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  • Published: 13 May 2022

Malaria in 2022: Increasing challenges, cautious optimism

  • Prasanna Jagannathan   ORCID: orcid.org/0000-0001-6305-758X 1 , 2 &
  • Abel Kakuru 3  

Nature Communications volume  13 , Article number:  2678 ( 2022 ) Cite this article

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Malaria cases and deaths remain unacceptably high and are resurgent in several settings, though recent developments inspire optimism. This includes the approval of the world’s first malaria vaccine and results from novel vaccine candidates and trials testing innovative combinatorial interventions.

Despite gains over the first 15 years of this millennium, malaria control has stagnated in the last several years, with resurgence and rising morbidity in several highly endemic countries exacerbated by service disruptions due to the COVID-19 pandemic 1 . In 2020, malaria was estimated to have resulted in 627,000 deaths and 241 million cases, with 77% of deaths in children <5 years of age 1 . Overall, 90% of malaria cases and deaths are reported in Africa, and six countries—Nigeria, DRC, Uganda, Mozambique, Angola, and Burkina Faso—account for 55% of all cases globally.

The main interventions used for prevention of malaria include vector control with long lasting insecticidal bednets (LLINs) and indoor residual spraying of insecticides (IRS). However, Anopheles vector resistance to pyrethroids, the main insecticide used in LLINs, has become widespread, and insecticide resistance also increasingly threatens the utility of IRS. In addition to vector controls, prompt treatment of malaria with artemisinin-based combination therapy (ACTs) is recommended in all settings where falciparum malaria is endemic. ACTs have played a crucial role in controlling malaria over the past 20 years 2 , with artemether-lumefantrine being the most widely used ACT in Africa. However, artemisinin-resistant Plasmodium falciparum parasites have spread in Southeast Asia 3 , resulting in reduced treatment efficacy of some ACTs 4 . More alarmingly, recent reports from Rwanda 5 , 6 and Northern Uganda 7 , 8 suggest the emergence of artemisinin-resistant parasites in Africa. Loss of artemesinin activity would threaten the activity of partner drugs such as lumefantrine; loss of both components of ACTs could have devastating consequences across the continent 9 .

To combat the emergence of artemisinin-resistant parasites, identification of novel therapeutic approaches has become critically important. Although new antimalarial drugs are being identified, they are still in various stages of clinical development ( www.mmv.org ). One such drug, KAF-156, was found to be active against artemisinin-resistant parasites in a small trial of adults 10 , and is currently being tested in Phase 2 trials in children when given with the partner drug lumefantrine (NCT 04546633). Another emerging therapeutic strategy is the use of artemisinins along with two long-acting partner drugs instead of one, similar to the therapeutic approach to HIV and tuberculosis (e.g., triple ACTs.). Triple ACTs have been found to be effective in clinical trials conducted in the setting of artemisinin-resistant parasites 11 , 12 , and may be useful as a “stop-gap” therapy for drug-resistant malaria until new antimalarials become available, or to prevent and/or delay the development of resistance to antimalarials in settings where resistance has not yet emerged 13 . Given potential safety and tolerability concerns, questions remain about which agents to use, and how and when to deploy such a strategy.

One of the most elusive interventions to aid malaria control has been an effective malaria vaccine that can prevent severe malaria and deaths. The WHO and partners set a strategic goal of achieving a malaria vaccine with >75% efficacy by 2030 14 . However, this goal has been a major challenge, and very few candidate vaccines have demonstrated significant efficacy 15 . The malaria vaccine RTS,S/AS01 is the only vaccine tested to reach Phase 3 trials with reproducible efficacy in different populations. This recombinant protein vaccine targets the circumsporozoite protein (CSP) of P. falciparum , which is expressed at the pre-erythrocytic stage of infection. Although RTS,S has been found to be efficacious, overall efficacy in the Phase 3 trial was low, with 36% protective efficacy against clinical malaria, and 32% against severe malaria, in the 4 years after vaccination among children who began the vaccination series between 5 and 17 months of age and received a booster 21 months later 16 . RTS,S efficacy was highest (~60–70%) in the first 6 months following vaccination, but rapidly decayed, and was limited or non-significant by 18 months 17 . This waning of vaccine efficacy was broadly mirrored by a decline in antibody responses against CSP 18 , although definitive correlates of protection remain unclear. Identification of correlates and mechanisms that contribute to malaria vaccine performance in endemic settings remains an active area of research.

Given results from the Phase 3 trial, the WHO launched pilot implementation studies of RTS,S in Malawi, Kenya and Ghana beginning in 2019 19 . These implementation studies showed that delivery of the vaccine was feasible, with high uptake of the vaccine, confirming demand. Importantly, these studies also reaffirmed vaccine safety and efficacy, observing that vaccination was associated with a 30% reduction in severe malaria 1 . Given these results, in October of 2021, after 30 years of development, the WHO-approved RTS,S for use in children living in regions with moderate to high transmission of malaria caused by P. falciparum .

Although RTS,S is now WHO-approved, its availability will be limited in the short term. GlaxoSmithKline (GSK), which produces the vaccine, is committed to donate up to 10 million vaccine doses to the pilot implementation regions of Ghana, Kenya, and Malawi through 2023, and to supply up to 15 million doses of vaccine per year to the end of 2028 if it is recommended for wider use, pending financing. However, this represents only ~10–15% of the annual doses required if provided to all children living in highly endemic settings 20 . GSK has committed to transfer the technology to manufacture RTS,S to Bharat Biotech (BBIL), and, by 2029, BBIL is expected to be the sole supplier of the vaccine, with increased production capacity expected. Given the relatively low efficacy of RTS,S, and its limited short-term availability, new vaccines are needed to reach the WHO target of malaria vaccines with >75% efficacy by 2030. One such candidate is R21, another CSP-based subunit vaccine with a similar construct to RTS,S but with more CSP antigen in the virus-like particle. In a phase 2 trial, R21 was recently shown to have 71–77% protective efficacy against a first episode of clinical malaria in the year following vaccination among children living in an area with seasonal malaria transmission 21 . However, this study only reported protection across one malaria transmission season; the durability of this protection, and whether R21 would be efficacious in areas with year-round malaria transmission, remains unclear. Phase 3 trials in 4 countries, with longer follow-up, are underway. In addition, several other vaccines for both P. falciparum and Plasmodium vivax are under development, targeting each of the life cycle stages of Plasmodium, including sporozoite/pre-erythrocytic, asexual/erythrocytic, and sexual/mosquito 22 .

Another promising intervention for malaria control is intermittent preventive therapy (IPT)—the provision of full treatment doses of antimalarial drugs to at risk populations to clear existing infections and prevent new infections. IPT with sulfadoxine-pyrimethamine (SP) given at the time of routine vaccination in infants (IPTi) has been shown to be safe and modestly effective against malaria in the first year of life 23 , but is only recommended in areas with low levels of SP resistance. Uptake of IPTi has therefore been very low, with only one country (Sierra Leone) recently adopting this strategy. Seasonal malaria chemoprevention (SMC) using monthly SP plus amodiaquine during the transmission season is a proven strategy to decrease morbidity and mortality in young children 24 , and is currently deployed in parts of West and Central Africa where annual malaria transmission is confined to a few months. However, neither IPTi nor SMC are recommended in areas with high level SP resistance and/or year-round malaria transmission as in much of Central and East Africa 25 . In these settings, the ACT dihydroartemisinin-piperaquine (DP) has emerged as an excellent candidate for use as IPT in children 26 , including as perennial malaria chemoprevention in areas with year-round malaria transmission 27 . IPT during pregnancy (IPTp) with DP has also been shown to be more effective than IPTp with SP for prevention of malaria in pregnancy in areas with high level SP resistance 28 , 29 , although IPTp with SP may result in improved birth outcomes independent of SP’s antimalarial activity 30 . As above, there are important concerns about selection of drug-resistance through IPT, though modeling suggests that this could be limited via prevention of infections and/or optimization of target drug concentrations 31 . IPT studies should therefore be accompanied by close monitoring for emergence of genotyping and phenotypic evidence of antimalarial drug resistance. An added concern is that preventing malaria in children may delay acquisition of antimalarial immunity, increasing the risk of malaria after IPT has stopped (rebound malaria). Though some studies have reported rebound following cessation of IPT 32 , 33 , other studies have reported either no increase 23 or evidence of sustained protection 27 , 34 following cessation. How IPT impacts the acquisition of immunity to malaria remains an important area of investigation.

Finally, exciting new data suggest that combinations of malaria control interventions might be more efficacious than individual interventions. Vaccination of malaria-naïve adults with P. falciparum sporozoites under prophylactic cover with either chloroquine or pyrimethamine induced durable sterile protection against controlled challenge with either a homologous or heterologous P. falciparum strain 35 . A follow-up study conducted in malaria-exposed Malian adults has recently been completed (NCT03952650), with results eagerly anticipated. However, studies of this strategy in malaria-exposed children will be needed, given prior vaccination studies showing limited efficacy in children despite higher vaccine efficacy in adults 36 . In another recent randomized controlled trial conducted in West Africa, investigators found that the combination of seasonal malaria chemoprevention (SMC) in children with amodiaquine + sulfadoxine-pyrimethamine (AQ + SP) along with RTS,S vaccination was superior to either intervention alone 37 . This promising dual intervention deserves additional study in settings where malaria transmission is seasonal. However, in settings with year-round malaria transmission and/or high SP resistance, alternative IPT + vaccine regimens require urgent evaluation.

In conclusion, despite earlier gains, malaria cases and deaths remain unacceptably high and are resurgent in several settings, and our ability to prevent and control malaria with current tools is challenged by the specter of insecticide-resistant vectors and drug-resistant Plasmodium parasites. Clearly, renewed focus—and new interventions—are needed to achieve the goals highlighted by the WHO “high burden to high impact” campaign to reduce cases and deaths in countries hardest hit by malaria. There are reasons for cautious optimism, including approval of the world’s first malaria vaccine and results from novel vaccine candidates and trials testing innovative combinatorial interventions. However, critical research gaps remain, and there is an urgent need to prioritize and fund development of novel therapeutic, prophylactic, and vaccine strategies against malaria.

Reporting summary

Further information on research design is available in the  Nature Research Reporting Summary linked to this article.

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Department of Medicine, Stanford University, Stanford, CA, United States

Prasanna Jagannathan

Department of Microbiology and Immunology, Stanford University, Stanford, CA, United States

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Abel Kakuru

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P.J. drafted the paper and A.K. provided critical revisions. Both authors approved the final paper.

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Jagannathan, P., Kakuru, A. Malaria in 2022: Increasing challenges, cautious optimism. Nat Commun 13 , 2678 (2022). https://doi.org/10.1038/s41467-022-30133-w

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malaria strategies case study

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  • Published: 21 February 2022

Treatment-seeking and uptake of malaria prevention strategies among pregnant women and caregivers of children under-five years during COVID-19 pandemic in rural communities in South West Uganda: a qualitative study

  • Ivan Mugisha Taremwa 1 ,
  • Scholastic Ashaba 2 ,
  • Rose Kyarisiima 2 ,
  • Carlrona Ayebazibwe 1 ,
  • Ruth Ninsiima 3 &
  • Cristina Mattison 4  

BMC Public Health volume  22 , Article number:  373 ( 2022 ) Cite this article

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Despite efforts to avert the negative effects of malaria, there remain barriers to the uptake of prevention measures, and these have hindered its eradication. This study explored the factors that influence uptake of malaria prevention strategies among pregnant women and children under-five years and the impact of COVID-19 in a malaria endemic rural district in Uganda.

This was a qualitative case study that used focus group discussions, in-depth interviews, and key informant interviews involving pregnant women, caregivers of children under-five years, traditional birth attendants, village health teams, local leaders, and healthcare providers to explore malaria prevention uptake among pregnant women and children under-five years. The interviews were audio-recorded, transcribed and data were analyzed using thematic content approach.

Seventy-two participants were enrolled in the Focus Group Discussions, 12 in the in-depth interviews, and 2 as key informants. Pregnant women and caregivers of children under-five years were able to recognize causes of malaria, transmission, and symptoms. All participants viewed malaria prevention as a high priority, and the use of insecticide-treated mosquito bed nets (ITNs) was upheld. Participants' own experiences indicated adverse effects of malaria to both pregnant women and children under-five. Home medication and the use of local herbs were a common practice. Some participants didn’t use any of the malaria prevention methods due to deliberate refusal, perceived negative effects of the ITNs, and family disparity. The Corona Virus Disease-2019 (COVID-19) control measures did not abate the risk of malaria infection but these were deleterious to healthcare access and the focus of malaria prevention.

Conclusions

Although pregnant women and caregivers of children under-five years recognized symptoms of malaria infection, healthcare-seeking was not apt as some respondents used alternative approaches and delayed seeking formal healthcare. It is imperative to focus on the promotion of malaria prevention strategies and address drawbacks associated with misconceptions about these interventions, and promotion of health-seeking behaviors. As COVID-19 exacerbated the effect of malaria prevention uptake and healthcare seeking, it’s critical to recommit and integrate COVID-19 prevention measures in normative living and restrict future barriers to healthcare access.

Peer Review reports

Infection with malaria possess a major public health challenge due to the associated morbidity, high cost of expenditure, and increased risk of mortality [ 1 ]. Its burden was reported at 229 million cases worldwide in 2019; of which sub-Saharan Africa accounted for over 90% of the cases [ 2 ]. Moreover, 11.6 million pregnant women in sub-Saharan Africa were infected with malaria [ 2 ]. In Uganda, malaria remains a perennial infection affecting an estimated 95% of the population [ 3 ], and it remains the primary cause of 15–20% of inpatient treatment, 30–50% outpatients’ care and up to 20% of all mortality [ 4 ].

