Capelli Copyright © 2014 A. M. Babiker et al. All rights reserved. Prevalence of Plasmodium falciparum Parasitaemia and Its Correlation with Haematological Parameters among HIV-Positive Individuals in Nigeria Tue, 04 Mar 2014 12:54:36 +0000 Malaria and HIV are the two most important health challenges of our time. Haematologic abnormalities are features in Plasmodium falciparum infection, and anaemia is a well-known outcome. The prevalence and haematological impact of P. falciparum parasitaemia were determined among HIV-infected individuals in Nigeria. Parasite detection was carried out using microscopy and Polymerase Chain Reaction (PCR). Haemoglobin concentration was determined using an automated machine while CD4+ T-cells count was analyzed using flow cytometer. Thirty-seven (18.5%) out of the 200 HIV individuals enrolled had malaria parasites detected in their blood. All the positive cases were detected by PCR while only 20 (10%) were detected by thick blood microscopy. The mean haemoglobin concentration and packed cell volume (PCV) of HIV individuals with malaria parasitaemia were lower compared to those without malaria parasitaemia but the difference was not statistically significant. Also no significant difference was observed in malaria positivity in respect to sex and mean CD4+ cell count. The study highlights the effects of P. falciparum parasitaemia on the haematologic and immune components of HIV individuals. Olusola Ojurongbe, Oluwatoyin Adeola Oyeniran, Oyebode Armstrong Terry Alli, Sunday Samuel Taiwo, Taiwo Adetola Ojurongbe, Adekunle Olugbenga Olowe, Oluyinka Oladele Opaleye, and Oluwaseyi Adegboyega Adeyeba Copyright © 2014 Olusola Ojurongbe et al. All rights reserved. Vaccination and Malaria Prevention among International Travelers Departing from Athens International Airport to African Destinations Sun, 02 Mar 2014 00:00:00 +0000 Background. International travel to Africa has grown dramatically over the last decade along with an increasing need to understand the health issues for travelers. The current survey aimed to assess vaccination and malaria prevention of travelers visiting Africa. Methods. A questionnaire-based survey was conducted from of November 1, 2011 to of April 30, 2013 at Athens International Airport. Results. A total of 360 travelers were studied; 68% were men. Their mean age was 39.9 years. Previous travel to tropical countries was reported by 71.9% of them. Most frequent destination was sub-Saharan Africa (60%). Most of them traveled for ≥1 month (62%). The main reason for travel was work (39.7%). Only 47% sought pretravel consultation. Hepatitis A, typhoid, and meningococcal vaccines were administered to 49.8%, 28%, and 26.6%, respectively, and malaria chemoprophylaxis to 66.8% of those who visited sub-Saharan Africa. A history of previous travel to a tropical country, elementary level of education, and traveling for visiting friends and relatives, and for short duration were significant determinants for not pursuing pretravel consultation. Conclusions. The current survey revealed important inadequacies in vaccine and malaria prophylaxis of travelers departing to Africa. Educational tools should be developed in order to improve awareness of travelers to risk destinations. Androula Pavli, Athina Spilioti, Paraskevi Smeti, Stavros Patrinos, and Helena C. Maltezou Copyright © 2014 Androula Pavli et al. All rights reserved. Molecular and Microscopic-Based Characterization of Plasmodium spp. in Fars and Hormozgan Provinces, South of Iran Thu, 06 Feb 2014 13:36:21 +0000 Despite malaria control programs in recent years, malaria transmission has not been eliminated in Iran. Molecular techniques including PCR, which has proved more sensitive and specific than microscopic examination methods, help to detect infection in low levels of parasitemia and mixed infections. Main our objectives were setting up nested PCR for detection of malaria and evaluating PCR based on plasmodia DNA from blood smears in Fars province, the comparison of this method with traditional microscopy and also evaluate the data in comparison with its neighboring province, Hormozgan. A total of 149 malaria positive samples including 116, 19, and 14 samples from Shiraz, Jask, and Lengeh ports were utilized in this study, respectively. Blood slides were prepared for microscopic observation. DNA from thin smears was extracted and nested PCR was analyzed using rPLU5 and rPLU6 for genus specification, rFAL1, rFAL2, and rVIV1, rVIV2 for P. falciparum and P. vivax detection, respectively. The results showed that 126 (84.6%), 16 (10.7%), and 7 (4.7%) out of 149 cases were positive for P. vivax, P. falciparum, and mixed infections, respectively, by