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Background Anaemia during pregnancy is major health problem. There is conflicting literature regarding the association between anaemia and its severity and maternal and perinatal outcomes. Methods This is a retrospective case-control study conducted at Kassala hospital, eastern Sudan. Medical files of pregnant women with severe anaemia (haemoglobin (Hb) < 7 g/dl, n = 303) who delivered from January 2008 to December 2010 were reviewed. Socio-demographic and obstetric data were analysed and compared with a similar number of women with mild/moderate anaemia (Hb = 7-10.9 g/dl, n = 303) and with no anaemia (Hb > 11 g/dl, n = 303). Logistic regression analysis was performed separately for each of the outcome measures: preeclampsia, eclampsia, preterm birth, low birth weight (LBW) and stillbirth. Results There were 9578 deliveries at Kassala hospital, 4012 (41.8%) women had anaemia and 303 (3.2%) had severe anaemia. The corrected risk for preeclampsia increased only in severe anaemia (OR = 3.6, 95% CI: 1.4-9.1, P = 0.007). Compared with women with no anaemia, the risk of LBW was 2.5 times higher in women with mild/moderate anaemia (95% CI: 1.1-5.7), and 8.0 times higher in women with severe anaemia (95% CI: 3.8-16.0). The risk of preterm delivery increased significantly with the severity of anaemia (OR = 3.2 for women with mild/moderate anaemia and OR = 6.6 for women with severe anaemia, compared with women with no anaemia). The corrected risk for stillbirth increased only in severe anaemia (OR = 4.3, 95% CI: 1.9-9.1, P < 0.001). Conclusions The greater the severity of the anaemia during pregnancy, the greater the risk of preeclampsia, preterm delivery, LBW and stillbirth. Preventive measures should be undertaken to decrease the prevalence of anaemia in pregnancy.

Background Crimean-Congo hemorrhagic fever (CCHF), a tick-borne disease caused by Crimean-Congo hemorrhagic fever virus (CCHFV), is a member of the genus Nairovirus in the family Bunyaviridae. Recently, CCHFV has been reported as an important emerging infectious viral pathogen in Sudan. Sporadic cases and multiple CCHF outbreaks, associated with nosocomial chain of transmission, have been reported in the Kordufan region of Sudan. Aims To confirm CCHF in an index patient and attending physician in North Kordufan region, Sudan, and to provide some information on virus genetic lineages. Methods Antibody captured ELISA, reverse transcription PCR, partial S segment sequences of the virus and subsequent phylogenetic analysis were used to confirm the CCHFV infection and to determine the virus genetic lineages. Results CCHF was confirmed by monitoring specific IgM antibody and by detection of the viral genome using RT-PCR. Treatment with oral ribavirin, replacement with fluid therapy, blood transfusion and administration of platelets concentrate resulted in rapid improvement of the health condition of the female physician. Phylogenetic analysis of the partial S segment sequences of the 2 CCHFV indicates that both strains are identical and belong to Group III virus lineage, which includes viruses from Africa including, Sudan, Mauritania, South Africa and Nigeria. Conclusion Further epidemiologic studies including, CCHFV complete genome analysis and implementation of improved surveillance are urgently needed to better predict and respond to CCHF outbreaks in the Kordufan region, Sudan.

BackgroundPregnant women are more susceptible to severePlasmodium falciparummalaria, which can lead to poor maternal and fetal outcomes. Few data exist on the epidemiology of severeP. falciparummalaria in pregnant women.A hospital-based study was carried out to assess the pattern of severeP. falciparummalaria among pregnant women at the Kassala and Medani maternity hospitals, which are located in areas of unstable malaria transmission, in eastern and central Sudan, respectively. Pre-tested questionnaires were used to gather socio-demographic, clinical and obstetrical data. Suitable tests were performed for clinical and biochemical investigations.ResultsAmong 222 pregnant women diagnosed with malaria at the two hospitals, 40 (18.0%) women at mean (SD) gestational age of 29.3 (6.7) weeks fulfilled one or more of the WHO criteria for severeP. falciparummalaria. These were hypoglycaemia (14; 35.5%), severe anaemia (12; 30%), hypotension (10; 25%), jaundice (9; 22.5%), cerebral malaria (6; 15%), repeated convulsions (4; 10%), hyperparasitaemia (4; 10.0%) and more than one manifestation (9; 22.5%). While the mean (SD) presenting temperature was significantly lower for women presenting with hypoglycaemia [38.2(0.6) versus 38.8(0.7) °C,P= 0.04], other clinical and biochemical characteristics were not significantly different among women with different manifestations of severeP. falciparummalaria.ConclusionPreventive measures for pregnant women such as insecticide-treated bednets and chemoprophylaxis may be beneficial in areas of unstable malaria transmission. Early detection and prompt treatment of severe malaria, especially in pregnant women with hypoglycaemia, are needed.

Objective: To study the glycaemic profile of patients with severe malaria (SM). Methods: For this purpose, 110 SM patients were recruited. Pre-treatment random blood glucose and plasma insulin were measured in a subset of donors. An ex-vivo experiment was developed for estimation of glucose consumption by parasitized erythrocytes. Results: Hyperglycaemia was frequent in SM but more commonly associated with cerebral malaria (CM), while hyperinsulinaemia was recognized in severe-malarial-hypotension (median, 25 %–75 %, 188.2, 93.8–336.8 pmol/L). The plasma insulin level was positively correlated with age (CC = 0.457, p < 0.001) and negatively with parasitaemia (CC = –0.368, p = 0.045). Importantly, fatalCM was associated with hyperglycaemia (12.22, 6.5–14.6 mmol/L), hyperinsulinaemia (141.0, 54.0–186.8 pmol/L) and elevated homeostasis model assessment (HOMA) values. However, there was a trend of higher glucose consumption by parasites in CM compared with that in uncomplicated malaria (UM). Conclusion: Hyperglycaemia, hyperinsulinaemia and elevated HOMA are evidence for insulin resistance and possibly pancreatic B-cell dysfunction in fatal-CM.

