Tropical splenomegaly is often associated with malaria and schistosomiasis. In 2014 and 2015, 145 Congolese refugees in western Uganda diagnosed with splenomegaly during predeparture medical examinations underwent enhanced screening for various etiologies. After anecdotal reports of unresolved splenomegaly and complications after U.S. arrival, patients were reassessed to describe long-term clinical progression after arrival in the United States. Post-arrival medical information was obtained through medical chart abstraction in collaboration with state health partners in nine participating states. We evaluated observed splenomegaly duration and associated clinical sequelae between 130 case patients from eastern Congo and 102 controls through adjusted hierarchical Poisson models, accounting for familial clustering. Of the 130 case patients, 95 (73.1%) had detectable splenomegaly after arrival. Of the 85 patients with records beyond 6 months, 45 (52.9%) had persistent splenomegaly, with a median persistence of 14.7 months (range 6.0-27.9 months). Of the 112 patients with available results, 65 (58.0%) patients had evidence of malaria infection, and the mean splenomegaly duration did not differ by Plasmodium species. Refugees with splenomegaly on arrival were 43% more likely to have anemia (adjusted relative risk [aRR]: 1.43, 95% CI: 1.04-1.97). Those with persistent splenomegaly were 60% more likely (adjusted relative risk [aRR]: 1.60, 95% CI: 1.15-2.23) to have a hematologic abnormality, particularly thrombocytopenia (aRR: 5.53, 95% CI: 1.73-17.62), and elevated alkaline phosphatase (aRR: 1.57, 95% CI: 1.03-2.40). Many patients experienced persistent splenomegaly, contradicting literature describing resolution after treatment and removal from an endemic setting. Other possible etiologies should be investigated and effective treatment, beyond treatment for malaria and schistosomiasis, explored.
All U.S.-bound refugees from sub-Saharan Africa receive presumptive antimalarial treatment before departing for the United States. Among U.S.-bound Congolese refugees, breakthrough malaria cases and persistent splenomegaly have been reported. In response, an enhanced malaria diagnostic program was instituted. Here, we report the prevalence of plasmodial infection among 803 U.S.-bound Congolese refugees who received enhanced diagnostics. Infections by either rapid diagnostic test (RDT) or PCR were detected in 187 (23%) refugees, with 78 (10%) by RDT only, 35 (4%) by PCR only, and 74 (9%) by both. Infections identified by PCR included 103 monoinfections (87 Plasmodium falciparum, eight Plasmodium ovale, seven Plasmodium vivax, and one Plasmodium malariae) and six mixed infections. Splenomegaly was associated with malaria detectable by RDT (odds ratio: 1.8, 95% CI: 1.0–3.0), but not by PCR. Splenomegaly was not strongly associated with parasitemia, indicating that active malaria parasitemia is not necessary for splenomegaly.
BackgroundP. falciparum is the most important Plasmodium species that causes high malaria morbidity and mortality. The distribution of diverse and multiple P. falciparum infections is a major setback to the control and eventual elimination of malaria globally. Little efforts have been made to systematically establish P. falciparum genetic diversity and multiplicity of infection (MOI) in African settings. Additionally, the choice of an effective P. falciparum genotyping approach for a specific endemic setting remains a challenge. The review aims to establish P. falciparum genetic diversity MOI, genotyping approaches, and methods of reporting it in Africa. This will aid the evaluation of the impact of malaria control interventions and development of new control strategies.MethodsThe review will consider Randomized Clinical Trials (RCTs), Quasi-experiments, Cross-sectional studies, Cohort and Case-control studies about P. falciparum genetic diversity and MOI. A literature search will be conducted in PubMed, Google scholar and MEDLINE databases for articles published from January 2010 to December 2020. Articles will be screened using Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. Risk of bias in RCTs will be assessed using Cochrane risk of bias assessment tool while New Castle Ottawa tools will be used to assess the risk of bias in observational studies. Publication bias will be assessed using a funnel plot as well as Begg and Mazumdar's rank correlation test or Egger's test. The Higgins I2 statistic and Galbraith plots will be used to assess heterogeneity. A meta-regression analysis will be performed to explain the low heterogeneity. DiscussionThe findings from the study will enhance our understanding of the distribution and dynamics of P. falciparum genetic diversity and MOI. This will provide insights to the changing landscape of malaria transmission and evaluation of malaria control interventions. Findings will also serve as baseline data for future studies on parasite population structure and antimalarial drug resistance surveillance across African countries.
Background: World Health Organization and Ministry of Health (Uganda) recommend use of microscopy for parasitological confirmation of malaria. Microscopy involves either Giemsa or Field’s staining techniques. Ministry of Health prefers and recommends use of Giemsa staining technique but most health facilities still use Field’s staining technique. The objective of this study was to compare the cost-effectiveness of Giemsa and Field’s staining techniques in order to inform malaria diagnosis policy and practice in Uganda. Methods: This was a cross sectional cost effectiveness analysis from the provider’s perspective covering the period between April 25, 2014 and June 15, 2014. The study involved 243 children below five years of age presenting at Acute Care Unit laboratory for malaria test before admission. Giemsa and Field’s staining techniques were compared with Polymerase Chain Reaction as the gold standard. Decision tree analytic model in TreeAge was used for the cost effectiveness analysis. Results : Field’s and Giemsa staining techniques cost US $ 0.030 and US $ 0.769 respectively. Correctly diagnosed cases were 227 and 230 for Field’s and Giemsa staining techniques respectively. The proportion of correctly diagnosed cases was 93.4% for Field’s and 94.7% for Giemsa. Incremental cost effectiveness ratio was 0.35 US $ per additional correctly diagnosed case. Conclusion: Field’s staining technique was more cost effective than Giemsa staining technique; provided a higher number of correctly diagnosed cases at a lower cost than Giemsa staining technique. Field’s staining technique is recommended as staining technique for malaria diagnosis at the Acute Care Unit of Mulago National Referral Hospital. This implies that even with introduction of more superior staining techniques for laboratory diagnosis of malaria, Field staining technique is still a cost effective technique to be used in resource limited settings with high malaria burden like Uganda and Africa at large.
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