microscopy. The PCR indicated that 95 (63.7%), 15 (10.1%), and 22 (14.8%) cases were infected with P. vivax, P. falciparum, and mixed mentioned species, respectively, and 17 (11.4%) cases were uninfected. Our results confirmed the considerable sensitivity of nested PCR for detection of the mixed infections. Simultaneous application of PCR even based on microscopy slides can facilitate access to the highest level of confidence in malaria researches. Tahereh Mohammadzadeh, Gholamreza Hatam, Mohsen Kalantari, Bahador Sarkari, Mohammad Hosein Motazedian, Seyed Mahmoud Sadjjadi, and Reza Safari Copyright © 2014 Tahereh Mohammadzadeh et al. All rights reserved. Effectiveness and Safety of Concurrent Use of First-Line Antiretroviral and Antituberculous Drugs in Rwanda Thu, 30 Jan 2014 06:53:25 +0000 Background. Overlapping toxicity between drugs used for HIV and TB could complicate the management of HIV/TB coinfected patients, particularly those carrying multiple opportunistic infections. This study aimed to evaluate the clinical outcomes and adverse drug events in HIV patients managed with first-line antiretroviral and first-line anti-TB drugs. Methods. This is a retrospective study utilizing medical dossiers from single-HIV infected and HIV/TB coinfected patients already initiated on ART. Predictors of outcomes included changes in CD4 cells/mm3, body weight, physical improvement, death rate, and adverse drug reactions. Results. Records from 60 HIV patients and 60 HIV/TB patients aged between 20 and 58 years showed that all clinical indicators of effectiveness were better in single-HIV infected than in HIV/TB coinfected patients: higher CD4 cell counts, better physical improvement, and low prevalence of adverse drug events. The most frequently prescribed regimen was TDF/3TC/EFV+RHZE. The mortality rate was 20% in HIV/TB patients compared to 8.3% in the single-HIV group. Conclusion. Treatment regimens applied are efficient in controlling the progression of the infection. However, attention should be paid to adjust dosing when combining nonnucleoside antiretrovirals (EFV and NVR) with anti-TB drugs to minimize the risk of death by drug intoxication. Justin Ntokamunda Kadima, Marie Françoise Mukanyangezi, and Claude Bernard Uwizeye Copyright © 2014 Justin Ntokamunda Kadima et al. All rights reserved. Introducing Single Dose Liposomal Amphotericin B for the Treatment of Visceral Leishmaniasis in Rural Bangladesh: Feasibility and Acceptance to Patients and Health Staff Mon, 20 Jan 2014 17:10:08 +0000 Background. For the treatment of visceral leishmaniasis in Bangladesh, single dose liposomal amphotericin B (ambisome) is supposed to be the safest and most effective treatment. Specific needs for application and storage raise questions about feasibility of its implementation and acceptance by patients and health staff. Methods. The study was carried out in the most endemic district of Bangladesh. Study population includes patients treated with ambisome or miltefosine, hospital staff, and a director of the national visceral leishmaniasis program. Study methods include direct observation (subdistrict hospitals), open interviews (heath staff and program personnel), structured questionnaires, and focus group discussions (patients). Results. Politicalcommitment for ambisome is strong; the general hospital infrastructure favours implementation but further strengthening is required, particularly for drug storage below 25°C (refrigerators), back-up energy (fuel for generators), and supplies for ambisome administration (like 5% dextrose solution). Ambisome created high satisfaction in patients and hospital staff, less adverse events, and less income loss for patients compared to miltefosine. Conclusions. High political commitment, general capacities of subdistrict hospitals, and high acceptability favour the implementation of ambisome treatment in Bangladesh. However, strengthening of the infrastructure and uninterrupted supplies of essential accessories is mandatory before introducing sLAB in Bangladesh. Eva-Maria Maintz, Mahbub Hassan, M. Mamun Huda, Debashis Ghosh, Md. Shakhawat Hossain, Abdul Alim, Axel Kroeger, Byron Arana, and Dinesh Mondal Copyright © 2014 Eva-Maria Maintz et al. All rights reserved. Mitochondrial PCR-RFLP Assay to Distinguish Triatoma brasiliensis macromelasoma from Triatoma brasiliensis brasiliensis Subspecies (Hemiptera: Reduviidae) Tue, 17 Dec 2013 10:35:27 +0000 Triatoma brasiliensis sensu lato (s.l.), the main vector of Chagas disease in northeastern Brazil, is a species complex comprising four species, one with two subspecies (T. brasiliensis brasiliensis, T. brasiliensis macromelasoma, T. juazeirensis, T. sherlocki, and