Objectives: Plasmodium knowlesi is a non-human parasite that causes zoonotic disease in humans. This systematic review aims to highlight and summarize studies describing human behaviors and activities that expose humans to mosquito bites. Design: English entries in PubMed, Web of Science, and Science Direct from 2010 to 2020 were systematically perused, and the results were synthesized. Methodological quality was assessed using the Joanna Briggs Institute quality appraisal checklists. Setting: Studies that described malaria preventive measures were included. Laboratory, in vivo, in vitro, and animal studies were excluded. Primary and secondary outcome measures: The main outcome of the review was findings from studies describing the behavior that exposed a person or a group to P. knowlesi infection. Results: Twelve eligible studies were of good or medium quality. Attitude, disease misconceptions, perceived threat of disease, lack of motivation, and supernatural or traditional beliefs causing individuals to seek treatment from traditional healers influenced the exposure of individuals or communities to P. knowlesi malaria. Other factors were forestry activities (2.48, 1.45–4.23,95% CI, p = 0.0010) and sleeping outdoors (3.611, 1.48–8.85, 95% CI, p = 0.0049). Conclusions: Future studies must consider the importance of human behavior and community perspective on the infection to provide novel information to improve the current zoonotic malaria programs. Policymakers should concentrate on understanding human behavior and activities that expose individuals or communities to mosquito bites, in order to better design socially feasible interventions.

In South-East Asia (SEA), there has been an increase in the trend of detected and reported cases of Plasmodium knowlesi malaria in the last few decades. This higher transmission rate within SEA countries is attributed to the distribution of the Macaque, banded leaf monkeys, and Anopheles mosquito in this region. This study aims to propose a concept that highlights the integration of vulnerability factors to P. knowlesi malaria infection. The relevant literature on the vulnerability factors of P. knowlesi was reviewed. Any theories and models that could be integrated to support the factors were also explored throughout this study. Exposure to P. knowlesi malaria was found to be influenced by sociodemographic, socioeconomic, environmental, social context, belief, and human behaviour factors. However, these factors were commonly discussed separately in existing studies. For better disease prevention and control, all these factors should be explored collectively, to facilitate research aimed at generating a deeper understanding of the vulnerability factors to P. knowlesi malaria from various perspectives, including the genetic, sociodemographic, socioeconomic, environmental, sociocultural beliefs, and human behaviour of the population.

Plasmodium knowlesi malaria infection in humans has been reported throughout southeast Asia. The communities at risk are those living in areas where Macaque monkeys and Anopheles mosquito are present. Zoonotic malaria control is challenging due to the presence of the reservoir host and the possibility of human-vector-human transmission. Current control measures, including insecticide-treated nets (ITNs) and indoor residual spraying (IRS), are insufficient to address this threat due to gaps in protection associated with outdoor and early evening vector biting and social and economic activities, such as agricultural and forest work. Understanding the challenges faced by affected communities in preventing mosquito bites is important for reducing disease transmission. This opinion paper discusses opportunities to improve P. knowlesi malaria control through understanding the challenges faced by communities at risk and increasing community engagement and ownership of control measures. The paper highlights this issue by describing how the concept of reimagining malaria can be adapted to zoonotic malaria control measures including identifying current gaps in vector control, understanding interactions between environmental, economic, and human behavioral factors, and increasing community participation in and ownership of control measures.

Every person diagnosed with diabetes mellitus (T2DM) is at risk of developing Diabetic retinopathy (DR). Thus, DR is one of the major chronic microvascular complications of T2DM. However, in Malaysia, research about DR is still scarce. This study aimed to determine the prevalence of DR among diabetic patients across 46 primary healthcare clinics in Sabah, Malaysia. Secondly, it purported to identify the factors influencing the development of DR. This cross-sectional study involved a total of 22,345 Type 2 diabetes mellitus (T2DM) patients in the Sabah Diabetic Registry from 2008 to 2015. Of the 22,345 T2DM patients, 13.5% (n = 3,029) of them were diagnosed with DR. Multiple logistic regression revealed seven major risk factors of DR, i.e. patients with diabetic foot ulcer [aOR: 95% CI 3.08 (1.96–4.85)], patients with diabetic nephropathy [aOR: 95% CI 2.47 (2.13–2.86)], hypertension [aOR: 95% CI 1.63 (1.43–1.87)], dyslipidaemia [aOR: 95% CI 1.30 (1.17–1.44)], glycated haemoglobin [(HbA1c) > 6.5 (aOR: 95% CI 1.25 (1.14–1.38)], duration of diabetes mellitus (T2DM) [aOR: 95% CI 1.06 (1.05–1.07)] and age of patient [aOR: 95% CI 1.01 (1.00–1.02)] respectively. DR is a preventable complication. The effective glycaemic control is crucial in preventing DR. In minimizing the prevalence of DR, the healthcare authorities should institute programmes to induce awareness on the management of DR’s risk factors among patient and practitioner.

The increasing incidence of P. knowlesi malaria infection among humans is a public health threat. This zoonotic disease is challenging to eliminate owing to the presence of animal reservoirs. Understanding the factors such as the community’s belief, social context, drivers, and barriers can provide insights into malaria preventive behavior. It is crucial to improve the current preventive measures. This study aims to achieve consensus among malaria experts based on evidence from literature reviews and experts’ opinions on possible factors influencing malaria preventive behavior among communities exposed to P. knowlesi malaria infection. A modified Delphi study protocol was developed to gather experts’ consensus on the study framework to explore the factors influencing preventive behavior among communities exposed to P. knowlesi malaria infection. The framework is adapted from the ideation model, and it is integrated with other relevant theories and extensive literature reviews. We will use the modified Delphi protocol to reach a consensus. The experts will respond to each questionnaire item and a related open-ended questionnaire. Consensus is predetermined at more than 70% agreement on the items. We will use descriptive statistics and thematic analysis to analyze the data. All experts will remain anonymous to maintain the characteristics of a traditional Delphi study.

