RESUMO
BACKGROUND: Although Plasmodium vivax infection is a frequent cause of malaria worldwide, severe presentations have been more regularly described only in recent years. In this setting, despite clinical descriptions of multi-organ involvement, data associating it with kidney dysfunction are relatively scarce. Here, renal dysfunction is retrospectively analyzed in a large cohort of vivax malaria patients with an attempt to dissect its association with disease severity and mortality, and to determine the role of inflammation in its progression. METHODS: A retrospective analysis of a databank containing 572 individuals from the Brazilian Amazon, including 179 patients with P. vivax monoinfection (161 symptomatic malaria, 12 severe non-lethal malaria, and 6 severe lethal disease) and 165 healthy controls, was performed. Data on levels of cytokines, chemokines, C-reactive protein (CRP), fibrinogen, creatinine, hepatic enzymes, bilirubin levels, free heme, and haptoglobin were analyzed to depict and compare profiles from patients per creatinine levels. RESULTS: Elevated creatinine levels were found predominantly in women. Vivax malaria severity was highly associated with abnormal creatinine increases, and nonsurvivors presented the highest values of serum creatinine. Indication of kidney dysfunction was not associated with parasitemia levels. IFN-γ/IL-10 ratio and CRP values marked the immune biosignature of vivax malaria patients, and could distinguish subjects with elevated creatinine levels who did not survive from those who did. Patients with elevated serum creatinine or severe vivax malaria displayed indication of cholestasis. Biomarkers of hemolysis did not follow increases in serum creatinine. CONCLUSION: These findings reinforce the hypothesis that renal dysfunction is a key component in P. vivax malaria associated with clinical severity and mortality, possibly through intense inflammation and immune imbalance. Our study argues for systematic evaluation of kidney function as part of the clinical assessment in vivax malaria patients, and warrants additional studies in experimental models for further mechanism investigations.
Assuntos
Creatinina/sangue , Inflamação , Rim/fisiopatologia , Malária Vivax/sangue , Malária Vivax/fisiopatologia , Plasmodium vivax/imunologia , Adulto , Proteína C-Reativa/análise , Citocinas/sangue , Progressão da Doença , Feminino , Haptoglobinas/análise , Hemólise , Humanos , Interferon gama/sangue , Interleucina-10/sangue , Malária Vivax/imunologia , Malária Vivax/mortalidade , Masculino , Pessoa de Meia-Idade , Parasitemia , Estudos Retrospectivos , Índice de Gravidade de DoençaRESUMO
Vaccine development against Plasmodium vivax malaria lags behind that for Plasmodium falciparum. To narrow this gap, we administered recombinant antigens based on P. vivax circumsporozoite protein (CSP) to mice. We expressed in Pichia pastoris two chimeric proteins by merging the three central repeat regions of different CSP alleles (VK210, VK247, and P. vivax-like). The first construct (yPvCSP-AllFL) contained the fused repeat regions flanked by N- and C-terminal regions. The second construct (yPvCSP-AllCT) contained the fused repeat regions and the C-terminal domain, plus RI region. Mice were vaccinated with three doses of yPvCSP in adjuvants Poly (I:C) or Montanide ISA720. We also used replication-defective adenovirus vectors expressing CSP of human serotype 5 (AdHu5) and chimpanzee serotype 68 (AdC68) for priming mice which were subsequently boosted twice with yPvCSP proteins in Poly (I:C) adjuvant. Regardless of the regime used, immunized mice generated high IgG titres specific to all CSP alleles. After challenge with P. berghei ANKA transgenic parasites expressing Pb/PvVK210 or Pb/PvVK247 sporozoites, significant time delays for parasitemia were observed in all vaccinated mice. These vaccine formulations should be clinically tried for their potential as protective universal vaccine against P. vivax malaria.