T. melanica), and each taxon displaying distinct ecological requirements. In order to evaluate the genetic relationships among nine T. brasiliensis s.l. populations from northeastern Brazil, we analyzed their mitochondrial cytochrome c oxidase subunit 1 sequences and suggested a PCR-RFLP assay to distinguish between T. b. macromelasoma and T. b. brasiliensis subspecies. All the specimens were morphologically identified as T. b. brasiliensis. The resulting phylogenies identified two major clades that are congruent with the geographical populations studied. Based on collection sites and in accordance with type-location, one clade was identified as the subspecies T. b. macromelasoma. The second clade grouped T. b. brasiliensis populations. Restriction endonuclease sites were observed in the sequences and used in PCR-RFLP assays, producing distinct fingerprints for T. b. macromelasoma and T. b. brasiliensis populations. The results suggest that these are different species and that gene flow occurs only among T. b. brasiliensis populations, possibly associated with human activity in the area. Daniel Pagotto Vendrami, Walter Ceretti-Junior, Marcos Takashi Obara, and Mauro Toledo Marrelli Copyright © 2013 Daniel Pagotto Vendrami et al. All rights reserved. Children with Kaposi Sarcoma in Two Southern African Hospitals: Clinical Presentation, Management, and Outcome Wed, 11 Dec 2013 08:38:52 +0000 Introduction. In 2010 more than 3 million children with human immunodeficiency virus (HIV) were living in Sub-Saharan Africa. The AIDS epidemic has contributed to an abrupt increase of the frequency of Kaposi sarcoma (KS), especially in Southern Africa. There is a need to describe the clinical features of this disease, its management, and its outcome in HIV positive children in Southern Africa. The aim of the study is to describe two different populations with HIV and KS from two African hospitals in Namibia and South Africa. Material and Methods. A retrospective descriptive study of patients with KS who presented to Tygerberg Hospital (TH) and Windhoek Central Hospital (WCH) from 1998 to 2010. Demographic data, HIV profile, clinical picture of KS, and survival were documented. Results. The frequency of KS declined from 2006 to 2010 in TH but showed an increase in the same period in WCH. Children in TH were diagnosed at a much younger age than those in WCH (44.2 months versus 90 months). Cutaneous lesions were the most common clinical presenting feature, followed by lymphadenopathy, intrathoracic and oral lesions. Conclusions. The clinical characteristics of KS in South Africa and Namibia differ in many aspects between the 2 countries. G. P. De Bruin and D. C. Stefan Copyright © 2013 G. P. De Bruin and D. C. Stefan. All rights reserved. Challenges in the Therapy of Visceral Leishmaniasis in Brazil: A Public Health Perspective Thu, 05 Dec 2013 13:29:37 +0000 Over 3,000 yearly cases of Visceral Leishmaniasis (VL) are reported in Brazil. Brazilian Public Health System provides universal free access to antileishmania therapeutic options: Meglumine Antimoniate, Amphotericin B deoxycholate, and Liposomal Amphotericin B. Even though Amphotericin formulations have been advised for severe disease, this recommendation is mostly based on the opinion of experts and on analogy with studies conducted in other countries. Presently, there are two ongoing multicenter clinical trials comparing the efficacy and safety of the available therapeutic options. Some other issues require further clarification, such as severity markers and the approach to VL/AIDS coinfection. Brazil is facing the challenge of providing access to diagnosis and adequate treatment, in order to avoid VL-related deaths. Edson Carvalho de Melo and Carlos Magno Castelo Branco Fortaleza Copyright © 2013 Edson Carvalho de Melo and Carlos Magno Castelo Branco Fortaleza. All rights reserved. Detecting and Responding to a Dengue Outbreak: Evaluation of Existing Strategies in Country Outbreak Response Planning Wed, 09 Oct 2013 13:55:11 +0000 Background. Dengue outbreaks are occurring with increasing frequency and intensity. Evidence-based epidemic preparedness and effective response are now a matter of urgency. Therefore, we have analysed national and municipal dengue outbreak response plans. Methods. Thirteen country plans from Asia, Latin America and Australia, and one international plan were obtained from the World Health Organization. The information was transferred to a data analysis matrix where information was extracted according to predefined and emerging themes and analysed for scope, inconsistencies, omissions, and usefulness. Findings. Outbreak response planning currently has a considerable number of