MALARIA: Exchange Transfusion for Severe Malaria

William Brieger

Date: Fri, Jul 19, 2013 4:16 am
Exchange Transfusion for Severe Malaria: Evidence Base and Literature Review http://cid.oxfordjournals.org/content/early/2013/07/17/cid.cit429.abstract When rapidly acting antimalarials, specifically artemisinins, become more widely available, the biologic plausibility argument for ET will become less relevant.
Kathrine R. Tan1, Ryan E. Wiegand2, and Paul M. Arguin1
 (ktan@cdc.gov).

Abstract
Background.  Exchange transfusion (ET) has biologic plausibility as an adjunct to antimalarial drugs in treating severe malaria and has been used for decades despite limited evidence of its efficacy in improving survival. We examined the efficacy of ET as an adjunct treatment for severe malaria using US surveillance data and reviewed the literature to update recommendations.
Methods.  Patients with severe malaria reported to the US national malaria surveillance system during 1985–2010 were matched, and survival outcomes were compared between patients receiving and not receiving ET. The literature review used search terms “severe malaria” and “exchange transfusion.” Case reports and series, observational and case-control studies, and meta-analysis were included.
Results. One hundred one patients receiving ET were matched to 314 patients not receiving ET. There was no statistically significant association between ET and survival outcome (odds ratio, 0.84; 95% confidence interval, .44–1.60). We found 87 articles, mostly case reports or series, showing successful use of ET, likely reporting bias. There were 12 comparative studies, most of which were retrospective cohort studies, underpowered with no significant differences in survival. A previously published meta-analysis of 8 comparative studies found no significant survival differences. Adverse events were rarely reported but included acute respiratory distress syndrome, ventricular fibrillation, and hypotension.
Conclusions.  Despite rapid parasite clearance times resulting from ET, there is no evidence for efficacy of ET as adjunctive therapy in severe malaria. Adjunct ET cannot be recommended. When rapidly acting antimalarials, specifically artemisinins, become more widely available, the biologic plausibility argument for ET will become less relevant.

MALARIA: Battle Is Not Lost, But We Must Redouble Our Effort

Rev. Larry Hollon

United Methodist Communications

The BBC story "Bed Nets for Malaria: Losing the Arms Race?," which aired on NPR, created a flurry of questions about the progress against this persistent disease.

Are bed nets continuing to be effective? Are bed nets the solution? Are we in danger of falling back and giving ground to a more virulent form of the parasite?

These questions are important and deserve a careful response. They are especially relevant to United Methodists who are closing in on raising $75 million for the Imagine No Malariacampaign.

From the outset of the current initiatives against malaria, it was clear that bed nets would be effective for a period of two to three years. It was also clear that resistance to existing medications and pesticides is one of the most frustrating capacities of the malaria parasite.

So the questions raised by the BBC story have been anticipated by malaria specialists for a number of years.

However, in my view the story emphasizes the importance of continuing to raise funds for several angles of attack against this resilient parasite. Bed nets do need to be replaced. Therefore, continuing to fund the manufacture and replacement of nets is part of the whole approach necessary to continue the fight. It's not the only part but one of the multiple steps that need to be taken.

Research and education are needed

In addition, it's important to continue to fund research into various prevention methods. Research at Vanderbilt University in Nashville, Johns Hopkins in Baltimore, and facilities inSeattle among other places must be continued and strengthened. These approaches range from finding ways to alter the reproductive abilities of the female mosquitoes that carry the parasite, to altering mosquito DNA and even to immobilizing the parasite itself through creative genetic manipulation, which goes beyond my layperson's understanding.

It's also necessary to continue to educate people in malaria-affected regions to keep their environment free of standing water and trash that serves to catch rainwater.

It's important to educate children (and adults as well) about wearing clothing that will protect them from mosquitoes when the insect is most active in the morning and evening. This, along with environmental cleanup, is known in the malaria world as behavior change communication.

Those who are fighting this disease have been addressing behavior change for many years, reinforced by the communications efforts of United Methodist Communications. The task is ongoing.

