Plasmodium knowlesi infection in a returning German traveller from Thailand: a case report on an emerging malaria pathogen in a popular low-risk travel destination

Background: Thailand is a major destination for German travellers with more than 760,000 arrivals in 2015. At the same time, malaria is a concern in travel recommendations with regard to this destination. The World Malaria Report of 2016 mentions only P. falciparum and P. vivax as prevalent species for Thailand, however, P. knowlesi infections have been occasionally reported in Thailand. In German travellers, only five cases of P. knowlesi infections have been reported to date. Case presentation: A 45-year-old German male tourist travelled to Thailand from 25 December 2016 to 13 January 2017. On 14 January he developed fever with no other symptoms, and presented on 17 January at the Division for Tropical Medicine and Infectious Diseases in Munich, Germany. Malaria was diagnosed, primarily based on a single parasite in the thin smear microscopy, while commercial rapid diagnostic testing remained negative. Only the result of a differential PCR assay revealed P. knowlesi infection. Conclusions: P. knowlesi has to be considered in travellers returning from Thailand. Cases may present with an extremely low parasitaemia. This is in contrast to the assumption that P. knowlesi was likely to cause high parasitaemia due to its short replication cycle

Trends in the incidence of AIDS-defining and non-AIDS-defining cancers in people living with AIDS: a population-based study from Sao Paulo, Brazil

People living with AIDS are at increased risk of developing certain cancers. Since the introduction of the highly active antiretroviral therapy (HAART), the incidence of AIDS-defining cancers (ADCs) has decreased in high-income countries. The objective of this study was to analyse trends in ADCs and non-AIDS-defining cancers (NADCs) in HIV-positive people with a diagnosis of AIDS, in comparison to the general population, in Sao Paulo, Brazil. A probabilistic record linkage between the 'Population-based Cancer Registry of Sao Paulo' and the AIDS notification database (SINAN) was conducted. Cancer trends were assessed by annual per cent change (APC). In people with AIDS, 2074 cancers were diagnosed. Among men with AIDS, the most frequent cancer was Kaposi's sarcoma (469;31.1%), followed by non-Hodgkin lymphoma (NHL;304;20.1%). A decline was seen for ADCs (APC = -14.1%). All NADCs have increased (APC = -7.4%/year) significantly since the mid-2000s driven by the significant upward trends of anal (APC = -24.6%/year) and lung cancers (APC = -15.9%/year). In contrast, in men from the general population, decreasing trends were observed for these cancers. For women with AIDS, the most frequent cancer was cervical (114;20.2%), followed by NHL (96;17.0%). Significant declining trends were seen for both ADCs (APC = -15.6%/ year) and all NADCs (APC = -15.8%/ year), a comparable pattern to that found for the general female population. Trends in cancers among people with AIDS in Sao Paulo showed similar patterns to those found in developed countries. Although ADCs have significantly decreased, probably due to the introduction of HAART, NADCs in men have shown an opposite upward trend

Morbidity profile and sociodemographic characteristics of unaccompanied refugee minors seen by paediatric practices between October 2014 and February 2016 in Bavaria, Germany

Background: This study aimed to investigate the morbidity profile and the sociodemographic characteristics of unaccompanied refugee minors (URM) arriving in the region of Bavaria, Germany, between October 2014 and February 2016. Methods: The retrospective cross sectional study included 154 unaccompanied refugee minors between 10 and 18 years of age. The data was derived from medical data records of their routine first medical examination in two paediatric practices and one collective housing for refugees in the region of Bavaria, Germany. Results: Only 12.3% of all participants had no clinical finding at arrival. Main health findings were skin diseases (31.8%) and mental disorders (25%). In this cohort the hepatitis A immunity was 92.8%, but only 34.5% showed a constellation of immunity against hepatitis B. Suspect cases for tuberculosis were found in 5.8% of the URM. There were no HIV positive individuals in the cohort. Notably, 2 females were found to have undergone genital mutilations. Conclusions: The majority of arriving URM appear to have immediate health care needs, whereas the pathologies involved are mostly common entities that are generally known to the primary health care system in Germany. Outbreaks due to hepatitis A virus are unlikely since herd immunity can be assumed, while this population would benefit from hepatitis B vaccination due to low immunity and high risk of infection in crowded housing conditions. One key finding is the absence of common algorithms and guidelines in health care provision to URM

Beyond Ebola treatment units: severe infection temporary treatment units as an essential element of Ebola case management during an outbreak

