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Boushab Mohamed Boushab,1 Fatim-Zahra Fall-Malick,2 Mamoudou Savadogo,3 Leonardo Kishi Basco,4 1Department of Internal Medicine, Aïoun Regional Hospital, Hodh El Gharbi, Mauritania; 2National Institute of Hepatology-Virology in Nouakchott, School of Medicine, Nouakchott, Mauritania; 3Department of Infectious Diseases, University Teaching Hospital Yalgado Ouédrago, Ouagadougou, Burkina Faso; 4Research Unit of Infectious and Tropical Diseases, Institut de Recherche pour le Développement (Research Institute for Development), Aix-Marseille University, Marseille, France Abstract: Malaria is one of the main reasons for outpatient consultation and hospitalization in Mauritania. Although four Plasmodium species, ie, Plasmodium (P.) falciparum, P. vivax, P. malariae, and P. ovale, cause malaria in Mauritania, recent data on their frequency is ­lacking. Since infections with P. falciparum generally result in serious disease, their identification is important. We report a case of oliguric renal injury associated with malaria in a 65-year-old shepherd. Clinical manifestations included anemia, oliguria, and elevated creatinine and urea. The rapid diagnostic test for malaria and microscopic examination of blood smears were positive for P. falciparum. On the basis of this, the patient was diagnosed as having acute kidney injury as a complication of severe malaria. The patient was treated for malaria with intravenous quinine for 4 days, followed by 3 days of oral treatment. Volume expansion, antipyretic treatment, and diuretics were administered. He also had two rounds of dialysis after which he partially recovered renal function. This outcome is not always the rule. Prognosis depends much on early diagnosis and appropriate supportive treatment. Keywords: malaria, oliguric kidney injury, shepherd, quinine, dialysis

OBJECTIVE: To evaluate the therapeutic efficacy of sulfadoxine-pyrimethamine, amodiaquine, and the sulfadoxine-pyrimethamine-amodiaquine combination for the treatment of uncomplicated Plasmodium falciparum malaria in young children in Cameroon. METHODS: In a randomized study we evaluated the effectiveness and tolerance of (i) sulfadoxine-pyrimethamine (SP) (25 mg/kg body weight of sulfadoxine and 1.25 mg/kg of pyrimethamine in a single oral dose), (ii) amodiaquine (AQ) (30 mg/kg body weight in three divided daily doses), and (iii) the sulfadoxine-pyrimethamine-amodiaquine combination (SP+AQ) (same doses as in the other two treatment groups, given simultaneously on day 0) in young children in southern Cameroon. The parasitological and clinical responses were studied until day 28 in accordance with the modified 1996 WHO protocol for the evaluation of the therapeutic efficacy of antimalarial drugs. FINDINGS: Of 191 enrolled patients, 6 and 8 were excluded or lost to follow-up before day 14 and between day 14 and day 28, respectively. For the AQ-treated patients, parasitological and clinical evaluation on day 14 showed late treatment failure in 2 of 61 (3.3%) and adequate clinical response with parasitological failure in one (1.6%). There was an adequate clinical response in all patients treated with SP or SP+AQ. Therapeutic failure rates on day 28 were 13.6%, 10.2% and 0% in the SP, AQ, and SP+AQ groups, respectively. Anaemia improved in all three regimens. AQ produced faster fever clearance but was associated with more transient minor side-effects than SP. SP+AQ reduced the risk of recrudescence between day 14 and day 28 but increased the incidence of minor side-effects. CONCLUSION: SP+AQ can be recommended as a temporary means of slowing the spread of multidrug resistance in Plasmodium falciparum in Africa while the introduction of other combinations, including artemisinin derivatives, is awaited. [ABSTRACT FROM AUTHOR]

Until 2020, Djiboutian health authorities relied on histidine-rich protein-2 (HRP2)-based rapid diagnostic tests (RDTs) to establish the diagnosis of Plasmodium falciparum . The rapid spread of P. falciparum histidine-rich protein-2 and -3 ( pfhrp2/3 ) gene-deleted parasite strains in Djibouti has led the authorities to switch from HRP2-based RDTs to lactate dehydrogenase (LDH)-based RDTs targeting the plasmodial lactate dehydrogenase (pLDH) specific for P. falciparum and P. vivax (RapiGEN BIOCREDIT Malaria Ag Pf/Pv pLDH/pLDH) in 2021. This study was conducted with the primary objective of evaluating the diagnostic performance of this alternative RDT. Operational constraints related, in particular, to the implementation of this RDT during the COVID-19 pandemic were also considered. The performance of BIOCREDIT Malaria Ag Pf/Pv (pLDH/pLDH) RDT was also compared to our previously published data on the performance of two HRP2-based RDTs deployed in Djibouti in 2018-2020. The diagnosis of 350 febrile patients with suspected malaria in Djibouti city was established using two batches of RapiGEN BIOCREDIT Malaria Ag Pf/Pv (pLDH/pLDH) RDT over a two-year period (2022 and 2023) and confirmed by real-time quantitative polymerase chain reaction. The sensitivity and specificity for the detection of P. falciparum were 88.2% and 100%, respectively. For P. vivax , the sensitivity was 86.7% and the specificity was 100%. Re-training and closer supervision of the technicians between 2022 and 2023 have led to an increased sensitivity to detect P. falciparum (69.8% in 2022 versus 88.2% in 2023; p < 0.01). The receiver operating characteristic curve analysis highlighted a better performance in the diagnosis of P. falciparum with pLDH-based RDTs compared with previous HRP2-based RDTs. In Djibouti, where pfhrp2 -deleted strains are rapidly gaining ground, LDH-based RDTs seem to be more suitable for diagnosing P. falciparum than HRP2-based RDTs. Awareness-raising and training for technical staff have also been beneficial.

During the past four decades, recurrent outbreaks of various arthropod-borne viruses have been reported in Mauritania. This review aims to consolidate the current knowledge on the epidemiology of the major arboviruses circulating in Mauritania. Online databases including PubMed and Web of Science were used to retrieve relevant published studies. The results showed that numerous arboviral outbreaks of variable magnitude occurred in almost all 13 regions of Mauritania, with Rift Valley fever (RVF), Crimean-Congo hemorrhagic fever (CCHF), and dengue (DEN) being the most common infections. Other arboviruses causing yellow fever (YF), chikungunya (CHIK), o'nyong-nyong (ONN), Semliki Forest (SF), West Nile fever (WNF), Bagaza (BAG), Wesselsbron (WSL), and Ngari (NRI) diseases have also been found circulating in humans and/or livestock in Mauritania. The average case fatality rates of CCHF and RVF were 28.7% and 21.1%, respectively. RVF outbreaks have often occurred after unusually heavy rainfalls, while CCHF epidemics have mostly been reported during the dry season. The central and southeastern regions of the country have carried the highest burden of RVF and CCHF. Sheep, cattle, and camels are the main animal reservoirs for the RVF and CCHF viruses. Culex antennatus and Cx. poicilipes mosquitoes and Hyalomma dromedarii , H. rufipes , and Rhipicephalus everesti ticks are the main vectors of these viruses. DEN outbreaks occurred mainly in the urban settings, including in Nouakchott, the capital city, and Aedes aegypti is likely the main mosquito vector. Therefore, there is a need to implement an integrated management strategy for the prevention and control of arboviral diseases based on sensitizing the high-risk occupational groups, such as slaughterhouse workers, shepherds, and butchers for zoonotic diseases, reinforcing vector surveillance and control, introducing rapid point-of-care diagnosis of arboviruses in high-risk areas, and improving the capacities to respond rapidly when the first signs of disease outbreak are identified.