Whereas global concerted efforts to control malaria have been intensified in the previous two-decades, limited success has been realized as its epidemiological burden has surpassed past incidences [ 2 ]. More, the United Nations Sustainable Development Goals (SDGs) report that focused on goal-3 asserts that interruption in service delivery due to high illnesses and deaths from communicable diseases may warrant a 100% increase in malaria deaths in sub Saharan Africa [ 5 ]. Further evidence by the global data affirms that response to malaria prevention has leveled off, and the disease burden had escalated in endemic settings [ 2 ]. This has necessitated a renewed focus on malaria prevention progress and end its catalyzed ‘high burden to high impact’ [ 2 , 6 ]. As a result, strategies to avert a worrying risk of malaria and portend global efforts towards attaining SDG-3 are a priority [ 5 , 7 ]. In this regard, the World Health Organization (WHO) Global Technical Strategy 2016–2030 initiative adopted novel strategies to fast-track malaria prevention and reduce the disease burden by at least 90% by 2030, and eventual elimination [ 7 ]. The new strategies involve primary vector control measures such as the use of insecticide-treated bed nets (ITNs), and where appropriate, in-door residual spray (IRS) with children under-five years and pregnant women as the focus [ 2 , 8 , 9 ].

Concurrently, a pandemic: the new corona virus disease-2019 (COVID-19) outbreak was declared by the WHO in March 2020 as a global pandemic. The seriousness of the pandemic necessitated an immediate response to curtail its spread and avert the associated effects. In Uganda, a series of vulnerability reduction and containment approaches including cessation of international passenger flights, closure of inland portals of entries for passengers with the exception of cargo drivers, closure of all learning institutions and other high congregation points, freezing of public and private means of transport, outlawing of all mass gatherings such as places of worship, institution of overnight curfew, and eventually a nationwide total lockdown was declared on 24 th March 2020 [ 10 ]. Further, a re-organization in the healthcare service delivery was needed diverting resources form other programs to direct them to COVID-19 control with limited consideration of their impact across other healthcare needs and services [ 11 ]. Presently, there is evidence of significant disruptions to essential healthcare services as a result of COVID-19 pandemic [ 11 , 12 , 13 ]. This has added to the malaria management burden. Malaria and COVID-19 infections have similar symptomatic presentation such as breathing difficulties, fever, acute headache, tiredness among others. Additionally, the outbreak of COVID-19 and use of restrictive measures to avert its spread limited access to healthcare, and instilled fear of visiting health facilities due to contagion. In addition, malaria prevention programs were disrupted due to the paradigm shift.

Despite the proven efficacy of prevention programs, the burden of malaria remains unacceptably high due to challenges related to new pyrethroid-resistant mosquito strains, and laxity in uptake of prevention measures [ 9 , 14 , 15 , 16 , 17 , 18 , 19 ]. A 2016 field survey in a rural district in Uganda [ 17 ], showed high malaria cases in the communities, despite the household possession of ITNs. As Uganda works towards malaria elimination, it is key to explore the specific local determinants that predict malaria prevention uptake. To the best of our knowledge, there is limited research that has explored the determinants of malaria prevention strategies among pregnant women and children under-five years during COVID-19 pandemic. This study explored the factors that are influencing the uptake of malaria prevention strategies among pregnant women and children under-five years in a rural district in south western Uganda during the COVID-19 pandemic.

Study design, site, and duration

This was a qualitative, explanatory single case study using focus group discussions, in-depth interviews and key informant interviews as the main sources of evidence. The case was defined as the common case conducted in Birere sub-county located in Isingiro district, southwestern Uganda between August to November 2020, to garner insights into the factors that influence the uptake of malaria prevention strategies among pregnant women and children under-five years [ 20 ]. Birere sub-county comprises 9 parishes and 76 villages, with a population of 26,000 people [ 2 ]. The study period overlapped with the second annual peak of the rainy season (September to November), and by this time, some of the instituted COVID-19 restrictions including in-country means of transport had been partially uplifted as of July 21 st 2020. Study activities were conducted in compliance with the COVID-19 guidelines.

Study participants and sampling strategy

The study purposively enrolled participants aged 18 years or above who were pregnant and/or provided care for pregnant women and newborns and had lived in Birere sub-county in Isingiro district for at least 6 months. These included pregnant women, caregivers of children under-five years, community health workers (village health teams) and tradition birth attendants and local leaders. For example, although the antenatal care (ANC)-based healthcare providers (HCPs) offer ANC services including malaria prevention and treatment; traditional birth attendants (TBAs) remain pivotal in the communities, partly due to persistent gaps in rural HCP availability and continued preferences for home-based deliveries. The auxiliary nurse midwives (ANMs) provide primary healthcare in community-level clinics and they support maternal-child health care provision. The village health teams (VHTs) act as community liaisons for the promotion of primary health care services, while the local council (LC) leaders supported community mobilization. Informed by previous qualitative studies, in which saturation is typically reached after interviewing 6–12 individuals with similar backgrounds [ 18 ], this study conducted 8 focus group discussions (FGDs), 13 in-depth interviews (IDIs), and 2 key informant interviews (KIIs)0.3. The details of the respondents are summarized in Table 1 .

The study participants were recruited from the 8-parishes in which, four parishes were selected for FGDs among pregnant women, and an equal number were considered for caregivers of children under-five years. Another parish was considered for each KII and IDI. The parishes were selected randomly to eliminate bias. The one parish that was not considered in either FGD for pregnant women or caregivers of children under-five years was prioritized for the in-depth interview respondents. Assisted by the local council-1 leaders, the VHTs compiled a list of households with a pregnant woman or a child under-five years. The list was used to randomly select households that participated in the FGD. Each FGD was clustered at the parish, with each village represented. Participants to the IDIs and KIIs were identified and contacted by the VHT coordinator, and the study team then followed up with those who were willing to participate.

Data instrument and collection

Guided by previous studies [ 21 , 22 , 23 , 24 , 25 ], data collection tools (supplementary files 1 and 2 ) were developed. FGD and KII questions focused on symptom recognition, healthcare seeking, knowledge, and behaviors towards malaria prevention. Also, the study assessed the impact of the COVID-19 pandemic on prevention uptake. The IDIs with pregnant women explored behavior to protect against malaria during pregnancy. On the other hand, IDIs with HCPs assessed the perceived behaviors of pregnant women and caregivers of children under-five towards malaria prevention uptake, and if malaria was emphasized during ANC. The interview guides were reviewed by two independent experts who were knowledgeable in the field of malaria. After the expert review, these were translated by 2-separate proficient persons who knew well both English and Runyankore-Rukiiga languages. Then, one of the research team members (CA) and the principal investigator (IMT) compared the translations, and compiled the final translated tools. These were then cross checked by two members of the team (RK and RN) for accuracy and comprehension in the Runyankore-Rukiiga language. The interview guides were pretested in communities within Mbarara City, Southwestern Uganda, and changes were made accordingly. Further, the interview guides were piloted in the first interview and edited during the data collection process in response to emerging themes. Additionally, participants’ socio-demographic information was captured.

Data collection was conducted by at least three members of the team supported by a research assistant who was conversant with the topic on malaria, and qualitative research methods. The research team liaised with the VHTs and LCs on the day of the appointment, and a convenient time as proposed by the participants was considered to convene. Each FGD was comprised of 8–10 participants in light of the COVID-19 guidelines. Individual introductions were done, and the research team sought individual written informed consent after explaining the purpose of the study. An interview guide in the local language (Runyankore-Rukiiga) was shared with the participants and guided the discussion with probing to pursue any emerging inquiry in major trends and cross-cutting themes. A member of the team led the discussion, and clarity to the question(s) was ensured by rephrasing where necessary. Participants were anonymized, and the discussion was guided by agreed rules to warrant appropriate communication. Field notes were recorded to contextualize the data and provide reflections on each interview, and the interviews were audio-recorded.

Data management and analysis

The audio recordings were transcribed and translated into English if conducted in the local language (Runyankore-Rukiiga language). Transcripts were carefully and independently studied by two dedicated members of the team, and reviewed by the lead author to assess translation quality and fidelity. Transcripts were read and re-read to allow familiarization with the text, and brief notes were taken to document the emerging themes. A codebook was developed based on the original and emerging themes. Content analysis was used to conduct the initial data analysis, and NVivo 10 (QRS International) was used to guide data analysis based on the emerging themes and patterns. Data from varied participants and sources (FGDs, IDIs, KIIs, and observations) were extracted and triangulated by three members of the team. The emerging concepts were categorized based on the study objective, coded, and subjected to conventional content analysis using a thematic approach with typical and atypical statements identified for sub-themes to illustrate key findings.

Ethical consideration

Ethical approval was obtained from the Mbarara University of Science and Technology Research and Ethics Committee (UG-REC-005) before the beginning of the study. Administrative permission was obtained from Isingiro district health office. The study obtained written informed consent, and permission to audio record the interviews from all participants. Legally authorized representatives (literate family member) of illiterate participants provided informed consent for the study. The anonymity of participants was ensured at all stages of data collection and analysis.

Eighty-six adult participants were recruited. Of these, 72 participants were enrolled in the FGDs, 12 in the IDIs, and 2 as key informants (KIs). Participants’ median age was 34 years (range: 18-57 years). About 98% percent of the participants (N = 84) were females and farming was the main source of livelihood ( N  = 61). Most participants were married ( N  = 66) with a median of 3 live-children, and the majority ( N  = 49) of the pregnant women were in their second gestation trimester. Participants had attained various levels of education as summarized in Table 2 .

The key themes that emerged from the data were: (1) knowledge of malaria causes, transmission, and symptoms, (2) effect of COVID-19 pandemic on healthcare-seeking and the prevention of malaria behaviors, and (3) perceived effects of malaria, its treatment and uptake of prevention strategies. Each of these themes and subthemes are diagrammatically illustrated in Fig.  1 , and are discussed in detail below.

figure 1

Showing illustration of the thematic analysis of the study. Key: ITNs: Insecticide Treated Nets, IPTp: Intermittent Presumptive Therapy during pregnancy

Knowledge of malaria causes, transmission, and symptoms

Knowledge of malaria, perceived cause and transmission of malaria.

Malaria was perceived as the major health problem, and a common life-threatening disease among pregnant women and children under-five years. In their own experiences, participants indicated that infection in malaria was high during the rainy season, and the onset of the disease was sudden. In a participant’s view; ‘Malaria is a life-time disease, and is transmitted by an infected a mosquito bite while feeding on humans’. (26 years old, pregnant woman).

Malaria was attributed to varied causes such as mosquito bites, poor sanitation, and hygiene, as well as harvest season of mangoes and maize.

Mosquito as a cause of malaria: Most study participants recognized that the female anopheles mosquito lived in bushy areas, heaps of rubbish, stagnant water, broken pots, water tanks, and open tins near homesteads, and is the causative agent of malaria as given in the narrative: ‘…when it rains, the female Anopheles mosquito begins to lay eggs, and the life cycle is completed when it feeds on human blood. Subsequently, as one fails to close the house entrances (doors and windows) early, mosquitos’ gains access to the house and unaware, they bite and infect a person at night if not protected. Biting occurs from one person to another; as a result, malaria is spread if one is infected’. (29 years old, pregnant woman).

Poor sanitation and hygiene as a cause of malaria: Six of the participants from the different FGDs referred to malaria as a disease caused by ‘poor sanitation and hygiene’. One of the participants elaborated that; ‘…if one lives in a dirty environment, the bushy compounds, gardens near the homestead, garbage, and decomposing matter attracts many illnesses including malaria’. (24 years old, mother to 1 year old).

The harvest season of mangoes and maize as a cause of malaria: Two participants from different FGDs narrated; ‘….since my childhood, I have always seen people suffer from malaria during the harvest time particularly for mangoes and maize’ (34 years old, mother of 2 children & 26 years old, pregnant woman).

Symptoms of malaria infection

Participants locally recognized the symptoms of malaria infection as wounds on the lips, feeling cold, loss of appetite, yellowing of eyes, headache, general body weakness, shivering, and high body temperature. A pregnant woman described the symptoms of malaria infection as ‘a weird presentation’ and was associated with craving for good food as given in this narrative: ‘…malaria causes unease! You begin to shiver, vomit, and become weak similar to the early stages of pregnancy! This can stigmatize as it looks unusual in the public. Also, one develops a sour taste, and craves good foods! Sometimes you ask for rare foods like fish, and you are not yourself!’ (31 years old, pregnant woman) The symptoms of malaria during pregnancy were described to resemble those of early pregnancy.

The caregivers of children under-five years considered the symptoms of malaria as ‘sudden changes to their wellbeing’ manifesting as diarrhea, unending crying, vomiting, and failure to feed as narrated; ‘…when a child suffers from malaria, s/he looks bad! S/he begins to vomit, cries endlessly, rejects all the foods and the as a mother you feel peaceless.’ (26 years old, mother to 3 years old) . Further, the onset of malaria among children under-five was sudden, and affected their emotions and behavior. The symptoms were not obvious, and one relied on the change to predict the dire state of their health. A caregiver specified the difficulty to recognize these symptoms among younger children, as described: ‘…symptoms of malaria are challenging among children! From nowhere, a child starts to cry a lot, the body temperature rises suddenly, they develop diarrhea, and they pass yellow smelly urine. The child rejects foods, feels a burning sensation while breastfeeding, and often rejects the breast. They occasionally vomit yellow kinds of stuff’. (41 years old, mother of five) More, malaria was associated with a change in behavior. There occurs a noticeably reduced activity such as playing among children, and a child would often fall sleep. The unending cry and high body temperatures associated with malaria among children under-five stirred swelling of the blood veins and led to the yellowing of eyes. These changes were considered to manifest later, and they would depict a late-stage of malaria infection which necessitated to seek for healthcare. Profoundly, parents who spent time away from their children didn’t recognize malaria symptoms in time, as reported; ‘…I had gone to work, and on my return, I found my 11-months baby very sick, and she had developed rigors, and if I had delayed to take her to the hospital, maybe the worst would have occurred’ (33 years old, pregnant woman). These narratives showed a good recognition of malaria symptoms, however, to some, these required a caregivers’ critical attention.

