1. Presented by MC. Pochong Uthaitas MC. Wuttipat Pusanasuwannasri 3 rd years medical cadet Phramongkutklao college of medicine 1 1

2. Background 2 2 Increasing in mortality rate of severe vivax malaria

3. Objectives To describe the geographical variation in prevalence of severe vivax malaria To describe the different presenting syndromes and characteristics 3

4. Methods Systematic reviews and meta analysis 4 4

5. Search term and search strategy Selection criteria Bias assessment and quality assurerance Data analysis Methods Search term and search strategy Patients: (1) Plasmodium vivax, (2) Severe OR complicated, (3) 1 AND 2. Outcomes: (4) Cerebral complication, (5) Convulsions, (6) Kidney injury, (7) Renal failure, (8) Hemoglobinuria, (9) Circulatory collapse, (10) Shock, (11) Jaundice, (12) Hyperbilirubinemia, (13) Hepatic dysfunction, (14) Bleeding, (15) Hemorrhage, (16) Thrombocytopenia, (17) Disseminated intravascular coagulation, (18) DIC, (19) Acute respiratory distress syndrome, (20) ARDS, (21) Pulmonary edema, (22) Metabolic acidosis, (23) Hyperlactatemia, (24) Severe anemia, (25) Hypoglycemia, (26) Death 5 5

6. Methods Search term and search strategy Selection criteria Bias assessment and quality assurerance Data analysis Selection criteria Inclusion criteria Thrombocytopenia and severe falciparum criteria Exclusion criteria Duplicate reporting Mixed infections Insufficient data 6 6

7. Methods Search term and search strategy Selection criteria Bias assessment and quality assurerance Data analysis Bias assessment and quality assurerance Eligibility for inclusion of every article was reviewed by independent reviewers Disagreements between reviews were validated by an independent person 7 7

8. Search Terms Patients: (1) Plasmodium vivax, (2) Severe OR complicated, (3) 1 AND 2. Outcomes: ( 4) Cerebral complication, (5) Convulsions, (6) Kidney injury, (7) Renal failure, (8) Hemoglobinuria, (9) Circulatory collapse, (10) Shock, (11) Jaundice, (12) Hyperbilirubinemia, (13) Hepatic dysfunction, (14) Bleeding, (15) Hemorrhage, (16) Thrombocytopenia, (17) Disseminated intravascular coagulation, (18) DIC, (19) Acute respiratory distress syndrome, (20) ARDS, (21) Pulmonary edema, (22) Metabolic acidosis, (23) Hyperlactatemia, (24) Severe anemia, (25) Hypoglycemia, (26) Death 8 8

9. Search strategy Medline (PubMed): (27) 4 OR 5 OR 6 OR 7 OR 8 OR 9 OR 10 OR 11 OR 12 OR 13 OR 14 OR 15 OR 16 OR 17 OR 18 OR 19 OR 20 OR 21 OR 22 OR 23 OR 24 OR 25 OR 26, (28) 3 AND 27. Scopus (Scopus): (27) 4 OR 5, (28) 6 OR 7 OR 8, (29) 9 OR 10, (30) 11 OR 12 OR 13, (31) 14 OR 15 OR 16, (32) 17 OR 18, (33) 19 OR 20 OR 21, (34) 27 OR 28 OR 29 OR 30 OR 31 OR 32 OR 33, (35) 34 OR 22 OR 23 OR 24 OR 25 OR 26, (36) 3 AND 35. 9 9

10. Statistical analysis Software STATA version 12 was used for statistical analysis 10 10

11. Results Medline 274 studies + Scopus 412 studies 686 studies - 289 Duplicated - 278 Ineligibility criteria 56 studies with severe vivax 63 studies with no severe vivax 11 11

12. Results + 21 studies before 1949 77 studies with severe vivax 56 studies with severe vivax Geographical origin : from 77 studies 42 (54.5%) South-east Asia 17 (22.1%) Americas 10 (13.0%) Eastern-Mediterranean 8 (10.4%) Western pacific 12 12 Results for 1 st objective

13. Results for 2 nd objective To describe the geographical variation in prevalence of severe vivax malaria To describe the different presenting syndromes and characteristics 13 13

14. Results 14 14 Severe Thrombocytopenia 52528 888 4.7 2.3-7.0

15. Results Severe Thrombocytopenia 45775 888 8.6 5.4-11.8 15 15

16. Results 16 16

17. Severe vivax malaria - increase large number in non-endermic area; India - In patient with vivax malaria mortality rate was 28.2% Most prevalent severity sign reported was thrombocytopenia(26.1%) Discussion 17 17

18. 1944 0.4% 1982 2.2% Present 15.0% 18 One contributor to this discrepancy is the inclusion of thrombocytopenia as a severity criterion in recent series Prevalence of severe vivax in India 18

19. Unclear description of Chloroquine resistance except in the island of new Guinea, Indonesia Papua and Amazonas Discussion 19 19

20. Discussion Misdiagnosis caused by other febrile illness and co-infection Non endemic area Endemic area 20 20

21. Change in strain virulence Discussion Increase in reported cases No hard data available to support this hypothesis 21 21

22. Conclusion Increase in reported case of severe vivax in certain geographical region Cannot be explained with the current knowledge The use of thrombocytopenia as an independent severity criterion required justification 22 22

23.  Title Systematic review and meta-analysis  Abstract Provide structured summary  Introduction Clear objectives Critical appraisal 23

24.  Methods Search strategy Search term Eligibility criteria Information source Bias assessment Critical appraisal 24  Results Precise Reasonable

25. 25