Background The Leishmania OligoC-TesT and NASBA-Oligochromatography (OC) were recently developed for simplified and standardised molecular detection of Leishmania parasites in clinical specimens. We here present the phase II evaluation of both tests for diagnosis of visceral leishmaniasis (VL), cutaneous leishmaniasis (CL) and post kala-azar dermal leishmaniasis (PKDL) in Sudan. Methodology The diagnostic accuracy of the tests was evaluated on 90 confirmed and 90 suspected VL cases, 7 confirmed and 8 suspected CL cases, 2 confirmed PKDL cases and 50 healthy endemic controls from Gedarif state and Khartoum state in Sudan. Principal Findings The OligoC-TesT as well as the NASBA-OC showed a sensitivity of 96.8% (95% CI: 83.8%–99.4%) on lymph node aspirates and of 96.2% (95% CI: 89.4%–98.7%) on blood from the confirmed VL cases. The sensitivity on bone marrow was 96.9% (95% CI: 89.3%–99.1%) and 95.3% (95% CI: 87.1%–98.4%) for the OligoC-TesT and NASBA-OC, respectively. All confirmed CL and PKDL cases were positive with both tests. On the suspected VL cases, we observed a positive OligoC-TesT and NASBA-OC result in 37.1% (95% CI: 23.2%–53.7%) and 34.3% (95% CI: 20.8%–50.9%) on lymph, in 72.7% (95% CI: 55.8%–84.9%) and 63.6% (95% CI: 46.6%–77.8%) on bone marrow and in 76.9% (95% CI: 49.7%–91.8%) and 69.2% (95% CI: 42.4%–87.3%) on blood. Seven out of 8 CL suspected cases were positive with both tests. The specificity on the healthy endemic controls was 90% (95% CI: 78.6%–95.7%) for the OligoC-TesT and 100% (95% CI: 92.9%–100.0%) for the NASBA-OC test. Conclusions Both tests showed high sensitivity on lymph, blood and tissue scrapings for diagnosis of VL, CL and PKDL in Sudan, but the specificity for clinical VL was significantly higher with NASBA-OC., Author Summary The leishmaniases are a group of vector-borne diseases caused by protozoan parasites of the genus Leishmania. The parasites are transmitted by phlebotomine sand flies and can cause, depending on the infecting species, three clinical manifestations of leishmaniasis: visceral leishmaniasis (VL), post kala-azar dermal leishmaniasis (PKDL) and cutaneous leishmaniasis (CL) including the mucocutaneous form. VL, PKDL as well as CL are endemic in several parts of Sudan, and VL especially represents a major health problem in this country. Molecular tests such as the polymerase chain reaction (PCR) or nucleic acid sequence based assay (NASBA) are powerful techniques for accurate detection of the parasite in clinical specimens, but broad use is hampered by their complexity and lack of standardisation. Recently, the Leishmania OligoC-TesT and NASBA-Oligochromatography were developed as simplified and standardised PCR and NASBA formats. In this study, both tests were phase II evaluated for diagnosis of VL, PKDL and CL in Sudan.

To study the glycaemic profile of patients with severe malaria (SM).For this purpose, 110 SM patients were recruited. Pre-treatment random blood glucose and plasma insulin were measured in a subset of donors. An ex-vivo experiment was developed for estimation of glucose consumption by parasitized erythrocytes.Hyperglycaemia was frequent in SM but more commonly associated with cerebral malaria (CM), while hyperinsulinaemia was recognized in severe-malarial-hypotension (median, 25 %-75 %, 188.2, 93.8-336.8 pmol/L). The plasma insulin level was positively correlated with age (CC = 0.457, p0.001) and negatively with parasitaemia (CC = -0.368, p = 0.045). Importantly, fatal-CM was associated with hyperglycaemia (12.22, 6.5-14.6 mmol/L), hyperinsulinaemia (141.0, 54.0-186.8 pmol/L) and elevated homeostasis model assessment (HOMA) values. However, there was a trend of higher glucose consumption by parasites in CM compared with that in uncomplicated malaria (UM).Hyperglycaemia, hyperinsulinaemia and elevated HOMA are evidence for insulin resistance and possibly pancreatic B-cell dysfunction in fatal-CM.

The study was conducted to investigate determinants (clinical, nutritional, and nonnutritional factors) of anemia among pregnant women in Kassala, eastern Sudan. Sociodemographic characteristics were gathered; serum ferritin, zinc, albumin, and C-reactive protein were measured using different laboratory methods in a cross-sectional study of 250 pregnant women. Of the 250 women, 58.4% had anemia (hemoglobin (HB)

This case-control study was conducted in Khartoum hospital, Sudan to investigate the levels of antioxidant enzymes (glutathione peroxidase, catalase and superoxide dismutase) in erythrocytes and plasma antioxidant vitamins (retinol and alpha-tocopherol) in Sudanese women with pre-eclampsia (37), in comparison with well-matched pregnant controls women with normal pregnancy (38). Enzymes were measured using ELISA and vitamins were measured using HPLC. There were no significant differences in the levels of these three antioxidant enzymes in pre-eclamptic women compared with the controls. Women with mild pre-eclampsia (diastolic blood pressure, DBP110) have slightly higher levels of erythrocyte glutathione peroxidase, and lower levels of catalase and superoxide dismutase compared with women with severe pre-eclampsia (DBPor = 110). A significantly negative correlation was observed between the levels of glutathione peroxidase and DBP, r = -0.371, p = 0.02. There was no significant correlation between catalase (r = -0.033, p = 0.840) or superoxide dismutase levels (r = 0.067, p = 0.6) and DBP. While retinol levels were not different, levels of alpha-tocopherol were significantly higher in women with pre-eclampsia than the control group, p = 0.026. The plasma levels of both vitamins were not statistically significantly different when women with mild and severe pre-eclampsia were compared.