flaws. Outbreak governance was weak with a lack of clarity of stakeholder roles. Late timing of responses due to poor surveillance, a lack of combining routine data with additional alerts, and lack of triggers for initiating the response weakened the functionality of plans. Frequently an outbreak was not defined, and early response mechanisms based on alert signals were neglected. There was a distinct lack of consideration of contextual influences which can affect how an outbreak detection and response is managed. Conclusion. A model contingency plan for dengue outbreak prediction, detection, and response may help national disease control authorities to develop their own more detailed and functional context specific plans. Julia Harrington, Axel Kroeger, Silvia Runge-Ranzinger, and Tim O'Dempsey Copyright © 2013 Julia Harrington et al. All rights reserved. Is the Dog a Possible Reservoir for Cutaneous Leishmaniasis in Suriname? Tue, 01 Oct 2013 16:09:57 +0000 Cutaneous leishmaniasis (CL) is an emerging disease in Suriname, with at least 200 cases per year. Little is known about the biology of CL in the country. The most important parasite species is Leishmania Viannia guyanensis, but possible vectors and reservoirs are hardly incriminated. In the present study, it was investigated whether the dog could possibly be a zoonotic reservoir for the disease in Suriname. Forty-seven dogs were examined for overt clinical signs of leishmaniasis, and blood samples were collected on filter paper for serology (direct agglutination test) and molecular biology (by polymerase chain reaction). Three dogs had clinical signs that could be compatible with canine cutaneous leishmaniosis: dermatitis (two) or nasal lesion (one). Two dogs were seropositive with DAT (titre > 1 : 1600), and three animals had a borderline titre (1 : 800). All other animals () were DAT negative. PCR analysis found Leishmania DNA equivalent to 1 parasite per mL in only one dog at a first round of analysis, but this animal was negative after retesting. The clinical, serological, and molecular data show some preliminary lines of evidence that canine leishmaniosis is present in Suriname, but further studies are needed to incriminate the reservoir, including a possible sylvatic cycle. Alida Kent, Prakash Ramkalup, Dennis Mans, and Henk Schallig Copyright © 2013 Alida Kent et al. All rights reserved. Evaluation of Polyethylene-Based Long Lasting Treated Bed Net Netprotect on Anopheles Mosquitoes, Malaria Incidence, and Net Longivity in Western Kenya Tue, 01 Oct 2013 10:08:45 +0000 We studied the effect on malaria incidence, mosquito abundance, net efficacy, net use rate, chemical analysis, and holes of a long lasting insecticide treated bed net (Netprotect) in western Kenya, 2007–2010. Nets were hung in 150 households 6 months before they were hung in a second, 2 km away. Indoor resting densities were monitored by pyrethrum spray catch and malaria cases by passive detection using clinical manifestations and rapid diagnostic test. The probability of finding An. arabiensis in the control area was 2.6 times higher than that in intervention area during the first 6 months. Human blood feeding index of Anopheles funestus declined 17%. After bed nets were hung in the second area, malaria incidence declined 25% down to the level in the first area. Incidence remained at this low level for 2 years. 90% of collected nets were efficacious after 3-year use. Deltamethrin dosage declined from 1.9 to 0.5 g/kg over 3 years. Attrition rate after 3 years was 21%. WHO hole index changed from 333 to 114 to 381 over the three years. This index summarizes the numbers of holes in size categories and multiplies with the mean hole area per category. It is very sensitive to the impact of big holes in a few nets. M. T. O. Odhiambo, O. Skovmand, J. M. Vulule, and E. D. Kokwaro Copyright © 2013 M. T. O. Odhiambo et al. All rights reserved. Factors Associated with Migration in Individuals Affected by Leprosy, Maranhão, Brazil: An Exploratory Cross-Sectional Study Mon, 30 Sep 2013 15:24:05 +0000 In Brazil, leprosy is endemic and concentrated in high-risk clusters. Internal migration is common in the country and may influence leprosy transmission and hamper control efforts. We performed a cross-sectional study with two separate analyses evaluating factors associated with migration in Brazil’s Northeast: one among individuals newly diagnosed with leprosy and the other among a clinically unapparent population with no symptoms of leprosy for comparison. We included 394 individuals newly diagnosed with leprosy and 391 from the clinically unapparent population. Of those with leprosy, 258 (65.5%) were birth migrants, 105 (26.6%) were past five-year migrants, and 43 (10.9%) were circular migrants. In multivariate logistic regression, three independent factors were found to be significantly associated with migration among those with leprosy: (1) alcohol consumption, (2) separation from family/friends, and (3) difficulty reaching the healthcare facility. Separation from family/friends was also associated with migration in the clinically unapparent population. The health sector may consider adapting services to meet the needs of migrating populations. Future research is needed to explore risks associated with leprosy susceptibility from life stressors, such as separation from family and friends, access to healthcare facilities, and alcohol consumption to establish causal relationships. C. Murto, C. Kaplan, L. Ariza, K. Schwarz, C. H. Alencar, L. M. M. da Costa, and J. Heukelbach Copyright © 2013 C. Murto et al. All rights reserved. Visceral Leishmaniasis with Associated Common, Uncommon, and Atypical Morphological Features on Bone Marrow Aspirate Cytology in Nonendemic Region Sun, 08 Sep 2013 17:44:58 +0000 Objectives. The present study was conducted to categorise the morphological features on bone marrow aspirate cytology into common, uncommon, and atypical features in a nonendemic region which would be helpful in clinching an early and correct diagnosis especially in clinically unsuspected cases. Methods. The morphological features on bone marrow were categorized into common, uncommon, and atypical in cases of leishmaniasis from non endemic region. Results. Out of total 27 cases, 77.7% were residents of places at the height of 500 m or above and fever was the most common presentation followed by hepatosplenomegaly. Plasmacytosis, hemophagocytosis were the common cytological features while dysmyelopoiesis, presence of leishmania bodies in nonhistiocytic cells, and granuloma with necrosis were uncommon features. Aggregates of LD bodies in form of ring, floret, or strap shapes along with giant cells constitute the atypical morphological features. Conclusion. The knowledge of common, uncommon, and atypical features on bone marrow aspirate cytology is helpful in clinching an early and correct diagnosis of leishmaniasis especially in non endemic areas where clinical suspicion is low. These features will guide the pathologist for vigilant search of LD bodies in the marrow for definite diagnosis and thus will also be helpful in preventing unnecessary workups. Harish Chandra, Smita Chandra, and Rajeev Mohan Kaushik Copyright © 2013 Harish Chandra et al. All rights reserved. Anemia among HIV-Infected Patients Initiating Antiretroviral Therapy in South Africa: Improvement in Hemoglobin regardless of Degree of Immunosuppression and the Initiating ART Regimen Tue, 27 Aug 2013 14:51:47 +0000 Among those with HIV, anemia is a strong risk factor for disease progression and death independent of CD4 count and viral load. Understanding the role of anemia in HIV treatment is critical to developing strategies to reduce morbidity and mortality. We conducted a prospective analysis among 10,259 HIV-infected adults initiating first-line ART between April 2004 and August 2009 in Johannesburg, South Africa. The prevalence of anemia at ART initiation was 25.8%. Mean hemoglobin increased independent of baseline CD4. Females, lower BMI, WHO stage III/IV, lower CD4 count, and zidovudine use were associated with increased risk of developing anemia during follow-up. After initiation of ART, hemoglobin improved, regardless of regimen type and the degree of immunosuppression. Between 0 and 6 months on ART, the magnitude of hemoglobin increase was linearly related to CD4 count. However, between 6 and 24 months on ART, hemoglobin levels showed a sustained overall increase, the magnitude of which was similar regardless of baseline CD4 level. This increase in hemoglobin was seen even among patients on zidovudine containing regimens. Since low hemoglobin is an established adverse prognostic marker, prompt identification of anemia may result in improved morbidity and mortality of patients initiating ART. Simbarashe Takuva, Mhairi Maskew, Alana T. Brennan, Ian Sanne, A. Patrick MacPhail, and Mathew P. Fox Copyright © 2013 Simbarashe Takuva et al. All rights reserved. Phytochemical Analysis and Antimalarial Activity Aqueous Extract of Lecaniodiscus cupanioides Root Thu, 01 Aug 2013 13:26:16 +0000 Root aqueous extract of Lecaniodiscus cupanioides was evaluated for antimalarial activity and analyzed for its phytochemical constituents. Twenty-four (24) albino mice were infected by intraperitoneal injection of standard inoculum of chloroquine sensitive Plasmodium berghei (NK 65). The animals were randomly