The presence of alphaviruses, such as chikungunya virus (CHIKV), has never been reported in Mauritania. We assessed the seroprevalence of CHIKV among Nouakchott residents. A cross-sectional study involving 1300 non-febrile patients consulting at the Nouakchott hospital center was conducted between January and June 2021. The presence of anti-CHIKV IgG and neutralizing antibodies against CHIKV, O'nyong-nyong virus (ONNV), and Semliki Forest virus (SFV) was determined by an enzyme-linked immunosorbent assay (ELISA) and a serum neutralization test, respectively, and the associated risk factors were investigated. Of the 1300 study participants, serological evidence of previous exposure to CHIKV was observed in 37 individuals (2.8%). Sex, age, reported use of repellants, and bed net ownership and usage were not associated with CHIKV seropositivity. Our results showed the co-circulation of two other alphaviruses, ONNV and SFV, in Nouakchott in 30 (2.3%) individuals. This is the first study that documents the co-circulation of CHIKV, ONNV, and SFV in Mauritania, albeit at low prevalence. Surveillance and routine testing for alphaviruses and other arboviruses in symptomatic patients should be implemented in health facilities to assess the health burden associated with these viruses. Efforts should also be made to strengthen the vector control measures.

Successfully developed in 1976, the continuous in vitro culture of Plasmodium falciparum has many applications in the field of malaria research. It has become an important experimental model that directly uses a human pathogen responsible for a high prevalence of morbidity and mortality in many parts of the world and is a major source of biological material for immunological, biochemical, molecular, and pharmacological studies. Until present, the basic techniques described by Trager and Jensen and Haynes et al. remain unchanged in many malaria research laboratories. Nonetheless, different factors, including culture media, buffers, serum substitutes and supplements, sources of erythrocytes, and conditions of incubation (especially oxygen concentration), have been modified by different investigators to adapt the original technique in their laboratories or enhance the in vitro growth of the parasites. The possible effects and benefits of these modifications for the continuous cultivation of asexual intraerythrocytic stages of P. falciparum , as well as future challenges in developing a serum-free cultivation system and axenic cultures, are discussed.

Background: The Republic of Djibouti is a malaria endemic country that was in pre-elimination phase in 2006-2012. From 2013, however, malaria has re-emerged in the country, and its prevalence has been increasing every year. Given the co-circulation of several infectious agents in the country, the assessment of malaria infection based on microscopy or histidine-rich protein 2 (HRP2)-based rapid diagnostic tests (RDT) has shown its limitations. This study, therefore, aimed to assess the prevalence of malaria among febrile patients in Djibouti city using more robust molecular tools., Methods: All suspected malaria cases reported to be microscopy-positive were randomly sampled (n = 1113) and included in four health structures in Djibouti city over a 4-year period (2018-2021), mainly during the malaria transmission season (January-May). Socio-demographic information was collected, and RDT was performed in most of the included patients. The diagnosis was confirmed by species-specific nested polymerase chain reaction (PCR). Data were analysed using Fisher's exact test and kappa statistics., Results: In total, 1113 patients with suspected malaria and available blood samples were included. PCR confirmed that 788/1113 (70.8%) were positive for malaria. Among PCR-positive samples, 656 (83.2%) were due to Plasmodium falciparum, 88 (11.2%) Plasmodium vivax, and 44 (5.6%) P. falciparum/P. vivax mixed infections. In 2020, P. falciparum infections were confirmed by PCR in 50% (144/288) of negative RDTs. After the change of RDT in 2021, this percentage decreased to 17%. False negative RDT results were found more frequently (P < 0.05) in four districts of Djibouti city (Balbala, Quartier 7, Quartier 6, and Arhiba). Malaria occurred less frequently in regular bed net users than in non-users (odds ratio [OR]: 0.62, 95% confidence interval [CI]: 0.42-0.92)., Conclusions: The present study confirmed the high prevalence of falciparum malaria and, to a lesser extent, vivax malaria. Nevertheless, 29% of suspected malaria cases were misdiagnosed by microscopy and/or RDT. There is a need to strengthen the capacity for diagnosis by microscopy and to evaluate the possible role of P. falciparum hrp2 gene deletion, which leads to false negative cases of P. falciparum., (© 2023. The Author(s).)

Background: Crimean-Congo hemorrhagic fever (CCHF) is a zoonotic arbovirosis. Humans are infected by tick bites or contact with blood of infected animals. CCHF can be responsible for severe outbreaks due to human-to-human transmission. Our aims were to increase awareness and promote the search for risk factors and disease monitoring to prevent CCHF epidemic, capacity building, appropriate measures to treat patients, and information for the local population., Methods: During the outbreak of hemorrhagic fever from February to May 2022, blood samples were collected from 88 patients suspected to be infected with the virus. Diagnosis was established by reverse-transcription polymerase chain reaction (RT-PCR) and/or enzyme-linked immunosorbent assay., Results: CCHF was confirmed by RT-PCR in 7 of 88 (8%) patients. Ticks were found in cattle, sheep, or goats in the areas where the subjects resided, with the exception of 1 CCHF-positive patient in close contact with fresh animal meat. Exposure to potential risk factors was found in all patients. The interval between the onset of symptoms and hospital admission was 2-3 days. All 7 patients were admitted to our hospital and treated promptly by blood transfusion. Two patients died., Conclusions: Mortality is high in patients with the hemorrhagic form of CCHF. Disease prevention is necessary by strengthening vector control, avoiding contact and consumption of organic products from diseased animals, and vaccinating animals in areas where the disease is endemic. Furthermore, it is essential to establish management procedures for patients infected with CCHF virus., (© The Author(s) 2022. Published by Oxford University Press on behalf of Infectious Diseases Society of America.)

Background: In the Republic of the Congo, malaria represents a major public health problem affecting all age groups. A regular surveillance of the current efficacy of first-line anti-malarial drugs is required in the face of possible emergence and spread of artemisinin-resistant Plasmodium falciparum strains in Africa. The purpose of this study was to determine the prevalence of malaria among febrile patients of all ages and assess the efficacy of artemether-lumefantrine (AL) and artesunate-amodiaquine (ASAQ) in Congolese children., Methods: Febrile patients of all ages were initially screened for malaria by both rapid diagnostic test (RDT) and microscopy. Patients less than 12 years of age, with parasitaemia ≥ 1000 asexual parasites of P. falciparum/µL of blood, without any signs of severity, were enrolled in a therapeutic efficacy study and treated after obtaining their parents' (or legal guardian's) informed consent in two health centres in Dolisie. The patients were followed for 28 days in accordance with the 2009 World Health Organization standard protocol. If parasitaemia reappeared on or after day 7, the genetic profiles (genes expressing merozoite surface protein-1 [msp1], merozoite surface protein-2 [msp2], and glutamine-rich protein [glurp]) of pre-treatment and post-treatment isolates were compared by nested polymerase chain reaction (PCR) followed by capillary electrophoresis to make a distinction between recrudescence and re-infection. The clinical and parasitological outcome was analysed by the per-protocol method and Kaplan-Meier survival curves., Results: A total of 994 febrile patients of all ages were screened by RDT and microscopy. Of 994 patients, 323 (32.5%) presented a positive RDT, and 266 (26.8%) were microscopy-positive. Based on microscopy as the reference diagnostic method, the sensitivity and the specificity of the RDT were 98.9 and 91.8%, respectively. The Cohen's kappa coefficient was 0.86. A total of 121 children aged less than 12 years (61 in AL treatment group and 60 in ASAQ treatment group) were included in therapeutic efficacy study. Before PCR correction, the proportions of adequate clinical and parasitological response were 96.6% for AL and 86.0% for ASAQ in the per-protocol population (P < 0.05). The PCR-corrected efficacy rates were 98.2% and 94.2% for AL and ASAQ, respectively (P > 0.05). Both treatments were well tolerated., Conclusions: AL and ASAQ remain highly effective for the first-line treatment of uncomplicated P. falciparum malaria in Dolisie. Despite high efficacy of first- and second-line treatment, there is a continuing need to scale up effective malaria preventive interventions and vector control strategies in the country., Trial Registration Number: ACTRN12616001422415., (© 2022. The Author(s).)