An interpretation of historical, clinical, and laboratory data was made to identify the correlates of and the diversity between cerebral malaria (CM) and severe malarial anemia (SMA) in a setting of low, seasonal, and unstable malaria transmission in eastern Sudan. Hemoglobin (Hb), random blood glucose (RBG), and anti-MSP antibodies were measured. Results showed that SMA and CM were significantly different with regard to age, malaria history, fever duration, convulsions, and hepatosplenomegaly. The MSP Ab response was inversely correlated with the number of previous malaria episodes but not with fever duration in the current attack. The spleen size was significantly inversely correlated with Hb level while hepatomegaly was significantly associated with low RBG. Furthermore, two malaria patients presented with neuropsychiatric upset. Finally, the correlates of SMA and CM fit perfectly with an adopted severity numeric scoring.

We obtained 10/192 and 3/384 antibody-secreting hybrids after immunization of Balb/c mice with either human growth hormone or affinity-purified rabbit anti-(human growth hormone) respectively. Radiolabelled rabbit anti-(human growth hormone) antibodies, but not human growth hormone, were specifically bound by supernatants from the 13 hybrids. The binding was completely inhibited by human-growth-hormone serum binding protein. However, anti-(human growth hormone antibodies) were detected in the sera of all the mice immunized with human growth hormone. In an independent fusion, which was carried out after immunization with fewer doses of human growth hormone, anti-(human growth hormone) antibodies were also obtained. Five hybrids, where the starting antigen was human growth hormone, were selected for ascites production, and the corresponding monoclonal antibodies were partially purified and characterized with respect to their immunoglobulin isotype and their interaction with human-growth-hormone receptors. These antibodies were found to enhance the binding of radioiodinated human growth hormone to human-growth-hormone serum binding protein from human and rabbit plasma by 40%. Scatchard analysis of the effect of one of the monoclonal antibodies showed that this enhancement was due to an increased number of binding sites. All of the partially purified antibodies but one (F12) inhibited the binding of human growth hormone to rat but not rabbit, liver microsomes to various extents, as well as to H-4-II-E rat hepatoma cells. Monoclonal antibody F12 enhanced the binding of radiolabelled human growth hormone to rat liver microsomes and H-4-II-E hepatoma cells. This enhancement was found to be due to an increase in the number of binding sites.

The parasite dynamics in severe malaria (SM) varies with malaria endemicity. This study was conducted in eastern Sudan, an area of seasonal and unstable malaria transmission. From the beginning of October to the end of December (malaria season) in the years 2000, 2001, and 2003, 99 patients with severe malarial anemia (SMA) and 54 patients with cerebral malaria (CM) were identified. There was marked variation in the incidence of SMA and CM (up to six folds) and in the CM/SMA incidence ratio, over 3 years. In the heavy season of 2003, CM peaked at the beginning of the season and declined within a month at a time that the SMA reached the peak. At diagnosis, the rate of gametocytemia had inclined from approximately 10% to 100% from the beginning to the end of the season. During follow-up, gametocytemia was more associated with SMA than with CM. Paradoxically, the late occurring SMA was associated with early gametocytemia (day 7) and the opposite was true in CM. In conclusion, within the season the transmission of CM and SMA was bimodal, the prevalence of the asexual and sexual parasitemia was reciprocal, and the peaks of transmission and gametocytemia were paradoxical.

In this study, antibodies (Ab) directed against three MSP antigens; MSP1(19), MSP2(A), and MSP2(B) were analyzed in blood samples obtained from 223 Sudanese patients who presented with either severe malaria (SM) or uncomplicated malaria (UM) and from 117 malaria-free donors (MF). The results showed that the prevalence of MSP Abs was associated with the clinical outcome of malaria infection, and the Ab prevalence was age-dependent (P

The severe malaria (SM) and uncomplicated malaria (UM) infections are expected to have different genetic makeup. In this study, blood samples were obtained from 325 donors with SM and UM and malaria-free donors (including asymptomatic submicroscopic malaria--ASUM), from Eastern Sudan. The SM group included patients with cerebral malaria (CM), severe malarial anemia (SMA), and other complications. The MSP2 locus was exploited for parasite genotyping. We found that the genetic diversity of the parasite population was marked (51 genotypes). The overall multiplicity of infection (MOI) was 1.5, and it was comparable between SM and UM. However, the MOI in ASUM (1.0) and fatal CM (1.14) was comparable and significantly lower than in UM (1.53), SMA (1.52), and nonfatal CM (1.7). The ratio of the IC1 to FC27 allele families was comparable between SM and UM, and the distribution of the allele sizes was correlated (correlation coefficient = 0.59 and 0.718; P < 0.001). It is interesting to note that the FC27 genotype was overrepresented in ASUM (68.2%) and was not recognized in fatal CM, while in mixed-clone infections, the clearance of IC1 after quinine treatment was faster than FC27 clearance. Finally, the composition of the multiclone infections (IC1 and FC27) was suggesting a stronger cross-immunity within rather than between MSP2 gene families.

The major histocompatibility complex (MHC) is the most polymorphic region of the human genome. Human leukocyte antigen-C (HLA-C) genes are located in the class I region of MHC. Most polymorphisms of HLA class I antigens are present in exons 2 and 3, which encode the alpha1 and alpha2 domains of the HLA-A heavy chain, involved in both peptide binding and HLA-restricted recognition by the T-cell receptor. Four new HLA-Cw alleles were identified in the Sudanese population during HLA class I and class II sequencing-based typing at the HLA-C locus of case-control study of Sudanese HIV patients, in individuals from different ethnic background. Based on the localization of the affected amino acid positions in an outer loop of the alpha-helix forming the side of the peptide-binding groove, we do not expect the replacement mutations to have an effect on peptide binding or T-cell receptor interaction.