It's important to continue research into more effective pesticides because the parasite has shown an amazing ability to adapt and resist. This may be the greatest challenge.

Artemisinin resistance was identified by the World Health Organization in some regions several years ago. The agency warned of the spread of the parasite into new areas and called for increased containment efforts.

Health workers in the field need to continue their efforts at quicker diagnosis and treatment of those suspected of contracting malaria. The sooner appropriate medications can be provided the more likely the worst of the disease's effects can be addressed.

And research must continue into effective drugs for treating the disease. These efforts, as others I've listed above, are taking place in many locations around the world.

Lives are at stake

One of the reasons this disease has persisted is its ability to adapt, but the effectiveness of these various inputs from the highly sophisticated to the most rudimentary have resulted in significant progress in reducing deaths and suffering in recent years. But the battle is not over, and it certainly isn't lost.

We must continue the fight, keeping our eyes wide open to the challenges the BBC has accurately identified.

And we must not lose heart and yield to the thought that the disease cannot be conquered. To do so is an invitation to an even greater calamity. The world experienced that about 30 years ago, when progress against the disease was made and the fight was abandoned prematurely.

The result was that the parasite came back even stronger and was more difficult to contain, causing many more deaths and posing a challenge that was far more difficult to treat.

The fight against this disease is challenging, but what is at stake are human lives. We have seen many places around the world, the United States and Panama for example, where malaria once claimed lives with impunity but is now under control.

This is not the time to let the challenges cause us to hesitate. It's time to redouble our efforts to enjoin the fight

MALARIA: US Tackles Malaria In Nigeria With N11.7 billion

FRIDAY, 19 JULY 2013 21:45 BY CHUKWUMA MUANYA NEWS - NATIONAL

• Partners ACC, NAFDAC On Counterfeit Anti-malaria Campaign 

ASpart of efforts to reduce an estimated 100 million malaria cases with over 300,000 deaths per year in the country, the United States Government (USG) has provided $73 million (N11.68 billion) to support the President’s Malaria Initiative in Nigeria.

     USG in partnership with Anti-Counterfeiting Collaboration Nigeria (ACC) led by its President, Tee Mac Iseli and the National Agency for Food Drug Administration and Control (NAFDAC), Friday, in Lagos, launched the Counterfeit Anti-malaria Medication Awareness Campaign (CAMAC).

     ACC is a non-political, non-governmental, non-profit making coalition, which was conceived in October 2006 with the aim of bringing brand owners, enforcement agencies and interested parties together, to form an effective ‘opposition party’ against counterfeiters, infringers and pirates in Nigeria. 

     ACC disclosed at the launch that it has resurrected two anti-counterfeiting laws from the National Assembly and plans to represent them after a public discuss on December 5, 2013.

     Also, the Commissioner for Health Ogun State, Dr. Olaokun Soyinka, has warned that 80 per cent of fevers treated as malaria in Nigeria are not even as he called for appropriate diagnosis before treatment.

      Acting Consul General of the US Embassy in Lagos, Dehab Ghebreab, at the launch of CAMAC said: “Given its devastating impact, malaria prevention and control are major foreign assistance objectives of the USG.  With Fiscal Year (FY) 2013 funds, the USG is providing $73 million to support the President’s Malaria Initiative in Nigeria, a comprehensive package of malaria interventions, implemented by the US Agency for International Development (USAID), which will reach an estimated population of 39 million people in eleven target states.”

       Ghebreab said the US President’s Malaria Initiative supports four scientifically proven key interventions to prevent and treat malaria. These, he said, are the promotion of insecticide-treated nets, indoor residual insecticide spraying, the scale-up of intermittent preventive treatment for pregnant women, and supporting better diagnostic services at public health facilities.

      The Acting US Consul General expressed her country’s optimism that the campaign will raise awareness of the dangers of counterfeit anti-malarials, and will help to reduce the high prevalence of counterfeit and substandard medicines in Nigerian markets.

