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Malaria Journal, 22.08.2022
Tilføjet 22.08.2022
Abstract
Background
Parasites are recognized for their ability to modify host physiology and behaviours in ways that increase parasite fitness. Protozoan parasites of the genus Plasmodium are a group of widespread vector-borne parasites of vertebrates, causing disease to a wide range of hosts, but most notably to human and avian hosts.
Methods
The hypothesis that infection with the avian malaria, Plasmodium relictum (GRW4 lineage) impacts flight activity in one of their natural vectors, Culex quinquefasciatus, was tested using both parasites and mosquitoes colonized from local populations in East-Central Texas, USA. Groups of Cx. quinquefasciatus were allowed to feed directly on canaries with active P. relictum infections and control canaries with no P. relictum exposure history. Additionally, how P. relictum sporozoite invasion of mosquito salivary glands impacts mosquito flight activity behaviour was tested using a Locomotor Activity Monitor for both control and infected females. Generalized linear mixed models were used to evaluate the influence of infection status on the response variables of flight activity (continuous) and probability of flight occurring (binomial).
Results
Infection status was a significant predictor of flight activity and flight probability and interactions between infection status and experimental period of infection as well as infection status and dusk were statistically significant predictors of flight activity. Plasmodium relictum infected mosquitoes had a mean flight activity of 3.10 and control mosquitoes had an overall mean flight activity of 3.13.
Discussion
Based on these results, avian malaria parasites increase the flight activity of these mosquitoes at hours known for peak host-seeking behaviour but decrease overall diel activity.
Conclusion
Although the ramifications of this behavioural change for P. relictum transmission are unclear, these results provide additional empirical evidence suggesting that avian malaria can influence mosquito behaviour and modulate transmission potential.
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Malaria Journal, 22.08.2022
Tilføjet 22.08.2022
Abstract
Background
The search for pharmacologically effective agents among molecules bearing multiple functionalities is commonly practiced. In continuation of the search for new anti-malarial agents, new pyrazole-hydrazine coupled Schiff-base derivatives previously synthesized were screened for anti-malarial property.
Methods
Here, in vivo prophylactic and curative activities of the compounds were assessed while their binding affinity for falcipain-2, a crucial enzyme in Plasmodium survival, was done using computational techniques.
Results
The two derivatives (BepINH and BepBeH) respectively led to a significant (p < 0.05) reduction in parasitaemia count (0.76 ± 1.11 and 0.79 ± 1.19) at day 3 post-treatment relative to the negative control (16.37 ± 1.25). For the prophylactic study, it was observed that the highest parasitaemia suppression level of 95.35% and 95.17% for BepINH and BepBeH at 15 mg/kg was slightly comparable to that obtained for ACT-Lonart (99.38%). In addition, their haematological profiles indicate that they are potentially beneficial in suppressing haemolytic damage to RBC, thereby protecting the body against infection-induced anaemia. Docking calculations on the derivatives toward the Plasmodium falciparum falcipain-2 revealed that they favourably interacted with a binding affinity higher than that of a known cocrystallized inhibitor.
Conclusion
This study confirms the relevance of multi-functional molecules in the search for new and effective anti-plasmodial agent and lay the foundation for further development of these compound series to potent anti-plasmodial agent that interacts with falcipain-2.
