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"Anemia remains health problem in developing countries including Indonesia especially the Eastern part despite many to efforts to solve the problem. Anemia has cost lives of many people by its complex mechanism in the body and health of individual in general. The consequences of anemia are not only life loss but also reduction of intellectual ability especially in school children. The magnitude of anemia among school children needs to be understood to optimize clinical and public health programs to improve nutritional and health status of children in developing countries. The objective of the study was to find the association between anemia and malaria together with other determinant factors among school children 6-10 years of Alor district.This report was prepared to partially fulfill the requirements for the degree of Masters of Science in Community Nutrition at the Faculty of Medicine Postgraduate Pro gram. University of Indonesia.This report is divided into three parts as follows:The first part is introduction-explaining background of the study, problem statement, literature review, causal model, hypothesis, objectives as well as variable-indicator-matrix. The literature review intentionally focused magnitude of anemia and causes of anemia such as malaria infection, worm infestation, chronic diseases, dietary intake and socioeconomic factors."

"Malaria masih menjadi masalah di Indonesia termasuk di Sulawesi Utara dengan Annual parasite incidence(API) 0,35. Parasitemia dapat menyebabkan perubahan profil hematologi.Adanya asosiasi antara parasitemia dengan profil hematologi,sehingga kegunaannya sebagai indikator pemeriksaan laboratorium malaria perlu diteliti.Penelitian ini bertujuan untuk mengetahui profil hematologi (Hb, hitung leukosit dan trombosit) pada penderita malaria rawat inap di daerah hipoendemis ) dan hubungannya dengan hitung parasit. Penelitian ini potong lintang menggunakan data rekam medis pasien malaria rawat inap dari tiga RS di kota Manado, kota Bitung and kab Minahasa Tenggara, Sulawesi Utara yang positif P. vivax atau P. falciparum dan memiliki data hematologi serta hitung parasit. Analisis data dan asosiasi menggunakan uji statistik bivariat pada perangkat lunak SPSS. Sebanyak 65 rekam medis pasien malaria berusia 1 bulan – 67 tahun dianalisis dan didapatkan 28 pasien (43,1%) terinfeksi Plasmodinum falciparum, 37 pasien (56,9%) terinfeksi P. vivax; pasien anak terdiri dari 10.8% balita dan 9,2% anak SD yang tinggal di kota Manado, Bitung dan kab Minahasa tenggara. Kelainan hematologi yang dominan adalah trombositopeni (90,3%), diikuti oleh anemia (61,6%). Sedangkan hitung lekosit umumnya normal, 15,4% lekopeni dan 12,3% lekositosis. Penderita malaria falciparum mengalami trombositopenia sedang-berat sedangkan malaria vivax ringan-berat, perbedaan ini bermakna pada uji statistik (p=0.034, p<0.05). Anemia yang terjadi pada subyek bersifat ringan sampai berat dan tidak ada perbedaan bermakna antara malaria falciparum dan vivax (p=0,278, p>0,05). Pada penghitungan parasitemia, 64,6% pasien dengan hitung parasit sedang, proporsi parasitemia sedang lebih banyak pada penderita malaria vivax dibanding malaria falciparum (78,4% versus 46,4).Pada P. vivax kadar trombosit berbanding terbalik dengan hitung parasit walaupun secara statistik tidak signifikan. Pada P. vivax kadar Hb dan leukosit tidak ada perbandingan terbalik dengan hitung parasit.Pada Plasmodinum falciparum kadar Hb,trombosit dan leukosit tidak ada perbandingan terbalik dengan hitung parasit.Tombositopenia merupakan parameter hematologi yang dapat menjadi indicator untuk penegakkan diagnosis malaria lebih lanjut.