The study was conducted in New Halfa teaching hospital, eastern Sudan to investigate the pharmacokinetics of quinine in pregnant Sudanese women.Sixteen (eight pregnant and eight non-pregnant) Sudanese women infected with Plasmodium falciparum malaria were given a single dose of quinine hydrochloride (10 mg/kg body weight) as intravenous infusion over 2 h. The women were treated with intramuscular artemether. Plasma was collected before quinine administration and up to 72 h thereafter. These were analysed for quinine and its metabolites, 3-hydroxyquinine, (10R)-10,11-dihydroxyquinine and (10S)-10,11-dihydroxyquinine using high-performance liquid chromatography.The two groups were well matched in their basic characteristics. There was no significant difference in the mean maximum plasma concentration attained (C(max)), the mean time at which C(max) was attained, the elimination half-life (t(1/2)) and the total area under the plasma concentration vs. time curve (AUC) of quinine and its metabolites between the pregnant in non-pregnant women.There was no significant difference in quinine metabolism between pregnant and non-pregnant women and there is no need to adjust quinine dose when treating pregnant women.

The haptoglobin phenotypes of Sudanese patients with complicated and uncomplicated falciparum malaria, and those of uninfected randomly selected individuals, were determined by electrophoresis of sera on polyacrylamide gels followed by benzidine staining of the gels. Among 273 malaria patients, the proportions with haptoglobin phenotypes (1-1), (2-1) and (2-2) were 60.8%, 29.7% and 9.5%, respectively, and in 72 cerebral malaria patients the proportions were 63.9%, 29.2%, and 6.9%. The distribution among 208 control individuals was 26.0%, 55.8% and 18.3%, respectively. The difference between patients and controls was highly significant (P < 0.001). The distribution of the different haptoglobin phenotypes among the randomly selected group of 208 Sudanese individuals was comparable to that in many other populations. The results suggests that the haptoglobin phenotype (1-1) is associated with susceptibility to falciparum malaria and the development of severe complications; alternatively, the other phenotypes may confer resistance.

Summary Objective To compare the efficacy of sulfadoxine–pyremethamine (SP) + chloroquine (CQ) combination treatment against falciparum malaria with SP treatment alone. Method In-vivo study of 254 patients with uncomplicated Plasmodium falciparum malaria in rural eastern Sudan, where the population is semi-immune. Results Sulfadoxine–pyremethamine treatment alone cured 68.3% (41/60) and SP + CQ cured 63.4% (123/194). Early and late treatment failures occurred in both treatment groups. Host age (as a marker for immunity) and parasite gametocytogenesis (as a marker for transmissibility) were significantly associated with SP resistance. Patients who were cured were significantly older (median age 21 years) than patients whose treatment failed (median age 12 years). Gametocyte production was significantly higher in patients with treatment failure (0.72 vs 0.45) and associated with younger age. Gametocyte counts were comparable between both groups until day 7 of follow up; thereafter, they were significantly higher in patients with treatment failure. However, the longevity of gametocytes was comparable in both treatment groups. Conclusion Chloroquine did not improve the parasite response to SP. Age was strongly associated with clearance of SP-resistant parasites. The fast rise of SP resistance may partially be due to selection of SP resistant parasites and expansion of the resistant population through the gametocytogenic effect of SP. Objectif Comparer l'efficacite de la combinaison sulfadoxine–pyrimethamine (SP) + chloroquine (CQ) et de la SP seule dans le traitement de malaria falciparum. Methode Etude in vivo sur 254 patients avec malaria non compliquee aP. falciparum en zone rurale dans l'est du Soudan ou la population est semi immune. Resultats Le traitement a la SP seule a gueri 68,3% (41/60) et la combinaison SP + CQ, 63,4% (123/194) des patients. Les echecs de traitement administre tot ou tardivement ont ete observes dans les 2 groupes compares. L’âge du patient (utilise comme marqueur de l'immunite) et la gametocytogenese du parasite (utilisee comme marqueur de transmissibilite) etaient significativement associes avec la resistance a la SP. Les patients gueris par le traitement etaient significativement plus âges (âge median: 21 ans) que les patients avec un echec therapeutique (âge median: 12 ans). La production de gametocytes etait significativement plus elevee chez les patients avec un echec therapeutique (0,72 vs 0,45) et etait associee avec l’âge. Le nombre de gametocytes etait comparable dans les deux groupes jusqu'au 7e jour de suivi, puis il devenait significativement plus eleve chez les patients avec un echec therapeutique. Cependant, la duree de vie des gametocytes etait comparable dans les deux groupes de traitement. Conclusion L'association de CQ a la SP n'a pas ameliore l'effet du traitement sur le parasite. L’âge des patients etait fortement associe avec la clearance des parasites resistants a la SP. L’emergence rapide de resistance a la SP pourrait etre due a la selection de parasites resistants a la SP et la propagation de population resistante sous l'effet gametocytogenique du SP. Objetivo Comparar la eficacia de la combinacion de sulfadoxina-pirimetamina (SP) + cloroquina (CQ) versus el SP solo, como tratamiento para la malaria por falciparum. Metodo Estudio in-vivo de 254 pacientes con malaria no complicada por P. falciparum en un area rural del este de Sudan, en donde la poblacion es semi-inmune. Resultados El tratamiento con solo SP curo al 68.3% (41/60) y SP + CQ curo a un 63.4% (123/194). Se observaron fallos terapeuticos tempranos y tardios en ambos grupos. La edad del hospedero (como un marcador de inmunidad) y la gametocitogenesis del parasito (como un marcador de transmisibilidad) estaban significativamente asociados con la resistencia a SP. Los pacientes que se curaron eran significativamente mayores (edad media 21 anos) que los pacientes con fallo terapeutico (edad media 12 anos). La produccion de gametocitos era significativamente mayor en pacientes con fallo terapeutico (0.72 vs 0.45) y estaba asociada a una menor edad. El conteo de gametocitos era comparable entre ambos grupos hasta el dia 7 de seguimiento; a partir de alli era significativamente mayor en los pacientes con fallo terapeutico. Sin embargo, la longevidad de los gametocitos era comparable en ambos grupos de tratamiento. Conclusion La CQ no mejoro la respuesta parasitaria al SP. La edad estaba fuertemente asociada con la eliminacion de parasitos SP resistentes. El rapido aumento de la resistencia al SP puede deberse en parte a la seleccion de parasitos SP resistentes y a la expansion de una poblacion resistente a traves del efecto gametocitongenico del SP.