Effects of malaria, its treatment, and uptake of prevention strategies

Perceived effects of malaria infection.

The participants stressed the effects of malaria as life-threatening to both pregnant women and children under-five years due to the risk of mortality, and its sudden onset that necessitates urgent attention as narrated by one of the participants: ‘…my child developed high temperatures. …I gave him a fraction of panadol, but the night was too long and worrying! Very early the next morning, I took him to a hospital where he was put on a drip (intravenous treatment) and he got well’. (28 years old, mother to 4 years old).

On the sad note, a participant reportedly lost a child to severe malaria as narrated in the following quote: ‘…my child presented with signs of malaria, and in a short time, his condition worsened! He became very unconscious, and I anticipated many possibilities including death! Unfortunately, he didn’t make it even when we struggled to get to the hospital’. (38 years old, mother of four).

Among pregnant women, participants were cognizant of the negative effects of malaria such as spontaneous abortions and stillbirths. Some pregnant women reportedly experienced peri-vaginal bleeding and resulted in pregnancy complications such as spontaneous abortion as a result of malaria. Resultantly, pregnant women greatly considered malaria prevention uptake, as narrated:

‘…pregnant women do it to protect their unborn babies, not even for themselves! Because one knows that if she gets affected by malaria she could be treated and gets healed but what about the unborn child? if you lose it, you have lost it…’. (22 years old, pregnant woman).

Economic challenges of malaria

Infection with malaria posed an economic challenge as it negated productivity. The reported effects were unfavorable as they negatively affected both the caregivers of children under-five years and pregnant women. Participants reported many days lost, and often led to huge expenditure on treatment bills, and this may lead to many debts.

Initial care and treatment for malaria

Most participants ( N  = 41) attested that usually when a child or pregnant woman becomes badly off, they used home-remedies and then rushed to the health facility for treatment. From there, they would get well or were referred to a higher health care facility. A participant narrated: ‘…I returned from the market and found my 2-year child unwell. Her elder sister whom I had left to baby-sit her informed me that she had vomited, and she had high temperatures. I then remembered that I had panadol in the house, and I gave her a small’ fraction of the tablet and I proceeded to the health center’. (35 years old, mother of three) Also, a non-medicinal approach was used to subvert the high temperatures as narrated: ‘…I got a clean cloth and soaked it in cold water, after which, I massaged the child as I prepared to go to a clinic’. (23 years old, mother to 2 years old) The use of home remedies was confirmed by the VHT who indicated that they are used to subdue the symptoms of malaria while still in the community before they seek healthcare. She elaborated that whenever a child or pregnant woman got sick, home remedies (tablets leftover from a previous dose, or one would buy them from a clinic) were used first. Also, it emerged that local herbs are used as narrated: ‘…there was when you find that you don’t have any tablet of panadol, and you don’t have any money with you! …so I went to the farm and searched for local herbs (‘eshabiko’), I boiled it and used it to massage, and gave some to drink. I then started looking for ways to go to the hospital when the child was somehow stable’. (37 years old, mother to 8 months old). To explore further the use of herbal remedies, another participant narrated that: ‘…I went to the hospital, and they could not detect the disease my child was suffering from. I requested for referral, however, on my way, I felt like even where I will go, they won’t get the disease. So, I went to the elderly woman who gave me herbs for the baby to drink and she became better’. (31 years old, mother of three).

Malaria prevention strategies

Participants knew and used varied malaria prevention approaches such as ITNs, insecticide home sprays, intermittent presumptive therapy during pregnancy (IPT) and emphasized homestead hygiene practices such as drainage of stagnant water, covering of water tanks, clearing of bushes around homesteads, destruction of broken pots and empty tins, as narrated: ‘…we practice varied malaria prevention methods, for example, most of us close our windows and doors early (by 7 pm), and ensure that our compounds are free from any water’. (36 years old, pregnant woman).

As the most available and widely used preventive method, the availability and effectiveness of ITNs was rated high. Participants expressed positive attributes and indicated that distribution and sensitization efforts had yielded positively as narrated: ‘…. there is strong evidence that ITNS work for us. Even when you go for antenatal care visit, they emphasize malaria prevention, and they also give us an ITN. At immunization, young children are given a free ITN, and their use is welcomed by all of us’. (34 years old, pregnant women). The ITNs were perceived to have reduced on the burden of malaria among the vulnerable groups, and majority of the participants expressed positive attributes towards their regular and correct use as narrated: ‘Ever since I started sleeping under an ITN, I have spent about four years without suffering from malaria. When people noticed that use of ITNs reduced malaria infection, they understood the importance of these nets, and loved using them’. (25 years old, pregnant woman).

Despite this, ITNs were not 100% effective since it only offered protection while one is asleep. The methods of spraying with an insecticide were not common as narrated: ‘….sometimes you can’t afford to buy that mosquito spray, others fear using the spray because it causes severe headaches, and others are allergic, so you may use it and you start breathing badly or get a skin rash’ (27 years old, pregnant woman) . Often, participants considered the use of ITNs as the only available method considering its (ITNs) availability and ease of use. Consequently, participants recognized the good attributes of ITN use, and they expressed an irresistible willingness to buy and use an ITN as narrated: ‘….ITNs were freely distributed by the government, and even if I was to buy one, it costs less than the treatment charge for malaria. While an ITN would cost about 10,000 Uganda Shillings (an equivalent of 2.78 United States Dollars), most of the private health facilities would charge an average fee of 68,000 Ugandan Shillings (an equivalent 18.89 United States Dollars); which is not affordable by the majority of the households, and it is more expensive if more than one individual in the household fell sick’ (43 years old, mother of six). To this, HCPs and VHTs asserted the positive attributes of ITN use and affirmed the positive perception and improved practices among communities as narrated; ‘…when they would announce that they are distributing ITNs, people would leave all they were doing to make sure that they also get. During the distribution, they don’t mention bad things about them (ITNs) (38 years old, mother of five/midwife) . The local leaders affirmed the positive attitude as given in the narrative: ‘…people have seriously taken up the call to malaria prevention. We usually monitor homes to find out whether the malaria prevention and control measures are practiced, and we are impressed by the majority’ (59 years old, father of eight/local council chairperson of P_cell). Participants reported a positive attitude as given in the verbatim: ‘…malaria infection has reduced in our communities. Most of the people now suffer from cough and flu’ (47 years old, VHT) . This was further affirmed by the healthcare provider who reported that: ‘…the cases of malaria have declined, and most of the patients we see at the health centre are due to respiratory tract infections’ (44 years old, mother of four/midwife).

Utilization and challenges of malaria prevention methods

The use of ITNs was preferred as people freely acquired them from the universal rollout programs. Besides, ITNs are quite easy to use. The use of insecticide sprays was not common as the spray is costly for a rural population, and the chemical caused adverse effects if inhaled. Despite the varied strategies and positive attributes of malaria prevention, some participants didn’t utilize such measures. These were ascribed to deliberate refusal, being careless with their health, others felt suffocated under ITNs, uncomfortable on hot nights, while health conditions like asthma portended consistent use of ITNs. Other participants considered ITNs as highly flammable, which would put the house at risk, as narrated: ‘Some people are scared of using ITNs because they can easily catch fire and burn the whole house down, as it has been reported in most fire outbreaks in school dormitories’. (29 years old, mother of 3 months). Also, family disparity as a wife may prefer sleeping under an ITN while the husband is uncomfortable was another reported factor for ITN non-use. More, some participants didn’t receive sufficient ITNs for all the members in their households as explained by the local council leader: ‘…usually, we distribute one ITN to two people in a household, so in the end, households that have many members sleeping in separate beds will have a problem of inadequate ITNs’. (40 years old, father of six/local council leader n_cell).

Effect of COVID-19 pandemic on healthcare-seeking and prevention methods

Effects of covid-19 towards healthcare access for malaria infection.

There were unprecedented challenges that affected healthcare access as narrated: ‘…at the start of the lockdown, public transport means were stopped and the curfew was put in place. These halted people accessing healthcare facilities’. (38 years old, mother of six) . Further, two participants expressed dismay as reported: ‘… that even when the lockdown was eased, the private cars were allowed to carry a limited capacity, and even then, it was expensive to hire someone’s car to access the healthcare facility’. (28 years old, pregnant woman) ‘…in the subsequent easing of the transport restrictions, public transport was allowed, but to carry half the capacity of the passengers. […] this led to exorbitant transport charges’ (21 years old, mother to 2 years old). To the greatest extent, COVID-19 negatively affected healthcare access. This was affirmed by local council authority as narrated: ‘…. when COVID-19 broke out, the world changed! The president stopped the movement of both motorcycles and cars. Whenever a child or even a pregnant woman fell sick, it was difficult to go to the hospital. Sometimes the motorcyclists would risk transporting you, but they would be badly beaten by the law enforcers. Also, the motorcyclists would charge much more money, and this discouraged people from accessing healthcare facilities’. (33 years old, father of three/local council leader q_cell).

Effect of COVID-19 pandemic on malaria prevention methods

As the most available and commonly utilized malaria prevention method, the use of ITNs was negatively affected by the COVID-19 pandemic. For example, COVID-19 increased family conflicts, and these affected the availability and use of malaria prevention as narrated; ‘…the outbreak of Corona (COVID-19) increased family conflicts! When such happened, it made it hard to share a bed with ITN! So a woman and her baby would go and sleep somewhere else! As we received limited ITNs, when you shift from the main bed, then you sleep on a mattress that is put down on the floor without an ITN’ (29 years old, mother to 11 months old).

Also, the sudden closure of schools with no clear understanding of when these would re-open for the learners posed great challenges in regard to ITN utilization. It emerged that most school supplies like ITNs were left behind, and as learners went back to their homes, resulting in a scarcity of ITNs there. For parents who did not want their children’s lives risked to mosquito bites, they gave in theirs to protect the children as narrated: ‘Due to COVID-19, schools closed abruptly and children left their ITNs at school. As a parent, it hurts to have an ITN when your three children who share a bed are not protected. So, I gave mine to protect my children, but now it is six months and schools haven’t opened. I think I will get another during my antenatal visit’. (31 years old, mother of three).

Further, the COVID-19 pandemic shifted the focus of priorities as reported: ‘…some government programs including ITN distribution were halted, and people spent several months without ITNs. […] also, malaria-related training reduced due to COVID-19 as a gathering is discouraged’ (37 years old, mother of four/VHT).

Furthermore, COVID-19 negatively affected household income, and this hampered malaria prevention as narrated: ‘…COVID-19 has reduced the utilization of malaria prevention using insecticide sprays as the standards of living were greatly impoverished as people lost jobs. …the major focus is on survival, and priorities have left households compromised with malaria prevention’ (23 years old, pregnant woman).

On the contrary, the curfews put in place ensured early return to home (from 07:00PM to 06:00AM), and this allowed people to be indoors much earlier than before, and this reduced the risk of mosquito bites as given in the verbatim: ‘…. everyone now returns so early because of the curfew, so we ensure that we cook in time and go to bed. This protects us from mosquitoes that bites us late in the night’. (36 years old, pregnant women).

The results of this study affirmed that the majority of participants knew that the causes and transmission of malaria were associated with mosquito bites, and further asserted that malaria was transmitted from person-to-person through a mosquito bite. This finding agrees with previous studies [ 26 , 27 , 28 ] and is indicative of ample community knowledge on malaria, which is key to its prevention. The observed malaria-related knowledge is ascribed to the awareness campaigns, and this is hoped to foster prevention uptake [ 29 ]. On the other hand, some participants did not correctly understand the causes, transmission, and symptoms of malaria which may impede prevention uptake, and risk community malaria infections. Also, the early signs of pregnancy overlapping symptoms of malaria have been reported [ 30 , 31 ], and may negatively affect healthcare seeking [ 32 , 33 , 34 ].

Misconceptions about malaria prevention still exist and may portend malaria prevention uptake. For example, studies conducted in Nigeria reported that misconceptions related to malaria prevention methods affected their uptake [ 35 , 36 ]. Mathania et al.[ 37 ] further assert that uptake of malaria prevention requires strategies that address misinformation on the various methods. Similar findings from Zimbabwe and Burkina Faso have affirmed this [ 36 , 38 ]. Misconceptions related to malaria causation have indicated spurious prevention strategies, which risks the lives of the vulnerable populations [ 39 , 40 ]. To this, overlapping knowledge on malaria causes, symptoms, and prevention has been observed between pregnant women and the caregivers of children under-five [ 41 ]. In Uganda, numerous studies have shown a knowledge gap in both malaria causes and prevention measures [ 17 , 40 ]. In our experience of exploring the knowledge, attitude, and behavioral practices towards the use of ITNs among pregnant women and children under-five years in Isingiro district, there was optimal knowledge of malaria prevention, however, major barriers existed related to texture, color, and chemical composition impeded their utilization [ 17 ]. The low uptake of malaria prevention among vulnerable groups raises critical health concerns.