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Manu De Rycker, Susan Wyllie, David Horn, Kevin D. Read, Ian H. Gilbert
Nat Rev Microbiol, 22.08.2022
Tilføjet 22.08.2022
Nature Reviews Microbiology, Published online: 22 August 2022; doi:10.1038/s41579-022-00777-yIn this Review, Gilbert and colleagues discuss recent progress in drug discovery for kinetoplastid diseases and how an improved understanding of parasite biology affects the drug discovery process
Læs mere Tjek på PubMedEnos Moyo, Godfrey Musuka, Grant Murewanhema, Perseverance Moyo, Tafadzwa Dzinamarira
International Journal of Infectious Diseases, 22.08.2022
Tilføjet 22.08.2022
Asbjørn Langeland Toft, Victor Næstholt Dahl, Armando Sifna, Olusoji Mayowa Ige, Valérie Schwoebel, Mahamadou Bassirou Souleymane, Alberto Piubello, Christian Wejse
International Journal of Infectious Diseases, 22.08.2022
Tilføjet 22.08.2022
Peter B. Gilbert, Yunda Huang, Allan C. deCamp, Shelly Karuna, Yuanyuan Zhang, Craig A. Magaret, Elena E. Giorgi, Bette Korber, Paul T. Edlefsen, Raabya Rossenkhan, Michal Juraska, Erika Rudnicki, Nidhi Kochar, Ying Huang, Lindsay N. Carpp, Dan H. Barouch, Nonhlanhla N. Mkhize, Tandile Hermanus, Prudence Kgagudi, Valerie Bekker, Haajira Kaldine, Rutendo E. Mapengo, Amanda Eaton, Elize Domin, Carley West, Wenhong Feng, Haili Tang, Kelly E. Seaton, Jack Heptinstall, Caroline Brackett, Kelvin Chiong, Georgia D. Tomaras, Philip Andrew, Bryan T. Mayer, Daniel B. Reeves, Magdalena E. Sobieszczyk, Nigel Garrett, Jorge Sanchez, Cynthia Gay, Joseph Makhema, Carolyn Williamson, James I. Mullins, John Hural, Myron S. Cohen, Lawrence Corey, David C. Montefiori, Lynn Morris
Nature, 22.08.2022
Tilføjet 22.08.2022
Nature Medicine, Published online: 22 August 2022; doi:10.1038/s41591-022-01953-6By integrating the serum concentration of a broadly neutralizing antibody (bNAb) with its in vitro 80% inhibitory concentration, the PT80 biomarker may be used to guide target levels of bNAbs for effective prevention of HIV-1 acquisition.
Læs mere Tjek på PubMedGeletta Tadele, Fatou K. Jaiteh, Mary Oboh, Eniyou Oriero, Sisay Dugassa, Alfred Amambua-Ngwa, Lemu Golassa aAklilu Lemma Institute of Pathobiology, Addis Ababa Universitygrid.7123.7, Addis Ababa, Ethiopia bMedical Research Council Unit the Gambia, London School of Hygiene and Tropical Medicine, Banjul, Gambia
Antimicrobial Agents And Chemotherapy, 22.08.2022
Tilføjet 22.08.2022
BMC Infectious Diseases, 22.08.2022
Tilføjet 22.08.2022
Abstract
Background and aim
It seems that acceptance of COVID-19 vaccination is the most effective way to tackle the COVID-19 pandemic now. Health care workers (HCWs) are one of the most important groups who are at risk for COVID-19 infection. This study aimed to assess the COVID‐19 vaccine acceptance among HCWs in Iran and its determinants.
Methods
A cross‐sectional survey was carried out among 3600 HCWs in Iran. Data were collected through a self-administered questionnaire by a trained team from February to March 2021. Multi-stage cluster sampling method was used for selecting respondents of the study. Multivariate logistic regression analysis was used to determine the key factors of COVID-19 vaccine acceptance among participants. P-value < 0.05 was considered statistically significant.
Results
Out of the 3536 respondents, 2191 (62.1%) intended to uptake the COVID-19 vaccine. Only about 10 percent of respondents said they did not trust any vaccine (domestic or foreign). Willing to accept a COVID-19 vaccine was relatively high among males, doctors, and those who had a history of hospitalization due to COVID-19 infection. The multivariate regression analysis showed respondents who were 40–50 years (aOR: 1.56; 95% CI: 1.47–1.66), had a history of COVID-19 infection (aOR: 0.85; 95% CI: 0.83–0.88), and hospitalized due to COVID-19 infection (aOR: 2.18; 95% CI: 1.97–2.39), were significantly associated with vaccine acceptance (p < 0.05).
Conclusion
Our study showed moderate acceptance of COVID-19 vaccination in the HCWs in the Islamic Republic of Iran. The most important factor in the acceptance of the COVID-19 vaccine by the health staff is having a history of hospitalization. Further training and justification of health personnel is needed to increase the acceptance of COVID 19 vaccine.
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BMC Infectious Diseases, 22.08.2022
Tilføjet 22.08.2022
Abstract
Background
COVID-19 outcomes among hospitalized patients may have changed due to new variants, therapies and vaccine availability. We assessed outcomes of adults hospitalized with COVID-19 from March 2020–February 2022.
Methods
Data were retrieved from electronic health medical records of adult COVID-19 patients hospitalized in a large community health system. Duration was split into March 2020–June 2021 (pre-Delta period), July–November 2021 (Delta period), and December 2021–February 2022 (Omicron period).
