Human African trypanosomiasis (HAT) has been an alarming global public health issue. The disease affects mainly poor and marginalized people in low-resource settings and is caused by two subspecies of haemoflagellate parasite, Trypanosoma brucei and transmitted by tsetse flies. Progress made in HAT control during the past decade has prompted increasing global dialogue on its elimination and eradication. The disease is targeted by the World Health Organization (WHO) for elimination as a public health problem by 2020 and to terminate its transmission globally by 2030, along-side other Neglected Tropical Diseases (NTD). Several methods have been used to control tsetse flies and the disease transmitted by them. Old and new tools to control the disease are available with constraints. Currently, there are no vaccines available. Efforts towards intervention to control the disease over the past decade have seen considerable progress and remarkable success with incidence dropping progressively, reversing the upward trend of reported cases. This gives credence in a real progress in its elimination. This study reviews various control measures, progress and a highlight of control issues, vector and parasite barriers that may have been hindering progress towards its elimination.

Background and objectives: Rocky Mountain spotted fever (RMSF) is a rapidly progressive and potentially fatal tickborne disease caused by Rickettsia rickettsii. Despite current recommendations and information on the severity of RMSF, studies show that delayed recognition and treatment continues to occur. Methods: A literature search was performed on cases published in English between 1990–2017. The frequencies for demographic, clinical, and treatment variables was calculated. Results: A total of 340 cases from 34 articles were included. Data on rash were available for 322 patients, and 261 (80%) noted rash. Mortality was 4% (2) in those who received doxycycline within the first five days of illness, and 35% (18) when treatment was delayed beyond Day five. Twenty-four (16%) reported chronic sequelae, including speech impairment (7, 5%) and ataxia (5, 3%). Interpretation and conclusion: These data highlight the importance of early treatment, and add to our understanding of long-term sequelae. Early recognition by providers will facilitate appropriate treatment and reduction in morbidity and mortality.

Background & objectives: Cutaneous leishmaniasis (CL) is still a public health threat in many rural areas of Iran. It causes considerable morbidity among a huge number of people in the endemic areas. Khuzestan is considered as a CL focus in Iran and recently several cases have been reported from Shush County. The aim of the current study was to determine different aspects of CL epidemiology in this County. Methods: The study was conducted in four villages in the rural district of Shush County. In order to survey the scar and acute rate of the disease, 100 inhabitants were questioned in each village. In addition, to determine the reservoir host and vector of the disease, rodents were captured using Sherman traps, and sandflies were collected from around the rodent burrows using sticky paper traps. Results: The scar and acute lesion rates were reported as 5.26 and 0.57% among inhabitants, respectively. Fifty-four rodents including Tatera indica (55.5%), Nesokia indica (33.3%), Mus musculus (9.3%) and Rattus norvegicus (1.9%) were captured and identified. Nested PCR showed 3 out of 54 rodents infected with Leishmania major. In total, 1122 sandflies were collected, and Leishmania major detected in Phlebotomus papatasi (4.35%), Sergentomyia dentata (23%), and Sergentomyia clydei (10%). Interpretation & conclusion: Zoonotic cutaneous leishmaniasis due to L. major prevailed in this area. The common and the main vector was Ph. papatasi and, T. indica seems to be the main while N. indica as a secondary reservoir host of the disease in this area.

Background & objectives: The black fly genus Simulium Latreille is one of the most important medical insect group of the family Simuliidae (Diptera) and many species of this genus are important pests of human and animals, while some of them also represent vectors of pathogens. Correct species identification is essential to the implementation of control measures for species of medical or agricultural importance. Methods: In this study, the usefulness of DNA barcoding was discussed in distinguishing species of Simulium. Results: Analysis showed hidden biodiversity, usually referred to in Simuliidae as cryptic species, which was detected in 15 species. Firstly, intraspecific divergences of eleven species was unexpectedly high and the maximum distances of them ranged from 5.1–16.8%. Based on the differential of K2P (Kimura 2-Parameter) distances, sequences were subdivided into two or three groups, respectively. Secondly, extremely low interspecific divergences were detected in eight groups of species, and shared haplotypes were also found among them. Furthermore, the subdivision within species and shared haplotypes among some species were all supported by the NJ (Neighbour-Joining) analysis. Interpretation & conclusion: Our results confirmed that DNA barcoding was a powerful tool for revealing hidden species diversity of black flies. Further work is needed to reveal ambiguous species delimitation in some problematic species groups.

