Asia ranks second to Africa in terms of malaria burden. In 19 countries of Asia, malaria is endemic and 2.31 billion people or 62% of the total population in these countries are at risk of malaria. In 2010, WHO estimated around 34.8 million cases and 45,600 deaths due to malaria in Asia. In 2011, 2.7 million cases and > 2000 deaths were reported. India, Indonesia, Myanmar and Pakistan are responsible for >85% of the reported cases (confirmed) and deaths in Asia. In last 10 yr, due to availability of donor's fund specially from Global fund, significant progress has been made by the countries in Asia in scaling-up malaria control interventions which were instrumental in reducing malaria morbidity and mortality significantly. There is a large heterogeneity in malaria epidemiology in Asia. As a result, the success in malaria control/elimination is also diverse. As compared to the data of the year 2000, out of 19 malaria endemic countries, 12 countries were able to reduce malaria incidence (microscopically confirmed cases only) by 75%. Two countries, namely Bangladesh and Malaysia are projected to reach 75% reduction by 2015 while India is projected to reach 50-75% only by 2015. The trend could not be assessed in four countries, namely Indonesia, Myanmar, Pakistan and Timor-Leste due to insufficient consistent data. Numerous key challenges need to be addressed to sustain the gains and eliminate malaria in most parts of Asia. Some of these are to control the spread of resistance in Plasmodium falciparum to artemisinin, control of outdoor transmission, control of vivax malaria and ensuring universal coverage of key interventions. Asia has the potential to influence the malaria epidemiology all over the world as well as to support the global efforts in controlling and eliminating malaria through production of quality-assured ACTs, RDTs and long-lasting insecticidal nets.

Background & objectives: A new irrigation canal system is under construction in Dhenkanal district of Odisha, to increase the production of rice crop and thereby improve the living standard of farmers in the project area. Construction of canal may increase the transmission of malaria by creating vector breeding habitats. Knowledge about bionomics of vectors will support authorities for appropriate management of the disease in a changing ecological set up. The aim of this study was to assess the malaria transmission in the bank of the canal area under construction. Methods: The entomological survey was carried out in three seasons, winter, summer and rainy during the period November 2008-October 2010 in the study area. Adult mosquitoes were collected by using suction tubes and flash lights. Mosquito species identification was done by using standard keys, separated according to abdominal conditions and were kept in an isopropanol for further molecular analysis of sibling species, presence of sporozoites and human blood meal. Larvae were collected by dippers and reared in the laboratory, and the emerged adults were identified to species. The epidemiology of malaria was evaluated from the data collected by the State Health Department. Insecticide succeptibility test was done by WHO method. Results: The adult mosquito collection from the study area showed the prevalence of 14 species belonging to three genera, i.e. Anopheles, Culex and Aedes. The per man hour densities (PMHD) of An. culicifacies were 3.8, 1.4, 4.8; that of An. annularis were 2.1, 1, 2.1; and that of An. fluviatilis were 1.4, 0.3, 0.6 during winter, summer and rainy seasons respectively. Sibling species identified were: An. culicifacies A, B, C and D, An. annularis A and An. fluviatilis S. Sporozoite rates of An. culicifacies A and C were 1.1 and 0.5% respectively and that of An. annularis A was 2% (reported for the first time in the state). Both the vectors (An. culicifacies and An. annularis) showed resistance to DDT and malathion and were susceptible to deltamethrin, whereas An. fluviatilis was susceptible to all the three insecticides tested. Interpretation & conclusion: Anopheles culicifacies, An. fluviatilis and An. annularis were prevalent in all the three seasons. The artificial ponds and seepage pools of canal are the major breeding sites for An. culicifacies and An. annularis. Thus, in the canal command area, control of malaria transmission requires use of insecticidetreated bednets and use of biolarvicides (seepage pools) and larvivorous fish (artificial ponds) wherever feasible.