divided into 6 groups of 3 mice each. Group 1 served as the control while groups II–IV were orally administered 50, 150, and 250 mg/kg body weights of extract. Groups 5 and 6 received 1.75 and 5 mg/kg of artesunate and chloroquine, respectively. The results of the phytochemical analysis showed the presence of alkaloids (2.37%), saponin (0.336), tannin (0.012 per cent), phenol (0.008 per cent), and anthraquinone (0.002 per cent). There was 100 per cent parasite inhibition in the chloroquine group and 70 per cent in the 50 mg/kg body weight on day 12, respectively. The mean survival time (MST), for the control group was 14 days, artesunate 16 days, and chloroquine 30 days, while the groups that received 50 and 250 mg/kg body weight recorded similar MST of 17 days and the 150 mg/kg body weight group recorded 19 days. The results obtained indicated that the aqueous extract of Lecaniodiscus cupanioides may provide an alternative antimalarial. Mikhail Olugbemiro Nafiu, Taoheed Adedeji Abdulsalam, and Musbau Adewumi Akanji Copyright © 2013 Mikhail Olugbemiro Nafiu et al. All rights reserved. Systematic Review into Diagnostics for Post-Kala-Azar Dermal Leishmaniasis (PKDL) Tue, 09 Jul 2013 10:52:55 +0000 Identification of post-kala-azar dermal leishmaniasis (PKDL) is important due to the long and toxic treatment and the fact that PKDL patients may serve as a reservoir for visceral leishmaniasis (VL). We summarized the published literature about the accuracy of diagnostic tests for PKDL. We searched Medline for eligible studies investigating the diagnostic accuracy of any test for PKDL. Study quality was assessed using QUADAS-2. Data were extracted from 21 articles including 43 separate studies. Twenty-seven studies evaluated serological tests (rK39 dipstick, ELISA, DAT, and leishmanin tests), six studies molecular tests, eight microscopy, and two cultures. Only a few of these studies reported a valid estimate of diagnostic accuracy, as most were case-control designs or used a reference standard with low sensitivity. The included studies were very heterogeneous, for example, due to a large variety of reference standards used. Hence, no summary estimates of sensitivity or specificity could be made. We recommend well-designed diagnostic accuracy trials that evaluate, side-by-side, all currently available diagnostics, including clinical symptoms, serological, antigen, molecular, and parasitological tests and possible use of statistical modelling to evaluate diagnostics when there is no suitable gold standard. Emily R. Adams, Inge Versteeg, and Mariska M. G. Leeflang Copyright © 2013 Emily R. Adams et al. All rights reserved. Immunological Consequences of Antihelminthic Treatment in Preschool Children Exposed to Urogenital Schistosome Infection Wed, 05 Jun 2013 13:15:14 +0000 Urogenital schistosomiasis, due to Schistosoma haematobium, is endemic in sub-Saharan Africa. Control is by targeted treatment with praziquantel but preschool age children are excluded from control programs. Immunological studies on the effect of treatment at this young age are scarce. In light of studies in older individuals showing that praziquantel alters antischistosome immune responses and responses to bystander antigens, this study aims to investigate how these responses would be affected by treatment at this young age. Antibody responses directed against schistosome antigens, Plasmodium falciparum crude and recombinant antigens, and the allergen house dust mite were measured in children aged 3 to 5 years before and 6 weeks after treatment. The change in serological recognition of schistosome proteins was also investigated. Treatment augmented antischistosome IgM and IgE responses. The increase in IgE responses directed against adult worm antigens was accompanied by enhanced antigen recognition by sera from the children. Antibody responses directed against Plasmodium antigens were not significantly affected by praziquantel treatment nor were levels of allergen specific responses. Overall, praziquantel treatment enhanced, quantitatively and qualitatively, the antiworm responses associated with protective immunity but did not alter Plasmodium-specific responses or allergen-specific responses which mediate pathology in allergic disease. Nadine Rujeni, Norman Nausch, Nicholas Midzi, Graeme J. Cowan, Richard Burchmore, David R. Cavanagh, David W. Taylor, Takafira Mduluza, and Francisca Mutapi Copyright © 2013 Nadine Rujeni et al. All rights reserved. HLA-B*44 Is Associated with Dengue Severity Caused by DENV-3 in a Brazilian Population Sun, 02 Jun 2013 11:35:29 +0000 Human leukocyte antigen (HLA) alleles have been correlated with susceptibility or resistance to severe