         According to her, given the importance of the programme, the Consul recently learned that the US State Department has provided the resources to continue the outreach next year, which they hope to do utilizing SMS technology to reach an even wider audience. “By using radio, the medium with the largest reach in Nigeria, we hope to spread the word to millions of Nigerians and help save lives,” she said.

According to statistics from the USAID, malaria is a major public health problem in Nigeria where it accounts for more cases and deaths than in any other country in the world.

      Ghebreab said: “There are an estimated 1000 million malaria cases with over 300,000 deaths per year in Nigeria. This compares with 215,000 deaths per year in Nigeria from Human Immuno-deficiency Virus (HIV)/Acquired Immune Deficiency Syndrome (AIDS).

     “Among those at risk are children. Malaria is the third leading cause of death for children under five years worldwide, after pneumonia and diarrheal disease.”

       Tee Mac Iseli said the campaign is appositive war against counterfeit medicines in Nigeria. He urged the federal government to return the Standard Organisation (SON) to the Ports and ensure 100 per cent inspection of all goods to prevent counterfeit medicines especially from China and India.

    Tee Mac said ACC has employed musicians, movie actors and wrestlers in the campaign to produce posters and radio jingles that are expected to reach most Nigerians even in the nook and crannies of this country. The celebrities include Emeka Ike, Yinka Davies, Sammy Okposun, The Ultimate Commander, among others.

       Soyinka said the major problem of public health in Nigeria is poor communication especially in the purchase and distribution ch

Infographic: Aids, TB and Malaria in Africa

Despite the gains, more Africans still die from Malaria even as the spotlight remains firmly fixed on HIV/AIDS. Alia Chughtai and Azad Essa Last Modified: 16 Jul 2013 13:31

Every 60 seconds a child dies from malaria in Africa, and despite the fact that infectious disease is the biggest threat to the continent, the spotlight remains focused elsewhere. Africa, with all the issues its 54 countries face, understands the urgent need to tackle killer diseases. Stemming the flow of HIV and AIDS, TB and malaria - while adequately treating existing cases - continues to be a challenge. African governments and international efforts have made great strides in combatting the scourge of disease on the continent. Over the past decade, the number of AIDS-related deaths and new infections decreased in Sub-Saharan Africa because of cheaper and improved access to treatment, and generally better health policies. Yet much of Africa is still plagued by deadly contagions and resources remain lacking. Al Jazeera takes a closer look at the state of Malaria, TB and HIV/Aids on a continent rife with challenges.

Source: Al Jazeera

POVERTY: Childbirthin Africa: A matter of life and death

Why is Africa still the world's most dangerous place to have a baby?

South to North Last Modified: 13 Jul 2013 08:01

No subject is off limits in the first ever global talk show hosted from Africa in which Redi Tlhabi talks frankly to inspiring and intriguing personalities from across the world.



This week on South2North Redi discusses maternal health and the impact it has on children, women and the communities in which they live.

A recent African Union report shows sub-Saharan Africa is trailing behind its 2015 Millennium Development Goal of reducing maternal mortality by 75 percent. Meanwhile some poor countries in Asia are en-route to achieving theirs.

So why is childbirth still such risky business in Africa? Why is Africa still the world's most dangerous place to have a baby? What is the secret behind other countries’ success? And what does it take to give all women the luxury of looking forward to a healthy baby?

Professor Hans Rosling, the co-founder of the Gapminder foundation explains how maternal health is a key factor needed for the future development of Africa.

"Africa will be big. It’s one billion people today two, three or even four billion is foreseen by the end of the century. The question is: will Africa be three billion rich or four billion poor? That’s about providing family planning today. Remember, China got rich after it had two-child families."

Rosling also uses a demonstration to explain the different healthcare needs of different income groups across the world.

Deliwe Nyathikazi, from the International Confederation of Midwifes, explains that women’s ability to control whether or not they get pregnant is a huge determinant for their health.