Background & objectives: India has switched over to artemisinin-based combination therapy (ACT) for the treatment of acute uncomplicated Plasmodium falciparum malaria and the ACT used in the national programme is artesunate + sulphadoxine-pyrimethamine. Since the efficacy of ACT is dependent also on the partner drug, there is a need to evaluate and deploy multiple ACTs. Methods: This multicentre, single-arm, open-label clinical trial was carried out to assess the efficacy, safety and population pharmacokinetics of a fixed dose combination (FDC) artesunate mefloquine (ASMQ) in P. falciparum infected, Indian adults at Panjim, Goa, and Mangalore, Karnataka between December 2007 and November 2008. Results: A total of 77 patients (males 74) were screened and enrolled: 42 at Goa and 35 at Mangalore with a median age of 25 yr (range 18-55 yr). One patient failed in treatment on D53, a PCR proven new infection, seven developed recurrent vivax parasitaemia and 11 did not have a parasitological endpoint. By per protocol analysis, the D63 cure rate was 58/59 (98.3; 95% C.I. 90.9-99.9%), and 58/58, with PCR correction. ASMQ was welltolerated and no serious adverse events were reported. Interpretation & conclusion: The study showed that the ASMQ FDC was efficacious and well-tolerated for the treatment of acute, uncomplicated P. falciparum malaria in highly endemic, chloroquine resistant areas of Goa and Mangalore. It is a viable option for India.

Background & objectives: The Balkans is an endemic region for Crimean-Congo hemorrhagic fever (CCHF), caused by the CCHF virus (CCHFV). Several Bulgarian regions comprised of smaller locations are categorized either as endemic or non-endemic for CCHF. However, little is known about the dynamics that underlie the development of endemicity within the locations throughout the years. Methods: Seven locations categorized as endemic in one central Bulgarian region (Stara Zagora) were compared to seven non-endemic areas. During the period 2006-12, a total of 1775 blood samples from cattle, were tested for anti-CCHFV antibodies using an indirect immunofluorescence antibody assay. Also, the infestation of 617 mature ticks for CCHFV was studied using a combination of an immunofluorescence haemocytes assay and molecularvirological methods. Results: Anti-CCHFV antibodies were established in 7.89% (140/1775) of the sera. The average CCHFV-infestation in the ticks was 1.46% (9/617). CCHFV was detected in three tick species: H.m. marginatum (3.73%, 6/161), being the main vector of the infection; R. sanguineus (1.63%, 2/123); and I. ricinus (1.96%, 1/51). Interpretation & conclusion: The data for the endemic and non-endemic locations did not reveal significant differences for the prevalence of CCHFV. Mosaic dispersion of the virus was determined in the studied region and the results did not vary significantly throughout the investigated years.

Background & objectives: Widespread resistance to chloroquine was the mainstay to implement artemisininbased combination therapy (ACT) in the year 2007 in few malaria endemic states in India including Jharkhand as the first line of treatment for uncomplicated Plasmodium falciparum malaria. This study was conducted in Jharkhand state of the country just after the implementation of ACT to assess the prevailing antimalarial drug prescribing practices, availability of antimalarial drugs and the acceptability of the new policy by the health professionals for the treatment of uncomplicated P. falciparum malaria patients particularly in children ≤15 yr of age. Methods: This is a cross-sectional study in children aged ≤15 yr with malaria or to whom antimalarial drug was prescribed. Main outcome measure was prescription of recommended ACT in children aged ≤15 yr with malaria in the selected areas of Jharkhand. Results: In the year 2008, artemisinin-based combination therapy (ACT) was implemented in 12 districts of the studied state; however, the availability of ACT was confirmed only in five districts. Antimalarial prescription was prevalent amongst the undiagnosed (8.4%), malaria negative (64.3%) and unknown blood test result (1.2%) suggesting the prevalence of irrational treatment practices. ACT prescription was very low with only 3.2% of confirmed falciparum malaria patients receiving it while others received either non-artesunate (NA) treatment (88.1%) including chloroquine (CQ) alone, CQ + Primaquine (PQ)/other drugs, sulphadoxine-pyrimethamine (SP) alone, SP + other drugs or artemisinin monotherapy (AM) treatment (6.3%). Still others were given nonantimalarial treatment (NM) in both malaria positive (0.3%) and malaria negative (2.1%) cases. Interpretation & conclusion: Despite the change in drug policy in the studied state the availability and implementation of ACT was a major concern. Nevertheless, the non-availability of blister packs for children aged ≤15 yr was the main hindrance in the implementation of the recommended antimalarial. Availability, training and participation of health professionals in decision-making are the key elements to improve adherence to new treatment guidelines. This study provided evidence for the requirement of age-specific blister packs in the country and the national programme has introduced age-specific blister packs in the country in 2010. This baseline information will be useful to monitor the progress in ACT implementation in the country.