Background: Cytoadhesion and sequestration of Plasmodium falciparum infected red blood cells (iRBC) in the microvasculature of vital organs are a major cause of malaria pathology. Several studies have provided evidence on the implication of the human host intercellular adhesion molecule-1 (ICAM-1) as a major receptor for iRBCs binding to P. falciparum erythrocyte membrane protein 1 (PfEMP1) in the development of severe and cerebral malaria. The genetic polymorphism K29M in the immunoglobulin-like domain of ICAM-1, known as ICAM-1 Kilifi , has been associated with either increased or decreased risk of developing cerebral malaria., Methods: To provide more conclusive results, the genetic polymorphism of ICAM-1 Kilifi was assessed by PCR and sequencing in blood samples from 215 Beninese children who presented with either mild or severe malaria including cerebral malaria., Results and Conclusions: The results showed that in this cohort of Beninese children, the ICAM-1 kilifi variant is present at the frequencies of 0.27, similar to the frequency observed in other African countries. This ICAM-1 kilifi variant was not associated with disease severity in agreement with other findings from the Gambia, Tanzania, Malawi, Gabon, and Thailand, suggesting no evidence of a direct link between this polymorphism and the pathogenesis of severe and cerebral malaria., (© 2022. The Author(s).)

The number of sporadic and epidemic dengue fever cases have reportedly been increasing in recent years in some West African countries, such as Senegal and Mali. The first epidemic of laboratory-confirmed dengue occurred in Nouakchott, the capital city of Mauritania situated in the Saharan desert, in 2014. On-site diagnosis of dengue fever was established using a rapid diagnostic test for dengue. In parallel, the presence of Aedes aegypti mosquitoes in the city was confirmed. The initial diagnosis was confirmed by RT-PCR, which showed that all samples from the 2014 dengue epidemic in Nouakchott were dengue virus serotype 2 (DENV-2). The whole genome or envelope protein gene of these strains, together with other DENV-2 strains obtained from travelers returning from West African countries to France between 2016 and 2019 (including two Mauritanian strains in 2017 and 2018), were sequenced. Phylogenetic analysis suggested a recent emergence of an epidemic strain from the cosmopolitan genotype belonging to West African cosmopolitan lineage II, which is genetically distinct from African sylvatic genotype. The origin of this DENV-2 lineage is still unknown, but our data seem to suggest a recent and rapid dispersion of the epidemic strain throughout the region. More complete genome sequences of West African DENV-2 are required for a better understanding of the dynamics of its circulation. Arboviral surveillance and outbreak forecasting are urgently needed in West Africa., Competing Interests: The authors have declared that no competing interests exist.

Filarioid nematodes are parasites of the tissues and tissue spaces of all vertebrates except fish. Females produce microfilariae that enter the host's blood circulation or skin and may cause ocular and neurological pathology, leading to important implications in veterinary and public health. The present work is the first investigation on Setaria labiatopapillosa conducted in Morocco to characterize the morphological features of both adult and microfilaria forms. Two adult female nematodes were found free in the thoracic cavity of a slaughtered 3.5-year-old (6 teeth) Moroccan enhanced cross-breed bull which was born and raised in Morocco. The worms were identified as S. labiatopapillosa by light microscope (LM) and scanning electron microscopy (SEM) on the basis of their characteristic features of the anterior and posterior parts of the worms. The two S. labiatopapillosa worms measured 90 mm and 105 mm in length and 0.55 and 0.64 mm in width, respectively. Microfilariae were detected in the fully developed eggs contained in the uterus of both nematodes. A detailed morphology of both the adult females and larvae of S. labiatopapillosa is described using LM and SEM. Although the origin of S. labiatopapillosa analyzed in the present study is unknown and there is currently no evidence that Setaria spp. have invaded Morocco, further surveillance is warranted to determine the incidence of setariasis, identify its vectors, and take appropriate measures to protect the livestock and cattle industry of the country.

Coronavirus disease 2019 (COVID-19), a pandemic affecting the world's population, is particularly threatening to dialysis patients. The purpose of this study was to propose recommendations for prevention and containment of COVID-19 in hemodialysis center situated in a regional hospital in Mauritania. Both COVID-19-infected (n = 11) and -uninfected (n = 16) dialysis patients were hospitalized up to three weeks to improve patient management. All COVID-19-infected patients were cured. Patient care and hygiene in a safe environment are the key factors for a favorable outcome, even in resource-limited settings., Competing Interests: The authors declare no competing interests., (Copyright: Boushab Mohamed Boushab et al.)

The distribution of Crimean-Congo hemorrhagic fever (CCHF), a tickborne arboviral disease, is not well known in West Africa. We report 2 recent human cases of CCHF with infectious syndrome and severe bleeding in Mauritania. CCHF was diagnosed by ELISA and real time reverse transcription PCR. No secondary CCHF cases were found.

Background: Miliary tuberculosis is a serious and uncommon form of tuberculosis due to hematogenous dissemination of Mycobacterium tuberculosis ., Objective: This study aimed to describe the epidemiological and clinical features of miliary tuberculosis., Patients and Methods: Data were collected from clinical files between August 2016 and July 2018., Results: In 2 years, 24 cases were recorded, representing a proportional morbidity of 13%. Among them, 71% were smokers and 38% had diabetes. The presence of a BCG vaccination scar was observed in 2 patients (8%). Human immunodeficiency virus (HIV) serology was positive in 4 cases (17%). The symptomatology was dominated by: fever (100%), cough (83%), and chest pain (79%). Radiological images with micronodular opacities were the most common (54%), followed by macronodular densities (33%), and reticulonodular densities (13%). The evolution was favorable in 77%, with no patient lost to follow-up, but 7/24 (29%) died, either before the initiation of therapy ( n  = 2) or during therapy ( n  = 5)., Conclusion: Miliary tuberculosis is an acute and severe form of life-threatening tuberculosis. It requires a prompt and accurate diagnosis and treatment. An improved accessibility to early diagnosis and treatment and prevention of TB infection should reduce its prevalence., (© 2019 Published by Elsevier Ltd.)

Background: The incidence of tuberculosis has increased in recent years in both developed and developing countries., Objective: This retrospective study aimed to review all cases of spinal tuberculosis diagnosed at the Department of Internal Medicine and Infectious Diseases in Kiffa Regional Hospital and assess the role of computed tomography (CT) scan in establishing definite diagnosis., Patients and Methods: Data were collected from clinical records of patients admitted to the hospital for rachialgia between August 2016 and July 2018., Results: Fourteen (12.2%) adults with spinal tuberculosis were found among 115 patients with all forms of tuberculosis during the study period. The mean (± standard deviation) age of our patients was 47.5 ± 22.0 years old with male:female (8/6) sex ratio of 1.3. The mean duration of evolution of the disease was 15 months. The presenting signs and symptoms included rachialgia in most patients (93%), associated with segmental spinal stiffness (50%) and/or neurological complications (50%). Diagnosis was established on the basis of clinical history, clinical examination, standard vertebral column radiography, and CT scan. Vertebral imaging showed a clear predominance of lumbar lesions (57%), followed by dorsal (36%) and cervical (7%) involvement. The evolution under treatment was favorable, with the exception of two cases of medullary compression., Conclusion: Spinal tuberculosis is the most common form of osteoarticular tuberculosis. It affects predominantly lumbar and dorsal vertebrae. In the absence of histological confirmation, the presence of back pain associated with major radiological signs of spondylosis disc disease seems to justify the use of CT scan to confirm the diagnosis of this pathology.

The standard in vitro cultivation procedure for Plasmodium falciparum requires gas exchange and a microaerophilic atmosphere. A novel system using a commercially available cell culture device (Petaka G3 ™ ; Celartia Ltd., Powell, OH) was assessed for long-term cultivation of a P. falciparum reference laboratory clone in normal air. Parasite growth during 30 days was similar, or better, in Petaka G3 than that in the standard cultivation method with gas exchange in a CO 2 incubator. The successful cultivation of P. falciparum in the Petaka G3 device suggests that low O 2 content available in hemoglobin and dissolved gas in the blood is sufficient for long-term cultivation. This finding may open the way to novel methods to cultivate and adapt P. falciparum field isolates to in vitro conditions with more ease.