Participants were cognizant of the negative effects of malaria, and these are key towards malaria prevention uptake [ 23 , 42 ]. Further, the reported effects were detrimental as they negatively affected both the caregivers of children under-five years and pregnant women [ 27 , 31 ]. These corroborate with previous reports [ 43 , 44 ], and these demonstrate the threat posed by malaria infection. Consequently, this shows the need to urgently seek healthcare to avert the fatal consequences of the disease. Further, although the majority of the participants who reported fever had sought formal healthcare, some had initially considered home-remedies in form of paracetamol, herbs, and tepid sponging before seeking formal health care. The alternative remedies were agitated by frequent drug stock-outs in public health facilities and exorbitant charges in private health facilities. This pattern of healthcare-seeking affected delivery as some pregnant women reportedly opted to deliver from their villages due to long distances, and transport barriers. This affirms a previous report [ 45 ], and further highlights the gap in timely healthcare-seeking [ 46 ]. COVID-19 control requirements made seeking outside medications more difficulty of finding and cost of transport and the decrease in income. This finding contravenes recommendations that oblige timely healthcare seeking [ 47 ]. Similar to our study, previous research reported participants adopting a thriving private market and caregivers practiced over-the-counter remedies [ 48 ]. This suggests that home treatment may provide a more attractive option than formal healthcare [ 49 , 50 ], since access to shop‐bought medicines can be easier, with less time spent traveling or waiting, longer opening hours, and customer‐orientated staff [ 50 ]. Additionally, as malaria infection occurs most during the rainy season when farming is at its peak, the use of home remedies may be preferred. From this study, paracetamol (also known as panadol) as an antipyretic monotherapy was reportedly used to ameliorate fever as an initial home remedy. This practice is inapt and is attributed to the negative influence of media advertisement of various antipyretics that acclaim for home treatment of fever with the addendum that ‘the doctor’ should be consulted if symptoms persist. Resultantly, healthcare seeking is delayed with the hope of getting better, a risky practice that aggravates unnecessary drug side effects, severe life-threatening complications, and preventable deaths [ 51 , 52 ]. Home and local remedies, as per opinions by participants were as a result of healthcare challenges, similar to previous studies [ 53 , 54 ].

Participants knew and reportedly utilized more than one malaria prevention method. Human vector control through the use of ITNs was the most available and participants expressed irresistible willingness to its use; consistent with a previous report [ 55 ]. Despite this, some participants did not use them due to perceived negative sentiments linked to the adverse risks of the insecticide, which corroborates well with previous reports [ 17 , 56 ]. On the other hand, insecticide spray presented severe adverse challenges only exacerbated by COVID-19’s negative impact on income and decrease in educational reminders because group gatherings to discuss health topics were curtailed. These health-impacting outcomes have been recognized, and previous studies have emphasized the need to limit children, and women's exposure to in-door insecticide use [ 57 , 58 ]. Again, some participants didn’t uptake malaria prevention measures, and this was ascribed to the consideration of ITNs as highly flammable, deliberate refusal, being careless with their health, others felt suffocated under ITNs, uncomforted night as it would be too hot, while conditions like allergy and asthma affected consistent use of ITNs. Also, family disparity as a wife may like sleeping under an ITN while the husband is uncomfortable, and conflicts in homes. Previous research has shown similar findings [ 17 , 59 , 60 ], and these affirm a previous report [ 61 ] that the malaria prevention uptake is not effectively used. It is plausible that when the government is going to distribute ITNs, a single ITN-to- a person in a home is ideal. Also, they government ought to consider tough punishments for people who misuse the ITNs.

The outbreak of the COVID-19 pandemic presented an unprecedented challenge towards malaria prevention uptake. For example, some malaria prevention interventions like ITN distribution and malaria-related training were halted because of discouraging gatherings. The observed pattern has been reported elsewhere [ 62 , 63 ]. Educational gatherings are helpful in supporting behaviors to prevent and control malaria. Also, movement restrictions reduced the mobility of healthcare workers in-country, limited the capacity of staff, community outreach activities, and logistical supplies that were supporting malaria prevention [ 64 ]. Furthermore, COVID-19 reduced functional health care facilities as healthcare workers were repurposed to support the COVID-19 control response [ 65 ]. Even when public transport resumed, there remained significant barriers particularly exorbitant transport fees as a result of a reduced carriage capacity, and less income to pay which hindered malaria prevention uptake particularly access to artemisinin combination therapies [ 64 ]. Further, increased time together increased family conflicts which negatively affected the consolidated use of malaria prevention. The findings of this study furthers affirms to the social and health impacts concluded in a commentary drawn on sub-Saharan African health researchers’ accounts of their countries’ responses to control the spread of COVID-19 [ 66 ]. These findings further underline the worrying negative effects experienced by the majority of the vulnerable population in rural southwestern Uganda. The findings of this study ought to be interpreted in light of the following: 1) the study interviewed caregivers to children under-five as the proxy to obtain data on presumed malaria cases at the household level, and 2) data presented is based on participants’ self-reports, which may be associated with socially desirable bias.

Our findings highlight that there is a need to reignite awareness promotion regarding malaria prevention, address misconceptions about malaria symptoms and early signs of pregnancy, and support interventions that promote formal and timely seeking of healthcare. Finally, response to COVID-19 ought to be integrated with malaria efforts by recommitting and integrating COVID-19 measures in the normative living and restrict future barriers to healthcare access.

The majority of the participants recognized the symptom of malaria, its transmission, and prevention measures. Their malaria prevention experience was highly influenced by the perceived causes and severe adverse effects of malaria infection. Furthermore, the use of home-remedies and non-formal approaches was a common practice. There were reported major negative effects of malaria prevention uptake due to the COVID-19 pandemic.

Availability of data and materials

All relevant data are within the paper. The interview guides are included as supplementary materials .

Abbreviations

Focus Group Discussion

In-depth Interview

Insecticide-Treated mosquito Net

Key Informant Interview

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Acknowledgements

We are grateful to the study participants, VHTs, and local council authorities. We acknowledge Nuwagaba Gabriel, Ssenyonga Pius, and Muhangi Steven who supported the data collection process. We are grateful to Robert Bortolussi and Noni E. MacDonald for critically reviewing this manuscript.

This study was supported by a MicroResearch ( www.microresearch.ca ) grant MR 19 N MUS 01. The funders had no role in study design, data collection, and analysis, or decision to publish.

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Ruth Ninsiima

McMaster Midwifery Research Centre, Hamilton, Canada

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IMT and RN conceived the study idea, participated in study design; data acquisition, analysis, and interpretation; and manuscript drafting and revision. RK, CA participated in drafting data collection tools, data acquisition, analysis, and interpretation; manuscript drafting and revision. SA and CM oversaw the research design, cross-checked data collection tools, manuscript drafting and critically reviewed the manuscript. All authors read and approved the final manuscript.

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Ethical approval was obtained from the Mbarara University of Science and Technology Research and Ethics Committee (UG-REC-005) affiliated to Mbarara University of Science and Technology (MUST) before the beginning of the study. Administrative permission was obtained from Isingiro district health office. The study obtained written informed consent/assent, and permission to audio record the interviews from all participants. Legally authorized representatives (literate family member) of illiterate participants provided informed consent for the study. The anonymity of participants was ensured at all stages of data collection and analysis. All methods were carried out in accordance with relevant guidelines and regulations (eg. Helsinki declaration).

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Taremwa, I.M., Ashaba, S., Kyarisiima, R. et al. Treatment-seeking and uptake of malaria prevention strategies among pregnant women and caregivers of children under-five years during COVID-19 pandemic in rural communities in South West Uganda: a qualitative study. BMC Public Health 22 , 373 (2022). https://doi.org/10.1186/s12889-022-12771-3

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DOI : https://doi.org/10.1186/s12889-022-12771-3

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  • Malaria prevention
  • Pregnant women
  • Children under-five

BMC Public Health

ISSN: 1471-2458

malaria strategies case study

Strategies and approaches to vector control in nine malaria-eliminating countries: a cross-case study analysis

Affiliations.

  • 1 Malaria Elimination Initiative, Global Health Group, University of California, San Francisco, 550 16th Street, 3rd Floor, San Francisco, CA, USA. [email protected].
  • 2 Malaria Elimination Initiative, Global Health Group, University of California, San Francisco, 550 16th Street, 3rd Floor, San Francisco, CA, USA. [email protected].
  • 3 Malaria Elimination Initiative, Global Health Group, University of California, San Francisco, 550 16th Street, 3rd Floor, San Francisco, CA, USA. [email protected].
  • 4 Centers for Disease Control and Prevention, 1600 Clifton Road, Atlanta, GA, USA. [email protected].
  • 5 London School of Tropical Medicine and Hygiene, Keppel Street, London, WC1E 7HT, UK. [email protected].
  • 6 The University of Queensland School of Public Health, Herston, QLD, Australia. [email protected].
  • 7 Swiss Tropical and Public Health Institute, Socinstrasse 57, 4051, Basel, Switzerland. [email protected].
  • 8 University of Basel, Basel, Switzerland. [email protected].
  • PMID: 26727923
  • PMCID: PMC4700736
  • DOI: 10.1186/s12936-015-1054-z

Background: There has been progress towards malaria elimination in the last decade. In response, WHO launched the Global Technical Strategy (GTS), in which vector surveillance and control play important roles. Country experiences in the Eliminating Malaria Case Study Series were reviewed to identify success factors on the road to elimination using a cross-case study analytic approach.

Methods: Reports were included in the analysis if final English language draft reports or publications were available at the time of analysis (Bhutan, Cape Verde, Malaysia, Mauritius, Namibia, Philippines, Sri Lanka, Turkey, Turkmenistan). A conceptual framework for vector control in malaria elimination was developed, reviewed, formatted as a matrix, and case study data was extracted and entered into the matrix. A workshop was convened during which participants conducted reviews of the case studies and matrices and arrived at a consensus on the evidence and lessons. The framework was revised and a second round of data extraction, synthesis and summary of the case study reports was conducted.

Results: Countries implemented a range of vector control interventions. Most countries aligned with integrated vector management, however its impact was not well articulated. All programmes conducted entomological surveillance, but the response (i.e., stratification and targeting of interventions, outbreak forecasting and strategy) was limited or not described. Indoor residual spraying (IRS) was commonly used by countries. There were several examples of severe reductions or halting of IRS coverage and subsequent resurgence of malaria. Funding and operational constraints and poor implementation had roles. Bed nets were commonly used by most programmes; coverage and effectiveness were either not measured or not articulated. Larval control was an important intervention for several countries, preventing re-introduction, however coverage and impact on incidence were not described. Across all interventions, coverage indicators were incomparable, and the rationale for which tools were used and which were not used appeared to be a function of the availability of funding, operational issues and cost instead of evidence of effectiveness to reduce incidence.

Conclusions: More work is required to fill gaps in programme guidance, clarify the best methods for choosing and targeting vector control interventions, and support to measure cost, cost-effectiveness and cost-benefit of vector surveillance and control interventions.

Publication types

  • Research Support, Non-U.S. Gov't
  • Research Support, U.S. Gov't, P.H.S.
  • Malaria / prevention & control*
  • Malaria / transmission
  • Mosquito Control / methods*
  • Philippines
  • Turkmenistan

Clinical Case Study 1: Fever 6 months after a visit to Pakistan

A 44-year-old man is seen at a physician’s office in the United States, during a week-end, for suspected malaria.

The patient was born in Pakistan but has lived in the United States for the past 12 years. He travels frequently back to Pakistan to visit friends and relatives. His last visit there was for two months, returning 11 months before the current episode. He did not take malaria prophylaxis then.

Five weeks ago, he was diagnosed with malaria and treated at a local hospital. The blood smear at that time was reported by the hospital as positive for malaria, species undetermined. He was then treated with 2 days of IV fluids (nature unknown) and tablets (nature unknown), and recovered.

The patient now presents with a history of low grade fever for the past few days, with no other symptoms. A blood smear is taken and examined at a hospital laboratory by the technician (no pathologist is available on this week-end). Through a telephone discussion, the technician states that she sees 4 parasites per 1000 red blood cells, with rings, “other forms with up to four nuclei,” and that some of the infected red blood cells are enlarged and deformed.

Question 1: What is your most probable diagnosis?

Not Malaria

That is incorrect. Please, try another answer.

Plasmodium falciparum

Plasmodium vivax

That is correct.

This is the most probable diagnosis. The reported microscopic findings are compatible with P. vivax: some infected red cells are enlarged and deformed, and the “other forms with four nuclei” are compatible with the presence of schizonts. Plasmodium vivax does occur in Pakistan, where it is found in slightly more than 50% of malaria cases.

The history suggests a relapse of P. vivax malaria, following an earlier episode five weeks ago. The earlier treatment apparently did not include primaquine, thus allowing the persistence of hypnozoites which caused this relapse.

An alternate explanation would be that the earlier infection was caused by chloroquine-resistant P. vivax (which has been reported in Pakistan), with recrudescence of blood-stage parasites occurring after an unsuccessful earlier treatment (if indeed the earlier treatment included chloroquine). However, recrudescences usually occur within 28 days of the intial episode, rather than at five weeks as described here.

The other species are less likely:

  • While P. falciparum does occur in Pakistan (slightly less than 50% of malaria cases), this patient reportedly did not develop symptoms until 10 months after departure from the exposure area: most cases of P. falciparum would have become symptomatic earlier.
  • P. ovale occurs mainly in Africa and has been found only occasionally in Asia (in the western Pacific).
  • P. malariae occurs worldwide, but its distribution is spotty, and its frequency in Pakistan is low to negligible.
  • Babesia would not fit with the microscopic description; in addition, babesiosis has not been reported in Pakistan, although admittedly the disease might have escaped detection.

Plasmodium ovale

Plasmodium malariae

Question 2: What treatment approach would you recommend, based on this clinical history and on the fact that the microscopy findings will not be confirmed by a pathologist for at least 24 hours?

Do not start treatment until a formal microscopic diagnosis is made (in 12-24 hours)

Treat as if chloroquine-sensitive Plasmodium falciparum malaria

A reasonable option, signifying that in the absence of definitive microscopic diagnosis, you prefer to play it safe and treat the patient for the most dangerous and rapidly progressing infection possible.

The safest course of action is to initially admit all cases of proven or suspected P. falciparum to the hospital until one can begin treatment and ensure that they are improving clinically and parasitologically.

However in this case, if the patient is only minimally symptomatic, one might elect against hospitalization and instead treat as an outpatient provided that close follow-up can be arranged. Once the definitive microscopic diagnosis is made the following day, you can always switch treatment.