An outbreak of Plasmodium malariae occurred in Sonsogon Paliu village in the remote area of Ulu Bengkoka sub-district of Kota Marudu, Northern Sabah, Malaysian Borneo from July through August 2019. This was the first outbreak of malaria in this village since 2014. On 11th July 2019 the Kota Kinabalu Public Health Laboratory notified the Kota Marudu District Health Office of a Polymerase Chain Reaction (PCR) positive case of P. malariae. This index case was a male from Sulawesi, Indonesia working for a logging company operating in Sonsogon Paliu. During the resulting outbreak, a total of 14 symptomatic cases were detected. All of these cases were positive by thick and thin blood smear examination, and also by PCR. During the outbreak, a mass blood survey screening was performed by light-microscopy and PCR. A total of 94 asymptomatic villagers 31 (33.0%) were PCR positive but thick and thin blood smear negative for P. malariae. Both symptomatic and asymptomatic cases received treatment at the district hospital. When symptomatic and asymptomatic cases were considered together, males (29/45. 64.5%) were infected more than females (16/45, 35.6%), the male:female ratio being 1.8:1. Adults were the predominant age group infected (22/45, 48.9%) followed by adolescents (19/45, 42.2%) and children under five years of age (4/45, 8.9%). This report illustrates that symptomatic and submicroscopic cases pose a challenge during P. malariae outbreaks and that PCR is a valuable tool for their identification. The rapid identification and control of imported malaria is crucial for the continued control of malaria in Malaysia.

Introduction. Dengue remains a public health threat. Clarifying the characteristics of future threats and prioritising intervention towards the highest risk potential can help to control and prevent dengue outbreaks. However, obtaining a consensus from panels of experts is certainly challenging due to the relative subjectivity of experience. Therefore, this article incorporates the fuzzy Delphi method (FDM) within a nominal group technique (NGT) as a multicriteria decision-making tool for (1) describing the characteristics of socioecological attributes (SEAs) with a high risk of causing dengue outbreak and (2) ranking those SEAs as priorities for intervention. Material and Methods. Experts were recruited using a purposive sampling technique. Informed consent was obtained before the start of the study. The NGT process began with an introductory presentation of dengue SEA by the moderator, followed by “silent generation.” Next, each participant provided information in a round-robin fashion. Ideas were collected by the moderator and displayed publicly. All experts were given ample time and space to contribute and justify their ideas without interruption during the discussion step to yield agreeable SEA characteristics. Ultimately, FDM was incorporated in the voting step to ensure rigorous analysis. The study was approved by an ethical committee before its commencement. Results. A total of 10 field experts participated in the study, with a median experience of 7.5 years working on a dengue team. The common characteristics of SEA prone to cause dengue outbreaks were the presence of human-made containers, in high quantities, left unattended, and covered from direct sunlight. Apart from that, all eight SEAs passed the triangulation of fuzzy numbers and defuzzification processes. The average fuzzy numbers ranged between 0.500 and 0.780, and the threshold value ( d ) ranged from 0.055 to 0.196. Of the potential risk factors identified, experts ranked illegal dumping sites as the most important, followed by old and unused items and construction sites. Conclusion. The NGT process successfully helped to obtain a consensus among the expert panels in describing SEA characteristics. Nevertheless, the integration of FDM offered a robust analysis that validated their ranking in dengue risk prioritisation. Therefore, we strongly recommend the application of FDM to be incorporated in any public health decision-making process.

IntroductionPlasmodium knowlesi malaria is a zoonotic mosquito-borne disease with complex epidemiology. According to the WHO, the prevention and control of vector-borne diseases require community participation to increase coherence between malaria interventions and sustainable public health programmes. We describe a participatory research (PR) design for a study aimed at exploring the key anthropological drivers of and barriers to zoonotic malaria preventive behaviour among communities exposed to P. knowlesi infection in Malaysia. Participatory approaches can facilitate policymakers in designing future zoonotic malaria control programmes by investigating community perspectives and concerns about zoonotic malaria in a local context.Methods and analysisThe PR will be conducted over a period of 12 months, from March 2022 to March 2023, among adults (>18 years old) who are permanent residents in a rural village exposed to P. knowlesi malaria in Sabah, Malaysia. We will select patients who were diagnosed with P. knowlesi infection from January to December 2021 for focus group discussions (FGDs), as they can provide perspectives on the disease from the point of view of those previously diagnosed with infection. In-depth interviews (IDIs) with people of importance in the community, such as village heads, will also be conducted. Both FGDs and IDIs will be conducted from March 2022 until June 2022. Concurrently, a photovoice with adults over 18 years old who reside in the community will be conducted. The target sample sizes for FGDs, IDIs and photovoice are 6–8, 12 and 10–15 participants, respectively. We will use a study framework as a theoretical lens to guide the exploration of the beliefs, social contexts, barriers and drivers surrounding zoonotic malaria preventive behaviour.Ethics and disseminationThis study has been approved by the Medical Research and Ethics Committee Ministry of Health Malaysia (NMRR ID-21-01980-JEH) and the Research and Innovation Secretariat, Faculty of Medicine, Universiti Kebangsaan Malaysia (FF-2021-462). All participants will provide consent prior to participation. The results will be reported in international peer-reviewed journals and presented at conferences and on other platforms.