Mutations in the Plasmodium falciparum pfcrt gene on chromosome 7 and possibly mutations in pfmdr1 on chromosome 5 have a role in conferring resistance against chloroquine (CQ), as do mutations of pfdhfr on chromosome 4 and pfdhps on chromosome 8 in terms of resistance against sulfadoxine/pyrimethamine (SP). The additive role of multiple mutations in the development of resistance to each drug suggests a non-random occurrence. In this study, parasite isolates were obtained from 50 patients with uncomplicated P. falciparum malaria from rural Eastern Sudan, an endemic setting with minimal overlap of infection. The parasite isolates were genotyped for detection of 12 alleles in CQ and SP resistance genes. Our main findings were: (1) the frequency of mutant alleles, pfcrt K76T, pfmdr1 N86Y, pfdhfr N51I, pfdhfr S108N, pfdhps K540E and pfdhps A581G were; 0.90, 0.86, 0.84, 0.84, 0.80 and 0.20, respectively. (2) No mutations were detected for the pfdhfr loci A16V, C59R and I164L, and for pfdhps loci S436A, A437G and A613S. (3) There was a statistically significant association between the mutations in: (i) the CQ resistance (CQR) genes, pfcrt T76 and pfmdr1 Y86 ( P ≤ 0.001), (ii) the SP resistance (SPR) genes, pfdhfr I51, pfdhfr N108 and pfdhps E540 ( P ≤ 0.001–0.04) and (iii) the CQ “i” and SP “ii” resistance genes ( P = 0.001) 4. The fitness cost of multiple mutations was revealed by a significantly reduced parasite density of isolates bearing the mutant alleles ( P = 0.048). However, the significantly higher gametocyte carriage rate among isolates with resistance mutations ( P = 0.001) is possibly an evolutionary mechanism for survival of mutant parasites.

In an open, randomized, clinical trial, conducted in New Halfa, eastern Sudan in September–October 2004, the efficacies and adverse effects of artesunate plus sulfadoxine–pyrimethamine (SP), in the treatment of uncomplicated, Plasmodium falciparum malaria, were compared with those of SP alone. Patients were randomized to receive either artesunate (4 mg/kg.day) on days 0–2 plus SP (25 mg sulfadoxine/kg) on day 0 or the SP alone, and then followed-up for 28 days. Sixty patients completed follow-up. Compared with the 30 given artesunate plus SP (ASP), the 30 given SP alone were much more likely to be febrile (30% v. 3.3%; P50.006) and parasitaemic (50% v. 6.7%; P,00001) on day 1. By day 3, 16.7% of the patients given SP alone were still febrile and 6.7% of them were still parasitaemic, although all the patients given ASP were then afebrile (P50.02) and aparasitaemic (P50.1). Five (16.7%) of the patients treated with SP alone but none of those given ASP appeared to be treatment failures (P,0.05). Parasite genotyping revealed that four of the five apparent treatment failures were true recrudescences but the other represented a re-infection detected on day 28. The true frequencies of cure by day 28 were therefore 100% for ASP and 86.7% for SP alone (P50.02). Adverse effects of treatment (nausea, itching and giddiness) were observed with similar frequencies in the two treatment arms (10.0% of the patients given ASP v. 13.3% of the patients given SP alone; P.0.05). The frequencies of gametocytaemia during follow-up were, however, much lower in the ASP arm than in the SP-only (0.0% v. 23.3%; P50.005). Thus, although the problems posed by adverse effects were similar in the two treatment arms, ASP appeared markedly better, in terms of fever- and parasite-clearance times and the prevalence of post-treatment gametocytaemia, than SP alone.

There are few published studies on the burden of malaria during pregnancy from areas of sub-Saharan Africa where the intensity of malarial transmission is low, and few on submicroscopic malarial infections in pregnant women. The present study was conducted in New Halfa, an area of low-intensity transmission in eastern Sudan, between August 2003 and July 2004. The main aims were to assess the prevalences of submicroscopic and multiple Plasmodium falciparum infections in pregnant women (using the P. falciparum merozoite surface protein-2 as a polymorphic marker in PCR-based assays) and to determine the effects of such infections on anaemia during pregnancy. Of the 142 pregnant women who were recruited, only 17 (11.9%) were found smear-positive for P. falciparum by microscopy. The results of the PCR-based assays revealed, however, that 40 (32%) of the 125 smear-negative women had submicroscopic P. falciparum infections. Blood samples from 32 (80%) of those with submicroscopic infections showed only the FC 27 allele (of merozoite surface protein-2), six (15%) showed only the ICI allele, and two (5%) showed both of these alleles. Although the age, parity, gestational age and haemoglobin concentrations of the women with submicroscopic P. falciparum infections were not significantly different from those of the women who were smear- and PCR-negative, such infections may have a significant impact on materno-foetal health.

Background Pregnant women are more susceptible to malaria, which is associated with serious adverse effects on pregnancy. The presentation of malaria during pregnancy varies according to the level of transmission in the area. Our study aimed to demonstrate the prevalence and risk factors for malaria (age, parity and gestational age) among pregnant women of eastern Sudan, which is characterized by unstable malaria transmission. Methods The prevalence and possible risk factors for Plasmodium falciparum malaria were investigated in 744 pregnant Sudanese women attending the antenatal clinic of New Haifa Teaching Hospital, eastern Sudan, during October 2003-April 2004. Results A total 102 (13.7%) had P. falciparum malaria, 18(17.6%) of these were severe cases (jaundice and severe anaemia). Univariate and multivariate analysis showed that, age and parity were not associated with malaria. Women who attended the antenatal clinic in the third trimester were at highest risk for malaria (OR = 1.58, 95% CI = 1.02–2.4; P < 0.05). Women with malaria had significantly lower mean haemoglobin (9.4 g/dl, 95% CI 9.1–9.7 versus 10.7, CI 10.6–10.8, P < 0.05). A significantly lower haemoglobin was observed in those with severe falciparum malaria compared to non-severe form (8.3 g/dl, 95% CI 7.6–9.1 versus 9.4, 95% CI 9.1–9.7, P = < 0.05). Conclusion The results suggest that P. falciparum malaria is common in pregnant women attending antenatal care and that anaemia is an important complication. Preventive measures (chemoprophylaxis and insecticide-treated bednets) may be beneficial in this area for all women irrespective of age or parity.