Assuntos
Vacinas Antimaláricas/imunologia , Malária Vivax/imunologia , Malária Vivax/prevenção & controle , Plasmodium vivax/imunologia , Proteínas de Protozoários/imunologia , Proteínas Recombinantes/imunologia , Adenoviridae/genética , Sequência de Aminoácidos , Animais , Anticorpos Antiprotozoários/imunologia , Afinidade de Anticorpos/imunologia , Modelos Animais de Doenças , Feminino , Vetores Genéticos/administração & dosagem , Vetores Genéticos/química , Imunização , Imunogenicidade da Vacina , Imunoglobulina G/sangue , Imunoglobulina G/imunologia , Vacinas Antimaláricas/genética , Malária Vivax/mortalidade , Camundongos , Plasmodium vivax/genética , Proteínas de Protozoários/química , Proteínas de Protozoários/genéticaRESUMO
Malaria, a major global public health problem, is mainly caused by Plasmodium falciparum and Plasmodium vivax, and is responsible for nearly half a million deaths annually. Although P. vivax malaria was not believed to cause severe disease, recent robust studies have proved otherwise. However, the clinical spectrum and pathogenesis of severe vivax malaria and, especially, its respiratory complications remain poorly understood. A systematic search for articles reporting respiratory complications associated with vivax malaria was performed in Lilacs, Cochrane, Scielo, Web of Science, and Medline databases irrespective of publication date. Prevalence of acute respiratory distress syndrome (ARDS) and associated mortality among vivax patients were calculated from cross-sectional and longitudinal studies, whereas factors associated with mortality were calculated from data pooled from case reports and series of cases. A total of 101 studies were included (49 cross-sectional or longitudinal and 52 case reports or series of cases). Prevalence of ARDS was 2.8% and 2.2% in children and adults, respectively, with nearly 50% mortality. Moreover, female sex (P = 0.013), having any comorbidity (P = 0.036), lower body temperature (P = 0.032), lower hemoglobin (P = 0.043), and oxygen saturation (P = 0.053) values were significantly associated with mortality. Plasmodium vivax malaria respiratory complications included ARDS and were associated with high mortality. Demographics and clinical characteristics upon presentation to hospital were associated with mortality among patients with respiratory complications in vivax malaria. This study reaffirms the evidence of severe and fatal complications of P. vivax malaria and its associated respiratory complications.
Assuntos
Malária Vivax/complicações , Doenças Respiratórias/etiologia , Saúde Global , Humanos , Malária Vivax/epidemiologia , Malária Vivax/mortalidade , Doenças Respiratórias/epidemiologia , Doenças Respiratórias/mortalidadeRESUMO
BACKGROUND: Malaria is a serious health problem in Colombia. This paper intends to analyse the frequency and tendencies of the disease in Colombia over the last 22 years. The researchers used the Box-Jenkins (ARIMA) methodology for the analysis of time series. METHODS: This descriptive study was done retrospectively by using the morbidity records of the Ministry of Health and of the System for the Monitoring of Public Health (SIVIGILA). The information about the population was obtained from the National Administrative Department of Statistics (DANE). The incidence rate according to age and sex was calculated from 1990 to 2011. Also, the Annual Parasite Index (API) for Plasmodium falciparum and for Plasmodium vivax was calculated. The mortality rates per year, from 1990 to 2011, were determined. Finally, the Box-Jenkins (ARIMA) methodology was used for the analysis of time series, grouped weekly. Information for ARIMA modelling was used from the year 2001. RESULTS: The total number of reported cases from 1990 to 2011 was 2,964,818 cases with an annual average of 134,764. In the period from 2001 to 2005 and from 2006 to 2011 a significant decrease of annual cases was observed. In general, a predominance of P. vivax over P. falciparum was observed. With respect to the API, it must be noted that there were peaks in 1994 in the departments of Guainía and Guaviare, and in 1998 in Guaviare and Chocó. The department of Antioquia showed a tendency towards a decrease of the API through the years.In the time series model there were no statistically significant seasonal patterns for the total number of cases of malaria. However, for P. falciparum the number of cases was statistically significant. Lastly, between 1990 and 2009, there were 1,905 deaths caused by malaria in Colombia with a significant tendency towards a decrease in deaths over those years. Plasmodium falciparum was more lethal than P. vivax. CONCLUSIONS: In Colombia, the transmission of malaria occurs in an endemic and epidemic context, which keeps an unstable endemic transmission pattern. Several factors specific to a country such as Colombia encourage the dissemination and permanence of the illness.