dengue; however, few immunogenetic studies have been performed in Latin American (LA) populations. We have conducted immunogenetic studies of HLA class I and II alleles in a cohort of 187 patients with DENV-3 infection and confirmed clinical diagnosis of either severe dengue, known as dengue hemorrhagic fever (DHF), or the less severe form, dengue fever (DF), in Recife, Pernambuco, Brazil. An association analysis was performed using Fisher’s association test, with odds ratios (ORs) calculated using conditional maximum likelihood estimates. HLA-B*44 (, OR = 2.025, 95% CI = 0.97–4.24) was found to be associated with increased susceptibility to DHF in response to DENV-3 infection. In addition, HLA-B*07 (, OR = 0.501, one-sided 95% CI = 0–0.99) and HLA-DR*13 (, OR = 0.511, one-sided 95% CI = 0–0.91) were found to be associated with resistance to secondary dengue infection by DENV-3. These results suggest that HLA-B*44 supertype alleles and their respective T-cell responses might be involved in susceptibility to severe dengue infections, whereas the HLA-B*07 supertype alleles and DR*13 might be involved in cross-dengue serotype immunity. Liciana Xavier Eurico de Alencar, Ulisses de Mendonça Braga-Neto, Eduardo José Moura do Nascimento, Marli Tenório Cordeiro, Ana Maria Silva, Carlos Alexandre Antunes de Brito, Maria da Paz Carvalho da Silva, Laura Helena Vega Gonzales Gil, Silvia Maria Lucena Montenegro, and Ernesto Torres de Azevedo Marques Júnior Copyright © 2013 Liciana Xavier Eurico de Alencar et al. All rights reserved. How Should Antibodies against P. falciparum Merozoite Antigens Be Measured? Thu, 18 Apr 2013 17:40:50 +0000 Immunity against malaria develops slowly and only after repeated exposure to the parasite. Many of those that die of the disease are children under five years of age. Antibodies are an important part of immunity, but which antibodies that are protective and how these should be measured are still unclear. We discuss the pros and cons of ELISA, invasion inhibition assays/ADCI, and measurement of affinity of antibodies and what can be done to improve these assays, thereby increasing the knowledge about the immune status of an individual, and to perform better evaluation of vaccine trials. Sriwipa Chuangchaiya and Kristina E. M. Persson Copyright © 2013 Sriwipa Chuangchaiya and Kristina E. M. Persson. All rights reserved. Treatment-Based Strategy for the Management of Post-Kala-Azar Dermal Leishmaniasis Patients in the Sudan Mon, 15 Apr 2013 17:35:18 +0000 Post-kala-azar dermal leishmaniasis (PKDL) is a dermatosis that affects more than 50% of successfully treated visceral leishmaniasis (VL) patients in Sudan. PKDL is considered an important reservoir for the parasite and its treatment may help in the control of VL. Currently, treatment is mainly with sodium stibogluconate (SSG), an expensive and fairly toxic drug and without universally in treatment protocols used. A literature review, a consensus of a panel of experts, and unpublished data formed the basis for the development of guidelines for the treatment of PKDL in the Sudan. Six treatment modalities were evaluated. Experts were asked to justify their choices based on their experience regarding of drug safety, efficacy, availability, and cost. The consensus was defined by assigning a categorical rank (first line, second line, third line) to each option. Regarding the use of AmBisome the presence of the drug in the skin was confirmed in smears from PKDL lesions. Recommendations: AmBisome at 2.5 mg/kg/day/20 days or SSG at 20 mg/kg/day/40 days plus four/weekly intradermal injection of alum-precipitated autoclave L. major vaccine are suggested as first- and second-treatment options for PKDL in the Sudan, respectively. SSG at 20 mg/Kg/day/60 or more days can be used if other options are not available. A. M. Musa, E. A. G. Khalil, B. M. Younis, M. E. E. Elfaki, M. Y. Elamin, A. O. A. Adam, H. A. A. Mohamed, M. M. M. Dafalla, A. A. Abuzaid, and A. M. El-Hassan Copyright © 2013 A. M. Musa et al. All rights reserved. Mucocutaneous Leishmaniasis: Knowledge, Attitudes, and Practices Among Paraguayan Communities, Patients, and Health Professionals Mon, 15 Apr 2013 09:44:39 +0000 Cutaneous leishmaniasis (CL) and mucocutaneous leishmaniasis (MCL) due to Leishmania (V.) braziliensis are endemic in Paraguay. We performed a series of knowledge, attitudes, and practice (KAP) surveys simultaneously with individuals in endemic communities in San Pedro department (), health professionals (), and patients (). Results showed that communities were exposed to high risk factors for transmission of L. braziliensis. In logistic regression analysis, age was the only factor independently associated