Background & objectives: Malaria infects around 216 million people annually with estimated 445,000 deaths globally. Anopheles culicifacies is the vector of malaria in Sri Lanka, a complex of five morphologically identical sibling species of which precise identification using DNA–based methods is still under experimentation. This study was carried out in Sri Lanka to observe the utility of BCE-PCR assay based on mitochondrial Cytochrome Oxidase II (COII) developed in India, in sibling species B and E identification in Sri Lanka, to characterize nucleotide and corresponding amino acid sequences of COII region in major vector sibling species E in Sri Lanka and to analyze the spatial distribution pattern of sibling species E in Sri Lanka using microsatellite markers. Methods: BCE-PCR was carried out for the samples to identify their sibling status. Sequencing of COII region was then carried out to investigate the genetic diversity of Sri Lankan sibling species E, sequences were aligned and compared; microsatellite genotyping was carried out and the spatial clustering pattern was analyzed. Results: Identification of sibling species B and E using BCE-PCR was confusing due to the heterogeneity in the COII region of sibling species in Sri Lanka. Non-synonymous substitutions were detected in COII gene amongst sibling species E. Spatial distributed two clusters were detected in the studied population. Interpretation & conclusion: Existence of genetic variants among sibling species is suggested in Sri Lanka. Further, the pattern of sibling species identification in BCE-PCR was reflected in the spatial clustering of sibling E in Sri Lanka.

Background & objectives: Scrub typhus (ST), an important zoonosis caused by Orientia tsutsugamushi, is now prevalent throughout India. While demonstration of IgM antibody by Indirect Immunofluorescence Assay (IFA) is the gold standard serological test, IgM ELISA is an alternative. Demonstration of O. tsutsugamushi DNA in the blood or eschar confirms infection in the early febrile period. Methods: Scrub typhus nested PCR (n-PCR) for 56 kDa, 47 kDa and groEL genes and ST IgM ELISA were performed for 210 clinically suspected ST patients. As healthy controls, 70 voluntary blood donors were included. Statistical analysis was performed for laboratory parameters using Fisher exact test/chi-square test. Ninety-five PCR products of n-PCR positive samples were purified and submitted for gene sequencing. Results: PCR was positive for one or more gene targets in 75.71% of IgM ELISA positive patients and 10% of antibody negative patients. All voluntary blood donors were negative for both antibodies and DNA. Gene sequences of 95 n-PCR positive products confirmed the presence of Orientia tsutsugamushi DNA in the samples and NCBI database accession numbers MG601875 to MG601969 were obtained. Interpretation & conclusion: Compared to IgM ELISA, sensitivity of three PCRs was 30, 51.43 and 61.43% for 56 kDa, 47 kDa and groEL targets, respectively. Since IgM ELISA positivity can persist up to one year, PCR confirms ST diagnosis in the acute phase of the illness, in the presence of IgM and even before IgM appears. Inclusion of all three genes – 56 kDa, 47 kDa and groEL, instead of a single 56 kDa target, identifies and confirms maximum number of ST patients.

Background & objectives: Aedes aegypti is the most prominent vector for dengue virus worldwide. Accurate identification of the species and understanding its colonization pattern are essential prerequisites in vector control. Thus, the present study was aimed to genetically characterize Ae. aegypti mosquitoes collected from different regions of Sri Lanka based on mitochondrial COI gene. Methods: Thirty-three Ae. aegypti larval samples were collected from 19 districts. A 735bp region of the mitochondrial COI gene was amplified and analyzed for genetic diversity indices. Phylogenetic trees were constructed using Sri Lankan samples and also including mosquito samples reported from other parts of the world. Results: High genetic diversity was observed within the samples analysed (gene diversity: 0.949; average number of nucleotide differences: 6.371). There were 20 haplotypes presented within the 19 localities investigated. The phylogenetic tree derived two main clades. However, no distinguishable clustering pattern was observed in the phylogenetic tree except for the districts in the northern corner indicating extensive admixing among different populations. When samples from other countries were included in the phylogenetic tree, Anuradhapura, and Mannar samples were clustered together with samples from India, Venezuela, USA, Portugal and Cambodia while Rathnapura was clustered with Bolivia and France. Interpretation & conclusion: Our results suggest that Sri Lanka has undergone multiple invasions of Ae. aegypti from various parts of the world over an extensive period. Further, the mosquito control campaigns had not caused a significant effect on the Ae. aegypti populations which is existing in mutation-drift equilibrium.

Background & objectives: Detection and treatment of post-kala-azar dermal leishmaniasis (PKDL) cases is considered important for kala-azar elimination. The objective of our study was to find out the proportion of different forms of lesions, interruption of treatment and rate of treatment completion, cure rates of PKDL, risk factors for developing severe forms of PKDL and utilization of services offered by the kala-azar elimination program. Methods: A cross-sectional survey of PKDL patients registered for treatment at all levels of care during 2015 and 2016 was done. Results: 576 PKDL patients who had started treatment in 2015 and 2016 were studied. Three-fourths of all patients were found to be clinically cured after a year of follow-up. Around 90% lesions were of macular type. Interruption of treatment was observed in one-fourth of PKDL patients. Median duration between kala-azar treatment and development of PKDL was 4.5 years. Around 79% patients had past history of kala-azar treatment. Discontinuation of treatment during earlier kala-azar episode was significantly associated with the development of papular and nodular forms of lesion. 43% of patients had received the incentive of INR 2000 after completion of treatment. Around three-fourths women in the reproductive age group were found not to use any contraceptive method during PKDL treatment. Interpretation & conclusion: PKDL treatment interruption should be reduced through ensuring drug supply and timely retrieval of patients. Directly observed treatment should be implemented and combination regimen should be explored to improve final cure rate. Delivery of financial incentive to PKDL patients and counselling and contraception to women of reproductive age group should be improved.