Assuntos
Malária Falciparum/epidemiologia , Malária Vivax/epidemiologia , Colômbia/epidemiologia , Doenças Endêmicas , Epidemias , Feminino , Humanos , Incidência , Malária Falciparum/mortalidade , Malária Falciparum/transmissão , Malária Vivax/mortalidade , Malária Vivax/transmissão , Masculino , Prevalência , Estudos Retrospectivos , Fatores de Risco , Análise de SobrevidaRESUMO
BACKGROUND: Plasmodium vivax is responsible for a significant proportion of malaria cases worldwide and is increasingly reported as a cause of severe disease. The objective of this study was to characterize severe vivax disease among children hospitalized in intensive care units (ICUs) in the Western Brazilian Amazon, and to identify risk factors associated with disease severity. METHODS AND FINDINGS: In this retrospective study, clinical records of 34 children, 0-14 years of age hospitalized in the 11 public pediatric and neonatal ICUs of the Manaus area, were reviewed. P. falciparum monoinfection or P. falciparum/P. vivax mixed infection was diagnosed by microscopy in 10 cases, while P. vivax monoinfection was confirmed in the remaining 24 cases. Two of the 24 patients with P. vivax monoinfection died. Respiratory distress, shock and severe anemia were the most frequent complications associated with P. vivax infection. Ninety-one children hospitalized with P. vivax monoinfections but not requiring ICU were consecutively recruited in a tertiary care hospital for infectious diseases to serve as a reference population (comparators). Male sex (pâ=â0.039), age less than five years (pâ=â0.028), parasitemia greater than 500/mm(3) (pâ=â0.018), and the presence of any acute (pâ=â0.023) or chronic (pâ=â0.017) co-morbidity were independently associated with ICU admission. At least one of the WHO severity criteria for malaria (formerly validated for P. falciparum) was present in 23/24 (95.8%) of the patients admitted to the ICU and in 17/91 (18.7%) of controls, making these criteria a good predictor of ICU admission (pâ=â0.001). The only investigated criterion not associated with ICU admission was hyperbilirubinemia (pâ=â0.513)]. CONCLUSIONS: Our study points to the importance of P. vivax-associated severe disease in children, causing 72.5% of the malaria admissions to pediatric ICUs. WHO severity criteria demonstrated good sensitivity in predicting severe P. vivax infection in this small case series.