In late 2003, the efficacies of mefloquine monotherapy and of an artesunate–mefloquine combination, for the oral treatment of uncomplicated, Plasmodium falciparum malaria, were investigated and compared in New Halfa, in eastern Sudan. Of the patients who completed the 28 days of follow-up, 40 were treated only with single-dose mefloquine (at a dose of 25 mg/kg), and 38 with artesunate (at 4 mg/kg.day) for 3 days followed by single-dose mefloquine (at 15 mg/kg), given on the third day. Compared with those given the combination, the patients given mefloquine alone were more likely to suffer nausea, vomiting and dizziness (25.0% v. 2.6%; P50.005) and to be found gametocytaemic (12.5% v. 0%; P50.02) after treatment, and more likely to be found febrile (i.e. with a temperature .37.5uC) on day 2 (25.0% v. 2.6%; P50.005), although no patients were found febrile on day 3. Six of the patients — three (7.5%) of those given mefloquine only and three (7.9%) of those given the combination (P.0.05) — appeared to be treatment failures. Parasite genotyping indicated, however, that, although five of these six patients had true recrudescences, one (who had been treated with the combination) had been re-infected during the follow-up. The true frequencies of cure were therefore 92.5% after mefloquine alone and 94.7% after the combination (P.0.05). Thus, although the treatments appeared equally effective in clearing parasitaemias, the combination was better at clearing gametocytaemias and was less likely to cause adverse side-effects. It remains unclear why mefloquine given alone was almost 10-fold more likely to trigger adverse effects than treatment with a combination that contained the same drug. This may be a reflection of the different mefloquine doses and, for the patients given the combination, of the use of artesunate before the mefloquine treatment. Malaria remains a serious challenge to world health. Estimates of the global burden vary but there are probably 400 million to 600 million cases each year, with Plasmodium falciparum causing much of the associated morbidity and almost all of the mortality (Snow et al., 1999). The reduction of malaria-attributable mortality depends on accurate and early diagnosis followed by prompt treatment with effective drugs (the choice of which depends on knowledge of the antimalarial sensitivity profile of the local strains of P. falciparum). During the

Summary An observational clinical trial was conducted in New Halfa, eastern Sudan, in November and December 2003. Sixty-two patients with uncomplicated Plasmodium falciparum malaria were treated with oral quinine (10 mg/kg thrice daily for 7 d); 47 (76%) of these patients were followed-up to day 28, and 5 (10.6%) of them appeared to have late treatment failures. The parasitological failures were early R1 in two (4.3%) patients and late R1 in three (6.4%) patients. The reappearance of parasites in three of these five patients were true recrudescences rather than a re-infection, based on genetic evidence. The present results and those of earlier investigations indicate that the response to quinine in this area may be faltering.

This study was conducted to investigate the morbidity pattern of malaria during pregnancy in New Halfa Teaching Hospital, Eastern Sudan, where malaria transmission is unstable.Pregnant (or in the puerperium) women presented with symptoms of falciparum malaria to the hospital during the period of November 2002 to March 2003 were enrolled to the study. Their socio-demographic characters, physical examinations, especially manifestations of severe falciparum malaria were performed and data were recorded. Blood films for malaria, urine, hemoglobin and blood glucose were tested.Fifty-nine pregnant (or in the puerperium) women with falciparum malaria were presented in this study. The mean +/- SD gravidity was 3.3 +/- 2.1. Fourteen (23.7%) out of 59 patients presented with one or more manifestations of severe malaria according to the World Health Organization criteria. Severe anemia (5), pulmonary edema (4), jaundice (3), hypoglycemia (3) and hypotension (1) were the manifestations of the severe illness. In comparison to non-severe group, patients with severe illness have significantly higher temperature and significantly lower hemoglobin level. The other parameters were not significantly different between the 2 groups of patients. In the severe cases, one patient was presented with missed second trimester abortion and the 6/59 (10.2%) patients delivered prematurely 4 were in the severe form. There were 4 perinatal deaths all in the severe group and there was one maternal death due to pulmonary edema.In this locality not only primigravidae but all parities were infected with falciparum malaria and different manifestations of severity were detected. Higher perinatal mortalities were documented.

The accurate diagnosis of malaria starts with clinical suspicion, confirmed by reliable laboratory results. A hospital-based study, described here, was carried out in a malaria mesoendemic area in eastern Sudan, where the inhabitants are semi-immune to malaria, and the fever threshold of parasitemia is not above the detection level of microscopy. Thus, we hypothesized that patients with symptoms highly suggestive of cerebral malaria (CM), but aparasitemic by microscopy, may have submicroscopic parasitemia. Patients in our malaria clinic were screened by microscopy, and 120 individuals were selected for the study, including febrile patients with and without microscopically detectable parasitemia, and apparently healthy individuals. In the two former groups there were patients with severe anemia and deep coma. Polymerase chain reaction (PCR) for parasite detection and ELISA tests for measuring serum antibody levels were carried out on all blood samples. A majority of the febrile patients who were parasite negative by microscopy showed the presence of a Plasmodium falciparum infection by PCR. The occurrence of P. falciparum infection with parasitemia below the detection level of microscopy was recognized more often in patients with CM symptoms than in those with severe malarial anemia (SMA), and in older rather than younger patients. Patients clinically suspected (CS) of having CM (CSCM) mostly were infected with a single clone, and a large proportion of them acquired antibodies (Abs) against merozoite surface protein (MSP) antigens (Ags). The therapeutic response to quinine treatment was comparable between patients with CSCM and CM. In conclusion, uniquely in this setting, CM can be associated with sub-patent parasitemia; thus, a diagnostic tool more sensitive than microscopy is needed.