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Malaria is still a problem in Indonesia, including in North Sulawesi with an annual parasite incidence (API) of 0.35. Parasitemia can cause changes in the hematological profile. There is an association between parasitemia and the hematological profile, so its use as an indicator for malaria laboratory tests needs to be studied. This research aims to determine the hematological profile (Hb, leukocyte and platelet count) in hospitalized malaria sufferers in hypoendemic areas) and relationship with parasite count.This cross- sectional study used medical record data from inpatient malaria patients from three hospitals in Manado city, Bitung city and Southeast Minahasa district, North Sulawesi who were positive for P. vivax or P. falciparum and had hematology data and parasite counts. Data and association analysis used bivariate statistical tests in SPSS software. A total of 65 medical records of malaria patients aged 1 month – 67 years were analyzed and it was found that 28 patients (43.1%) were infected with Plasmodinum falciparum, 37 patients (56.9%) were infected with P. vivax; Pediatric patients consist of 10.8% toddlers and 9.2% elementary school children living in the cities of Manado, Bitung and southeast Minahasa district. The predominant hematological disorder was thrombocytopenia (90.3%), followed by anemia (61.6%). Meanwhile, the leukocyte count was generally normal, 15.4% leukopenia and 12.3% leukocytosis. Patients with falciparum malaria experienced moderate-severe thrombocytopenia while vivax malaria had mild-severe, this difference was significant in statistical tests (p=0.034, p<0.05). The anemia that occurred in the subjects was mild to severe and there was no significant difference between falciparum and vivax malaria (p=0.278, p>0.05). In calculating parasitemia, 64.6% of patients had a moderate parasitemia count, the proportion of moderate parasitemia was greater in vivax malaria sufferers than falciparum malaria (78.4% versus 46.4). statistically insignificant. In P. vivax there is no inverse comparison of Hb and leukocyte levels with the parasite count. In Plasmodinum falciparum there is no inverse comparison of the Hb, platelet and leukocyte levels with the parasite count. Thrombocytopenia is a hematological parameter that can be an indicator for further diagnosis of malaria."

"Malaria merupakan penyakit menular yang penyebab utamanya adalah parasite (Protozoa) dari genus Plasmodium. Masih tingginya kejadian malaria di Kab. Belu Nusa Tenggara Timur Indonesia. Tujuan dari penelitian ini untuk menganalisis dan mengukur besarnya faktor risiko yang berhubungan terhadap kejadian malaria. Penelitian ini menggunakan desain study cross-sectional. Penelitian ini merupakan bagian dari penelitian mass screening & selective treatment oleh Sutanto et al pada tahun 2013 di Kabupaten Belu, NTT, Indonesia. Jumlah sampel dalam penelitian sebanyak 1113 Subjek. Analisis menggunakan cox regression dengan tingkat kemaknaan α = 5% dan nilai confidence interval 95%. Hasil analisis multivariat dengan cox regression, menunjukkan faktor risiko yang berhubungan dengan kejadian malaria di Kab. Belu NTT yaitu umur PR 4.901 95% CI (3.093-7.766) p value 0.000, pekerjaan PR 3.838 95% CI (2.536-5.808) p value 0.000, penggunaan obat malaria PR 0.448 95% CI (0.239-0.839) p value 0.012, dan Desa. Disimpulkan bahwa umur, pekerjaan, konsumsi obat antimalaria, dan Desa merupakan faktor risiko kejadian malaria di Kabupaten Belu, Nusa Tenggara Timur Indonesia.

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Malaria is an infectious disease transmitted by Protozoa of the genus Plasmodium. This study is conducted due to the high malaria incidence in Kab. Belu, East Nusa Tenggara, Indonesia, which presents itself as a public health threat. Study aims include analyzing and measuring the magnitude of the risk factors associated with malaria incidence. This study utilized a cross-sectional study design, and is part of a larger surveillance study by Sutanto et al in 2013, which conducts large-scale mass screening and selective treatment in Belu Regency, NTT, Indonesia. The number of samples included in the study were 1113 subjects, with statistical analysis using cox regression models with 5% significance level and 95% confidence interval. The results of multivariate analysis suggested that the the risk factors associated with the malaria incidence were (1) age PR 4.901 95% CI (3.093-7.766) p value 0.000, (2) occupation PR 3.838 95% CI (2.536-5.808) p value 0.000, (4) malaria drug use PR 0.448 95% CI (0.239-0.839) p value 0.012, and (4) Village. Therefore, malaria incidence in Belu District, East Nusa Tenggara Indonesia, were heavily influenced by age, occupation, consumption of antimalarial drugs, and village.