Background & objectives: In Colombian Amazonia, Uitoto indigenous people use a preparation of Curarea toxicofera (Menispermaceae) to prevent and treat malaria. To open the way for the production of a standardized herbal remedy, we compared the activity of the traditional preparation with laboratory preparations. Methods: People were interviewed on their mode of use and preparation of what is considered the best remedy against fevers in this area. The herbal remedy was prepared according to the healer’s recommendations. The plant was also submitted to continuous distillation and percolation extraction. The preparations were then tested against Plasmodium falciparum, in vitro. Traditional preparation and extract obtained by percolation were tested on Plasmodium berghei infected mice. Chemical profiles were also explored by thin-layer chromatography. Results: Yields of extraction were around 7% in the preparations (percolation was the most efficient). The phytochemical profile showed a mix of steroids, flavonoids and alkaloids qualitatively similar in all preparations. In vitro, the extracts showed inhibitory concentration 50 <10μg/mL: the traditional preparation was almost three times less active than laboratory preparations. In vivo, percolation was also more active than traditional preparation, inhibiting 78% of the parasite growth at 400mg/kg/day by oral route. Interpretation & conclusion: Pharmacological activities suggest that both the original remedy (prepared according to traditional pharmacopeia) and the extracts obtained by percolation extraction exhibit relevant antiparasitic activity. C. toxicofera should therefore be considered for the elaboration of an improved traditional medicine by implementing toxicological studies and carefully following quality control guidelines for its preparation.

Background & objectives: The state of Punjab, India is highly endemic for dengue fever as high number of confirmed dengue cases have been reported since 2013. A better understanding of vectors distribution and their seasonal variation is necessary to control the disease. Therefore, the present study was conducted in both rural and urban areas of 11 out of 22 districts of Punjab to highlight seasonal prevalence of Aedes vector mosquitoes. Methods: Entomological surveys were carried out in different seasons and all kinds of indoor and outdoor breeding habitats were examined and Aedes immatures were collected. The Stegomyia indices were calculated and compared from urban and rural areas in different seasons. Results: Both vectors of dengue, i.e. Aedes aegypti and Ae. albopictus were recorded to be prevalent. Ae. aegypti mosquitoes were observed in all districts surveyed while Ae. albopictus were found only in seven districts of Punjab. The Stegomyia indices were significantly high during monsoon as compared to pre- and post- monsoon periods. Occurrence of dengue cases were found to be correlated with the Stegomyia indices. Interpretation & conclusion: This is the first detailed study of prevalence of dengue mosquito vectors in Punjab showing the presence of Ae. aegypti and Ae. albopictus in both urban and rural areas of the state, thereby demonstrating wide distribution of this vector. Different breeding habitats identified in the study should be subjected to targeted intervention such as source reduction in order to achieve effective control of dengue cases.

India contributes to over 40% of the global Plasmodium vivax disease burden, and P. vivax contributes to approximately one-third of all malaria in India. Government of India has set goals to eliminate malaria by 2030. Doing so will require scaling up existing and new strategies, treatments and diagnostic tools. Access to appropriate diagnosis and treatment for P. vivax malaria is currently limited, and it is unclear how new tools will be rolled out. To support the government in its malaria elimination efforts, the current challenges associated with access to best clinical management of vivax malaria must be understood and mitigated to effectively deploy new tools and scale up existing solutions. The recent Food and Drug Administration (US-FDA) as well as Therapeutics Goods Administration (Australian TGA) approval of tafenoquine, developed by GSK GlaxoSmithKline and Medicines for Malaria Venture (MMV) as a new single-dose radical cure treatment for P. vivax malaria, and the commercial availability of new point-of-care glucose-6-phosphate dehydrogenase (G6PD) tests provide new opportunities to improve clinical management of vivax malaria in India. This report discusses the background, objectives, implementation strategies, and next steps that came out of the Stakeholder Workshop on Malaria Radical Cure in New Delhi, India on 4 February 2019. The focus was to understand the risks and opportunities associated with access to best clinical practices for managing vivax malaria in India. A key outcome was to propose a framework for articulating and segmenting important investment opportunities for improving access to best clinical practices for P. vivax radical cure in India.

Malaria is still a major public health problem, even after many preventive strategies. Plasmodium vivax is also a major health concern now due to the addition of new unusual manifestations day by day in its clinical profile. Herewith, we report a case of a 15-yr-old male of severe P. vivax malaria (complicated with thrombocytopenia, hepatitis, acute lung injury, and shock), who developed chest pain. Later, he was confirmed to have acute myocardial infarction based on electrocardiography, cardiac enzymes, and echocardiography. PubMed and Google-based literature search found that it was the first confirmed case of this type. Fortunately, timely diagnosis and appropriate management saved his life.