Introduction: Artemisinin-based combination therapies (ACTs) are the first-line antimalarial drugs used to treat uncomplicated Plasmodium falciparum alaria in many endemic countries worldwide. The present work reviewed the therapeutic efficacy of ACT in Cameroon more than 10 years after the initial change in national drug policy in 2004., Methods: A PubMed literature search was performed to analyse clinical trials conducted in Cameroon from 2001 to May 2017. Clinical studies that evaluated ACT for the treatment of uncomplicated falciparum malaria in children or adults, and reported efficacy and/or safety, were included. In addition, a small network meta-analysis (NMA) with a frequentist approach was performed., Results: Six papers were selected from 48 articles screened and were full-text reviewed. The efficacy of both artemether-lumefantrine (AL) and artesunate-amodiaquine (ASAQ) ranged from moderate to high, with polymerase chain reaction-corrected cure rates ranging from 96.7 to 100% and 88.2 to 100%, respectively, in per-protocol analysis, and 86.2 to 96.7% and 74.0 to 90.6%, respectively, in intention-to-treat analysis. The malaria evidence network suggested that AL and ASAQ efficacies were comparable. The highest day 3 parasite positivity rate was 8.2% for ASAQ and 4% for AL. A novel ACT, artesunate-atovaquoneproguanil (ASATPG) was tested once and showed a cure rate of 100%. Based on an ITT approach, the NMA revealed that AL was more efficacious than ASAQ, but the difference was not statistical significant (706 participants, three randomised clinical trials (RCT); OR 1.25, 95%CI 0.78-2.00). Adverse events ranged from mild to moderate severity but were not directly attributed to drug intake., Conclusion: ACTs are still effective and safe in Cameroon; however, there are insufficient data on their efficacy, safety and tolerability, therefore more RCTs should be conducted, including novel ACTs.

The Institut Hospitalo-Universitaire Méditerranée Infection is positioned for the diagnosis, prevention and treatment of the 'big three' killer diseases: malaria, tuberculosis and HIV. We implemented the use of new diagnostic samples such as stools and new diagnostic tests such as mass spectrometry for the dual identification of vectors and pathogens. Furthermore, advances in the prevention and treatment of malaria and tuberculosis are reviewed, along with advances in the understanding of the role of microbiota in the resistance to HIV infection. These achievements represent a major step towards a better management of the 'big three' diseases worldwide.

Background: Mauritania is one of the African countries with ongoing malaria transmission where data on insecticide resistance of local malaria vectors are limited despite an increasing use of long-lasting insecticide-treated nets (LLINs) as the main intervention for vector control. This study presents an evaluation of the level of insecticide resistance of Anopheles arabiensis in Nouakchott., Methods: Anopheles gambiae (s.l.) larvae were collected in breeding sites during the rainy season (August-September) in 2015 and 2016 from two selected sites in Nouakchott and reared until emergence. Adult anopheline mosquitoes were tested against malathion (5%), bendiocarb (0.1%), permethrin (0.75%) and deltamethrin (0.05%) using standard World Health Organization (WHO) insecticide-impregnated papers. PCR assays were used for the identification of An. gambiae (s.l.) sibling species as well as knockdown resistance (kdr)., Results: The mean knockdown times 50% (KDT 50 ) and 95% (KDT 95 ) were 66 ± 17 and 244 ± 13 min, respectively, for permethrin in 2015. The KDT 50 and the KDT 95 were 39 ± 13 and 119 ± 13 min, respectively, for deltamethrin. The KDT 50 and the KDT 95 doubled for both molecules in 2016. The mortality rates 24 h post-exposure revealed that An. arabiensis populations in Nouakchott were fully susceptible to bendiocarb and malathion in 2015 as well as in 2016, while they were resistant to permethrin (51.9% mortality in 2015 and 24.1% mortality in 2016) and to deltamethrin (83.7% mortality in 2015 and 39.1% mortality in 2016). The molecular identification showed that Anopheles arabiensis was the only malaria vector species collected in Nouakchott in 2015 and 2016. Both the West and East African kdr mutant alleles were found in An. arabiensis mosquitoes surviving exposure to pyrethroid insecticide, with a high rate of homozygous resistant genotypes (54.3% for the West African kdr mutation and 21.4% for the East African kdr mutation) and a significant departure from Hardy-Weinberg proportions (χ 2 = 134, df = 3, P < 0.001)., Conclusions: The study showed high levels of pyrethroid resistance in An. arabiensis populations in Nouakchott and presence of both West and East African kdr alleles in the resistant phenotype. These results highlight a need for routine monitoring of susceptibility of malaria vector populations to insecticides used in public health programs.

Background: Mucocutaneous manifestations are one of the first clinical signs in patients infected with human immunodeficiency virus (HIV). To the best of our knowledge, there has been no previous study describing dermatologic manifestations in Mauritanians infected with HIV. The aim of the present study was to determine the profiles of mucocutaneous manifestations in relation to CD 4 T cell count in HIV-positive Mauritanian patients., Methods: A total of 86 adult patients aged > 18 years old attending the Ambulatory Treatment Center of the National Hospital of Nouakchott, Mauritania, with newly diagnosed HIV and who were not under antiretroviral treatment were included in the study in 2015. Dermatologic manifestations were documented before initiating antiretroviral treatment., Results: Most of the included patients were in clinical stage 3 of the World Health Organization classification at initial diagnosis, with the mean CD 4 T cell count (± SD) of 514 ± 319 cells/mm 3 (range, 2-1328 cells/mm 3 ), and 19 of 86 (22.1%) patients had CD 4 T cell counts below 200 cells/mm 3 . More than half (64%) of newly diagnosed HIV-infected patients had dermatoses, including the following: pruritic papular eruption (44.2%), seborrheic dermatitis (4.7%), Kaposi's sarcoma (3.5%), extensive xerosis cutis (2.3%), drug-induced skin reactions (1.2%), and various infectious dermatoses (dermatophyte infections [16.3%], oral candidiasis [11.6%], herpes zoster [8.1%], and scabies [2.3%]). A low CD 4 T cell count (< 200 cells/mm 3 ) was significantly correlated (P < 0.05) with the presence of following dermatoses: dermatophytosis, oral candidiasis, Kaposi's sarcoma, seborrheic dermatitis, and extensive xerosis cutis., Conclusion: Mucocutaneous lesions occur throughout the course of HIV infection, and dermatologic findings in Mauritanian HIV-positive patients are similar to those of patients in other countries. Early detection of skin disorders in some patients may help establish the diagnosis of HIV and management of HIV-associated diseases, limiting the cost of care in low-resource countries., (© 2017 The International Society of Dermatology.)

Background: Artemisinin-based combination therapy (ACT) and novel drug combinations are available and used in African countries to treat uncomplicated malaria. Network meta-analysis methods are rarely and poorly applied for the comparison of their efficacies. This method was applied on a set of randomized controlled trials to illustrate its usefulness., Methods: A literature review available in Pubmed was conducted in July 2016. Eligible studies, conducted in sub-Saharan Africa, published between 2002 and 2016, focused on randomized controlled trials of at least two artemisinin-based combinations to treat uncomplicated malaria in children and adults. Agglomerate data were: the number of PCR-corrected adequate clinical and parasitological response (ACPR) on day 28, used as the primary enDHAPoint in all interventions, the number of participants and the list of treatments. A Bayesian random effect meta-analysis using a binary outcome was the method to compare the efficacy. Ranking measure was used to obtain a hierarchy of the competing interventions., Results: In total, 76 articles were included; 13 treatment regimens were involved and tested in 36,001 patients. Using artemether-lumefantrine (AL) as the common comparator for the entire network, 12 relative treatment effects were estimated and indirect comparisons were obtained. Dihydroartemisinin-piperaquine (DHAP) was shown to be more effective than AL (odds ratio [OR] = 1.92; 95% CI 1.30-2.82; 19,163 patients), ASAQ (OR = 1.70; 95% CI 1.10-2.64; 14,433 patients), and amodiaquine-sulfadoxine-pyrimethamine (AQSP): OR = 2.20; 95% CI 1.21-3.96; 8863 patients. Artesunate-amodiaquine (ASAQ) was comparable to AL (OR = 1.11; 95% CI 0.84-1.45; 21,235 patients). No significant difference was found between artesunate and mefloquine (ASMQ) and AL (OR = 1.20; 95% CI = 0.52-2.8; 13,824 participants). According to treatment ranking, among the WHO-recommended ACT medicines, DHAP was shown to be the most efficacious., Conclusions: Based on the available evidence, this study demonstrated the superiority of DHAP among currently recommended artemisinin-based combinations. The application of the methods described here may be helpful to gain better understanding of treatment efficacy and improve future decisions. However, more data are needed to allow robust conclusions about the results in comparison with novel drugs. Further surveillance of the efficacy of anti-malarial drugs and clinical trials are needed to closely follow the evolution of the epidemiology of drug-resistant malaria in Africa.