with having seen a CL/MCL lesion (). The pervasive attitude in communities was that CL was not a problem. Treatment seeking was often delayed, partly due to secondary costs, and inappropriate remedies were applied. Several important cost-effective measures are indicated that may improve control of CL. Community awareness could be enhanced through existing community structures. Free supply of specific drugs should continue but ancillary support could be considered. Health professionals require routine and standardised provision of diagnosis and treatment algorithms for CL and MCL. During treatment, all patients could be given simple information to increase awareness in the community. Mónica Ruoti, Rolando Oddone, Nathalie Lampert, Elizabeth Orué, Michael A. Miles, Neal Alexander, Andrea M. Rehman, Rebecca Njord, Stephanie Shu, Susannah Brice, Bryony Sinclair, and Alison Krentel Copyright © 2013 Mónica Ruoti et al. All rights reserved. Kinship and Leprosy in the Contacts of Leprosy Patients: Cohort at the Souza Araújo Outpatient Clinic, Rio de Janeiro, RJ, 1987–2010 Wed, 10 Apr 2013 10:32:44 +0000 A broad variety of factors have been associated with leprosy among contacts, including socioeconomic, epidemiological, and genetic characteristics. Data from 7,174 contacts of leprosy patients from a leprosy outpatient clinic in Rio de Janeiro, Brazil, 1987–2010, were analyzed to investigate the effects of kinship, individual, and contextual factors on leprosy. Multivariate analyses were performed using a robust estimation method. In the prevalence analysis, close kinship (sibling OR = 2.75, offspring OR = 2.00, and other relatives OR = 1.70), socioeconomic factors, and the duration of exposure to the bacillus were associated to leprosy. In the incidence analysis, significant risks were found for all categories of kinship (parents RR = 10.93, spouse, boyfriend/girlfriend, and bride/groom RR = 7.53, sibling RR = 7.03, offspring RR = 5.34, and other relatives RR = 3.71). Once the treatment of the index case was initiated, other factors lost their significance, and the index case bacteriological index and BCG (Bacillus Calmette-Guérin vaccine) protection had a greater impact. Our findings suggested that both genetic susceptibility and physical exposure play an important role in the epidemiology of leprosy, but it was not possible establishing the role of genetic factor. Analyses of other factors related to the genotype of individuals, such as genetic polymorphisms, are needed. Daiane Santos dos Santos, Nadia Cristina Duppre, Anna Maria Sales, José Augusto da Costa Nery, Euzenir Nunes Sarno, and Mariana Andréa Hacker Copyright © 2013 Daiane Santos dos Santos et al. All rights reserved. Endemic Diseases: Globalization, Urbanization, and Immunosuppression Sun, 07 Apr 2013 11:54:51 +0000 Maria Aparecida Shikanai Yasuda and Pedro Albajar Viñas Copyright © 2013 Maria Aparecida Shikanai Yasuda and Pedro Albajar Viñas. All rights reserved. Public Health Responses to a Dengue Outbreak in a Fragile State: A Case Study of Nepal Wed, 03 Apr 2013 15:52:23 +0000 Objectives. The number of countries reporting dengue cases is increasing worldwide. Nepal saw its first dengue outbreak in 2010, with 96% of cases reported in three districts. There are numerous policy challenges to providing an effective public health response system in a fragile state. This paper evaluates the dengue case notification, surveillance, laboratory facilities, intersectoral collaboration, and how government and community services responded to the outbreak. Methods. Qualitative data were collected through 20 in-depth interviews, with key stakeholders, and two focus-group discussions, with seven participants. Results. Limitations of case recognition included weak diagnostic facilities and private hospitals not incorporated into the case reporting system. Research on vectors was weak, with no virological surveillance. Limitations of outbreak response included poor coordination and an inadequate budget. There was good community mobilization and emergency response but no routine vector control. Conclusions. A weak state has limited response capabilities. Disease surveillance and response plans need to be country-specific and consider state response capacity and the level of endemicity. Two feasible solutions for Nepal are (1) go upwards to regional collaboration for disease and vector surveillance, laboratory assistance, and staff training; (2) go downwards to expand upon community mobilisation, ensuring that vector control is anticipatory to outbreaks. Karolina Griffiths, Megha Raj Banjara, T. O'Dempsey, B. Munslow, and Axel Kroeger Copyright © 2013 Karolina Griffiths et al. All rights reserved.