Treat as if chloroquine-resistant Plasmodium falciparum malaria

Treat as if Plasmodium vivax malaria

Plasmodium vivax schizont

P. Vivax schizont

The diagnosis of P. vivax malaria is later confirmed by review of a blood smear available from the first episode (Figure), and by a PCR positive for P. vivax on blood collected during the current episode.

The microscopic diagnosis  of P. vivax is based on the following:

  • The infected red cells are enlarged and deformed;
  • The schizont shown contains 20 merozoites (schizonts of P. malariae and P. ovale have fewer merozoites; and in P. falciparum , schizonts are not usually seen in the peripheral blood);
  • The round gametocyte shown, contained in an enlarged red cell. (In this case, the typical Schüffner’s dots were not visible, probably due to staining problems.)

Question 3. To prevent further relapses from dormant liver stages, what would you recommend?

No further measures needed

A lab test to determine if the patient has dormant liver stages

Treatment immediately with a drug that kills dormant liver stages

A lab test, followed by treatment with a drug that kills dormant liver stages

You should exclude G6PD deficiency first, then give the patient primaquine, 30 mg per day for 14 days.

In case of G6PD deficiency, consultation with an expert in infectious diseases or tropical medicine is advised to discuss options for relapse prevention. For some patients with partial G6PD deficiency, an alternative regimen of primaquine 45 mg weekly for 8 weeks can sometime be used. Alternatively, weekly chloroquine prophylaxis may also be considered. Treatment with primaquine is justified because this patient probably has already had a relapse, and is at risk for further relapses. No test exists to detect the presence of liver stage parasites.

Question 4. Should this patient have taken preventive measures against malaria for his visit to Pakistan, considering that he was born there?

Even to visit friends and relatives, preventive measures must be taken. Chloroquine-resistant Plasmodium falciparum occurs in Pakistan, and thus the drugs recommended would be atovaquone-proguanil (Malarone®), doxycycline or mefloquine. Other preventive measures against mosquito bites also apply. Even though the patient was born in Pakistan, whatever acquired immunity he has developed would most likely have waned; negligence of preventive measures often occurs in individuals visiting friends and relatives , a situation that needs to be remedied.

Main Points

Travelers to Pakistan (including those visiting friends and relatives) need to take prophylaxis (atovaquone-proguanil [Malarone®], doxycycline or mefloquine).

Clinical history and travel history, and careful microscopic examination, probably would have directed the diagnosis toward P. vivax during the earlier episode, so that the relapse could have been prevented.

P. vivax malaria should be treated with chloroquine, except when acquired in Papua New Guinea and Indonesia, areas with high prevalence of chloroquine-resistant P. vivax . After a normal G6PD test, patients should get a radical cure with primaquine (30 mg per day for 14 days).

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Malaria: The Past and the Present

Jasminka talapko.

1 Faculty of Dental Medicine and Health, Josip Juraj Strossmayer University of Osijek, Crkvena 21, HR-31000 Osijek, Croatia; rh.zmdf@okpalatj (J.T.); rh.zmdf@vecva (A.V.)

Ivana Škrlec

Tamara alebić.

2 Faculty of Medicine, Josip Juraj Strossmayer University of Osijek, Josipa Huttlera 4, HR-31000 Osijek, Croatia; [email protected] (T.A.); moc.liamg@71ikujm (M.J.)

Melita Jukić

3 General Hospital Vukovar, Županijska 35, HR-32000 Vukovar, Croatia

Aleksandar Včev

Malaria is a severe disease caused by parasites of the genus Plasmodium , which is transmitted to humans by a bite of an infected female mosquito of the species Anopheles . Malaria remains the leading cause of mortality around the world, and early diagnosis and fast-acting treatment prevent unwanted outcomes. It is the most common disease in Africa and some countries of Asia, while in the developed world malaria occurs as imported from endemic areas. The sweet sagewort plant was used as early as the second century BC to treat malaria fever in China. Much later, quinine started being used as an antimalaria drug. A global battle against malaria started in 1955, and Croatia declared 1964 to be the year of eradication of malaria. The World Health Organization carries out a malaria control program on a global scale, focusing on local strengthening of primary health care, early diagnosis of the disease, timely treatment, and disease prevention. Globally, the burden of malaria is lower than ten years ago. However, in the last few years, there has been an increase in the number of malaria cases around the world. It is moving towards targets established by the WHO, but that progress has slowed down.

1. Introduction

Malaria affected an estimated 219 million people causing 435,000 deaths in 2017 globally. This burden of morbidity and mortality is a result of more than a century of global effort and research aimed at improving the prevention, diagnosis, and treatment of malaria [ 1 ]. Malaria is the most common disease in Africa and some countries in Asia with the highest number of indigenous cases. The malaria mortality rate globally ranges from 0.3–2.2%, and in cases of severe forms of malaria in regions with tropical climate from 11–30% [ 2 ]. Different studies showed that the prevalence of malaria parasite infection has increased since 2015 [ 3 , 4 ].

The causative agent of malaria is a small protozoon belonging to the group of Plasmodium species, and it consists of several subspecies. Some of the Plasmodium species cause disease in human [ 2 , 5 ]. The genus Plasmodium is an amoeboid intracellular parasite which accumulates malaria pigment (an insoluble metabolite of hemoglobin). Parasites on different vertebrates; some in red blood cells, and some in tissue. Of the 172 of Plasmodium species, five species can infect humans. These are P. malariae , P.falciparum , P.vivax , P.ovale , and P.knowlesi . In South-East Asia, the zoonotic malaria P.knowlesi is recorded. Other species rarely infect humans [ 5 , 6 , 7 , 8 ]. All the mentioned Plasmodium species cause the disease commonly known as malaria (Latin for Malus aer —bad air). Likewise, all species have similar morphology and biology [ 9 ].

The Plasmodium life cycle is very complex and takes place in two phases; sexual and asexual, the vector mosquitoes and the vertebrate hosts. In the vectors, mosquitoes, the sexual phase of the parasite’s life cycle occurs. The asexual phase of the life cycle occurs in humans, the intermediate host for malaria [ 9 , 10 ]. Human malaria is transmitted only by female mosquitoes of the genus Anopheles . The parasite, in the form of sporozoite, after a bite by an infected female mosquito, enters the human blood and after half an hour of blood circulation, enters the hepatocytes [ 11 ]. The first phase of Plasmodium asexual development occurs in the hepatocytes, and then in the erythrocytes. All Plasmodium species lead to the rupture of erythrocytes [ 7 , 9 , 12 , 13 ].

The most common species in the Americas and Europe are P.vivax and P.malariae , while in Africa it is P.falciparum [ 14 ].

2. Discovery of Malaria

It is believed that the history of malaria outbreaks goes back to the beginnings of civilization. It is the most widespread disease due to which many people have lost lives and is even thought to have been the cause of major military defeats, as well as the disappearance of some nations [ 15 ]. The first descriptions of malaria are found in ancient Chinese medical records of 2700 BC, and 1200 years later in the Ebers Papyrus [ 2 ]. The military leader Alexander the Great died from malaria [ 15 ]. The evidence that this disease was present within all layers of society is in the fact that Christopher Columbus, Albrecht Dürer, Cesare Borgia, and George Washington all suffered from it [ 16 , 17 ].

Although the ancient people frequently faced malaria and its symptoms, the fever that would occur in patients was attributed to various supernatural forces and angry divinities. It is, thus, stated that the Assyrian-Babylonian deity Nergal was portrayed as a stylized two-winged insect, as was the Canaan Zebub (‘Beelzebub, in translation: the master of the fly’) [ 17 ]. In the 4th century BC, Hippocrates described this disease in a way that completely rejected its demonic origins and linked it with evaporation from swamps which, when inhaled, caused the disease. That interpretation was maintained until 1880 and Laveran’s discovery of the cause of the disease [ 18 ]. Laveran, a French military surgeon, first observed parasites in the blood of malaria patients, and for that discovery he received the Nobel Prize in 1907 [ 19 ].

Cartwright and Biddis state that malaria is considered to be the most widespread African disease [ 14 ]. The causative agent of malaria is a small protozoon belonging to the group of Plasmodium species, and it consists of several subspecies [ 14 ].

3. The Development of Diagnostic Tests for Proving Malaria through History

Malaria can last for three and up to five years, if left untreated, and depending on the cause, may recrudesce. In P. vivax and ovale infections, the persistence of the merozoites in the blood or hypnozoites in hepatocytes can cause relapse months or years after the initial infection. Additionally, relapse of vivax malaria is common after P. falciparum infection in Southeast Asia. Relapse cases were observed in P. falciparum infections, which can lead to a rapid high parasitemia with subsequent destruction of erythrocytes [ 20 , 21 ]. Children, pregnant women, immunocompromised and splenectomized patients are especially vulnerable to malaria infection, as well as healthy people without prior contact with Plasmodium . A laboratory test for malaria should always confirm clinical findings. The proving of malaria is carried out by direct methods such as evidence of parasites or parts of parasites, and indirect methods that prove the antibodies to the causative agents ( Table 1 ) [ 2 , 5 , 22 ].

Diagnostic tests for proving malaria.

The gold standard method for malaria diagnosis is light microscopy of stained blood films by Giemsa. Due to a lack of proper staining material and trained technicians, this method is not available in many parts of sub-Saharan Africa. The sensitivity of the method depends on the professional expertise, and it is possible to detect an infection with 10–100 parasites/μL of blood. A negative finding in patients with symptoms does not exclude malaria, but smears should be repeated three times in intervals of 12–24 h if the disease is still suspected [ 23 , 24 ]. Diagnosis of malaria using serologic testing has traditionally been done by immunofluorescence antibody testing (IFA). IFA is time-consuming and subjective. It is valuable in epidemiological studies, for screening possible blood donors. It also demands fluorescence microscopy and qualified technicians [ 23 , 25 , 26 ].

Rapid Diagnostic Tests (RDT) for the detection of antigens in the blood are immunochromatographic tests to prove the presence of parasite antigens. No electrical equipment, and no special experience or skills are required to perform these tests. The RDTs are now recommended by WHO as the first choice of test all across the world in all malaria-endemic areas. The sensitivity of the antigen test varies depending on the selected antigens represented in the test. For some RDTs is 50–100 parasites/μL (PfHRP2) to <100 parasites/μL [ 27 , 28 ]. The FDA approved the first RDT test in 2007. It is recommended that the results of all RDT tests should be confirmed by microscopic blood analysis [ 29 ]. It is known that antigens detected with RDT test remain in the blood after antimalarial treatment, but the existence of these antigens varies after treatment. The false-positive rates should be less than 10% [ 30 ]. Several RDT tests in the eight rounds of testing revealed malaria at a low-density parasite (200 parasites/μL), had low false-positive rates and could detect P. falciparum or P. vivax infections or both [ 30 ]. False-positive rates of P. vivax were typically small, between 5% and 15%. On the other hand, the false-positive rates of P. falciparum range from 3–32% [ 30 , 31 ]. Good RDTs might occasionally give false-negative results if the parasite density is low, or if variations in the production of parasite antigen reduce the ability of the RDT to detect the parasite. False negative results of the RDT test for P. falciparum ranged between 1% and 11% [ 31 , 32 , 33 , 34 ]. The overall sensitivity of RDTs is 82% (range 81–99%), and specificity is 89% (range 88–99%) [ 35 ].

Polymerase chain reaction (PCR) is another method in the detection of malaria. This method is more sensitive and more specific than all conventional methods in the detection of malaria. It can detect below one parasite/μL. PCR test confirms the presence of parasitic nucleic acid [ 23 , 36 ]. PCR results are often not available fast enough to be useful in malaria diagnosis in endemic areas. However, this method is most helpful in identifying Plasmodium species after diagnosis by microscopy or RDT test in laboratories that might not have microscopic experts. Additionally, PCR is useful for the monitoring of patients receiving antimalaria treatment [ 36 , 37 ].

Indirect methods are used to demonstrate antibodies to malaria-causing agents. Such methods are used in testing people who have been or might be at risk of malaria, such as blood donors and pregnant women. The method is based on an indirect immunofluorescence assay (IFA) or an ELISA test. The IFA is specific and sensitive but not suitable for a large number of samples, and the results are subjective evaluations. For serological testing, ELISA tests are more commonly used [ 26 ].

Rapid and accurate diagnosis of malaria is an integral part of appropriate treatment for affected person and the prevention of the further spread of the infection in the community.

4. Malaria Treatment through History

Already in the 2nd century BC, a sweet sagewort plant named Qinghai (Latin Artemisia annua ) was used for the treatment of malaria in China [ 38 ]. Much later, in the 16th century, the Spanish invaders in Peru took over the cinchona medication against malaria obtained from the bark of the Cinchona tree (Latin Cinchona succirubra ). From this plant in 1820 the French chemists, Pierre Joseph Pelletie, and Joseph Bienaimé Caventou isolated the active ingredient quinine, which had been used for many years in the chemoprophylaxis and treatment of malaria. In 1970, a group of Chinese scientists led by Dr. Youyou Tu isolated the active substance artemisinin from the plant Artemisia annua , an antimalarial that has proved to be very useful in treating malaria. For that discovery, Youyou Tu received the Nobel Prize for Physiology and Medicine in 2015 [ 39 , 40 , 41 ]. Most of the artemisinin-related drugs used today are prodrugs, which are activated by hydrolysis to the metabolite dihydroartemisinin. Artemisinin drugs exhibit its antimalarial activity by forming the radical via a peroxide linkage [ 42 ]. WHO recommends the use of artemisinin-based combination therapies (ACT) to ensure a high cure rate of P. falciparum malaria and reduce the spread of drug resistance. ACT therapies are used due to high resistance to chloroquine, sulfadoxine-pyrimethamine, and amodiaquine [ 1 ]. Due to the unique structure of artemisinins, there is much space for further research. Extensive efforts are devoted to clarification of drug targets and mechanisms of action, the improvement of pharmacokinetic properties, and identifying a new generation of artemisinins against resistant Plasmodium strains [ 42 ].