Primaquine, an 8-aminoquinoline, is a relatively unknown and underutilized drug in French-speaking African countries. It acts against the liver stage parasites of all human malaria species, asexual blood stages of Plasmodium vivax and, to a lesser degree, Plasmodium falciparum; P. falciparum mature gametocytes, and P. vivax and Plasmodium ovale hypnozoites. Gastrointestinal disturbances are its most common side effects. The clinical utility of primaquine is limited due to its hematological side effects in individuals with glucose-6-phosphate dehydrogenase (G6PD) deficiency and other contraindications (pregnant woman, breastfeeding woman, infants less than 6 months old). In the light of the recent recommendations of the World Health Organization (WHO), we propose to examine how primaquine can be used in French-speaking Africa to improve malaria control and move towards malaria elimination. Two indications supported by the WHO are of relevance in Africa. First, artemisinin-based combination therapies and primaquine given as a single low dose (0.25 mg base/kg) are effective to kill asexual and sexual parasites of P. falciparum, are well-tolerated, and have very little risk even in mild to moderate G6PD-deficient patients. This strategy may be helpful to contain transmission in an area in Africa where P. falciparum malaria incidence has decreased considerably. There is an ethical concern in administering primaquine as a gametocytocide as it does not confer any direct benefit to the treated patient. However, the single low-dose primaquine is most likely associated with very low risk for adverse hematological effects, and WHO recommends its use even without prior G6PD testing. In our opinion, clinical studies including G6PD test should be conducted to assess the safety of low-dose primaquine in African patients. Second, primaquine is effective and necessary for radical treatment of P. vivax and P. ovale, but the standard 14-day treatment (0.25-0.5 mg base/kg/day) is not recommended in patients with G6PD deficiency. Prior G6PD testing is required before prescribing primaquine for radical treatment. The use of primaquine for radical treatment in patients without contraindications does not raise any major ethical problem since the probability of relapse in patients who do not receive anti-hypnozoite treatment can be relatively high and each relapse can cause or aggravate anemia, especially in children. In our opinion, patients with mild or moderate G6PD deficiency should not be treated with primaquine at present. Further clinical studies are necessary to define the role of this drug for radical treatment in G6PD-deficient African patients. Without primaquine, the eventual elimination of P. vivax and P. ovale malaria appears to be very difficult. Updated epidemiological data on G6PD, Duffy antigen, and the current distribution of and burden due to P. vivax and P. ovale are required for a rational use of primaquine in the African continent. Moreover, clinical studies on primaquine are required in Africa.

Artemisinin-resistant malaria has not been reported from Africa, but resistance can possibly spread from Asia or arise independently in Africa. The emergence of artemisinin resistance in Africa can be monitored by molecular assay of Kelch 13 (K13) propeller sequences. A total of 251 archived DNA samples of Plasmodium falciparum isolates collected in 2002, 2003, and 2006 in Yaounde, Cameroon, and 47 samples collected in 2006 and 2013 in Abidjan, Côte d'Ivoire, were analyzed for K13-propeller sequence polymorphism. Only one isolate carried a mutant K13-propeller allele (E602D). None of the isolates carried the key mutant alleles (Y493H, R539T, I543T, and C580Y) associated with artemisinin resistance in Cambodia. The presence of the mutant allele was not correlated with in vitro response to dihydroartemisinin determined by the classical hypoxanthine incorporation assay. There was no evidence of K13 mutations associated with artemisinin resistance before and soon after the introduction of artemisinin-based combination therapies in Cameroon and Côte d'Ivoire.

Background: A malaria hotspot in the southeastern region of Mauritania, near the Malian border, may hamper malaria control strategies. The objectives were to estimate the prevalence of genetic polymorphisms associated with drug resistance in Plasmodium falciparum isolates and establish baseline data., Methods: The study was conducted in two malaria-endemic areas in Hodh Elgharbi, situated in the Malian-Mauritanian border area. Blood samples were collected from symptomatic patients. Single nucleotide polymorphisms in Pfcrt, Pfmdr1, Pfdhfr, and Pfdhps were genotyped using PCR-restriction fragment length polymorphism, DNA sequencing and primer extension. The Pfmdr1 gene copy number was determined by real-time PCR., Results: Of 280 P. falciparum-infected patients, 193 (68.9%) carried the Pfcrt 76T mutant allele. The Pfmdr1 86Y and 184F mutations were found in 61 (23.1%) of 264 isolates and 167 (67.6%) of 247 samples that were successfully genotyped, respectively. Pfmdr1 mutant alleles 1034C, 1042D and 1246Y were rarely observed. Of 102 P. falciparum isolates analysed, ten (9.8%) had more than one copy of Pfmdr1 gene. The prevalence of isolates harbouring at least triple mutant Pfdhfr 51I, 59R, 108 N/T was 42% (112/268), of which 42 (37.5%) had an additional Pfdhps 437G mutation. The Pfdhps 540E mutation was observed in four isolates (1.5%), including three associated with Pfdhfr triple mutant. Only two quintuple mutants (Pfdhfr-51I-59R-108N Pfdhps-437G-540E) were observed., Conclusions: The observed mutations in Pfdhfr, Pfdhps, Pfmdr1, and Pfcrt may jeopardize the future of seasonal malaria chemoprevention based on amodiaquine-sulfadoxine-pyrimethamine, intermittent preventive treatment for pregnant women using sulfadoxine-pyrimethamine, and treatment with artesunate-amodiaquine. Complementary studies should be carried out to document the distribution, origin and circulation of P. falciparum populations in this region and more widely in the country to assess the risk of the spread of resistance.

Summary: People living with HIV/AIDS (PLWHA) are often discriminated against in their daily lives. The objective of this descriptive and transversal study was to describe the experiences of PLWHA followed at a specialized outpatient center in Nouakchott to assess the forms of stigma from the perspective of those who suffer from discrimination., Methods: All HIV-positive patients over the age of 18 years who were aware of their HIV status and provided consent to participate in the study were included from June 1 to 29, 2015. Data collection was conducted using a pre-tested questionnaire., Results: A total of 210 PLWHA were interviewed. Men accounted for 54% of the sample population with a sex ratio of 1.2. About half of respondents were married (51%) and resided in Nouakchott (55%). Subjects who had never attended school represented 42% of the cases. Among our respondents, 64% knew their HIV status for over a year and admitted that they refused to reveal this information to any person. The distribution of forms of stigma experienced by PLWHA by demographic category was, in descending order, stigma in interpersonal relationships (78%), self-stigma (20%), and stigma in health services (2%). There was a significant association between the form of stigma and marital status (p = 0.007) and between the form of stigma and knowledge of HIV status for a period greater than one year (p = 0.02)., Conclusion: The forms of stigma can be sources of discrimination and are a major obstacle to reintegration and support of PLWHA. This creates a vicious circle that, on the one hand, leads to the suffering, marginalization, and isolation of PLWHA, and on the other hand, has deleterious effects on their family and social relationships, self-esteem and self-confidence.