In the course of the Ebola outbreak in West Africa that was witnessed since early 2014, the response mechanisms showed deficits in terms of timeliness, volume and adequacy. The authors were deployed in the Ebola campaign in the West African country Liberia, where by September 2014 the changing epidemiological pattern made reconsiderations of guidelines and adopted procedures necessary. A temporary facility set up as a conventional Ebola Treatment Unit in the Liberian capital Monrovia was re- dedicated into a Severe Infections Temporary Treatment Unit. This facility allowed for stratification based on the nosocomial risk of exposure to Ebola virus for a growing subgroup of admitted patients that in the end would turn out as Ebola negative cases. At the same time, adequate diagnostic measures and treatment for the non- Ebola conditions of these patients could be provided without compromising work safety of the employed staff. The key elements of the new unit comprised a Suspect Cases Area similar to that of conventional Ebola treatment units for newly arriving patients, an Unlikely Cases Area for patients with a first negative Ebola PCR result, and a Confirmed Negative Cases Area for patients in whom Ebola could be ruled out. The authors, comprising representatives of the Liberian Ministry of Health and Social Welfare, as well as infectious disease specialists from the German Ebola Task Force are presenting key features of the adapted concept, and are highlighting its relevance in raising acceptance for outbreak counter- measures within the population at stake

Non-communicable diseases (NCDs) in developing countries: a symposium report

In recent years, non-communicable diseases (NCDs) have globally shown increasing impact on health status in populations with disproportionately higher rates in developing countries. NCDs are the leading cause of mortality worldwide and a serious public health threat to developing countries. Recognizing the importance and urgency of the issue, a one-day symposium was organized on NCDs in Developing Countries by the CIHLMU Center for International Health, Ludwig-Maximilians-Universität, Munich on 22nd March 2014. The objective of the symposium was to understand the current situation of different NCDs public health programs and the current trends in NCDs research and policy, promote exchange of ideas, encourage scientific debate and foster networking, partnerships and opportunities among experts from different clinical, research, and policy fields. The symposium was attended by more than seventy participants representing scientists, physicians, academics and students from several institutes in Germany and abroad. Seven key note presentations were made at the symposium by experts from Germany, UK, France, Bangladesh and Vietnam. This paper highlights the presentations and discussions during the symposium on different aspects of NCDs in developing countries. The symposium elucidated the dynamics of NCDs in developing countries and invited the participants to learn about evidence-based practices and policies for prevention and management of major NCDs and to debate the way forward

Determination of clusters and factors associated with dengue dispersion during the first epidemic related to Dengue virus serotype 4 in Vitoria, Brazil

Dengue occurrence is partially influenced by the immune status of the population. Consequently, the introduction of a new Dengue virus serotype can trigger explosive epidemics in susceptible populations. The determination of clusters in this scenario can help to identify hotspots and understand the disease dispersion regardless of the influence of the population herd immunity. The present study evaluated the pattern and factors associated with dengue dispersion during the first epidemic related to Dengue virus serotype 4 in Vitoria, Espirito Santo state, Brazil. Data on 18,861 dengue cases reported in Vitoria from September 2012 to June 2013 were included in the study. The analysis of spatial variation in temporal trend was performed to detect clusters that were compared by their respective relative risk, house index, population density, and income in an ecological study. Overall, 11 clusters were detected. The time trend increase of dengue incidence in the overall study population was 636%. The five clusters that showed a lower time trend increase than the overall population presented a higher incidence in the beginning of the epidemic and, compared to the six clusters with higher time trend increase, they presented higher relative risk for their inhabitants to acquire dengue infection (P-value = 0.02) and a lower income (P-value < 0.01). House index and population density did not differ between the clusters. Early increase of dengue incidence and higher relative risk for acquiring dengue infection were favored in low-income areas. Preventive actions and improvement of infrastructure in low-income areas should be prioritized in order to diminish the magnitude of dengue dispersion after the introduction of a new serotype

Evidence for significant influence of host immunity on changes in differential blood count during malaria

Background: Malaria has been shown to change blood counts. Recently, a few studies have investigated the alteration of the peripheral blood monocyte-to-lymphocyte count ratio (MLCR) and the neutrophil-to-lymphocyte count ratio (NLCR) during infection with Plasmodium falciparum. Based on these findings this study investigates the predictive values of blood count alterations during malaria across different sub-populations. Methods: Cases and controls admitted to the Department of Infectious Diseases and Tropical Medicine from January 2000 through December 2010 were included in this comparative analysis. Blood count values and other variables at admission controlled for age, gender and immune status were statistically investigated. Results: The study population comprised 210 malaria patients, infected with P. falciparum (68%), Plasmodium vivax (21%), Plasmodium ovale (7%) and Plasmodium malariae (4%), and 210 controls. A positive correlation of parasite density with NLCR and neutrophil counts, and a negative correlation of parasite density with thrombocyte, leucocyte and lymphocyte counts were found. An interaction with semi-immunity was observed; ratios were significantly different in semi-immune compared to non-immune patients (P <0.001). The MLCR discriminated best between malaria cases and controls (AUC = 0.691; AUC = 0.741 in non-immune travellers), whereas the NLCR better predicted severe malaria, especially in semi-immune patients (AUC = 0.788). Conclusion: Malaria causes typical but non-specific alterations of the differential blood count. The predictive value of the ratios was fair but limited. However, these changes were less pronounced in patients with semi-immunity. The ratios might constitute easily applicable surrogate biomarkers for immunity

Where is the 'global' in the European Union's Health Research and Innovation Agenda?