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"Infeksi malaria saat kehamilan telah dilaporkan berasosiasi dengan peningkatan risiko lahirnya bayi berat badan lahir rendah (BBLR, berat badan lahir < 2500 g) di negara-negara endemis malaria, termasuk di Timika, Papua, Indonesia. Infeksi Plasmodium falciparum (P. falciparum) mengakibatkan penumpukkan eritrosit terinfeksi di plasenta, sehingga berkontribusi pada gangguan fungsi plasenta dan terhambatnya petumbuhan janin. Penelitian bertujuan untuk mengetahui pola ekspresi transkrip mRNA yang terlibat dalam aksis insulin-like growth factor (IGF) dan persinyalan leptin yang berperan dalam mengatur fungsi plasenta selama kehamilan. Plasenta ibu hamil terinfeksi malaria falciparum yang melahirkan bayi tunggal sebanyak 55 sampel digunakan untuk isolasi RNA total. RNA hasil isolasi kemudian ditranskripsi balik menjadi complementary DNA (cDNA) dengan reverse transcription polymerase chain reaction (RT PCR), kemudian diukur ekspresinya dengan quantitative real-time PCR (qPCR). Ekspresi IGF-I (r = 0,232, p = 0,089) dan reseptor leptin isoform pendek (OBRa) (r = 0,215, p = 0,115) pada plasenta cenderung berkorelasi positif terhadap skor-z berat badan lahir. Ekspresi OBRa juga berkorelasi negatif secara terhadap umur kehamilan ( = -0,294, p = 0,029). Sedangkan, ekspresi IGFBP-1 cenderung berkorelasi negatif terhadap berat plasenta (r = -0,237, p = 0,081). Ekspresi leptin dan reseptor leptin isoform panjang (OBRb) plasenta menunjukkan korelasi yang lemah terhadap berat badan lahir, skor-z berat badan lahir, berat plasenta, maupun umur kehamilan. Faktor berat plasenta dan ekspresi OBRa menunjukkan kontribusi yang nyata terhadap skor-z berat badan lahir dibandingkan variabel lainnya. Keterkaitan antara ekspresi komponen aksis IGF-I dan persinyalan leptin pada plasenta dari kehamilan terinfeksi malaria menunjukkan respon plasenta terhadap kondisi intrauterin yang merugikan akibat infeksi malaria.

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Malaria infection during pregnancy has been reported to be associated with an increased risk for delivering low birth weight (LBW, birth weight < 2500 g) infants in malaria-endemic area, including in Timika, Papua, Indonesia. Plasmodium falciparum (P. falciparum) infection leads to placental sequestration of infected erythrocytes, causing impaired placental function and altered fetal growth. This study was aimed to investigate the expression pattern of mRNA transcripts involved in insulin-like growth factor (IGF) axis and leptin signaling which play a role in modulating placental function during pregnancy. A total of 55 placenta samples collected from falciparum malaria-infected mothers who delivered singleton infant were employed for total RNA isolation. The isolated RNA was reverse transcribed into complementary DNA (cDNA) using reverse transcription polymerase chain reaction (RT PCR), followed by measurement of gene expression using quantitative real-time PCR (qPCR). Placental expressions of IGF-I (r = 0,232, p = 0,089) and long isoform of leptin receptor (OBRa) (r = 0,215, p = 0,115) were tend to be positively correlated with birth weight z-score. The expression of OBRa was also negatively correlated with gestational age ( = - 0,294, p = 0,029). Meanwhile, the expression of IGFBP-1 showed a tendency to be negatively correlated with placental weight (r = -0,237, p = 0,081). Placental leptin and long isoform of leptin receptor (OBRb) expressions showed weak correlations with birth weight, placental weight, and gestational age. Placental weight and OBRa expression represent a significant contribution to determination of birth weight z-score as compared to the others variables. Correlation between placental expression of IGF axis and leptin signaling in malaria-infected pregnancies might reflect placental response to adverse intrauterine condition due to malaria infection."