The German chemist Othmer Zeidler synthesized dichlorodiphenyltrichloroethane (DDT) in 1874 during his Ph.D. At that time, no uses of DDT was found, and it just became a useless chemical [ 43 ]. The insecticide property of DDT was discovered in 1939 by Paul Müller in Switzerland. DDT began to be used to control malaria at the end of the Second World War [ 40 ]. During the Second World War, the success of DDT quickly led to the introduction of other chlorinated hydrocarbons which were used in large amounts for the control of diseases transmitted by mosquito [ 43 ]. From the late Middle Ages until 1940, when DDT began to be applied, two-thirds of the world’s population had been exposed to malaria, a fact that represented a severe health, demographic, and economic problem [ 29 , 40 , 41 , 44 , 45 ]. DDT is an organochlorine pesticide which was applied in liquid and powder form against the insects. During the Second World War people were sprayed with DDT. After the war, DDT became a powerful way of fighting malaria by attacking the vector [ 43 ].

Five Nobel Prizes associated with malaria were awarded: Youyou Tu in 2015. Ronald Ross received the Nobel Prize in 1902 for the discovery and significance of mosquitoes in the biology of the causative agents in malaria. In 1907, the Nobel was awarded to the already-mentioned Charles Louis Alphonse Laveran for the discovery of the causative agent. Julius Wagner-Jauregg received it in 1927 for the induction of malaria as a pyrotherapy procedure in the treatment of paralytic dementia. In 1947 Paul Müller received it for the synthetic pesticide formula dichlorodiphenyltrichloroethane.

Attempts to produce an effective antimalarial vaccine and its clinical trials are underway. Over the past several decades’ numerous efforts have been made to develop effective and affordable preventive antimalaria vaccines. Numerous clinical trials are completed in the past few years. Nowadays are ongoing clinical trials for the development of next-generation malaria vaccines. The main issue is P. vivax vaccine, whose research requires further investigations to identify novel vaccine candidates [ 46 , 47 , 48 ]. Despite decades of research in vaccine development, an effective antimalaria vaccine has not yet been developed (i.e., with efficacy higher than 50%) [ 49 , 50 , 51 ]. The European Union Clinical Trials Register currently displays 48 clinical trials with a EudraCT protocol for malaria, of which 13 are still ongoing clinical trials [ 52 ]. The malaria parasite is a complex organism with a complex life cycle which can avoid the immune system, making it very difficult to create a vaccine. During the different stages of the Plasmodium life cycle, it undergoes morphological changes and exhibits antigenic variations. Plasmodium proteins are highly polymorphic, and its functions are redundant. Also, the development of malaria disease depends on the Plasmodium species. That way, a combination of different adjuvants type into antigen-specific formulations would achieve a higher efficacy [ 53 , 54 ]. Drugs that underwent clinical trials proved to be mostly ineffective [ 5 , 7 , 55 ]. However, many scientists around the world are working on the development of an effective vaccine [ 56 , 57 , 58 ]. Since other methods of suppressing malaria, including medication, insecticides, and bed nets treated with pesticides, have failed to eradicate the disease, and the search for a vaccine is considered to be one of the most important research projects in public health by World Health Organization (WHO).

The best way to fight malaria is to prevent insect bites. Malaria therapy is administered using antimalarial drugs that have evolved from quinine. According to its primary effect, malarial vaccines are divided into pre-erythrocytic (sporozoite and liver-stage), blood-stage, and transmission-blocking vaccines [ 9 , 54 ]. Most medications used in the treatment are active against parasitic forms in the blood (the type that causes disease) ( Table 2 ) [ 59 ]. The two crucial antimalarial medications currently used are derived from plants whose medical importance has been known for centuries: artemisinin from the plant Qinghao ( Artemisia annua L, China, 4th century) and quinine from Cinchona (South America, 17th century). Side-by-side with artemisinin, quinine is one of the most effective antimalarial drugs available today [ 13 , 39 , 40 ]. Doxycycline is indicated for malaria chemoprophylaxis for travel in endemic areas. It is also used in combination with the quinine or artesunate for malaria treatment when ACT is unavailable or when the treatment of severe malaria with artesunate fails. The disadvantage of doxycycline is that children and pregnant women cannot use it [ 29 ]. Due to the global resistance of P. falciparum to chloroquine, ACTs are recommended for the treatment of malaria, except in the first trimester of pregnancy. ACTs consist of a combination of an artemisinin derivative that fast decreases parasitemia and a partner drug that eliminates remaining parasites over a more extended period. The most common ACTs in use are artemether-lumefantrine, artesunate-amodiaquine, dihydroartemisinin-piperaquine, artesunate-mefloquine, and artesunate with sulfadoxine-pyrimethamine. The ACTs were very efficient against all P. falciparum until recently when numbers of treatment failures raised in parts of Southeast Asia. Atovaquone-proguanil is an option non-artemisinin-based treatment that is helpful for individual cases which have failed therapy with usual ACTs. Although, it is not approved for comprehensive implementation in endemic countries because of the ability for the rapid development of atovaquone resistance. Quinine remains efficient, although it needs a long course of treatment, is poorly tolerated, especially by children, and must be combined with another drug, such as doxycycline or clindamycin. Uncomplicated vivax, malariae, and ovale malaria are handled with chloroquine except in case of chloroquine-resistant P. vivax when an ACT is used [ 7 , 29 , 60 , 61 , 62 ].

Overview of the most commonly used antimalarials.

CNS—central nervous system.

4.1. Malaria in Europe

In Europe, malaria outbreaks occurred in the Roman Empire [ 63 , 64 ] and the 17th century. Up until the 17th century it was treated as any fever that people of the time encountered. The methods applied were not sufficient and included the release of blood, starvation, and body cleansing. As the first effective antimalarial drug, the medicinal bark of the Cinchona tree containing quinine was mentioned and was initially used by the Peruvian population [ 14 ]. It is believed that in the fourth decade of the 17th century it was transferred to Europe through the Spanish Jesuit missionaries who spread the treatment to Europe [ 65 ].

Contemporary knowledge of malaria treatment is the result of the work of a few researchers. Some of researchers are Alphonse Laveran, Ronald Ross, and Giovanni Battista Grassi. In November 1880, Laveran, who worked as a military doctor in Algeria, discovered the causative agents of malaria in the blood of mosquitoes and found that it was a kind of protozoa [ 66 ]. Laveran noticed that protozoa could, just like bacteria, live a parasitic way of life within humans and thus cause disease [ 66 ]. Nearly two decades later, more precisely in 1898, Ronald Ross, a military doctor in India, discovered the transmission of bird malaria in the saliva of infected mosquitos, while the Italian physician Giovanni Battista Grassi proved that malaria was transmitted from mosquitoes to humans, in the same year. He also proved that not all mosquitoes transmit malaria, but only a specific species ( Anopheles ) [ 17 ]. This discovery paved the way for further research.

The global battle against malaria started in 1955, and the program was based on the elimination of mosquitoes using DDT and included malarial areas of the United States, Southern Europe, the Caribbean, South Asia, but only three African countries (South Africa, Zimbabwe, and Swaziland). In 1975, the WHO announced that malaria had been eradicated in Europe and all recorded cases were introduced through migration [ 67 , 68 ].

4.2. Malaria in Croatia

In Croatia, the first written document that testifies to the prevention of malaria is the Statute of the town of Korčula from 1265. In 1874, the Law on Health Care of Croatia and Slavonia established the public health service that was directed towards treating malaria. There was no awareness nor proper medical knowledge about malaria, but the drainage was carried out to bring the ‘healthy air’ in the cities [ 69 , 70 ]. In 1798 physician Giuseppe Arduino notified the Austrian government about malaria in Istria. A government representative Vincenzo Benini accepted a proposed sanitary measure of the drainage of wetlands [ 71 ]. In 1864, the drainage of wetlands around Pula and on the coastal islands began, and since 1902 a program for the suppression of malaria by treatment of patients using quinine has been applied [ 72 ]. In 1922, the Institute for Malaria was founded in Trogir. In 1923, on the island of Krk, a project was started to eradicate malaria by the sanitation of water surfaces and the treatment of the patients with quinine, led by Dr. Otmar Trausmiller [ 66 ]. Since 1924, besides chemical treatment, biological control of mosquitoes has been established by introducing the fish Gambusia holbrooki to Istria and the coast [ 73 ]. In 1930 legislation was passed to enforce village sanitation, which included the construction of water infrastructure and safe wells, contributing to the prevention of malaria. Regular mosquito fogging with arsenic green (copper acetoarsenite) was introduced, and larvicidal disinfection of stagnant water was carried out.

Since malaria occurs near swamps, streams, ravines, and places where mosquitoes live near water, this disease has been present throughout history in Croatia, and it has often become an epidemic [ 74 ]. It was widespread in the area of Dalmatia, the Croatian Littoral region, Istria, and river flows. In the area of the Croatian Littoral, it was widespread on some islands, such as Krk, Rab, and Pag, while the mainland was left mainly clear of it [ 75 ]. The ethnographer Alberto Fortis (1741–1803) who traveled to Dalmatia, noted impressions recording details of malaria that was a problem in the Neretva River valley. Fortis wanted to visit that area, but the sailors on ship were afraid, probably because the were afraid to go to a place where there had been a disease outbreak known as the Neretva plague [ 76 ]. This Neretva plague was, in fact, malaria, and it is believed that due to it, the Neretva was nicknamed “Neretva—damned by God” [ 77 , 78 ]. Speaking of the Neretva region, Fortis states that the number of mosquitoes in that wetland area was so high that people had to sleep in stuffy canopy tents to defend themselves. Fortis also states that there were so many mosquitoes that he was affected by it. During the stay, Fortis met a priest who had a bump on the head claiming it had occurred after a mosquito bite and believed that the fever that infected the people of the Neretva Valley was also a consequence of the insect bites there [ 76 ]. In a manuscript, Dugački described some of the epidemics in Croatia. Thus, noted the small population of Nin in 1348, which was the result of the unhealthy air and high mortality of the population. Three centuries later, in 1646, the fever was mentioned in Novigrad, while the year 1717 was crucial for to the Istrian town of Dvigrad, which was utterly deserted due to malaria. At the beginning of the 20th century, more precisely in 1902, the daily press reported that the Provincial Hospital in Zadar was full of people affected by malaria. The extent to which this illness was widespread is proved by the fact that at the beginning of the 20th century about 180,000 people suffered from it in Dalmatia [ 18 ]. The volume and frequency of epidemics in Dalmatia resulted in the arrival of the Italian malariologist Grassi and the German parasitologist Schaudin. The procedures of quininization began to be applied, and in 1908 25 physicians and 423 pill distributors were to visit the villages and divide pills that had to be taken regularly to the people to eradicate malaria [ 75 ].

Likewise, in Slavonia, malaria had also a noticeable effect, and it was widespread in the 18th century due to a large number of swamps that covered the region. Such areas were extremely devastating for settlers who were more vulnerable to the disease than its domestic population [ 79 ]. Friedrich Wilhelm von Taube (1728–1778) recorded the disease and stated that the immigrant Germans were primarily affected by malaria and that the cities of Osijek and Petrovaradin can be nicknamed "German Cemeteries" [ 80 ]. According to Skenderović, the high mortality of German settlers from malaria was not limited only to the Slavonia region but also to the Danubian regions in which the Germans had settled in the 18th century, with Banat and Bačka [ 79 ] having the most significant number of malaria cases. The perception of Slavonia in the 18th century was not a positive one. Even Taube stated that Slavonia was not in good standing in the Habsburg Monarchy and that the nobility avoided living there. As some of the reasons for this avoidance, Taube mentioned the unhealthy air and the many swamps in the area around in which there was a multitude of insects. Taube noted that mosquitoes appear to be larger than in Germany and that its bite was much more painful. A change in the situation could only be brought about by drying the swamp, in his opinion [ 80 ]. Since malaria had led to the death of a large number of people, the solution had to be found to stop its further spread. Swamp drying was finally accepted by the Habsburg Monarchy and some European countries as a practical solution and, thus, its drainage began during the 18th century, resulting in cultivated fields [ 79 ].

Since epidemics of malaria continued to occur, there is one more significant record of the disease in the Medical Journal of 1877. In it, the physician A. Holzer cites his experiences from Lipik and Daruvar where he had been a spa physician for a long time. Holzer warns of the painful illness noticed at spa visitors suffering from the most in July and August. As a physician, Holzer could not remain indifferent to the fact that he did not see anyone looking healthy. It also pointed out that other parts of Croatia were not an exception. As an example, Holzer noted Virovitica County, where malaria was also widespread. He wanted to prevent the development and spread of the illness. Believing that preventing the toxic substances from rising into the air would stop the disease, the solution was to use charcoal that has the properties of absorbing various gases and, thus, prevents vapor rising from the ground [ 81 ].

Dr. Andrija Štampar (1888–1958) holds a prominent place in preventing the spread of malaria. Štampar founded the Department of Malaria, and numerous antimalaria stations, hygiene institutes, and homes of national health. Dr. Štampar devoted his life to educating the broader population about healthy habits and, thus, prevents the spread of infectious diseases. Many films were shown, including a film entitled ‘Malaria of Trogir’ in Osijek in 1927, with numerous health lectures on malaria [ 82 ]. After the end of the Second World War, a proposal for malaria eradication measures was drafted by Dr. Branko Richter. These measures, thanks to Dr. Andrija Štampar, are being used in many malaria-burdened countries. For the eradication of malaria in Croatia and throughout Yugoslavia, DDT has been used since 1947 [ 83 ].

