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      Comparison of the diagnostic performance of microscopic examination with nested polymerase chain reaction for optimum malaria diagnosis in Upper Myanmar

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          Accurate diagnosis of Plasmodium infection is crucial for prompt malaria treatment and surveillance. Microscopic examination has been widely applied as the gold standard for malaria diagnosis in most part of malaria endemic areas, but its diagnostic value has been questioned, particularly in submicroscopic malaria. In this study, the diagnostic performance of microscopic examination and nested polymerase chain reaction (PCR) was evaluated to establish optimal malaria diagnosis method in Myanmar.


          A total of 1125 blood samples collected from residents in the villages and towns located in Naung Cho, Pyin Oo Lwin, Tha Beik Kyin townships and Mandalay of Upper Myanmar were screened by microscopic examination and species-specific nested PCR method.


          Among the 1125 blood samples, 261 samples were confirmed to be infected with malaria by microscopic examination. Evaluation of the 1125 samples by species-specific nested PCR analysis revealed that the agreement between microscopic examination and nested PCR was 87.3% (261/299). Nested PCR successfully detected 38 Plasmodium falciparum or Plasmodium vivax infections, which were missed in microscopic examination. Microscopic examinations also either misdiagnosed the infected Plasmodium species, or did not detect mixed infections with different Plasmodium species in 31 cases.


          The nested PCR method is more reliable than conventional microscopic examination for the diagnosis of malaria infections, and this is particularly true in cases of mixed infections and submicroscopic infections. Given the observed higher sensitivity and specificity of nested PCR, the molecular method holds enormous promise in malaria diagnosis and species differentiation, and can be applied as an effective monitoring tool for malaria surveillance, control and elimination in Myanmar.

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          Most cited references 56

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          A review of malaria diagnostic tools: microscopy and rapid diagnostic test (RDT).

          The absolute necessity for rational therapy in the face of rampant drug resistance places increasing importance on the accuracy of malaria diagnosis. Giemsa microscopy and rapid diagnostic tests (RDTs) represent the two diagnostics most likely to have the largest impact on malaria control today. These two methods, each with characteristic strengths and limitations, together represent the best hope for accurate diagnosis as a key component of successful malaria control. This review addresses the quality issues with current malaria diagnostics and presents data from recent rapid diagnostic test trials. Reduction of malaria morbidity and drug resistance intensity plus the associated economic loss of these two factors require urgent scaling up of the quality of parasite-based diagnostic methods. An investment in anti-malarial drug development or malaria vaccine development should be accompanied by a parallel commitment to improve diagnostic tools and their availability to people living in malarious areas.
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            Identification of the four human malaria parasite species in field samples by the polymerase chain reaction and detection of a high prevalence of mixed infections.

            Genus- and species-specific sequences are present within the small subunit ribosomal RNA genes of the four human malaria parasites. Oligonucleotide primer pairs specific to each species were designed for specific amplification by the Polymerase Chain Reaction (PCR), to detect each malaria species. DNA equivalent to 5 microliters of blood was sufficient for the detection of each of the species. Blood samples obtained from 196 patients attending a malaria clinic in Trad province (Thailand) were analyzed. Detection and identification of the parasites, solely by electrophoretic analysis of the PCR products, has proven to be more sensitive and accurate than by routine diagnostic microscopy. A high proportion of mixed species infections were brought to light by the PCR assay. Implications for medical treatment and epidemiological studies are discussed.
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              Spread of artemisinin-resistant Plasmodium falciparum in Myanmar: a cross-sectional survey of the K13 molecular marker

              Summary Background Emergence of artemisinin resistance in southeast Asia poses a serious threat to the global control of Plasmodium falciparum malaria. Discovery of the K13 marker has transformed approaches to the monitoring of artemisinin resistance, allowing introduction of molecular surveillance in remote areas through analysis of DNA. We aimed to assess the spread of artemisinin-resistant P falciparum in Myanmar by determining the relative prevalence of P falciparum parasites carrying K13-propeller mutations. Methods We did this cross-sectional survey at malaria treatment centres at 55 sites in ten administrative regions in Myanmar, and in relevant border regions in Thailand and Bangladesh, between January, 2013, and September, 2014. K13 sequences from P falciparum infections were obtained mainly by passive case detection. We entered data into two geostatistical models to produce predictive maps of the estimated prevalence of mutations of the K13 propeller region across Myanmar. Findings Overall, 371 (39%) of 940 samples carried a K13-propeller mutation. We recorded 26 different mutations, including nine mutations not described previously in southeast Asia. In seven (70%) of the ten administrative regions of Myanmar, the combined K13-mutation prevalence was more than 20%. Geospatial mapping showed that the overall prevalence of K13 mutations exceeded 10% in much of the east and north of the country. In Homalin, Sagaing Region, 25 km from the Indian border, 21 (47%) of 45 parasite samples carried K13-propeller mutations. Interpretation Artemisinin resistance extends across much of Myanmar. We recorded P falciparum parasites carrying K13-propeller mutations at high prevalence next to the northwestern border with India. Appropriate therapeutic regimens should be tested urgently and implemented comprehensively if spread of artemisinin resistance to other regions is to be avoided. Funding Wellcome Trust–Mahidol University–Oxford Tropical Medicine Research Programme and the Bill & Melinda Gates Foundation.

                Author and article information

                Malar J
                Malar. J
                Malaria Journal
                BioMed Central (London )
                16 March 2017
                16 March 2017
                : 16
                [1 ]ISNI 0000 0001 0661 1492, GRID grid.256681.e, Department of Parasitology and Tropical Medicine, and Institute of Health Sciences, , Gyeongsang National University School of Medicine, ; Jinju, 52727 Republic of Korea
                [2 ]ISNI 0000 0001 0661 1492, GRID grid.256681.e, BK21Plus Team for Anti-Aging Biotechnology and Industry, Department of Convergence Medical Science, , Gyeongsang National University, ; Jinju, 52727 Republic of Korea
                [3 ]ISNI 0000 0001 2364 8385, GRID grid.202119.9, Department of Tropical Medicine and Inha Research Institute for Medical Sciences, , Inha University School of Medicine, ; Incheon, 22212 Republic of Korea
                [4 ]Department of Medical Research Pyin Oo Lwin Branch, Pyin Oo Lwin, Myanmar
                [5 ]ISNI 0000 0001 0842 2126, GRID grid.413967.e, Department of Convergence Medicine, , University of Ulsan College of Medicine and Asan Institute for Life Sciences, Asan Medical Center, ; Seoul, 05505 Republic of Korea
                © The Author(s) 2017

                Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (, which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( applies to the data made available in this article, unless otherwise stated.

                Funded by: NRF-2015K1A3A9A01034893
                Award ID: NRF-2015K1A3A9A01034893
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                Funded by: NRF-2015R1A2A2A01004310
                Award ID: NRF-2015R1A2A2A01004310
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