Results
Of included patients (n = 9582), 75% were admitted during pre-Delta, 9% during Delta, 16% during Omicron period. The COVID-positive inpatients were oldest during Omicron period but had lowest rates of COVID pneumonia and resource utilization (p < 0.0001); 46% were vaccinated during Delta and 61% during Omicron period (p < 0.0001). After adjustment for demographics and comorbidities, vaccination was associated with lower inpatient mortality (OR = 0.47 (0.34–0.65), p < 0.0001). The Omicron period was independently associated with lower risk of inpatient mortality (OR = 0.61 (0.45–0.82), p = 0.0010). Vaccination and Omicron period admission were also independently associated with lower healthcare resource utilization (p < 0.05). Magnitudes of associations varied between age groups with strongest protective effects seen in younger patients.
Conclusion
Outcomes of COVID-19 inpatients were evolving throughout the pandemic and were affected by changing demographics, virus variants, and vaccination.
Key point
In this observational study of almost 10,000 patients hospitalized from March 2020–February 2022 with COVID-19, age and having multiple comorbidities remained consistent risk factors for mortality regardless of the variant. Vaccination was high in our hospitalized patients. Vaccination conveyed less severe illness and was associated with lower inpatient mortality.
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Carolina T. Rath, Áislan C. Vivarini, José Vitorino dos Santos, Jorge M. Medina, Alessandra M. Saliba, Jeremy C. Mottram, Ana Paula C. A. Lima, Teresa Cristina Calegari-Silva, Renata M. Pereira, Ulisses G. Lopes aInstituto de Biofísica Carlos Chagas Filho, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil bDepartmento de Microbiologia e Imunologia, Faculdade de Ciências Médicas, Universidade Estadual do Rio de Janeiro, Rio de Janeiro, Brazil cYork Biomedical Research Institute, Department of Biology, University of York, Heslington, York, United Kingdom dInstituto de Microbiologia Paulo de Góes, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil, Andreas J. Bäumler
Infection and Immunity, 22.08.2022
Tilføjet 22.08.2022
Hwan Keun Kim aCenter for Infectious Diseases, Department of Microbiology and Immunology, Stony Brook Universitygrid.36425.36, Stony Brook, New York, USA, Karen M. Ottemann
Infection and Immunity, 22.08.2022
Tilføjet 22.08.2022
Michael Sharland, Veronica Zanichelli, Loice Achieng Ombajo, Joel Bazira, Bernadette Cappello, Ronald Chitatanga, Pem Chuki, Sumanth Gandra, Haileyesus Getahun, Stephan Harbarth, Mark Loeb, Marc Mendelson, Lorenzo Moja, Celine Pulcini, Hatim Sati, Evelina Tacconelli, Mei Zeng, Benedikt Huttner
Clinical Microbiology and Infection, 22.08.2022
Tilføjet 22.08.2022
The 22nd WHO Model List of Essential Medicines (EML) (and 8th EMLc for children) released in 2021 includes 39 antibiotics (1, 2). In 2017, the EML introduced a new classification of antibiotics; Access (narrower spectrum), Watch (broader spectrum) and Reserve groups (last-resort) to standardise metrics of use and support stewardship (3). Overall, 265 antibiotics (including the 39 in the EML and EMLc: 20 Access, 11 Watch, 8 Reserve) have now been categorized into AWaRe groups. The EML has listed antibiotics since 1977 but for most infections the WHO has not previously given detailed guidance on how they should be used.
Læs mere Tjek på PubMedVivi Maketa, Flory Luzolo, Hypolite Muhindo‐Mavoko, Yves Claeys, Felicien Munday, Yemesi Benge Robert, Willy Bongo‐Pasi, Darius Mankindu, Samuel Mampunza, Philippe Lukanu, Mutheo Kasongo, Ntabe Namegabe Edmond, Kambale Karafuli Leopold, Delphin Phanzu Mavinga, Emmanuel Milandu Massamba, César‐Augustin Muaka Khoso, Raffaella Ravinetto
Tropical Medicine & International Health, 21.08.2022
Tilføjet 22.08.2022
Malaria Journal, 21.08.2022
Tilføjet 21.08.2022
Abstract
Background
Targeted research on residual malaria transmission is important to improve strategies in settings pursuing elimination, where transmission reductions prove challenging. This study aimed to detect and characterize spatial heterogeneity and factors associated with Plasmodium falciparum infections and exposure, P. falciparum apical membrane antigen 1 (PfAMA1) antibody (Ab) response, in the Central Highlands of Madagascar (CHL).