Malaria is still one of the most infectious diseases that cause far more deaths than all parasitic diseases together. Malaria was eradicated in Europe in 1975. After that year, malaria cases in Europe are linked to travel and immigrants coming from endemic areas. Although the potential for malaria spreading in Europe is very low, especially in its western and northern parts, it is still necessary to raise awareness of this disease and keep public health at a high level in order to prevent the possibility of transmitting the disease to the most vulnerable parts of Europe [ 84 ].

Unofficial data show that malaria disappeared from Croatia in 1958, while the World Health Organization cites 1964 as the year when malaria was officially eradicated in Croatia [ 45 , 75 ]. Nonetheless, some cases of imported malaria have been reported in Croatia since 1964. The imported malaria is evident concerning Croatia’s orientation to maritime affairs, tourism, and business trips. Namely, malaria is introduced to Croatia by foreign and domestic sailors, and in rare cases by tourists, mainly from the countries of Africa and Asia [ 75 , 85 ]. According to the reports of the Croatian Institute of Public Health, since the eradication of this disease 423 malaria cases have been reported, all imported [ 86 ]. Figure 1 shows the number of imported malaria cases in Croatia from 1987–2017, and Figure 2 the causative Plasmodium species of those cases ( Figure 1 and Figure 2 ) [ 86 , 87 ].

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Imported malaria cases in Croatia from 1987–2017.

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The causative agents of imported malaria in Croatia.

There is also massive and uncontrollable migration from Africa and Asia (mostly due to climate change) of both humans and birds, from countries with confirmed epidemics. This issue is an insurmountable problem if measured by the traditional approach. Insecticides (DDT, malathion, etc.) synthetic pyrethroids, in addition to inefficiency, impact the environment (harm bees, fruits, vines, etc.). Consequently, scientists have patiently established a mosquito control strategy (University of Grenoble, Montpellier) which includes a meticulous solution to the mosquito vector effect (malaria, arbovirus infection, West Nile virus) by changes in agriculture, urbanism, public services hygiene [ 88 ].

Northeastern Slavonia is committed to applying methods that are consistent with such achievements, with varying success, as certain limitations apply to protected natural habitats (Kopački rit) [ 89 ].

There is a historical link between population movement and global public health. Due to its unique geostrategic position, in the past, Croatia has been the first to experience epidemics that came to Europe through land and sea routes from the east. Adriatic ports and international airports are still a potential entry for the import of individual cases of communicable diseases. Over the past few years, sailors, as well as soldiers who worked in countries with endemic malaria, played a significant role in importing malaria into Croatia. Successful malaria eradication has been carried out in Croatia. Despite that in Croatia are still many types of Anopheles , which means that the conditions of transmission of the imported malaria from the endemic areas still exist. The risk of malaria recrudesce is determined by the presence of the vector, but also by the number of infected people in the area. Due to climate change, it is necessary to monitor the vectors and people at risk of malaria. Naturally- and artificially-created catastrophes, such as wars and mass people migration from endemic areas, could favor recrudescing of malaria. Once achieved, eradication would be maintained if the vector capacities are low and prevention measures are implemented. The increased number of malaria cases worldwide, the recrudesce of indigenous malaria cases in the countries where the disease has been eradicated, the existence of mosquitoes that transmit malaria and the number of imported malaria cases in Croatia are alarming facts. Health surveillance, including obligatory and appropriate prophylaxis for travelers to endemic areas, remains a necessary public health care measure pointed at managing malaria in Croatia.

5. Malaria Trends in the World

The WHO report on malaria in 2017 shows that it is difficult to achieve two crucial goals of a Global Technical Strategy for Malaria. These are a reduction in mortality and morbidity by at least 40% by 2020. Since 2010, there has been a significant reduction in the burden of malaria, but analysis suggests a slowdown, and even an increase in the number of cases between 2015 and 2017. Thus, the number of malaria cases in 2017 has risen to 219 million, compared to 214 million cases in 2015 and 239 million cases in 2010. Figure 3 presents the reported number of malaria cases per WHO region from 1990–2017 [ 1 , 90 ]. The most critical step in the global eradication of malaria is to reduce the number of cases in countries with the highest burden (many in Africa). The number of deaths from disease is declining, thus, in 2017 there were 435,000 deaths from malaria globally, compared with 451,000 in 2016, and 607,000 deaths in 2010. Figure 4 presents the number of malaria deaths from 1990-2017 [ 1 , 90 ]. Despite the delay in global progress, there are countries with decreasing malaria cases during 2017. Thus, India in 2017, compared with 2016, recorded a 24% decline of malaria cases. The number of countries reporting less than 10,000 malaria cases is growing, from 37 countries in 2010, to 44 in 2016, and to 46 in 2017. Furthermore, the number of countries with fewer than 100 indigenous malaria cases growing from 15 in 2010, to 26 countries in 2017 [ 1 ].

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Reported malaria cases per WHO region from 1990–2017.

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Reported malaria deaths per WHO region from 1990–2017.

Funding in malaria has not changed much. During 2017, US$3.1 billion was invested in malaria control and elimination globally. That was 47% of the expected amount by 2020. The USA was the largest single international donor for malaria in 2017 [ 1 , 91 ].

The most common global method of preventing malaria is insecticide-treated bed nets (ITNs). The WHO report on insecticide resistance showed that mosquitoes became resistant to the four most frequently used classes of insecticides (pyrethroids, organochlorines, carbamates, and organophosphates), which are widespread in all malaria-endemic countries [ 1 , 7 , 92 ].

Drug resistance is a severe global problem, but the immediate threat is low, and ACT remains an effective therapy in most malaria-endemic countries [ 1 , 93 ].

According to the WHO, Africa still has the highest burden of malaria cases, with 200 million cases (92%) in 2017, then Southeast Asia (5%), and the Eastern Mediterranean region (2%). The WHO Global Technical Strategy for Malaria by 2020 is the eradication of malaria from at least ten countries that were malaria-endemic in 2015 [ 1 ].

The march towards malaria eradication is uneven. Indigenous cases in Europe, Central Asia, and some countries in Latin America are now sporadic. However, in many sub-Saharan African countries, elimination of malaria is more complicated, and there are indications that progress in this direction has delayed. Elimination of vivax and human knowlesi malaria infections are another challenge [ 7 ].

6. Conclusions

The campaign to eradicate malaria began in the 1950s but failed globally due to problems involving the resistance of mosquitoes to the insecticides used, the resistance of malaria parasites to medication used in the treatment, and administrative issues. Additionally, the first eradication campaigns never included most of Africa, where malaria is the most common. Although the majority of forms of malaria are successfully treated with the existing antimalarials, morbidity and mortality caused by malaria are continually increasing. This issue is the consequence of the ever-increasing development of parasite resistance to drugs, but also the increased mosquito resistance to insecticides, and has become one of the most critical problems in controlling malaria over recent years. Resistance has been reported to all antimalarial drugs. Therefore, research into finding and testing new antimalarials, as well as a potential vaccine, is still ongoing, mainly due to the sudden mass migration of humans (birds, parasite disease vector insects) from areas with a large and diverse infestation.

The process towards eradication in some countries confirms that current tools could be sufficient to eradicate malaria. The spread of insecticide resistance among the vectors and the rising ACT failures indicate that eradication of malaria by existing means might not be enough.

Thus, given the already complicated problem of overseeing and preventing the spread of the disease, it will be necessary to supplement and change the principles, strategic control, and treatment of malaria.

Abbreviations

Author contributions.

Writing the manuscript: J.T., I.Š., and T.A.; updating the text: J.T., I.Š., T.A., and A.V.; literature searches: J.T., I.Š., T.A., and M.J.; tables and figures drawing: I.Š. and M.J.; critical reviewing of the manuscript: A.V.; organization and editing of the manuscript: I.Š. and A.V.

This research received no external funding. The article processing charges (APC) was funded by Faculty of Dental Medicine and Health, Osijek, Croatia.

Conflicts of Interest

The authors declare no conflict of interest.

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7 Strategies to Get Your Employees On Board with GenAI

  • Tomas Chamorro-Premuzic

malaria strategies case study

A culture that accepts this new technology can also learn how to innovate with it.

As with any aspect of digital transformation, the effective deployment of generative AI will depend less on technological capability than on human adaptability. Indeed, the human factor — people and culture — will drive the adoption of AI, or lack thereof. Looking at scientific research and real-world case studies, there are seven generalizable lessons for improving your ability to adopt GenAI, and any novel technology, at an organizational level: innovation boosts your organization’s immunity, focus on the problem, less is more, intuition is the common enemy, everyone loves change until they have to do it, process eats culture for lunch, and be proactive about ethical concerns.

Despite record rapid adoption and persistent media hype — ranging from dystopian to utopian coverage — generative AI is more of an area of intellectual promise or concern for businesses than an operational reality. Amidst estimates of an AI market that could reach almost $670 billion by 2030, adding up to $4.4 trillion in productivity, business leaders are still wondering what exactly to do with AI, how to leverage it, and how exactly it will deliver the advertised economic benefits. And there is no shortage of hope or belief in AI’s potential, especially during turbulent economic times.

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  • Tomas Chamorro-Premuzic is the Chief Innovation Officer at ManpowerGroup, a professor of business psychology at University College London and at Columbia University, co-founder of  deepersignals.com , and an associate at Harvard’s Entrepreneurial Finance Lab. He is the author of  Why Do So Many Incompetent Men Become Leaders? (and How to Fix It ) , upon which his  TEDx talk  was based. His latest book is I, Human: AI, Automation, and the Quest to Reclaim What Makes Us Unique.   Find him at  www.drtomas.com . drtcp

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  • Published: 08 March 2023

Community case management of malaria in Western Kenya: performance of community health volunteers in active malaria case surveillance

  • Wilfred Ouma Otambo 1 ,
  • Kevin O. Ochwedo 1 ,
  • Collince J. Omondi 1 ,
  • Ming-Chieh Lee 2 ,
  • Chloe Wang 2 ,
  • Harrysone Atieli 1 ,
  • Andew K. Githeko 3 ,
  • Guofa Zhou 2 ,
  • James Kazura 4 ,
  • John Githure 1 &
  • Guiyun Yan 2  

Malaria Journal volume  22 , Article number:  83 ( 2023 ) Cite this article

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In western Kenya, not all malaria cases are reported as stipulated in the community case management of malaria (CCMm) strategy. This underreporting affects the equity distribution of malaria commodities and the evaluation of interventions. The current study aimed to evaluate the effectiveness of community health volunteers’ active case detection and management of malaria in western Kenya.

Cross-sectional active case detection (ACD) of malaria survey was carried out between May and August 2021 in three eco-epidemiologically distinct zones in Kisumu, western Kenya: Kano Plains, Lowland lakeshore and Highland Plateau. The CHVs conducted biweekly ACD of malaria household visits to interview and examine residents for febrile illness. The Community Health Volunteers (CHVs) performance during the ACD of malaria was observed and interviews done using structured questionnaires.

Of the total 28,800 surveyed, 2597 (9%) had fever and associated malaria symptoms. Eco-epidemiological zones, gender, age group, axillary body temperature, bed net use, travel history, and survey month all had a significant association with malaria febrile illness (p < 0.05). The qualification of the CHV had a significant influence on the quality of their service. The number of health trainings received by the CHVs was significantly related to the correctness of using job aid (χ 2  = 6.261, df = 1, p  = 0.012) and safety procedures during the ACD activity (χ 2  = 4.114, df = 1, p  = 0.043). Male CHVs were more likely than female CHVs to correctly refer RDT-negative febrile residents to a health facility for further treatment (OR = 3.94, 95% CI = 1.85–5.44, p  < 0.0001). Most of RDT-negative febrile residents who were correctly referred to the health facility came from the clusters with a CHV having 10 years of experience or more (OR = 1.29, 95% CI = 1.05–1.57, p  = 0.016). Febrile residents in clusters managed by CHVs with more than 10 years of experience (OR = 1.82, 95% CI = 1.43–2.31, p  < 0.0001), who had a secondary education (OR = 1.53, 95% CI = 1.27–1.85, p < 0.0001), and were over the age of 50 (OR = 1.44, 95% CI = 1.18–1.76, p  < 0.0001), were more likely to seek malaria treatment in public hospitals. All RDT positive febrile residents were given anti-malarial by the CHVs, and RDT negatives were referred to the nearest health facility for further treatment.

Conclusions

The CHV’s years of experience, education level, and age had a significant influence on their service quality. Understanding the qualifications of CHVs can assist healthcare systems and policymakers in designing effective interventions that assist CHVs in providing high-quality services to their communities.

Kenya is currently ramping up malaria control efforts in order to reduce the disease's burden and eventually eliminate malaria. Despite increased efforts by the Ministry of Health to scale up intervention strategies, the malaria burden in Kenya remains high [ 1 , 2 , 3 ]. Accurate, reliable and early diagnosis followed by effective malaria treatment is the key to reducing malaria burden [ 4 , 5 ]. The ultimate goal of the Kenya National Malaria Control Programme is to provide access to effective malaria preventive interventions while also drastically lowering the incidence and mortality of malaria among those who live in malaria-risk areas [ 3 ]. The burden of malaria is exacerbated by challenges in accessing healthcare facilities, especially in rural areas, where there is often limited access to health services.

Access to effective malaria treatment and prevention has been hampered by accessibility, availability, and affordability of diagnostic and treatment services [ 6 ]. Topographic features of the local landscape major correlates with malaria infection in the Lake Victoria area of western Kenya [ 7 ]. Clinical malaria incidence remains highest in the Lakeshore of western Kenya despite high long-lasting insecticidal nets (LLINs) coverage [ 4 ]. Fever is the most common symptom of clinical malaria, and its severity drives people to seek treatment at health care facilities [ 8 ]. Only a small percentage of the residents with fever seek treatment at a health facility, with the vast majority self-medicating at home [ 9 ]. The fact that the majority of febrile residents seeking malaria treatment use over-the-counter medication without a confirmed laboratory test and prescription is a major concern, as anti-malarial overuse may promote drug resistance to current anti-malarial drugs [ 4 ]. Treatment that is ineffective or fails to treat true blood stage infections can result in increased healthcare costs [ 5 , 10 ]. As a result, the emphasis should be on the accuracy of community malaria diagnosis and treatment in order to reduce the persistence of malaria febrile illness in the community. Emphasis should be active case surveillance of malaria.to optimize the accuracy of malaria diagnosis and treatment at the community.