"Relaps masih menjadi masalah dalam eradikasi malaria vivaks. Primakuin adalah satu-satunya antihipnozoit yang saat ini tersedia di pasaran. Efikasi primakuin diperoleh oleh farmakokinetik dan farmakodinamik obat. Kemampuan CYP2D6 memetabolisme primakuin menjadi bentuk aktif akan memengaruhi kadar primakuin dan efikasi klinisnya. Pada penelitian ini dilakukan analisis farmakokinetik dan farmakodinamik primakuin dengan pendekatan populasi pada subjek dengan malaria vivaks; serta menganalisis hubungan variasi jumlah salinan gen CYP2D6 dengan kejadian relaps.Subjek studi adalah 174 orang Tentara Nasional Indonesia yang terinfeksi malaria vivaks dan diterapi dengan kombinasi skizontisida dan primakuin selama 14 hari. Kejadian relaps diamati selama satu tahun. Model farmakokinetik-farmakodinamik primakuin yang dikembangkan dengan metode mixed effect non linier menggunakan piranti lunak NONMEM versi 7.4.1. Kuantifikasi jumlah salinan gen CYP2D6 dilakukan pada 49 subjek. Jumlah salinan ditentukan berdasarkan nilai Cq hasil amplifikasi intron 6 dengan qPCR real-time. Jumlah salinan dihitung sesuai dengan rumus 2-ΔΔCq x jumlah salinan DNA Kalibrator, ΔΔCq = ΔCq (kalibrator)  ΔCq (sampel) dan ΔCq = Cq (CYP2D6) - Cq (RNAse P). Hubungan jumlah salinan gen CYP2D6 dan kejadian relaps malaria vivaks dianalisis dengan uji Chi-square.Hasil penelitian menunjukkan bahwa kadar primakuin plasma paling baik dideskripsikan oleh model satu kompartemen dengan penyerapan orde pertama. Berat badan diimplementasikan sebagai fungsi alometrik pada clearance (CL) dan distribusi volume (Vd). Piperakuin maupun pironaridin menurunkan CL dan Vd primakuin sebesar 3354%. Faktor genetik CYPD6 tidak memengaruhi CL primakuin. Risiko kejadian relaps malaria vivaks dideskripsikan dengan model constant hazard pada model time-to-event. Peningkatan satu poin skor aktivitas gen CYP2D6 menurunkan risiko relaps sebesar 88,3%, sehingga dapat disangkal bahwa faktor genetik CYP2D6 menjadi salah satu faktor yang dapat memengaruhi risiko kambuh vivaks malaria. Tidak didapatkan hubungan antara AUC primakuin dan kejadian relaps, sehingga hasil ini tidak dapat digunakan untuk menghitung dosis primakuin yang optimal. Kuantifikasi jumlah salinan gen CYPD6 dilakukan pada 21 subjek relaps dan 28 subjek kontrol. Mayoritas subjek memiliki jumlah salinan ≥ 2 (39 dari 49 orang). Tidak ditemukan hubungan antara jumlah salinan gen CYP2D6 dan kejadian relaps (p = 0,155).Relapse is still a problem in vivax malaria eradication. Primakuine is the only antihipnozoite currently available on the market. The efficacy of primaquine is obtained by the pharmacokinetics and pharmacodynamics of the drug. The ability of CYP2D6 to metabolize primaquine to its active form will affect primakuine levels and clinical efficacy. In this study, a pharmacokinetic and pharmacodynamic analysis of primaquine was carried out with a population approach in subjects with vivax malaria; and to analyze the relationship between variations in the number of copies of the CYP2D6 gene with the incidence of relapse.Study subjects were 174 Indonesian National Armed Forces infected with vivax malaria and treated with a combination of schizonticides and primaquine for 14 days. Relapse incidence was observed for one year. The primakuine pharmacokinetic-pharmacodynamic model was developed using a non-linear mixed effect method using NONMEM software version 7.4.1. Quantification of the number of copies of the CYP2D6 gene was performed in 49 subjects. The number of copies is determined based on the Cq value of the intron 6 amplification with real-time qPCR. The number of copies is calculated according to the formula 2-ΔΔCq x number of copies of the DNA Calibrator, ΔΔCq = ΔCq (calibrator)  ΔCq (sample) and ΔCq = Cq (CYP2D6) - Cq (RNAse P). The association between copy number of CYP2D6 gene and the incidence of vivax malaria relapse was analyzed using Chi-square test.The results showed that plasma primquine levels were best described by a one-compartment model with first-order absorption. Body weight is implemented as an allometric function on clearance (CL) and volume distribution (Vd). Piperakuine and pyronaridin reduce CL and Vd primakuin by 3354%. CYPD6 genetic factor does not affect CL primaquine. The risk of vivax malaria relapse was described using the constant hazard model in the time-to-event model. One point increase in the CYP2D6 gene activity score reduced the risk of relapse by 88.3%, so it can be denied that CYP2D6 genetic factor is one of the factors that can affect the risk of malaria vivax relapse. There was no relationship between AUC of primaquine and the incidence of relapse, so these results cannot be used to calculate the optimal primquine dose. CYPD6 gene copy count quantification was performed in 21 relapsed subjects and 28 control subjects. The majority of subjects had a number of copies ≥ 2 (39 of 49 people). No association was found between the number of copies of the CYP2D6 gene and the incidence of relapse (p = 0.155)."