Methods
From May to July 2014, a cross-sectional school-based survey was carried out in 182 fokontany (villages) within 7 health districts of the CHL. Rapid diagnostic tests (RDTs) and a bead-based immunoassay including PfAMA1 antigen biomarker were used to estimate malaria prevalence and seroprevalence, respectively. Local Moran’s I index was used to detect spatial “hotspots”. Remotely sensed environmental data—temperature, vegetation indices, land covers, and elevation—were used in multivariable mixed-effects logistic regression models to characterize factors associated with malaria infection and cumulative exposure.
Results
Among 6,293 school-children ages 2–14 years surveyed, RDT prevalence was low at 0.8% (95% CI 0.6–1.1%), while PfAMA1 Ab seroprevalence was 7.0% (95% CI 6.4–7.7%). Hotspots of PfAMA1 Ab seroprevalence were observed in two districts (Ankazobe and Mandoto). Seroprevalence increased for children living > 5 km from a health centre (adjusted odds ratio (OR) = 1.6, 95% CI 1.2–2.2), and for those experiencing a fever episode in the previous 2 weeks (OR 1.7, 95% CI 1.2–2.4), but decreased at higher elevation (for each 100-m increase, OR = 0.7, 95% CI 0.6–0.8). A clear age pattern was observed whereby children 9–10 years old had an OR of 1.8 (95% CI 1.2–2.4), children 11–12 years an OR of 3.7 (95% CI 2.8–5.0), and children 13–14 years an OR of 5.7 (95% CI 4.0–8.0) for seropositivity, compared with younger children (2–8 years).
Conclusion
The use of serology in this study provided a better understanding of malaria hotspots and associated factors, revealing a pattern of higher transmission linked to geographical barriers in health care access. The integration of antibody-assays into existing surveillance activities could improve exposure assessment, and may help to monitor the effectiveness of malaria control efforts and adapt elimination interventions.
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Emerging Infectious Diseases, 19.08.2022
Tilføjet 21.08.2022
Emerging Infectious Diseases, 19.08.2022
Tilføjet 21.08.2022
Dispatch - Coccidioidomycosis Seroincidence and Risk among Military Personnel, Naval Air Station Lemoore, San Joaquin Valley, California, USA
Læs mere Tjek på PubMedEmerging Infectious Diseases, 19.08.2022
Tilføjet 21.08.2022
Research Letter - Fatal Fungicide-Associated Triazole-Resistant Aspergillus fumigatus Infection, Pennsylvania, USA
Læs mere Tjek på PubMedEmerging Infectious Diseases, 19.08.2022
Tilføjet 21.08.2022
Research Letter - Molecular Epidemiology of Blastomyces gilchristii Clusters, Minnesota, USA
Læs mere Tjek på PubMedEmerging Infectious Diseases, 19.08.2022
Tilføjet 21.08.2022
Emerging Infectious Diseases, 16.08.2022
Tilføjet 21.08.2022
H. influenzae is as a rare but major cause of pregnancy-associated invasive disease.
Læs mere Tjek på PubMedEmerging Infectious Diseases, 16.07.2022
Tilføjet 21.08.2022
Research - Increasing Incidence of Invasive Group A Streptococcus Disease, Idaho, USA, 2008-2019
Læs mere Tjek på PubMedOjo-Ajogu Akuh, Rubayet Elahi, Sean T. Prigge, Frank Seeber
Trends in Parasitology, 20.08.2022
Tilføjet 21.08.2022
The apicoplast, a relict plastid found in most species of the phylum Apicomplexa, harbors the ferredoxin redox system which supplies electrons to enzymes of various metabolic pathways in this organelle. Recent reports in Toxoplasma gondii and Plasmodium falciparum have shown that the iron-sulfur cluster (FeS)-containing ferredoxin is essential in tachyzoite and blood-stage parasites, respectively. Here we review ferredoxin’s crucial contribution to isoprenoid and lipoate biosynthesis as well as tRNA modification in the apicoplast, highlighting similarities and differences between the two species.