Assuntos
Malária Vivax/complicações , Malária Vivax/epidemiologia , Adolescente , Brasil/epidemiologia , Criança , Pré-Escolar , Coinfecção/epidemiologia , Feminino , Hospitalização , Humanos , Lactente , Unidades de Terapia Intensiva Pediátrica , Malária Falciparum/complicações , Malária Falciparum/epidemiologia , Malária Falciparum/mortalidade , Malária Vivax/mortalidade , Masculino , Parasitemia/epidemiologia , Plasmodium vivax , Estudos Retrospectivos , Fatores de Risco , Índice de Gravidade de DoençaRESUMO
The resurgence of the malaria eradication agenda and the increasing number of severe manifestation reports has contributed to a renewed interested in the Plasmodium vivax infection. It is the most geographically widespread parasite causing human malaria, with around 2.85 billion people living under risk of infection. The Brazilian Amazon region reports more than 50% of the malaria cases in Latin America and since 1990 there is a marked predominance of this species, responsible for 85% of cases in 2009. However, only a few complicated cases of P. vivax have been reported from this region. A systematic review of the Brazilian indexed and non-indexed literature on complicated cases of vivax malaria was performed including published articles, masters' dissertations, doctoral theses and national congresses' abstracts. The following information was retrieved: patient characteristics (demographic, presence of co-morbidities and, whenever possible, associated genetic disorders); description of each major clinical manifestation. As a result, 27 articles, 28 abstracts from scientific events' annals and 13 theses/dissertations were found, only after 1987. Most of the reported information was described in small case series and case reports of patients from all the Amazonian states, and also in travellers from Brazilian non-endemic areas. The more relevant clinical complications were anaemia, thrombocytopaenia, jaundice and acute respiratory distress syndrome, present in all age groups, in addition to other more rare clinical pictures. Complications in pregnant women were also reported. Acute and chronic co-morbidities were frequent, however death was occasional. Clinical atypical cases of malaria are more frequent than published in the indexed literature, probably due to a publication bias. In the Brazilian Amazon (considered to be a low to moderate intensity area of transmission), clinical data are in accordance with the recent findings of severity described in diverse P. vivax endemic areas (especially anaemia in Southeast Asia), however in this region both children and adults are affected. Finally, gaps of knowledge and areas for future research are opportunely pointed out.
Assuntos
Malária Vivax/epidemiologia , Malária Vivax/patologia , Plasmodium vivax/patogenicidade , Brasil/epidemiologia , Feminino , Geografia , Humanos , Malária Vivax/complicações , Malária Vivax/mortalidade , Masculino , Gravidez , Complicações Infecciosas na Gravidez/epidemiologia , Análise de SobrevidaRESUMO
Malaria is currently one of the most serious public health problems in Colombia with an endemic/epidemic transmission pattern that has maintained endemic levels and an average of 105,000 annual clinical cases being reported over the last five years. Plasmodium vivax accounts for approximately 70% of reported cases with the remainder attributed almost exclusively to Plasmodium falciparum. A limited number of severe and complicated cases have resulted in mortality, which is a downward trend that has been maintained over the last few years. More than 90% of the malaria cases in Colombia are confined to 70 municipalities (about 7% of the total municipalities of Colombia), with high predominance (85%) in rural areas. The purpose of this paper is to review the progress of malaria-eradication activities and control measures over the past century within the eco-epidemiologic context of malaria transmission together with official consolidated morbidity and mortality reports. This review may contribute to the formulation of new antimalarial strategies and policies intended to achieve malaria elimination/eradication in Colombia and in the region.
Assuntos
Doenças Endêmicas/prevenção & controle , Malária Falciparum/epidemiologia , Malária Vivax/epidemiologia , Distribuição por Idade , Colômbia/epidemiologia , Doenças Endêmicas/estatística & dados numéricos , Geografia , Humanos , Incidência , Malária Falciparum/mortalidade , Malária Falciparum/prevenção & controle , Malária Vivax/mortalidade , Malária Vivax/prevenção & controle , Topografia Médica/estatística & dados numéricosRESUMO
Malaria is currently one of the most serious public health problems in Colombia with an endemic/epidemic transmission pattern that has maintained endemic levels and an average of 105,000 annual clinical cases being reported over the last five years. Plasmodium vivax accounts for approximately 70 percent of reported cases with the remainder attributed almost exclusively to Plasmodium falciparum. A limited number of severe and complicated cases have resulted in mortality, which is a downward trend that has been maintained over the last few years. More than 90 percent of the malaria cases in Colombia are confined to 70 municipalities (about 7 percent of the total municipalities of Colombia), with high predominance (85 percent) in rural areas. The purpose of this paper is to review the progress of malaria-eradication activities and control measures over the past century within the eco-epidemiologic context of malaria transmission together with official consolidated morbidity and mortality reports. This review may contribute to the formulation of new antimalarial strategies and policies intended to achieve malaria elimination/eradication in Colombia and in the region.