"In Africa, if we look at Sierra Leone for instance, the contraception rate there is 17 percent, compared to about 97 percent or 93 percent in Brazil, which is a huge difference. I agree completely that contraception plays a very major role in preventing unwanted pregnancies to start with, but also the spacing of the children. Because another problem when you are not having access to contraception is the spacing might not be correct, so the woman’s body does not get time to recuperate from the last child, and now she’s pregnant again."

Sanjana Bhardwaj, the UNICEF chief of health, explains how the state of maternal health in is an important indicator of how well countries are doing.

"It’s one of those conditions that reflects a lot about a country. So it’s about your health system, of course, but it also shows how your whole fabric is organised. What is the importance of women in that country, for example? What are the social norms? What are the traditions? What’s the access to care? What’s the health-seeking behaviour? So it’s not just to say that you should have the health centres set up, and you should have doctors everywhere and it’ll all get solved. It will not, because there are multiple factors that lead to it.

MALARIA: Cote d'Ivoire: Inland valley rice production systems and malaria

Inland valley rice production systems and malaria infection and disease in the forest region of western Cote d'Ivoire
Serge-Brice Assi, Marie-Claire Henry, Christophe Rogier, Joël Dossou-Yovo, Martine Audibert, Jacky Mathonnat,Thomas Teuscher and Pierre Carnevale

Malaria Journal 2013, 12:233 doi:10.1186/1475-2875-12-233Published: 10 July 2013
Background

This study aimed to determine the epidemiological impact of rice cultivation in inland valleys on malaria in the forest region of western Cote d'Ivoire. The importance of malaria was compared in terms of prevalence and parasite density of infections and also in terms of clinical malaria incidence between three agro-ecosystems: (i) uncultivated inland valleys, (R0), (ii) inland valleys with one annual rice cultivation in the rainy season, (R1) and (iii) developed inland valleys with two annual rice cultivation cycles, (R2).
Methods

Between May 1998 and March 1999, seven villages of each agro-ecosystem (R0, R1 and R2) were randomly selected among villages pooled by farming system. In these 21 villages, a total of 1,900 people of all age groups were randomly selected and clinically monitored during one year. Clinical and parasitological information was obtained by active case detection of malaria episodes carried out during eight periods of five consecutive days scheduled at six weekly intervals and by cross-sectional surveys.
Results

Plasmodium falciparum was the principal parasite observed in the three agro-ecosystems. A level of holoendemicity of malaria was observed in the three agro-ecosystems with more than 75% of children less than 12 months old infected. Geometric mean parasite density in asymptomatic persons varied between 180 and 206 P. falciparum asexual forms per muL of blood and was associated with season and with age, but not with farming system. The mean annual malaria incidence rate reached 0.7 (95% IC 0.5-0.9) malaria episodes per person in R0, 0.7 (95% IC 0.6-0.9) in R1 and 0.6 (95% IC 0.5-0.7) in R2. The burden of malaria was the highest among children under two years of age, with at least four attacks by person-year. Then malaria incidence decreased by half in the two to four-year age group. From the age of five years, the incidence was lower than one attack by person-year. Malaria incidence varied with season with more cases in the rainy season than in the dry season but not with farming system.
Conclusion

In the forest area of western Cote d'Ivoire, inland valley rice cultivation was not significantly associated with malaria burden.



The complete article is available as a provisional PDF. The fully formatted PDF and HTML versions are in production.

MALARIA: Malaria deaths in Africa reduced by one-third from Year 2000

Published:July 14,2013

The Executive Director, Roll Back Malaria Partnership said this on Saturday.
The Executive Director, Roll Back Malaria Partnership, Fatoumata Nafo-Traoré, said malaria-related deaths in Africa had reduced by one-third from the 2,000 figure.

Ms. Nafo-Traoré stated this on Saturday during the launch of `Malaria Situation Room’ at the AU Abuja +12 Special Summit on HIV/AIDS, Tuberculosis and Malaria.

The theme of the summit is “Ownership, Accountability and Sustainability of HIV and AIDS, TB and Malaria Response in Africa: Past, Present and the Future’’.

The malaria situation room is an intelligence gathering endeavour that focuses on the 10 most affected African countries to develop more effective solutions to its cure and control.