Læs mere Tjek på PubMedMalaria Journal, 20.08.2022
Tilføjet 20.08.2022
Abstract
Background
Pyrethroid resistance observed in populations of malaria vectors is widespread in Ethiopia and could potentially compromise the effectiveness of insecticide-based malaria vector control interventions. In this study, the impact of combining indoor residual spraying (IRS) and insecticide-treated nets (ITNs) on mosquito behaviour and mortality was evaluated using experimental huts.
Methods
A Latin Square Design was employed using six experimental huts to collect entomological data. Human volunteers slept in huts with different types of nets (pyrethroid-only net, PBO net, and untreated net) either with or without IRS (Actellic 300CS). The hut with no IRS and an untreated net served as a negative control. The study was conducted for a total of 54 nights. Both alive and dead mosquitoes were collected from inside nets, in the central rooms and verandah the following morning. Data were analysed using Stata/SE 14.0 software package (College Station, TX, USA).
Results
The personal protection rate of huts with PermaNet® 2.0 alone and PermaNet® 3.0 alone was 33.3% and 50%, respectively. The mean killing effect of huts with PermaNet® 2.0 alone and PermaNet® 3.0 alone was 2% and 49%, respectively. Huts with PermaNet® 2.0 alone and PermaNet® 3.0 alone demonstrated significantly higher excito-repellency than the control hut. However, mosquito mortality in the hut with IRS + untreated net, hut with IRS + PermaNet® 2.0 and hut with IRS + PermaNet® 3.0 were not significantly different from each other (p > 0.05). Additionally, pre-exposure of both the susceptible Anopheles arabiensis laboratory strain and wild Anopheles gambiae sensu lato to PBO in the cone bioassay tests of Actellic 300CS sprayed surfaces did not reduce mosquito mortality when compared to mortality without pre-exposure to PBO.
Conclusion
Mosquito mortality rates from the huts with IRS alone were similar to mosquito mortality rates from the huts with the combination of vector control intervention tools (IRS + ITNs) and mosquito mortality rates from huts with PBO nets alone were significantly higher than huts with pyrethroid-only nets. The findings of this study help inform studies to be conducted under field condition for decision-making for future selection of cost-effective vector control intervention tools.
Graphical Abstract
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Malaria Journal, 20.08.2022
Tilføjet 20.08.2022
Abstract
Background
Globally, nearly half of all deaths among children under the age of 5 years can be attributed to malaria, diarrhoea, and pneumonia. A significant proportion of these deaths occur in sub-Saharan Africa. Despite several programmes implemented in sub-Saharan Africa, the burden of these illnesses remains persistently high. To mobilise resources for such programmes it is necessary to evaluate their costs, costs-effectiveness, and affordability. This study aimed to estimate the provider costs of treating malaria, diarrhoea, and pneumonia among children under the age of 5 years in routine settings at the health facility level in rural Uganda and Mozambique.
Methods
Service and cost data was collected from health facilities in midwestern Uganda and Inhambane province, Mozambique from private and public health facilities. Financial and economic costs of providing care for childhood illnesses were investigated from the provider perspective by combining a top-down and bottom-up approach to estimate unit costs and annual total costs for different types of visits for these illnesses. All costs were collected in Ugandan shillings and Mozambican meticais. Costs are presented in 2021 US dollars.
Results
In Uganda, the highest number of outpatient visits were for children with uncomplicated malaria and of inpatient admissions were for respiratory infections, including pneumonia. The highest unit cost for outpatient visits was for pneumonia (and other respiratory infections) and ranged from $0.5 to 2.3, while the highest unit cost for inpatient admissions was for malaria ($19.6). In Mozambique, the highest numbers of outpatient and inpatient admissions visits were for malaria. The highest unit costs were for malaria too, ranging from $2.5 to 4.2 for outpatient visits and $3.8 for inpatient admissions. The greatest contributors to costs in both countries were drugs and diagnostics, followed by staff.
Conclusions
The findings highlighted the intensive resource use in the treatment of malaria and pneumonia for outpatient and inpatient cases, particularly at higher level health facilities. Timely treatment to prevent severe complications associated with these illnesses can also avoid high costs to health providers, and households.
Trial registration: ClinicalTrials.gov, identifier: NCT01972321.