The efficacies of several antimalarial drugs in the treatment of uncomplicated Plasmodium falciparum malaria were compared, during an open, randomized trial, in New Halfa, eastern Sudan. The 96 patients who completed the 28 days of follow-up were treated with chloroquine (N = 26), sulfadoxine-pyrimethamine (N = 38) or quinine (N = 32). No treatment failures were observed among the patients given sulfadoxine-pyrimethamine. Only 23.1% of the patients given chloroquine showed adequate clinical response, however, the rest showing early (15.4%) or, more frequently, late (61.5%) treatment failure. In terms of parasitological failure, 54.1% of the patients given chloroquine showed early RI resistance, 7.7% showed late RI, and 15.1% showed RIII. Most (90.6%) of the patients treated with quinine had adequate treatment responses, the rest having late treatment failures (and late RI). The frequency of treatment failure was significantly higher, however, among the patients given chloroquine than in the quinine-treatment arm. The present results and those of earlier investigations indicate that the problem of chloroquine resistance is worsening in eastern Sudan, and that the use of chloroquine as the first-line drug for the treatment of uncomplicated malaria in this area is now compromised. The response to quinine may also be faltering.

To test the efficacy and toxicity of mefloquine therapy both on expectant mothers and the outcome of their pregnancies.We performed a prospective non-comparative clinical trial in New Halfa Teaching Hospital, Eastern Sudan, during the period October 1998 to June 2001. Pregnant Sudanese women were given mefloquine 25 mg/kg for treatment of falciparum malaria following chloroquine failure. The women were followed every 2 weeks in the antenatal clinic until delivery. The babies were followed until the age of one year.Forty pregnant women were enrolled in the second and third trimesters. Itching which occurred in 17.5% and nausea which occurred in 35% were the cardinal side effects of the patients. Recrudescence or re-infection occurred on day 14 in one patient (2.5%). One patient that received mefloquine at 34 weeks gestational age delivered low birth weight (2.1 kg) at 39 weeks gestational age. One child died at the age of 7 months due to unexplained febrile illness. There was no abortion, no stillbirth and no congenital abnormality in the newborn children and no maternal death.This relatively small study reported that mefloquine could be used safely for the treatment of malaria in the second and third trimester of pregnancy and a larger study is recommended.

The attractiveness of pregnant women for mosquitoes was investigated in a peri-urban site in New Halfa, eastern Sudan, in September-October 2003. For 20 nights, the mosquitoes feeding on nine pregnant and nine non-pregnant women sleeping under untreated bednets were collected. The women slept outdoors, in the yards of nine houses, each yard holding one pregnant and one non-pregnant woman. In general, each pregnant woman attracted significantly more Anopheles arabiensis (the main vector of Plasmodium falciparum in the area) than each non-pregnant women, with mean biting rates of 0.94 and 0.49 bites/woman-night, respectively (P = 0.005). In contrast, the two groups of women attracted similar numbers of the other mosquito species collected, which were all culicine. Impregnated bednets need to be used in the study area, at least by the pregnant women (who appear to be at particularly high risk of acquiring malaria).

In November-December 2002, 98 patients presented at the Elhara Eloula health centre, in the New Halfa area of eastern Sudan, with Plasmodium falciparum malaria that had failed to respond to chloroquine treatment. After informed consent was obtained, 93 of these patients were randomly allocated to one of three regimens for quinine treatment, being given the drug, orally and sometimes intravenously, for 7 days, at doses of 10 mg/kg thrice daily (32 patients), 10 mg/kg twice daily (31 patients) or 15 mg/kg once daily (30 patients). All the patients were followed daily until day 7 and then weekly until day 28. There was no significant difference in the parasite-clearance times observed in the three groups. Parasitaemias re-occurred by day 28 in 12 patients: two (6.3%) of the patients treated thrice daily, five (16.1%) of those treated twice daily, and five (16.7%) of those treated once daily (P > 0.05). Genotyping indicated that in nine of these 12 patients the parasitaemias that developed post-treatment represented true recrudescences and not re-infections. In the treatment of chloroquine-resistant, P. falciparum malaria in Sudan, once-daily treatment with quinine, in a relatively low daily dose (15 mg/kg. day), appears as effective as the thrice-daily treatment (at 30 mg/kg. day) often recommended.

Summary A hospital-based study was carried out in Gedarif town, eastern Sudan, an area of markedly unstable malaria transmission. Among the 2488 diagnosed malaria patients, 4.4% fulfilled the WHO criteria for severe malaria, and seven died of cerebral malaria. The predominant complication was severe malarial anemia (45.4%), followed by convulsions (21%), cerebral malaria (16. 4%) and hypotension (11.8%). Severe malaria was recognized in all age groups, but 44.5% of patients were aged 2 to 4 years. The mean ages of patients with severe anemia (5.6 years) and convulsions (5.9 years) were significantly lower than the mean ages of patients with cerebral malaria (14.1 years) or hypotension (35.2 years). Patients with convulsions and cerebral malaria had significantly higher mean parasite count (69 972 and 56 110 parasites/μL, respectively) than patients with severe anemia (24 637parasites/μL) or hypotension (13 667 parasites/μL). The mean blood glucose level was higher in patients with cerebral malaria than in patients with anemia, and higher in patients who died than in patients who survived. In this setting, the clinico-epidemiological pattern of severe malaria varies considerably from that of hyperendemic regions in sub-Saharan Africa, and there is considerable variation between the individual complications of severe malaria.

The aim of this study was to conduct a sero-epidemiological survey of toxoplasmosis in pregnant Sudanese women.Four hundred and eighty-seven pregnant women attending antenatal clinics in Khartoum and Omdurman, Maternity Hospitals, Sudan during the period June through to December 2000 were counselled for socio-demographic and obstetrical risk factors for toxoplasmosis, and screened for immunoglobin G (IgG) and IgM anti-toxoplasma antibodies using enzyme linked immunoassay.Immunoglobin G anti-toxoplasma antibodies were positive (titre11 IU/ml) in 166/487 (34.1%), while 321/487(65.9%) were sero-negative. The sera of 35 women showed very high titres (100 IU/ml), 5/35 (14.3%) were IgM-positive. The risk factors for IgG anti-toxoplasma seropositivity were; Southern ethnic origin and consumption of raw meat. Thirty (18.1%) out of 166 women who were IgG anti-toxoplasma seropositive gave history of intrauterine fetal death, while 31 (9.7%) out of 321 women who were sero-negative gave history of intrauterine fetal death, the difference was statistically significant (P0.05).Over 65% Sudanese women screened for anti-toxoplasma IgG antibodies were sero-negative and they were at risk of sero-conversion during pregnancy. Southers and eating raw meat were the risk factors for toxoplasmosis in Sudanese pregnant women.