She said that the achievement was due to the massive increase in financial and technical support by countries over the past years.

“More than a million lives have been saved from malaria since year 2,000, most of them among African children under five years of age.

“Forty-four African nations have recorded more than 50 per cent reductions in malaria cases over the past decade,” she said.

Ms. Nafo-Traoré said malaria situation room was an initiative meant to support the 10 hardest-hit malaria-endemic countries in their efforts to achieve the 2015 malaria targets.

Dr. Alexandre Manguele, Mozambique’s Minister of Health, said a WHO report noted that the gains were confined to smaller countries in Africa.

Mr. Manguele said the gains were still low in bigger countries with complex epidemiological settings and operational needs.

“The toll of the disease will continue to affect the majority of the population in our region, if it is not managed in a more focused and co-ordinated manner, especially in bigger countries.

“We have the tools and the resources needed to scale-up the interventions, ’’ he said.

He said the problems countries encountered in the fight against malaria were financial, and also complex and multifaceted.

“Most of these problems are related to insufficient implementation capacity, such as in areas of human resources, supply of commodities and information-sharing among the stakeholders,” he said.

The Minister of Health, Professor Onyebuchi Chukwu, said that the initiative would enable Nigeria to secure much-needed resources to upscale some of the under-emphasised intervention strategies.

“As we count down to the target date for the Millennium Development Goals, it has become imperative to accelerate progress in the areas where we are either not on track or are far from target.

“This initiative is therefore timely and provides the framework for the scientific monitoring of progress and identification of specific gaps in implementation.

“It will enable us in Nigeria to secure much-needed resources to upscale some of the under emphasised intervention strategies without which the fight against malaria cannot be won,” he said.

(NAN)

MALNUTRITION: Uganda: Food insecurity threatens 1.2 million in Uganda’s northeast

Photo: Kate Holt/IRIN

In Karamoja, people are resorting to reducing their food rations to cope

KAMPALA, 10 July 2013 (IRIN) - A deteriorating food security situation in Uganda’s northeastern region of Karamoja could affect an estimated 1.2 million people, according to reports from the government and aid agencies. 

A June 2013 Integrated Food Security Phase Classification (IPC) analysis, carried out by food security partners and led by the Ministry of Agriculture, Animal Industry and Fisheries (MAAIF), revealed that up to 975,000 people in the semi-arid region face “stressed” levels of food insecurity, while 234,000 more cannot meet their minimum food needs. 

An assessment carried out in May by the UN World Food Programme (WFP) and the University of Makerere showed a poor food and nutrition situation in five of the region’s seven districts - Kotido, Kaabong, Moroto, Napak and Nakapiripirit. 

“The food security situation in the rest of the districts appears to be poor, but not unusually so for this time of the year,” said the report. 

Already, Nakapiripirit is experiencing global acute malnutrition (GAM) rates of 14.9 percent, just shy of the emergency threshold of 15 percent. 

According to the June 2013 food security outlook released by the Famine Early Warning Systems Network (FEWS NET), food security outcomes in Karamoja will remain unfavourable for the next two to three months. 

Crop production down 

“Erratic and poorly distributed rainfall in Karamoja to-date has impacted staple crop production. From March to mid-April, heavy rainfall resulted in water-logging and seedling damage in lowland areas, particularly in Kaabong, Kotido and Moroto districts. The remainder of April was characterized by erratic rains, followed by a long dry spell during much of May into June that resulted in atypical dry conditions and water stress, more severely in Kaabong district,” said the FEWS NET report. 

Michael Dunford, WFP deputy country director said: “At this stage, WFP would not suggest that people are actually starving, but certainly a significant proportion of the populations are suffering deteriorating food security. This has been highlighted by the poorer-than-usual food security and nutrition indicators.” 

He added, “Coupled with worse-than-usual harvest projections, we are naturally concerned of the short- and medium-term implications for the population in Karamoja. This [situation] will be very dependent upon the harvest and the rains over the coming months. The current prediction is that this year’s harvest will be substantially down due to a lack and poorly timed rains.” 