"Munculnya resistansi parasit yang cepat terhadap obat antimalaria yang tersedia saat ini telah menarik perhatian dalam penemuan obat. Andrografolida (ANDRO), suatu senyawa yang diisolasi dari tanaman obat Andrographis panniculata Nees, memperlihatkan sifat antimalaria secara in vitro dan in vivo, tetapi mekanisme kerjanya yang tepat belum dipahami. Penelitian ini bertujuan untuk menjelaskan mekanisme yang mendasari sifat antimalaria dari ANDRO terhadap parasit malaria hewan pengerat, Plasmodium berghei. Parasit diinjeksikan pada mencit BALB/c dan kemudian diberi perlakuan dengan ANDRO dan butionin sulfoksimin (BSO) sebagai kontrol pada konsentrasi berbeda secara ex vivo. Selanjutnya dilakukan pengukuran beberapa parameter status oksidatif, seperti konsentrasi GSH, rasio GSH/GSSG, rasio NADPH/NADP+, aktivitas spesifik dan ekspresi mRNA tioredoksin reduktase (TrxR), kadar malondialdehid (MDA) dan pertumbuhan parasit ex vivo. Pengaruh ANDRO terhadap detoksifikasi hem juga diukur secara in vitro ( cell-parasite free). Hasil menunjukkan bahwa ANDRO mendeplesi GSH tetapi meningkatkan rasio GSH/GSSG. Rasio NADPH/NADP+ dan aktivitas spesifik TrxR mengalami penurunan pada semua konsentrasi yang diuji tetapi ekspresi mRNA TrxR sedikit meningkat pada konsentrasi yang lebih rendah dan meningkat bermakna pada 60 M. ANDRO memperlihatkan efek yang berbeda terhadap pertahanan antioksidan parasit dibandingkan BSO dan peningkatan stres oksidatif tidak menyebabkan peningkatan kadar MDA. Andrografolida juga menghambat pertumbuhan parasit ex vivo dan mengganggu polimerisasi hem dengan IC50 367±171 M serta menghambat degradasi hem bergantung GSH, hambatan maksimal dihasilkan pada konsentrasi 15 g/mL. Kesimpulan, ANDRO menghasilkan aktivitas antimalaria dengan mengganggu sistem pertahanan antioksidan parasit yang dibuktikan dengan penurunan konsentrasi GSH dan aktivitas enzim TrxR. ANDRO memiliki potensi untuk dikembangkan menjadi antimalaria baru baik sebagai obat tunggal atau dalam kombinasi dengan obat antimalaria lainnya.

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The rapid emergence of parasite resistance to currently available antimalarial drugs has re-newed interest on drug discovery. Andrographolides, a compound isolated from the medicinal plant, Andrographis panniculata, Nees, exhibited antimalarial properties in vitro and in vivo but its precise mechanism of action remains elusive. The present study aims to elucidate the mechanism (s) underlying the antimalarial property of the andrographolides in the rodent malarial parasite, Plasmodium berghei. The parasite was initially propagated in BALB/c mice and subsequently be propagated ex vivo in the presence of different concentrations of andrographolide and buthionin sulphoximine (BSO) as control. Several parameters of the oxidative status, such as GSH concentration, GSH/GSSG ratio, NADPH/NADP+ ratio, specific activity and mRNA expression of thioredoxin reductase (TrxR), malondialdehyde (MDA) level and the parasite growth ex vivo were measured. Effect of the andrographolide on heme polymerization and GSH-dependent heme degradation were also tested using cell-free assay system.

The results indicated that the andrographolide depleted the GSH but increased the GSH/GSSG ratio. The NADPH/NADP+ ratio and the specific activity of the TrxR were decreased at all tested concentrations but expression of TrxR mRNA slightly increased at lower concentrations and increased significantly at 60 M. Andrographolide exerted a different effect on the antioxidant defense of the parasite than that BSO and increase in oxidative stress did not result in the increase of the MDA level. Andrographolide also inhibited the parasite growth ex vivo and interfered with the heme polymerization with IC50 of 367±171 M and GSH-dependent heme degradation with maximum concentration of 15 g/mL. In conclusion, andrographolide exerted its antimalarial properties through interference with the parasite oxidant defense system as evidenced by GSH depletion and decrease thioredoxin reductase enzyme activity. Andrographolide is potentially developed into a novel antimalaria either as a single prescription or in combination with other antimalarial drug."