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Malaria Journal, 20.08.2022
Tilføjet 20.08.2022
Abstract
Background
Malaria infection during pregnancy can cause significant morbidity and mortality to a pregnant woman, her fetus and newborn. In areas of high endemic transmission, gravidity is an important risk factor for infection, but there is a complex relationship with other exposure-related factors, and use of protective measures. This study investigated the association between gravidity and placental malaria (PM), among pregnant women aged 14–49 in Kintampo, a high transmission area of Ghana.
Methods
Between 2008 and 2011, as part of a study investigating the association between PM and malaria in infancy, pregnant women attending antenatal care (ANC) clinics in the study area were enrolled and followed up until delivery. The outcome of PM was assessed at delivery by placental histopathology. Multivariable logistic regression analyses were used to investigate the association between gravidity and PM, identify other key risk factors, and control for potential confounders. Pre-specified effect modifiers including area of residence, socio-economic score (SES), ITN use and IPTp-SP use were explored.
Results
The prevalence of PM was 65.9% in primigravidae, and 26.5% in multigravidae. After adjusting for age, SES and relationship status, primigravidae were shown to have over three times the odds of PM compared to multigravidae, defined as women with 2 or more previous pregnancies [adjusted OR = 3.36 (95% CI 2.39–4.71), N = 1808, P < 0.001]. The association appeared stronger in rural areas [OR for PG vs. MG was 3.79 (95% CI 3.61–5.51) in rural areas; 2.09 (95% CI 1.17–3.71) in urban areas; P for interaction = 0.07], and among women with lower socio-economic scores [OR for PG vs. MG was 4.73 (95% CI 3.08–7.25) amongst women with lower SES; OR = 2.14 (95% CI 1.38–3.35) among women with higher SES; P for interaction = 0.008]. There was also evidence of lower risk among primigravidae with better use of the current preventive measures IPTp and LLIN.
Conclusions
The burden of PM is most heavily focused on primigravidae of low SES living in rural areas of high transmission. Programmes should prioritize primigravidae and young women of child-bearing age for interventions such as LLIN distribution, educational initiatives and treatment to reduce the burden of malaria in first pregnancy.
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Malaria Journal, 20.08.2022
Tilføjet 20.08.2022
Abstract
Background
As Indonesia aims for malaria elimination by 2030, provisional malaria epidemiology and risk factors evaluation are important in pursue of this national goal. Therefore, this study aimed to understand the risk factor of malaria in Northern Sumatera.
Methods
Malaria cases from 2019 to 2020 were obtained from the Indonesian Ministry of Health Electronic Database. Climatic variables were provided by the Center for Meteorology and Geophysics Medan branch office. Multivariable logistic regression was undertaken to understand the risk factors of imported malaria. A zero-inflated Poisson multivariable regression model was used to study the climatic drivers of indigenous malaria.
Results
A total of 2208 (indigenous: 76.0% [1679] and imported: 17.8% [392]) were reported during the study period. Risk factors of imported malaria were: ages 19–30 (adjusted odds ratio [AOR] = 3.31; 95% confidence interval [CI] 1.67, 2.56), 31–45 (AOR = 5.69; 95% CI 2.65, 12.20), and > 45 years (AOR = 5.11; 95% CI 2.41, 10.84). Military personnel and forest workers and miners were 1,154 times (AOR = 197.03; 95% CI 145.93, 9,131.56) and 44 times (AOR = 44.16; 95% CI 4.08, 477,93) more likely to be imported cases as compared to those working as employees and traders. Indigenous Plasmodium falciparum increased by 12.1% (95% CrI 5.1%, 20.1%) for 1% increase in relative humidity and by 21.0% (95% CrI 9.0%, 36.2%) for 1 °C increase in maximum temperature. Plasmodium vivax decreased by 0.8% (95% CrI 0.2%, 1.3%) and 16.7% (95% CrI 13.7%, 19.9%) for one meter and 1 °C increase of altitude and minimum temperature. Indigenous hotspot was reported by Kota Tanjung Balai city and Asahan regency, respectively. Imported malaria hotspots were reported in Batu Bara, Kota Tebing Tinggi, Serdang Bedagai and Simalungun.
Conclusion
Both indigenous and imported malaria is limited to a few regencies and cities in Northern Sumatera. The control measures should focus on these risk factors to achieve elimination in Indonesia.
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