Dunford said people had adopted “negative coping strategies, including reducing meals, skipping meals and increasing the levels of indebtedness” to deal with the situation. 

“People are dying” 

Local leaders told IRIN that some people had died as a result of hunger and malnutrition, and they decried inadequate supplies of food rations from the government. 

“The situation is very bad in the region, especially in my district [Kaabong]. People are dying because of hunger. We have buried over 20 people in the last few weeks,” Rose Lilly Akello, the member of parliament representing Kaabong, told IRIN. 
“Although [the] government has delivered some 400 bags of food, this is not enough. My prayer is for the government and WFP to intervene by providing relief food for the next six to seven months. If they don’t, the situation will worsen and more deaths will be recorded,” she added. 

Officials said the government will continue to mobilize resources to scale-up food distribution to Karamoja. 

“The government is closely working with WFP to feed the population. We have dispatched food to the region. We shall continue to mobilize more food and resources to address the situation,” said Musa Ecweru, the state minister for relief and disaster preparedness. 

WFP, which ended blanket food distributions in Karamoja in 2009, says it needs US$7 million for its relief activities. 

so/ko/rz 

MALARIA: Malaria in the Americas presents a complex picture

		IMAGE: Ananias Escalante is a researcher in Biodesign's Center for Evolutionary Medicine and Informatics and a professor in the College of Liberal Arts and Sciences, School of Life Sciences. Click here for more information.

Human migrations – from the prehistoric epoch to the present day – have extended cultures across the globe. With these travelers have come unwanted stowaways: mosquito-borne parasites belonging to the Plasmodium species – a group responsible for malaria, worldwide.

As part of a team of collaborators from 10 countries, Ananias Escalante, a researcher at Arizona State University's Biodesign Institute, has been tracking the tenacious global spread of one of these malarial parasite species: Plasmodium vivax, the most prevalent cause of malaria in many countries outside of Africa. In a new study, this international team explores the genetic diversity of P. vivax in the Americas and other areas of the world.

"The strongest results from the study are that the populations of this parasite in the Americas are highly diversified," Escalante says. The analysis further found that, contrary to most existing assumptions, some genetic lineages in the Americas are very old (though they may not have originated in the New World). Much of this genetic diversity had been missed in previous surveys, due to insufficient sampling of large regions of the continent.

The new findings—which recently appeared in the journal Molecular Biology and Evolution, co-authored by ASU researchers Jesse Taylor and Maria A. Pacheco, together with a team of collaborators from 12 institutions —undermine earlier assumptions about the low genetic diversity of P. vivax across the Americas and raise new questions about the time of arrival and events leading to its New World introduction.

Given that genes evolve in measurable time frames, greater diversity suggests earlier and/or multiple introductions of the pathogen. The findings in the new study stand in contrast to earlier assumptions of a recent, single introduction of P. vivax in the Americas, which were based on the limited genetic diversity previously reported. The surprising results indicate that the diversity of vivax in the Americas is comparable to Asia and Oceania, and several divergent South American sequences may indicate multiple independent introductions.

In addition to changing the predominant picture of malarial diversity in the Americas, the study has important implications for control and eradication efforts, as well as potential vaccine design. The geographic distribution of malarial diversity in the Americas was shown to be a distinct relative to Asia and Ocenania (where this malarial parasite is also highly prevalent), indicating different migrational patterns. While many Asian populations usually show wide genetic diversity, the picture is different in the Americas, where large geographic swaths may remain fairly isolated.

		IMAGE: The anopheles mosquito is the vector carrying malaria around the globe, but as this map illustrates, there are many varieties within the anopheles genus. Click here for more information.

"The population structure we observed is, relatively speaking, good news because it means that malaria can actually be controlled or eliminated in the Pacific coast of Colombia, independently of what is happening in the Pacific coast of Peru, with only mild risk of reimportation," Escalante says. "One could envision independent malaria control programs by defining a spatial scale at which the low migration of infected humans makes the risk of reintroduction neglible."