Background & objectives: Artemisinin isolated from Artemisia annua is the most potent antimalarial drug against chloroquine-resistant Plasmodium falciparum malaria. Artemisia vulgaris, an invasive weed, is the only Artemisia species available in Sri Lanka. A pilot study was undertaken to investigate the antiparasitic activity of an A. vulgaris ethanolic leaf extract (AVELE) in a P. berghei ANKA murine malaria model that elicits pathogenesis similar to falciparum malaria. Methods: A 4-day suppressive and the curative assays determined the antiparasitic activity of AVELE using four doses (250, 500, 750 and 1000 mg/kg), Coartem® as the positive control and 5% ethanol as the negative control in male ICR mice infected with P. berghei. Results: The 500, 750 and 1000 mg/kg doses of AVELE significantly (p ≤0.01) inhibited parasitaemia by 79.3, 79.6 and 87.3% respectively, in the 4-day suppressive assay, but not in the curative assay. Chronic administration of the high dose of AVELE ruled out overt signs of toxicity and stress as well as hepatotoxicity, renotoxicity and haematotoxicity. Interpretation & conclusion: The oral administration of a crude ethonolic leaf extract of A. vulgaris is non-toxic and possesses potent antimalarial properties in terms of antiparasitic activity.

Background & objectives: Recently, vivax malaria is also presenting as severe malaria causing multiorgan dysfunction similar to falciparum malaria. The present study was undertaken to evaluate the involvement of cardiovascular system in severe malaria. Methods: This is a clinical prospective study conducted on the cases of severe malaria in S.P. Medical College and PBM Hospital, Bikaner, India. In total, 100 cases (45 males, 55 females; age range 13-75 yr) of severe malaria (P. vivax 60; P. falciparum 28; and mixed 12) diagnosed by peripheral blood smear examination, rapid card test and PCR were studied. Evaluation of cardiovascular system was done by clinical examination, chest Xray, ECG, high resolution transthoracic echocardiography and estimation of cardiac markers. Results: In all, 17% cases (9 P. falciparum, 5 P. vivax and 3 mixed) were found to be suffering from cardiovascular involvement (11% circulatory failure, 7% congestive cardiac failure and 2% pulmonary edema). ECG showed sinus tachycardia in all the 17 patients, one had atrial ectopic and eight had non-specific ST-T changes. Cardiomegaly was seen in eight cases and pulmonary edema in two on X-ray chest. Echocardiography was within normal range but cardiac dimensions were increased in all the 17 cases. Troponin-I and CPK-MB were increased in 14 cases. Cardiovascular involvement in P. falciparum and mixed infection was associated with high parasite density but P. vivax infection was associated with relatively low parasite density. Involvement of cardiovascular system was associated with increased hospital stay (7.67 ± 2.23 vs 6.59 ± 0.87 days; p <0.001) and high mortality (5 died out of 17 patients). Significant ECG changes and cardiac markers indicate myocardial involvement in severe malaria. Interpretation & Conclusion: The present study indicates involvement of cardiovascular system in severe malaria as evidenced by changes in ECG and cardiac markers (Trop 1 and CPK-MB). The present study also highlights that vivax malaria is no more benign and pathophysiology of vivax malaria should be re-evaluated.