Assuntos
Humanos , Doenças Endêmicas , Malária Falciparum , Malária Vivax , Distribuição por Idade , Colômbia , Doenças Endêmicas/estatística & dados numéricos , Geografia , Incidência , Malária Falciparum/mortalidade , Malária Falciparum , Malária Vivax/mortalidade , Malária Vivax , Topografia Médica/estatística & dados numéricosAssuntos
Malária Vivax/epidemiologia , Malária Vivax/prevenção & controle , Plasmodium vivax , População Rural/estatística & dados numéricos , Agricultura , Animais , Brasil/epidemiologia , América Central/epidemiologia , Conservação dos Recursos Naturais/tendências , Culicidae , Humanos , Malária/epidemiologia , Malária/prevenção & controle , Malária Vivax/diagnóstico , Malária Vivax/mortalidade , Malária Vivax/transmissão , Plasmodium vivax/isolamento & purificação , Rios , América do Sul/epidemiologiaRESUMO
BACKGROUND: Imported cases of malaria constitute an important public health problem in many countries, even in those with autochthonous cases, where disease could be acquired in these areas and then seen in non-endemic regions. Non-immune populations are susceptible to complications due to malaria infection, particularly in malaria caused by Plasmodium falciparum. However, Plasmodium vivax the predominant Plasmodium spp. in Venezuela can also lead to severe malaria. METHODS: We reviewed retrospectively cases of malaria to identify the clinical features of those imported cases diagnosed at two institutions in Margarita Island (a non-endemic area), Venezuela, in an 8-year period. We conducted a retrospective observational study to identify the clinical and epidemiological features among hospitalized patients at Hospital Central and Hospital Agustin Hernández with malaria acquired at malaria-endemic locations. RESULTS: We identified eighteen imported cases of malaria confirmed by thin and thick peripheral blood smears at these two institutions over an 8-year period. The mean age of diagnosis was 27 years. P. vivax was responsible for the majority of cases. All patients presented with fever, 89% with malaise, 78% with chills, and 67% with myalgia, among others symptoms. Mean haemoglobin levels on admission were 8.1g/dL (100% <12g/dL); platelets: 79,283cells/mm(3) (89% had platelets below 150,000); and a mean total leukocyte count: 3.4x10(3)cells/mm(3) (78% had leukopenia). Thirty nine percent of patients required blood transfusions. Two fatalities were identified (CFR=11%), one associated to severe malaria due to P. falciparum and the other due to a complicated case of P. vivax malaria. DISCUSSION: Imported cases of malaria due to P. vivax and P. falciparum in the studied population are associated with significant hematological complications. These findings illustrate the importance of educating non-immune populations about the malaria risk and prevention strategies; and from a pubic health perspective, the need to develop further malaria prevention strategies at a national level.
Assuntos
Antimaláricos/uso terapêutico , Insetos Vetores/parasitologia , Malária Falciparum/epidemiologia , Malária Vivax/epidemiologia , Viagem , Adolescente , Adulto , Animais , Transfusão de Sangue , Diagnóstico Diferencial , Surtos de Doenças , Feminino , Hospitalização/estatística & dados numéricos , Humanos , Malária Falciparum/sangue , Malária Falciparum/mortalidade , Malária Falciparum/terapia , Malária Vivax/sangue , Malária Vivax/mortalidade , Malária Vivax/terapia , Masculino , Estudos Retrospectivos , Análise de Sobrevida , Venezuela/epidemiologia , Adulto JovemRESUMO
INTRODUCTION: Valle del Cauca is one of the states in Colombia that reports a high number of deaths due to malaria. Understanding the basis of malarial deaths is useful for assessing the efficacy of the health system and to identify areas where improvements are necessary to decrease malaria mortality. OBJECTIVE: Potential determinants of mortality in malaria cases are characterized in a demographic study centered in Valle del Cauca. MATERIALS AND METHODS: A descriptive analysis was directed to 25 cases of malaria death occurring in Valle del Cauca during 2005 and 2006. RESULTS: The mean age was 31.3 years (range, 2 to 71 yr), 11 were women (1 pregnant), 11 were from the malaria-endemic port of Buenaventura, and 5 from other Pacific coastal states. After entering the health system facility, the standard malaria diagnostic, the thick smear, was not ordered for 7 cases at any time during the treatment period. In cases where a thick smear was taken at first contact, 11 had a positive and 5 had a negative initial report. Cerebral malaria (7/18 cases) and renal failure (6/18 cases) were the most frequent complications. During hospitalization, 13/18 cases developed other complications, mainly acute lung edema (8/18 cases) and shock (5/18 cases). CONCLUSIONS: Failures in primary health care of patients with malaria were recognized. This information has been used to implement actions aimed at improving initial care of malaria subjects in the health services of Valle del Cauca. The study recommends that other states in Colombia increase their efforts to decrease malaria mortality.