Based on the statistical analysis of a worldwide expanded sample of complete mitochondrial genome sequences, the study estimates that the global population of P. vivax increased slowly until about 60,000 years ago. After this time it underwent rapid, exponential growth, tapering off around 10,000 years ago. Such estimates are in general agreement with known demographic histories of human migration, particularly the rapid divergence of African and European populations.

While the origins of vivax in the New World remain speculative, the study proposes two plausible models that are consistent with the data on genetic divergence and that do not exclude each other. In one scenario, ancient vivax strains may have been introduced into the Americas with pre-Colombian migrations via Beringia, 15,000 to 30,000 years ago. Alternatively, many vivax lineages in the Americas could have originated from now-extinct vivax variants from Europe or other regions.

Current theory suggests that the pathogen originally made a host switch from a non-human primate – an event that most likely occurred in Asia. The high genetic diversity of P. vivax observed in Asia and Oceania lends support to the idea. By contrast, the demographics of vivax in the Americas have received less attention and the dynamics of the new world populations remain somewhat shadowy.

Persistent and deadly

Malaria continues to cut a swath of destruction in many parts of the world. Globally, some 2.6 billion people are at risk of malarial infection and around 200 million cases occur each year, according to the World Health Organization. Some 3,000 children per day die of the disease in sub-Saharan Africa, or about one child every 30 seconds. The Americas also have been seriously impacted, though here, most cases of the disease are caused by the P. vivax parasite, as opposed to the highly virulent P. falciparum species, which reigns supreme in Africa.

While falciparum malaria remains the leading killer, vivax is the most geographically widespread malarial parasite. Due to lower mortality rates associated with P. vivax compared with P. falciparum, vivax malaria has been referred to in the past as "benign tertian malaria," though Escalante insists this is a misnomer. "People are starting to see vivax with different eyes. It's more aggressive. It may not be as aggressive as falciparum, but there's nothing benign about it."

Indeed, severe health complications associated with vivax malaria may be more common than once appreciated and include anemia, low neonatal birth weight and a dangerous decrease in the amount of platelets in the blood (a condition known as thrombocytopenia). Additionally, the complex nature of P. vivax infection makes eradication challenging. The disease is contagious very early in the infection process, increasing the probability of transmission while a patient is still pre-clinical and symptom-free.

Thorough treatment leading to the complete elimination of the P. vivax parasite from the body requires an intense regimen of medication, lasting for 14 days. A failure in strict compliance can result in the parasite surviving in the liver and redeveloping over time to produce another full-blown bout of malaria, (which may again be transmitted through mosquitoes).

A more complete understanding of P. vivax genetic diversity and its evolution are essential for improving control measures. The low local but high regional diversity of vivax in the Americas points to low rates of gene flow between geographically distinct regions. Many of these areas are primarily agricultural, with very limited in- or out-migration of the populations. Escalante notes that this significantly improves the possibilities for malarial containment and perhaps, thorough elimination of the disease in many parts of the Americas. At the same time, the greatly expanded genetic diversity of P. vivax presents new challenges for the eventual development of a comprehensive vaccine.

Contact: Joseph Caspermeyer
Joseph.Caspermeyer@asu.edu
Arizona State University 

POVERTY: Pakistan’s coast - where the sea is an enemy not a friend

Photo: Sumaira Jajja/IRIN

Rickety boats are the only means to get between settlements on the Indus river delta near Keti Bandar

KETI BUNDER, 11 July 2013 (IRIN) - On a theoretical level, climate change and sea intrusion are not things Din Muhammad Chandio, a fisherman and farmer, understands much about. 

But practically-speaking Chandio has seen them push him deeper into poverty in the town of Keti Bunder in Thatta District on the coast of Pakistan’s Sindh Province. 

“I earned a living mainly through fishing, and some farming. Now both are impossible because our lands have become barren due to seawater flowing in. The lack of fresh water flowing down the [Indus] river also means fishing is affected.” 