Background & objectives: There is lack of adequate information on the association between severe malaria and some human genetic markers like ABO blood types. The study was undertaken to evaluate the association between severe malaria infection and ABO blood types among febrile patients attending Felegeselam Health Center, northwestern Ethiopia. Methods: A total of 398 febrile patients were examined for malaria and tested for ABO blood groups in December 2011. The blood samples were collected by finger pricking, stained with Giemsa and slides were examined microscopically. ABO blood group was determined by agglutination test using agglutinating A and B monoclonal anti-sera together with parasite load count. Chi-square and ANOVA tests were used to assess the difference between frequencies and means, respectively. Results: Out of 398 acute febrile patients, 201 (50.5%) were found to be infected with Plasmodium parasites. Of which 194 (48.74%) and 7 (1.76%) belong to Plasmodium falciparum and P. vivax, respectively. The distribution of ABO blood groups was O (46%), A (27.1%), B (23.1%) and AB (3.8%). The percentage of severe malaria with respect to blood group A, B, AB and O was found to be 40, 34.1, 14.3 and 5.1%, respectively. The association of severe malaria with non 'O' blood types was statistically significant (χ2 = 31.246, p <0.01). Interpretation & conclusion: The present findings indicate that individuals with blood groups A, B and AB are more susceptible for severe malaria infection than blood group O.

Background & objectives: Crimean-Congo haemorrhagic fever (CCHF) can be fatal with bleeding, shock and disseminated intravascular coagulopathy (DIC). Although similar genetic strains have been defined, the causes of the clinical differences between the cases are yet to be found. We aimed to demonstrate the balance between oxidant and antioxidant system in CCHF. Methods: In this study, the patient group consisted of 72 cases with a positive diagnosis of CCHF according to PCR/ELISA outcome among the patients referred to Cumhuriyet University, Medical Faculty in 2010. A total of 74 volunteers who were not having any viral or metabolic disease, non-smokers and age and sex matched with the patients group were enrolled as the control group. Both in the controls and the patients, individuals aged under 16 yr were defined as group 1 and the individuals aged over 16 yr as group 2. The serum samples were stored at -80°C until the study was carried out. All the samples were simultaneously thawed. In these cases, total antioxidant capacity (TAC), total oxidative status (TOS), oxidative stress index (OSI), lipid peroxide (LPO), paraoxonase (PON) and arylesterase were analyzed with the ELISA method. OSI was calculated. Results: Levels of TOS, OSI and LPO were found significantly higher in CCHF patients in both the groups (p <0.05), whereas levels of TAC, PON1 and arylesterase were lower in CCHF patients compared to the controls, but low level of TAC in the group 1 was not statistically significant. Interpretation & conclusion: Our study demonstrated increased oxidative stress in CCHF patients in both groups 1 and 2. In order to prevent tissue damage which might be developed due to the oxidative stress in CCHF patients, further comprehensive studies should be conducted to define whether the adding antioxidants to the treatment would be helpful or not.

Background & objectives: Despite the increasing number of reported autochthonous malaria cases in Nouakchott and the identification of Anopheles arabiensis as the major malaria vector in this Saharan city, anopheline larval habitats have never been identified so far. The objective of this study was to identify and characterize anopheline larval habitats in Nouakchott. Methods: During September and October 2012, samples from pools of rainwater, water discharged from standpipes and household drinking water tanks in the districts of Dar Naim, Teyarett and Arafat were analyzed for the presence/absence of anopheline larvae and physicochemical characterization of breeding habitats. Results: Of the 51 prospected water bodies, eight consisting of seven water discharged from standpipes and one household drinking water tank were productive for Anopheles sp. All emerged anopheline mosquitoes from the positive dipping were morphologically identified as members of the An. gambiae complex. Multivariate regression analyses showed that a salinity up to 0.1 g/l and a shaded situation were respectively protective factors against high larval density in breeding sites (adjusted odds ratio = 0.62, 95% CI [0.44-0.87], p = 0.0052 and adjusted odds ratio = 0.56, 95% CI [0.44-0.71, p <0.0001] and a pH up to 7.61 was a risk factor for high larval density in breeding sites (adjusted odds ratio = 1.56, 95% CI [1.25-1.95], p = 0.0001). Interpretation & conclusion: The study demonstrated in Nouakchott that despite an arid and dry climate, human practices have contributed to the establishment of favourable environmental conditions for the development of anopheline mosquitoes and, therefore, maintaining malaria transmission in this Saharan city. The core malaria vector control intervention as the use of long-lasting insecicidal nets (LLINs) could be complemented in Nouakchott by larval source control. In this area, appropriate larval control measures may be recommended in line with an integrated vector management (IVM) approach.