Background: Chloroquine had been used extensively during the last five decades in Cameroon. Its decreasing clinical effectiveness, supported by high proportions of clinical isolates carrying the mutant pfcrt haplotype (CVIET), led the health authorities to resort to amodiaquine monotherapy in 2002 and artemisinin-based combination therapy (ACT) in 2004 (artesunate-amodiaquine, with artemether-lumefantrine as an alternative since 2006) as the first-line treatment of uncomplicated malaria. The aim of the present study was to investigate whether the withdrawal of chloroquine was associated with a reduction in pfcrt mutant parasite population and reemergence of chloroquine-sensitive parasites in southeastern Cameroon between 2003 and 2012., Methods: The frequency of pfcrt haplotypes at positions 72-76 in Plasmodium falciparum isolates collected from individuals in 2003 and 2012 in southeastern Cameroon was determined by sequence specific oligonucleotide probes-enzyme linked immunosorbent assay (SSOP-ELISA)., Results: The proportions of parasites carrying the mutant haplotype CVIET and the wild-type CVMNK were 53.0 and 28.0% in 2003, respectively. The proportion of the mutant haplotype in samples collected 9 years later decreased to 25.3% whereas the proportion of parasites carrying the wild-type CVMNK haplotype was 53.7%., Conclusions: Even though the proportion of chloroquine-sensitive parasites seems to be increasing in southeastern Cameroon, a reintroduction of chloroquine cannot be recommended at present in Cameroon. The current national anti-malarial drug policy should be implemented and reinforced to combat drug-resistant malaria.

Background: To successfully eliminate malaria, an integrated system that includes a number of approaches and interventions-aimed at overcoming the threat of antimalarial drug resistance-is required. Significant progress has been made in reducing malaria incidence through large-scale use of artemisinin-based combination therapies and insecticide-treated nets. To consolidate these gains, attention should be paid to the missing links in the elimination of malaria. One of these gaps is the residual reservoir of submicroscopic resistant parasites, which remains after case management or other control measures have been carried out. Therefore, the present opinion piece highlights the importance of exploring the role that submicroscopic resistant parasites could play in hindering malaria elimination by allowing the persistence of transmission, particularly in areas of low transmission or in the pre-elimination and/or elimination phase., Discussion: If malaria elimination interventions are to be effective, the relative role of the hidden reservoir of resistant parasites needs to be assessed, particularly in regions that are low-transmission settings and/or in pre-elimination and/or elimination phases. Various ongoing studies are focusing on the role of submicroscopic malaria infections in malaria transmission but overlook the possible build-up of resistance to antimalarial drugs among submicroscopic parasite populations. This is an important factor as it may eventually limit the effectiveness of malaria elimination strategies., Conclusions: An evidence-based estimation of the "true" reservoir of resistant parasites can help target the existing and emerging foci of resistant parasites before they spread. Emergence and spread of artemisinin-resistant Plasmodium falciparum malaria in Southeast Asia underline the need to contain drug resistance.

Background: Rift Valley Fever epizootics are characterized by numerous abortions and mortality among young animals. In humans, the illness is usually characterized by a mild self-limited febrile illness, which could progress to more serious complications.Objectives. The aim of the present prospective study was to describe severe clinical signs and symptoms of Rift Valley Fever in southern Mauritania., Patients and Methods: Suspected cases were enrolled in Kiffa (Assaba) and Aleg (Brakna) Hospital Centers from September 1 to November 7, 2015, based on the presence of fever, hemorrhagic or meningoencephalitic syndromes, and probable contact with sick animals. Suspected cases were confirmed by enzyme-linked immunosorbent assay (ELISA) and reverse transcriptase-polymerase chain reaction (RT-PCR)., Results: There were thirty-one confirmed cases. The sex ratio M/F and the average age were 2.9 and 25 years old [range, 4-70 years old], respectively. Mosquito bites, direct contact with aborted or dead animals, and frequent ingestion of milk from these animals were risk factors observed in all patients. Hemorrhagic and neurological manifestations were observed in 81% and 13% of cases, respectively. The results of laboratory analysis showed high levels of transaminases, creatinine, and urea associated with thrombocytopenia, anemia, and leukopenia. All patients who died (42%) had a hemorrhagic syndrome and 3 of them had a neurological complication. Among the cured patients, none had neurologic sequelae., Conclusion: The hemorrhagic form was the most common clinical manifestation of RVF found in southern Mauritania and was responsible for a high mortality rate. Our results justify the implementation of a continuous epidemiological surveillance.

Background: Until 2006, the Mauritanian Ministry of Health recommended chloroquine and sulfadoxine-pyrimethamine for first- and second-line treatment of uncomplicated malaria, respectively. This study assessed the clinical efficacy of sulfadoxine-pyrimethamine in Kobeni as first-line treatment., Materials and Methods: This study included 55 patients with Plasmodium falciparum infections, who were treated with sulfadoxine-pyrimethamine and followed up for 28 days. Isolates were genotyped to distinguish between recrudescence and reinfection. Treatment success rates and survival were analysed per protocol to evaluate drug efficacy., Results: After inclusion, 2 patients were excluded for protocol violations, and 3 patients were lost to follow-up. Of the remaining 50 patients (per protocol population), 43 (86%) had adequate clinical and parasitological responses. Of the 7 patients with treatment failure, 5 (10%) were early failures, while 2 (4%) had initially responded and had late clinical failure on day 7, associated with recrudescence. With the exception of one adult weighing 91 kg, all treatment failures occurred in children aged from 7 to 12 years., Conclusions: Sulfadoxine-pyrimethamine monotherapy was moderately effective but insufficiently reliable in view of the relatively high rate of early treatment failure. The high prevalence of chloroquine resistance found in earlier studies and the results of the present study on sulfadoxine-pyrimethamine justify the change in national policy and systematic use of artemisinin-based combination therapy for first-line treatment of P. falciparum malaria in Mauritania.

Background: Plasmodium falciparum infection can lead to several clinical manifestations ranging from asymptomatic infections (AM) and uncomplicated malaria (UM) to potentially fatal severe malaria (SM), including cerebral malaria (CM). Factors implicated in the progression towards severe disease are not fully understood., Methods: In the present study, an enzyme-linked immunosorbent assay (ELISA) method was used to investigate the plasma content of several biomarkers of the immune response, namely Neopterin, sCD163, suPAR, Pentraxin 3 (PTX3), sCD14, Fractalkine (CX3CL1), sTREM-1 and MIG (CXCL9), in patients with distinct clinical manifestations of malaria. The goal of this study was to determine the relative involvement of these inflammatory mediators in the pathogenesis of malaria and test their relevance as biomarkers of disease severity., Results: ROC curve analysis show that children with AM were characterized by high levels of Fractalkine and sCD163 whereas children with UM were distinguishable by the presence of PTX3 in their plasma. Furthermore, principal component analysis indicated that the combination of Fractalkine, MIG, and Neopterin was the best predictor of AM condition, while suPAR, PTX3 and sTREM-1 combination was the best indicator of UM when compared to AM. The association of Neopterin, suPAR and Fractalkine was strongly predictive of SM or CM compared to UM., Conclusions: The results indicate that the simultaneous evaluation of these bioactive molecules as quantifiable blood parameters may be helpful to get a better insight into the clinical syndromes in children with malaria.