These trends are being studied by the World Wide Fund for Nature Pakistan (WWF-P) which is in the middle of a five-year project to build climate change resistance on Pakistan’s coastline, where communities are vulnerable to cyclones, rising sea levels and storm surges. 

According to their baseline study, published last year, encroaching seas are leaving farmland increasingly saline and water-logged, and leading to a decline in fresh water fish stocks. 

In one of the villages studied, Kharo Chan, the report’s authors found 45 percent of income declines were a result of the environmental degradation of fisheries, and 65 percent due to the environmental degradation of agricultural land. 

The River Indus, which is Pakistan’s longest and runs the length of the country, has seen its flow reduced in recent years by the creation of hydroelectric dams upstream, retreating Himalayan glaciers and poor water management. 

In Keti Bunder 77 percent of household heads surveyed in the study depend exclusively on fishing for their livelihood, making them vulnerable to changes in catch sizes. 

Chandio said his monthly income had dropped by a third to around US$120 in the past three years, and feeding his family of eight has become increasingly difficult. Seeing the way things were going, his two adult sons recently left to try and find work in Karachi. 

“Because of sea erosion, people in areas such as Badin District, Thatta District and so on, have lost homes because the sea has literally taken them away,” Ayub Khaskheli, information secretary of Karachi-based NGO Pakistan Fisher-folks Forum, told IRIN. 

He said that due to the loss of their homes, people were desperate and had in some cases been forced to move further inland or leave coastal areas altogether. 

"The continued loss of land will destroy us. The barley my father and grandfather planted simply does not grow here any longer"

“Crops such as potatoes and vegetables grown by women and used to feed families cannot be cultivated any longer. They simply do not grow in the now barren soil.” 

Khaskheli said the fact that seawater had entered drinking water supplies obtained through wells and hand pumps had “also caused many problems for people in these communities”. 

Despondency 

Environmental journalist Afia Salam told IRIN climate variability had created a “striking despondency among people”. 

“The town of Keti Bunder has been relocated three times, having to move inwards because of the encroachment of the sea. The able-bodied young men have left looking for livelihoods elsewhere as agriculture is no more, and marine catch has been severely reduced.” 

This sense of despondency exists too in other areas of Thatta, such as Kharo Chan, a `taluka’ (administrative unit) where Shamshad Bibi, the mother of four young children, lives in her village. 

“The 10 acres or so of land we had is mainly destroyed. Nothing grows on it because of the salt water. Now we just keep a small herd of goats and my husband tries to fish when he can. There is no future here for my children,” she told IRIN. 

Tahir Qureshi, senior adviser (coastal) for the International Union for the Conservation of Nature (IUCN) in Karachi, blamed the construction of dams and barrages on the Indus for the sea’s intrusion into the Indus Delta. 

“So far no scientific work has been done by the academia or national research institutions on sea level rise in order to investigate its contribution to this ecological disaster along the coast of Sindh. Mangroves are the soil binder and are the first defence line against all natural disasters,” he said. 

The IUCN has, with other groups, promoted mangrove cultivation to hold back erosion. Mangrove cover along the 350km Sindh coastline is 200,000 hectares - sharply down, according to environmentalists. 

“Loss of land will destroy us” 

WWF-P says it is working to build both disaster preparedness in coastal communities and help farming and fishing to adapt. 

“Communities react through coping measures, e.g. moving inland, or through reactive adaption when they respond to a new situation as it arises. We are trying to promote planned adaption to the change,” said WWF-P’s Bajwa. Modes of adaptation being considered for promotion include changing planting periods and the types of crops farmers grow. 

Certainly, people living in coastal areas are desperate to see change come their way. 

“The continued loss of land will destroy us. The barley my father and grandfather planted simply does not grow here any longer,” said Hussain Ahmed from his village in Thatta. 

“Even fodder for livestock is hard to grow, and the shrimp we used to take to markets in huge baskets have shrunk drastically in number.” 

He said that, as a direct result, “there is less food to place on the family table, less money to educate my children and nothing at all for health care. The sea, which once helped us by providing fish, has turned against us and is taking over our lands.” 

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