To compare the efficacy of intramuscular artemether and intravenous quinine in the treatment of severe falciparum malaria.An open randomized controlled clinical trial.New Halfa Teaching Hospital, Eastern Sudan, in the period November 2001-January 2002.Forty one male and female children; 21 on artemether and 20 on quinine.Fever clearance time, parasite clearance time, coma resolution time and side effects of the two drugs.The two groups (artemether and quinine) were well matched in the admission variable. The mean +/- (SD) fever clearance time was 30.5 +/- (20.9) hours in the artemether group, while it was 18.0 +/- (8.1) hours in the quinine group; the difference was highly significant (P=0.02). The mean parasite clearance time was shorter in the artemether group than in the quinine group, but it was not statistically significant, (16.0 vs. 22.4 hours; p0.05). In comatose patients (three in the artemether group, three in the quinine group) the time of recovery from coma was significantly shorter in artemether group than in quinine group (12.5 vs. 20.16 hours; P0.05). Recrudescence of P. falciparum (confirmed by polymerase chain reaction) occurred in one out of fifteen patients (6.6%) in the quinine group seen on day 28, which was successfully treated by sulphadoxine-pyrimethamine. In the quinine group, one patient died and one patient developed hypoglycaemia.Artemether caused faster parasite clearance than quinine, but quinine lowered the temperature in shorter time than artemether. The results obtained show that artemether can be used as safe and effective alternative drug for the treatment of severe falciparum malaria in the wake of the growing resistance to quinine in Sudan.

To investigate the levels of serum cortisol in patients with uncomplicated Plasmodium falciparum (P. falciparum) malaria in an area of unstable malaria transmission in eastern Sudan.The concentrations of cortisol were measured in sera of 25 patients with uncomplicated P. falciparum malaria (at presentation, 24 h and 7 d later) and 25 healthy volunteers using radioimmunoassay gamma counter.There was no significant difference in mean (SD) of total cortisol levels in patients with malaria in comparison with the control group; 602.2 (369.6) vs. 449.2(311.7) ng/mL, P=0.12. In patients with uncomplicated P. falciparum malaria, the mean (SD) presenting cortisol levels were significantly higher in comparison to the levels on day 7; 602.2 (369.6) vs. 373.6(139.1) ng/mL, P=0.009. In the patients with uncomplicated P. falciparum malaria (on presentation) cortisol levels were not correlated with initial temperature or the presenting parasitaemia.Thus, cortisol levels were not significantly different between the patients and the controls.

Protein G, an immunoglobulin (Ig)-binding protein isolated from group C or G streptococci, binds to the Fc portion of IgG. Protein L, from the anaerobic bacterium Peptostreptococcus magnus, specifically binds light chains of Ig. In this study, protein G and L were used to measure the production of antibodies in immunized rabbits. Two rabbits were immunized with a mixture of human urinary proteins from a patient with tubular proteinuria, and blood samples were collected regularly from the animals for 6 weeks after the immunization. The antibody levels of the blood samples against six of the proteins in the antigen mixture were then measured by ELISA. Microtiter plates were coated with each of the antigens, incubated with the rabbit serum samples, and the specific antibodies of the IgG class measured by incubation with biotinylated protein G, and antibodies of all Ig classes with biotinylated protein L. Alternatively, Western blotting was employed, where the antibodies which bound to each antigen after separation by SDS-PAGE and transfer to nitrocellulose membranes, were detected by protein G or L. The results showed that antibody production against five of the antigens, albumin, alpha 1 gamma-acid glycoprotein, alpha 1 gamma-microglobulin, Ig light chains, and retinol-binding protein, showed a similar pattern, although the magnitude of the initial IgM response differed somewhat. After 6 weeks, the levels of the protein G-binding antibodies had reached a plateau, while those of protein L-binding antibodies were still increasing. The response to the sixth antigen, beta 2 microglobulin, was considerably different. A dramatic increase of anti-beta 2 gamma-microglobulin antibodies was seen during the 4th week after immunization when protein L was used.

BackgroundPrevalence of placental malaria has been widely used as a standard indicator to characterize malaria infection in epidemiologic surveys. Placental malaria poses a greater diagnostic challenge, accurate and sensitive diagnostic tool for malaria infections in pregnancy is needed.MethodsA cross sectional study was conducted at Medani Hospital, which serves catchment area which is characterized by unstable malaria transmission. One hundred and seven placentae were investigated for malaria infection using polymerase chain reaction (PCR) and histology.Resultsout of 107 investigated placentae, 33 (30.8%) and 34 (31.8%) were positive for malaria by histology (two (2%) and 31(29.0%) were acute and past infections, respectively) and PCR, respectively. Out of 33 positive by histology, 15 were positive by the PCR while 18 were negative. The sensitivity of the PCR was 45.5% (95% CI: 29.2%- 62.5%). Out of 74 which were negative by histology, 19 were positive by the PCR. This is translated in specificity of 74.3% (95% CI: 63.5%- 83.3%). Of those tested positive by the PCR, 15 were positive by the histology, while 19 were negative. This is translated into a positive predictive value of 44.1% (95% CI: 28.3%- 61.0%). Of those 73 tested negative by the PCR, 55 were negative according to histology while 23 were positive. This is translated into a negative predictive value of 75.3% (95% CI: 64.5%-84.2%).ConclusionPCR had low sensitivity and specificity in comparison to placental histology, perhaps because the vast majority of the placental infections were past infections. Further research is needed.