Assuntos
Malária Falciparum/mortalidade , Injúria Renal Aguda/etiologia , Injúria Renal Aguda/mortalidade , Adolescente , Adulto , Idoso , Antimaláricos/provisão & distribuição , Antimaláricos/uso terapêutico , Criança , Pré-Escolar , Colômbia/epidemiologia , Diagnóstico Tardio , Notificação de Doenças , Feminino , Acessibilidade aos Serviços de Saúde , Humanos , Incidência , Malária Cerebral/mortalidade , Malária Falciparum/complicações , Malária Falciparum/tratamento farmacológico , Malária Falciparum/prevenção & controle , Malária Falciparum/terapia , Malária Vivax/mortalidade , Masculino , Pessoa de Meia-Idade , Gravidez , Complicações Infecciosas na Gravidez/mortalidade , Complicações Infecciosas na Gravidez/parasitologia , Encaminhamento e Consulta , Adulto JovemRESUMO
Morbidity and mortality burden of malaria in the childhood represents a public health threat not only in countries with high levels of transmission, but also in those, such as Venezuela and others in Latin America, with moderate to low transmission. Usually its mortality has been attributed just to Plasmodium falciparum malaria, but the changing patterns of increase in Plasmodium vivax malaria morbidity and mortality are now causing concern. We studied malaria mortality by analyzing different epidemiological variables during a 10-year period in Venezuela, finding mortality rates ranging 0.10-0.36 deaths/100,000 population, with almost a third of deaths in children (<10 years old), corresponding 270 deaths to P. falciparum cases and 30 to P. vivax; but along the period with a decrease trend for P. falciparum and an increase trend for P. vivax.
Assuntos
Malária Vivax/mortalidade , Adolescente , Adulto , Distribuição por Idade , Criança , Pré-Escolar , Atestado de Óbito , Feminino , Humanos , Lactente , Malária Falciparum/diagnóstico , Malária Falciparum/epidemiologia , Malária Falciparum/mortalidade , Malária Vivax/diagnóstico , Malária Vivax/epidemiologia , Masculino , Sistema de Registros , Distribuição por Sexo , Venezuela/epidemiologiaRESUMO
OBJECTIVE: To assess characteristics and outcome of emergency patients with acute malaria. PATIENTS AND METHODS: We retrospectively assessed the clinical and laboratory parameters of 137 consecutive patients (87 males, 50 females; median age 37 years, range 17 - 67 years) presenting with acute malaria to our tertiary care center between 1992 and 2002. RESULTS: Falciparum malaria was diagnosed in 116/137 and tertian malaria in 19/137 patients; a single patient was infected with both parasites while in another case the type of parasite remained unclear. Infections were acquired in Africa (121), Asia , and in the Americas . One traveler visited multiple continents. Only 36 % (50/137) of patients had used malaria chemoprophylaxis. 128/137 patients were treated as in-patients; 22 of these had to be treated on an intensive care unit. According to the criteria of the German Society of Tropical Medicine, 44/137 (32 %; 95 % confidence interval (CI): 25 - 40 %) patients suffered from complicated malaria. The overall mortality rate was 2/137 (1.5 %; 95 % CI: 0,4 - 5.2 %); the mortality rate of complicated malaria tropica was 2/44 (4,5 %; 95 % CI 1,3 - 15 %). Patients with complicated malaria were significantly older than those with uncomplicated malaria. Median length of hospital stay was 4 days in uncomplicated and 9 days in complicated cases. Based on costs of EUR 2500 per case, an attack rate of > 3 % in East African travelers and a cost of EUR 55 for a chemoprophylaxis with mefloquine, chemoprophylaxis is cost-effective. CONCLUSION: In our retrospective analysis, complicated malaria tropica was associated with older age. Although malaria causes considerable morbidity, the overall mortality from severe malaria is low. Reinforcement of chemoprophylaxis especially in travelers to Africa could reduce malaria cases and is cost-effective.