Background: Malaria epidemiology in Mauritania has been characterized on the basis of epidemiological strata, defined by climatic and geographic features, which divide the country into three zones: Sahelian zone, Sahelo-Saharan transition zone, and Saharan zone. The association between geographic stratification and malaria transmission was assessed through a series of parasitological and entomological surveys., Methods: Surveys were conducted during the 'cool' dry season in 2011, 'hot' dry season in 2012, and rainy season in 2013 in a total of 12 sentinel sites. Finger-prick capillary blood samples were collected from children aged 2-9 years old in randomly selected households for microscopic examination and rapid diagnostic test for malaria. Adult mosquitoes were sampled by pyrethrum spray catch and CDC light traps and identified using morphological keys and molecular tools., Results: Of 3445 children included, 143 (4.15 %) were infected with malaria parasites including Plasmodium falciparum (n = 71, 2.06 %), Plasmodium vivax (57, 1.65 %), P. falciparum-P. vivax (2, 0.06 %), Plasmodium ovale (12, 0.35 %), and Plasmodium malariae (1, 0.03 %). A large majority of P. falciparum infections were observed in the Sahelo-Saharan zone. Malaria prevalence (P < 0.01) and parasite density (P < 0.001) were higher during the rainy season (2013), compared to cool dry season (2011). Plasmodium vivax was mainly observed in the Saharan region [43 of 59 (73 %) P. vivax infections], mostly in Nouakchott districts, with no significant seasonal variation. Of 3577 mosquitoes captured, 1014 (28.3 %) belonged to Anopheles spp. Anopheles gambiae was the predominant species in all three epidemiological strata during the 'cool' dry season in 2011 but was absent in all study sites, except for Teyarett district in Nouakchott, during the 'hot' dry season in 2012. During the rainy season in 2013, An. gambiae, Anopheles arabiensis, Anopheles pharoensis, and Anopheles rufipes were abundant in different zones., Conclusions: The results of the present study support the stratification of malaria in Mauritania. However, the Sahelian zone had the lowest malaria prevalence, while the Sahelo-Saharan zone had the highest malaria burden. Local changes due to anthropogenic factors (i.e., human migration, urbanization, malaria interventions) should be considered in order to optimize the control strategy.

Background: In the Republic of Congo, previous epidemiological studies have only been conducted in the south of the country where it is most accessible. Nationally representative data on the efficacy of new anti-malarial tools are lacking in the country. As an initial step to close the gap, clinical efficacy of two artemisinin-based combinations, artesunate-amodiaquine (ASAQ) and artemether-lumefantrine (AL), was assessed in Owando, a city in equatorial flooded forest in northern Republic of Congo., Methods: Under 12 years old febrile children attending public health facilities were screened for malaria parasites using lactate dehydrogenase (LDH)-based rapid diagnostic test (RDT) for malaria and microscopic examination of thick blood films. Patients with at least 1,000 asexual Plasmodium falciparum parasites/µl of blood were clinically examined, included after informed consent, and followed up for 28 days, according to the 2009 World Health Organization protocol. Patients were randomly assigned to co-formulated ASAQ (Coarsucam(®)) or AL (Coartem(®)) treatment groups. Plasmodium falciparum recrudescent isolates were compared to pre-treatment isolates by polymerase chain reaction (PCR) using msp1, msp2, and glurp genes to distinguish between re-infection and recrudescence., Results: Between November 2012 and February 2013, 857 under 12 years old febrile children were screened, of whom 198 (23.1%) had positive RDT and 167 (19.5%) positive thick films. ASAQ and AL efficacies were 92.7 and 94.2% before PCR correction, respectively. After genotyping, the overall efficacy was 100% for ASAQ and 98.0% for AL., Conclusion: The data reported here represent partially the burden of malaria in 0-11 years old febrile children examined in public health centres of Owando city and serve as reference for further studies. Both artemisinin-based combinations were highly efficacious in patients under 12 years old with acute uncomplicated malaria. ASAQ was associated with more adverse events, which may reduce compliance in unsupervised treatment., Trial Registration: ACTRN12612000940875.

Reliable epidemiological data based on laboratory-confirmed cases are scarce in Mauritania. A large majority of reported malaria cases are based on presumptive clinical diagnosis. The present study was conducted to establish a reliable database on malaria morbidity among febrile paediatric and adult patients consulting spontaneously at public health facilities in Nouakchott, situated in the Saharan zone, and in Hodh Elgharbi region in the Sahelian zone in south-east Mauritania during the peak transmission periods. Giemsa-stained thin and thick films were examined under the microscope, and the parasite density was determined according to the procedures recommended by the World Health Organization. Microscopy results were confirmed by rapid diagnostic test for malaria. A total of 1161 febrile patients (498 in Nouakchott and 663 in Hodh Elgharbi region) were enrolled during two successive peak transmission periods in 2009 and 2010. In Nouakchott, 253 (50.8%) febrile patients had positive smears (83% Plasmodium vivax monoinfections and 17% Plasmodium falciparum monoinfections). In Hodh Elgharbi, 378 of 663 patients (57.0%) were smear-positive, mostly due to P. falciparum monoinfections (96.6%). Unlike in Nouakchott, mixed P. falciparum-P. vivax infections, as well as P. vivax, P. ovale, and P. malariae monoinfections, were also observed at a very low prevalence in southern Mauritania. In Nouakchott, malaria occurred more frequently (P<0.05) with higher slide positivity rates (42-53%) among children aged >5 years old and adults than in young children aged <5 years old in both 2009 and 2010. In Hodh Elgharbi, high slide positivity rates (60.9-86.2%) were observed in all age groups in 2010, and there was no significant trend (P>0.05) in relation with age groups. The present study confirmed the predominance of P. falciparum in southern Mauritania reported in previous studies. The presence of P. vivax in Nouakchott is a new epidemiological reality that requires an urgent adoption of novel strategies for parasitological and vector control to combat urban malaria. Moreover, the present study provides evidence-based data on malaria burden in two regions in Mauritania that may serve as a springboard to establish and develop a national surveillance system of malaria epidemiology., (Copyright © 2015 Elsevier B.V. All rights reserved.)

Background: The Republic of Congo adopted a new anti-malarial treatment policy in 2006, with artesunate-amodiaquine (ASAQ) and artemether-lumefantrine (AL) as the first- and second-line anti-malarial drugs, respectively. Only three clinical studies had been conducted before the policy change. A randomized study on these two artemisinin-based combinations was conducted, and the effect that sickle cell trait may have on treatment outcomes was evaluated in children under 10 years old followed during 12 months in Brazzaville in 2010-2011., Methods: A cohort of 330 children under 10 years of age living in a suburban area in the south of Brazzaville were passively followed for registration of malaria episodes. Uncomplicated Plasmodium falciparum episodes were randomly treated with co-formulated ASAQ (Coarsucam(®)) or AL (Coartem(®)). Patients were followed according to the 2009 World Health Organization protocol for the evaluation of anti-malarial drug efficacy. Plasmodium falciparum recrudescent isolates were compared to pre-treatment isolates by polymerase chain reaction (PCR) to distinguish between re-infection and recrudescence. PCR-uncorrected and PCR-corrected responses to treatment were determined using per protocol analysis. Haemoglobin type (AA, AS, SS) was determined by PCR., Results: Of 282 clinical malaria episodes registered during 1-year follow-up period, 262 children with uncomplicated malaria were treated with ASAQ (129 patients) or AL (133 patients). The PCR-corrected efficacy, expressed as the percentage of adequate clinical and parasitological response, was 97.0 % for ASAQ and 96.4 % for AL. Among ASAQ-treated patients, 112 (86.8 %) carried AA genotype and 17 (13.2 %) were AS carriers. The PCR-corrected efficacy was 96.4 % for AA-carriers and 100 % for AS-carriers treated with ASAQ [relative risk (RR) = 0.96; 95 % confidence interval, 0.93-1.00, p = 0.5]. Among 133 AL-treated children, 109 (82 %) carried AA, and 24 (18 %) AS genotypes. The PCR-corrected efficacy was 96.7 % among AA-carriers and 95.2 % among AS-carriers [RR = 1.01 (0.92-1.12), p = 0.6]. Nausea, jaundice, headache, dizziness, vomiting, pruritus, abdominal pain, and diarrhoea were registered as adverse events in both groups. ASAQ was associated with significantly more frequent adverse events (P < 0.05)., Conclusion: This first randomized study in Brazzaville confirmed the excellent efficacy of these co-formulated anti-malarial drugs in children. Sickle cell genotype did not influence the treatment efficacy of artemisinin-based combination therapy.