Global Health has not featured as prominently in the European Union (EU) research agenda in recent years as it did in the first decade of the new millennium, and participation of low-income and middle-income countries (LMICs) in EU health research has declined substantially. The Horizon Europe Research and Innovation Framework adopted by the European Parliament in April 2019 for the period 2021-2027 will serve as an important funding instrument for health research, yet the proposed health research budget to be finalised towards the end of 2019 was reduced from 10% in the current framework, Horizon 2020, to 8% in Horizon Europe. Our analysis takes the evolvement of Horizon Europe from the initial framework of June 2018 to the framework agreed on in April 2019 into account. It shows that despite some improvements in terms of Global Health and reference to the Sustainable Development Goals, European industrial competitiveness continues to play a paramount role, with Global Health research needs and relevant health research for LMICs being only partially addressed. We argue that the globally interconnected nature of health and the transdisciplinary nature of health research need to be fully taken into account and acted on in the new European Research and Innovation Framework. A facilitated global research collaboration through Horizon Europe could ensure that Global Health innovations and solutions benefit all parts of the world including EU countries

Retrospective clinical case series study in 2017 identifies Plasmodiumknowlesi as most frequent Plasmodium species in returning travellers from Thailand to Germany

Febrile illnesses are common in travellers returning from south-east Asia. However, malaria is a rare diagnosis in this population. A series of Plasmodium knowlesi infections was noted in German travellers returning from Thailand since 2012. Infectious disease and tropical medicine facilities registered by the German Society for Tropical Medicine and International Health were contacted in March 2017, and asked to report previous P. knowlesi cases. In addition, surveillance data from the Robert Koch-Institute were analysed. The facilities reported a total of six P. knowlesi-positive cases, all were returning travellers from Thailand. The P. knowlesi-positive cases made up 6/9 of all diagnosed malaria cases imported from Thailand in the time period 2012 to 2017. In 4/5 of cases where a malaria rapid diagnostic test had been applied it revealed a negative result. P. knowlesi is an important differential diagnosis in travellers returning from south-east Asia with itineraries that include Thailand. This study highlights the importance of this Plasmodium species in this patient subgroup. Whenever malaria is suspected in a returning traveller from Thailand, P. knowlesi should be taken into consideration and a differential PCR be executed as currently the unequivocal diagnosis of P. knowlesi is based on nuclear amplification techniques

Serotype influences on dengue severity: a cross-sectional study on 485 confirmed dengue cases in Vitória, Brazil

Abstract Background Dengue is caused by a RNA virus of the family Flaviviridae, which presents four serotypes (DENV-1 to DENV-4) capable of inducing hemorrhage. The purpose of this study was to evaluate the influence of serotype on the outcome of dengue. Methods This cross-sectional study included data from dengue cases with serotyping results that occurred between 2009 and 2013 in Vitória, Espírito Santo, Brazil. Data were accessed through the Information System for Notifiable Diseases. Chi-square test, Fisher exact test, Mann–Whitney U test, and logistic regression were performed to assess associations between different serotypes and dengue severity, while considering gender and age. Results The sample consisted of 485 laboratory confirmed dengue cases, of which 46.4 % were females, with median age of 26 years. Regarding overall samples, 77.3 % were caused by DENV-1, 16.1 % by DENV-4, 6.4 % by DENV-2, and 0.2 % by DENV-3. Severe dengue affected 6.6 % of all cases, of which 32.3 % of the cases caused by DENV-2, 6.4 % of those caused by DENV-4, 4.5 % of those caused by DENV-1, and none of those caused by DENV-3. Severe dengue was found to be seven times more frequent among cases of DENV-2 than among those of the other serotypes. Conclusions The present study found that cases of DENV-2 had a higher proportion of severe dengue than among those of DENV-1 and DENV-4. Consequently, early detection of serotypes circulating in the territory could be an important approach to prevent increasing numbers of severe outcomes during dengue outbreaks by predicting the health support needed for early diagnoses and treatment of dengue cases