Assuntos
Malária Falciparum/epidemiologia , Malária Vivax/epidemiologia , Malária/epidemiologia , Plasmodium ovale , Adolescente , Adulto , África , Fatores Etários , Idoso , Ásia , América Central , Quimioprevenção/economia , Análise Custo-Benefício , Serviços Médicos de Emergência , Feminino , Alemanha/epidemiologia , Humanos , Tempo de Internação , Malária/tratamento farmacológico , Malária/mortalidade , Malária/prevenção & controle , Malária Falciparum/tratamento farmacológico , Malária Falciparum/mortalidade , Malária Falciparum/prevenção & controle , Malária Vivax/tratamento farmacológico , Malária Vivax/mortalidade , Malária Vivax/prevenção & controle , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , América do Sul , Viagem , Resultado do TratamentoRESUMO
Throughout Central America, a traditional malaria control strategy (depending on heavy use of organic pesticides) became less effective during the 1970s. In Nicaragua, an alternative strategy, based on frequent local epidemiological assessments and community participation, was developed in the 1980s. Despite war-related social instability, and continuing vector resistance, this approach was highly successful. By the end of the contra war, there finally existed organisational and ecological conditions that favoured improved malaria control. Yet the expected improvements did not occur. In the 1990s, Nicaragua experienced its worst recorded malaria epidemics. This situation was partly caused by the country's macroeconomic structural adjustment programme. Volunteers now take fewer slides and provide less treatment, malaria control workers are less motivated by the spirit of public service, and some malaria control stations charge for diagnosis or treatment. To "roll back malaria", in Nicaragua at least, will require the roll-back of some erroneous aspects of structural adjustment.
PIP: This paper examines the social and political influences on malaria transmission and control activities in Nicaragua. In politically unstable Central America, methods that depend on community participation and planning on the basis of routine surveillance data may be sufficient to control malaria transmission. The Nicaraguan experience in the 1980s and 1990s shows how an integrated approach can prove to be effective where social stability, health education, and strong program administration exists. During the Contra war in the 1980s, implementation of the community-based strategy was limited, resulting in increasing rates of P. vivax transmission in the war zone. The loss of timely epidemiological reporting and the decrease in use of local volunteers for blood slide detection and directly observed therapy resulted in a greater epidemic. More recently, WHO has initiated "Roll Back Malaria" and "Roll Back Structural Adjustment" programs which aim to make more efficient use of limited resources in the health sector to help eradicate malaria. Several components were needed for the strategy: the technical capacity of the national staff needed strengthening, the staff needed to be re-evaluated, additional funds were needed to assure competitive salaries, and malaria control programs needed to be identified for appropriation of funds as essential components to national development planning during structural adjustment. National leadership and the establishment of public service and social solidarity will help mobilize volunteers to work toward the goal of preventing malaria transmission.