Standard anti-malarial drug efficacy and drug resistance assessments neglect the gametocyte parameters in their protocols. With the spread of drug resistance and the absence of clinically proven vaccines, the use of gametocytocidal drugs or drug combinations with transmission-blocking activity is a high priority for malaria control and elimination. However, the limited repertoire of gametocytocidal drugs and induction of gametocytogenesis after treatment with certain anti-malarial drugs necessitate both regular monitoring of gametocytocidal activities of anti-malarial drugs in clinical use and the effectiveness of candidate gametocytocidal agents. Therefore, updating current protocols of anti-malarial drug efficacy is needed to reflect the effects of anti-malarial drugs or drug combinations on gametocyte carriage and gametocyte density along with asexual parasite density. Developing protocols of anti-malarial drug efficacy that include gametocyte parameters related to both microscopic and submicroscopic gametocytaemias is important if drugs or drug combinations are to be strategically used in transmission-blocking interventions in the context of malaria elimination. The present piece of opinion highlights the challenges in gametocyte detection and follow-up and discuss the need for including the gametocyte parameter in anti-malarial efficacy studies.

Background: The malaria situation has been worsening in Angola, partly due to armed conflict until the recent past and drug-resistant Plasmodium falciparum. Malaria transmission is heterogeneous within the country, and data on drug-resistant malaria in different parts of the country are incomplete. The aim of the present study was to evaluate resistance to 4-aminoquinolines and antifolate drugs in P. falciparum isolates collected in Benguela province, central Angola, using molecular markers., Methods: Fingerprick capillary blood was collected from asymptomatic children aged less than 15 years old during a household survey in and around Balombo town in 2010-2011. Samples were screened for P. falciparum by nested PCR. Molecular markers (P. falciparum dihydrofolate reductase [pfdhfr], P. falciparum dihydropteroate synthase [pfdhps], P. falciparum chloroquine resistance transporter [pfcrt], and P. falciparum multidrug-resistance gene 1 [pfmdr1]) were sequenced to determine the key codons associated with drug resistance., Results: A total of 60 blood samples were positive for P. falciparum. Most isolates with successful PCR amplification had mutant pfdhfr alleles, with either double mutant AICNI (69%) or triple mutant AIRNI (21%) haplotypes. A16V, S108T, and I164L substitutions were not found. Many of the isolates were carriers of either SGKAA (60%) or AGKAA (27%) pfdhps haplotype. K540E substitution was absent. There were only two pfcrt haplotypes: wild-type CVMNK (11%) and mutant CVIET (89%). Wild-type pfmdr1 NYSND haplotype was found in 19% of the isolates, whereas single mutant pfmdr1 YYSND and NFSND haplotypes occurred in 48% and 11%, respectively. Double mutant pfmdr1 haplotypes (YFSND and YYSNY) occurred rarely., Conclusions: The results suggest that the high prevalence of mutant pfcrt CVIET haplotype is in agreement with low clinical efficacy of chloroquine observed in earlier studies and that the double pfdhfr mutant AICNI and single pfdhps mutant SGKAA are currently the predominant haplotypes associated with antifolate resistance in Benguela province. The hallmark of clinical resistance observed in East Africa, i.e. triple pfdhfr mutant haplotype (AIRNI) and double pfdhps mutant haplotype (SGEAA), was absent. These molecular findings need to be further evaluated in parallel with clinical studies, in particular with the efficacy of intermittent preventive treatment using sulphadoxine-pyrimethamine in pregnant women and artesunate-amodiaquine for uncomplicated malaria.

Malaria has become a major public health problem in Mauritania since the 1990s, with an average of 181,000 cases per year and 2,233,066 persons at risk during 1995-2012. This paper provides the first publicly available overview of malaria incidence and distribution in Mauritania. Information on the burden and malaria species distribution is critical for guiding national efforts in malaria control. As the incidence of malaria changes over time, regular updates of epidemiological data are necessary.

The occurrence of Plasmodium vivax malaria was reported in Nouakchott, Mauritania in the 1990s. Several studies have suggested the frequent occurrence of P. vivax malaria among Nouakchott residents, including those without recent travel history to the southern part of the country where malaria is known to be endemic. To further consolidate the evidence for P. vivax endemicity and the extent of malaria burden in one district in the city of Nouakchott, febrile illnesses were monitored in 2012-2013 in the Teyarett health center. The number of laboratory-confirmed P. vivax cases has attained more than 2,000 cases in 2013. Malaria transmission occurs locally, and P. vivax is diagnosed throughout the year. Plasmodium vivax malaria is endemic in Nouakchott and largely predominates over Plasmodium falciparum., (© The American Society of Tropical Medicine and Hygiene.)

Background: In 2006, the Mauritanian Ministry of Health adopted a new therapeutic strategy based on the systematic use of artemisinin-based combination therapy (ACT), artesunate-amodiaquine and artemether-lumefantrine, for the first- and second-line treatment of uncomplicated malaria, respectively, regardless of Plasmodium spp. In the Saharan zone of the country, recent studies have shown that Plasmodium vivax largely predominates over Plasmodium falciparum. Anti-malarial drug response of P. vivax has not been evaluated in Mauritania. The aim of the present study was to evaluate the clinical efficacy and tolerance of chloroquine to treat P. vivax malaria in Mauritanian patients., Methods: Plasmodium vivax-infected patients aged > 6 months old were enrolled in Nouakchott and Atar in September-October 2013. Chloroquine was administered at the standard dose of 25 mg base/kg body weight over three days. Patients were followed until day 28, according to the standard 2009 World Health Organization protocol., Results: A total of 128 patients (67 in Nouakchott and 61 in Atar) were enrolled in the study. Seven patients (5.5%) were either excluded or lost to follow-up. Based on the per protocol analysis, chloroquine efficacy (adequate clinical and parasitological response) was 100%. Treatment was well-tolerated. One patient was excluded on day 1 due to urticaria and treated with artesunate-amodiaquine., Conclusions: Although the current national treatment guideline recommends artesunate-amodiaquine for the first-line treatment of uncomplicated malaria, including P. vivax malaria, chloroquine may still have an important role to play in anti-malarial chemotherapy in Mauritania. Further epidemiological studies are required to map the distribution of P. vivax and P. falciparum in the country.

Background: A regular evaluation of therapeutic efficacy in sentinel sites and a system of surveillance are required to establish treatment guidelines and adapt national anti-malarial drug policy to the rapidly changing epidemiology of drug-resistant malaria. The current anti-malarial treatment guideline in Mauritania, officially recommended since 2006, is based on artemisinin-based combination therapy. The aim of the present study was to evaluate clinical efficacy and tolerance of artesunate-amodiaquine, the first-line treatment for acute uncomplicated malaria, in Mauritanian paediatric and adult patients to validate its continued use in the country., Methods: Plasmodium falciparum-infected symptomatic patients aged > six months were enrolled in Kobeni and Timbedra in southern Mauritania in September to October 2013. Co-formulated artesunate-amodiaquine was administered at the recommended dose over three days. Patients were followed until day 28. Parasitological and clinical response was classified according to the standard 2009 World Health Organization protocol., Results: A total of 130 patients (65 in Kobeni and 65 in Timbedra) were enrolled in the study. Seventeen patients (13.1%) were either excluded (before PCR correction) or lost to follow-up. Based on the per protocol analysis, artesunate-amodiaquine efficacy (i.e., the proportion of adequate clinical and parasitological response) was 96.6% in Kobeni and 98.2% in Timbedra before PCR correction. Late clinical failure was observed in two patients in Kobeni and one patient in Timbedra. After PCR correction, the efficacy rate in the two study sites was 98.2%. On day 3, all patients were afebrile and had negative smears. Treatment was well tolerated., Conclusions: Artesunate-amodiaquine is well tolerated and highly efficacious for the treatment of uncomplicated P. falciparum malaria. In the majority of patients, fever and parasitaemia were rapidly cleared before day 3. The results support the national anti-malarial drug guideline for a continued use of artesunate-amodiaquine as a first-line drug for uncomplicated malaria in southern Mauritania.