Active malaria case surveillance strategy is essential for effective malaria control in areas where the disease is endemic [ 11 ]. Active surveillance aids in the identification of potential malaria risk factors, and by analysing the data, public health experts can identify any environmental factors that may be contributing to the persistence of malaria [ 7 ]. The effectiveness of active surveillance is determined by the system's implementation as well as how well it is monitored and maintained. If the system is not effectively monitored and maintained, it may be unable to detect any increase in malaria cases or potential risk factors [ 12 ]. In Western Kenya, community health volunteers (CHVs) have been engaged in active malaria case surveillance through routine visits to households to identify and report suspected malaria cases [ 4 ]. This approach ensures that malaria cases are detected early, and appropriate treatment can be provided promptly. Active surveillance of malaria necessitates the collection of reliable and accurate data in order to track disease trends, inform public health policies, and provide an evidence base for healthcare providers to make treatment and community case management of malaria decisions.

Community case management of malaria (CCMm) strategy aims to improve access to and quality of malaria treatment while also reaching a larger proportion of the population, particularly the poorer segments of society, with primary health care [ 13 ]. Bringing care into the community may remove barriers to seeking care in health facilities, such as distance, transportation costs, travel time, and fixed operating hours. The approach involves training community health workers, such as CHVs, to diagnose and treat uncomplicated malaria cases in their communities [ 14 ]. As CHVs should be more acceptable sources of care for villagers than facility-based personnel, well-trained and supervised CHVs can provide prompt and adequate treatment and care to patients close to their homes [ 15 ]. In order to educate and motivate their community members to seek early malaria treatment, CHVs should have a basic understanding of malaria, its transmission, and its signs and symptoms, as well as good communication skills. However, in many areas, the use of CHV services remains suboptimal, with families unaware that they exist and inconsistency in drug supplies [ 16 ]. The services of the CHVs are critical to the success of CCMm, and any gaps in their needs must be identified for optimal performance and subsequent malaria burden reduction.

Despite the proven effectiveness of CCM and active malaria case surveillance, there are still challenges in scaling-up and sustaining their implementation in many parts of Western Kenya due to insufficient resources and lack of support from the community and health system, as well as a lack of the necessary knowledge and skills to provide high-quality care [ 16 ]. Identifying and addressing these issues is critical for the successful implementation and scaling up of CCM and active malaria case surveillance in Western Kenya. The purpose of this study is to assess CHVs' active case detection and management of malaria in western Kenya, as well as gaps in strengthening CCMm.

Study area and design

The study was carried out in the Nyakach and Muhoroni Sub-County of Kisumu County in western Kenya near the shores of Lake Victoria at latitude 0.333333°S and longitude 34.99100°E . Based on malaria prevalence and incidence, malaria vector densities and topographical features [ 4 , 7 , 17 , 18 ], the study area was divided into three eco-epidemiological zones: Kano Plains, Lowland Lakeshore and Highland Plateau. The Kano Plains is characterized by a shallow inland plain with an elevation of about 1150 m to 1200 m, frequented by flooding during the rainy season, with rice irrigation and sugarcane plantation as the main cash crops. The Lowland Lakeshore and Highland Plateau eco-epidemiological zones have previously been described [ 7 ]. Each ecological zone was further randomly selected with 24 clusters for study. Based on the administrative village or natural boundary, such as a river or major road, a cluster was delineated with approximately 1 km2 area. Each study area had around 150 households, with an average of about 400 residents under the management of a CHV. Malaria prevalence in the study area is estimated to be around 18% [ 7 ], with the common vectors of malaria transmission being Anopheles funestus and Anopheles gambiae [ 18 ] .

Study participation and data collection

Active case detection of malaria.

Cross-sectional community surveys were carried out between May to August 2021 when malaria transmission was at its peak in Western Kenya [ 4 , 7 , 18 ]. The CHVs were trained on recording febrile cases in each household, taking blood samples for RDT, and preparing dry blood spots for real-time-PCR (RT-PCR) analysis. A febrile malaria case was defined as an individual with fever (axillary temperature ≥ 37.5 °C) at the time of examination or complaints of fever and other nonspecific symptoms 1–2 days prior to examination [ 19 ]. The CHVs used an active case detection (ACD) questionnaire to interview residents about their fever status. Febrile residents’ age, sex, and active fever, fever days, treatment-seeking behaviours, primary occupation, travel history, and bed net usage, health insurance coverage, transportation method to the health facility, and reasons for delaying in treatment were collected in the questionnaire. The questionnaire results were reviewed daily by team supervisors for quality assurance.

Finger-prick blood samples were taken from febrile cases for parasite examination with ultra-sensitive Alere ® malaria RDT (Reference number: 05FK140, Republic of Korea) and RT-PCR on dry blood spots. The samples were then transported to the International Centre of Excellence for Malaria Research (ICEMR) at the University of California Irvine-Tom Mboya University Joint Laboratory in Homa Bay, Kenya [ 4 , 5 ], for further analysis. The Chelex resin (Chelex-100) saponin method was used with minor modifications [ 20 ]. Primers and probes specific to Plasmodium species were used to target 18S ribosomal RNA [ 21 ] to confirm the presence of parasite DNA on QuantStudio™ 3 Real-Time PCR.

Assessment of CHVs qualification on quality of service

A total of 72 CHVs working with the Ministry of Health Kenya in Kisumu County in the Kano plains, Lakeshore zone and the Highland Plateau zones were surveyed and sought to ascertain their performance of CCMm. Questionnaire was used by the project team to collected information on CHVs age, gender, income-generating activity, years of experience, education level, and the community health and professional trainings attended. A service quality questionnaire was used by the project team to interview all 72 CHVs, and another observational checklist was used to evaluate the preparedness and how they performed the malaria diagnosis and treatment during the ACD survey. The assessment of the CHVs quality of service and CCMm were standardized based previous studies [ 22 , 23 , 24 ]. The service quality was defined as the correctness of using ACD job aid, classification of malaria symptoms, experience with commodity stock-out, and safety procedure to perform the ACD visits. These criteria were evaluated using a checklist as satisfactory or unsatisfactory.

The CHV assessment of malaria diagnosis included the following aspects: maintaining a good rapport with residents and community acceptance, the correctness of taking body temperature, recording ACD report, explaining the necessity of malaria testing, adequate testing preparation, labelling test kit, using the glove, disinfection for pricking, collecting blood samples, reading results at the appropriate time, interpreting results, and communicating results to the patients. The evaluation of malaria treatment and management included these aspects: following the MOH treatment guidelines to administer the AL in the appropriate dosage, explaining treatment duration, following up on the treatment of febrile residents, proper waste disposal, difficulties of referral, and the need for supportive supervision. An additional 12 CHVs from the study clusters were pretested with those questionnaires to ensure the completeness of survey processes and data quality.

Data analysis

Data were analysed using IBM SPSS Statistics (version 21). The demographic profiles of the study participants were described using descriptive statistics. The multivariate binary logistic regression model was used for risk factor analysis. Chi square test and Odds ratio, determined the association between the CHVs qualification and the quality of service. Regression analysis determined the influence of CHVs' qualifications on treatment seeking patterns of febrile residents. For all analyses, p  ≤ 0.05 was considered statistically significant. Additional file 1 : Table S1 categorizes the demographic characteristics of CHVs and febrile residents.

Febrile resident’s demographic information

A total of 2597 (9%) residents with fever and associated malaria symptoms from 10,800 households with a total population of 28,800 agreed to participate in the study. The demographic information of the febrile residents is summarized in Table 1 .

Risk factors associated with malaria febrile illness

Malaria febrile illness differed significantly across eco-epidemiological zones (χ 2  = 16.006, df = 2, p  < 0.0001). The RDT positivity rate was highest in the Kano Plains at 47.0% (448/954), followed by the Lowland Lakeshore at 43.9% (354/807) and the Highland Plateau at 37.7% (315/836) (Fig.  1 ).

figure 1

RDT positivity rates across eco-epidemiological zones. Error bar represents 95% confidence interval

The zone of residence, gender, age group, axillary body temperature, bed net usage, travel history, and survey month were significantly association with malaria febrile illness (Table 2 ).

Demographics information of the CHVs

A total of 72 CHVs were recruited for the study. The majority of CHVs in the study zones were females 65 (90%), over the age of 52 (72%), had more than 10 years of experience as a CHVs 43 (60%), had a secondary education 37 (51%), and had received more than ten trainings 44 (61%) on community health work (Table 3 ).

Influence of CHVs qualifications on the quality of service

The CHV years of experience, education level, health training received, age and gender significantly influenced their quality of service. The number of community health trainings received by the CHVs was significantly related to the correctness of using job aid (χ 2  = 6.261, df = 1, p  = 0.012) and safety procedures during the ACD activity (χ 2  = 4.114, df = 1, p  = 0.043). Regardless of age, gender, experience, education, or received training, all 72 CHVs correctly classified malaria symptoms (Additional file 1 : Table S2).

Male CHVs were more likely than female CHVs to correctly refer RDT-negative febrile residents to a health facility for further treatment (OR = 3.94, 95% CI = 1.85–5.44, p  < 0.0001). Most of RDT-negative febrile residents who were correctly referred to the health facility came from the clusters with a CHV having 10 years of experience or more (OR = 1.29, 95% CI = 1.05–1.57, p  = 0.016). Conversely, most of RDT-positive febrile residents who had received anti-malarial medication came from the clusters with a CHV having more than ten years of experience (OR = 2.49, 95% CI = 1.90–3.27, p  < 0.0001) and had secondary education (OR = 1.95, 95% CI = 1.60–2.37, p  < 0.0001) (Table 4 ).

Influence of CHVs qualifications on malaria febrile residents’ treatment-seeking pattern

The CHVs' qualifications significantly influenced treatment-seeking patterns of febrile residents in their clusters. Febrile residents in clusters managed by CHVs with more than 10 years of experience were more likely to seek treatment at health facility (OR = 1.82, 95% CI = 1.43–2.31, p  < 0.0001) but less likely to do nothing (OR = 0.56, 95% CI = 0.46–0.68, p  < 0.0001) compared to those in clusters managed by CHVs with less than 10 years. Similarly, in clusters where the CHV had secondary education, febrile residents were more likely to visit health facilities (OR = 1.53, 95% CI = 1.27–1.85, p < 0.0001), but less likely to do nothing (OR = 0.78, 95% CI = 0.66–0.92, p  = 0.003) compared to clusters where the CHV had primary education. In clusters with male CHVs, febrile residents were more likely to do nothing (OR = 2.33, 95% CI = 1.69–3.21, p  < 0.0001) and less likely buy drugs from the drug shops (OR = 0.28, 95% CI = 0.17–0.47, p  < 0.0001) compared to clusters with female CHVs. In clusters with a CHV aged 50 or above, febrile residents were more likely to seek treatment at the health facility (OR = 1.44, 95% CI = 1.18–1.76, p  < 0.0001), but less likely to buy drugs from the drugs shops (OR = 0.66, 95% CI = 0.55–0.79, p  < 0.0001) compared to those clusters with CHVs in age below 50 years old (Table 5 ).

Factor associated with febrile residents’ decision to seek malaria treatment

The CHVs evaluated 754 of the total 2597 febrile residents to assess determinants of the decision to seek treatment. The decision to seek treatment was significantly associated with the reasons for the delay in treatment (χ 2  = 67.633, df = 4, p  < 0.0001), transportation method to the health facility (χ 2  = 75.316, df = 6, p  < 0.0001), and availability of medical insurance coverage (χ 2  = 24.125, df = 2, p  < 0.0001). Compared to the Lowland Lakeshore and Highland Plateau, the affordability of treatment (76.4%, 201/263) and the severity of disease (11.8%, 31/263) in the Kano Plain contributed to the delay in seeking treatment. In addition, Kano Plain residents (60.5%, 159/263) preferred walking, while Highland Plateau residents (53.4%, 125/234) preferred motorbikes and Lowland Lakeshore residents (15.6%, 40/257) preferred vehicles in the transportation method question. In comparison to the Kano Plain (8.7%, 23/263) and the Highland Plateau (12.0%, 28/234), the Lowland Lakeshore (23.3%, 60/257) had the highest insurance coverage (Table 6 ).

The current study evaluated the effectiveness of CHVs in active malaria surveillance and CCMm in rural community of western Kenya. In the current study ACD survey conducted by the CHVs, eco-epidemiological zones, gender, age group, axillary body temperature, bednet use, travel history, and survey month were significantly association with malaria febrile illness. The CHV’s years of experience, education level, and age had a significant influence on their service quality. The CHVs correctly classified malaria symptoms, used the ACD malaria job aid satisfactorily, promptly reported commodity stock-outs, and followed safety precautions during the ACD. The number of health trainings received by the CHVs was significantly related to the correctness of using job aid and safety procedures during the ACD activity. Male CHVs were more likely than female CHVs to correctly refer RDT-negative febrile residents to a health facility for further treatment. Most of RDT-negative febrile residents who were correctly referred to the health facility came from the clusters with a CHV having 10 years of experience or more. Febrile residents in clusters managed by CHVs with more than 10 years of experience, secondary education, and were over the age of 50, were more likely to seek malaria treatment in public hospitals. All RDT positive febrile residents were given anti-malarial by the CHVs and RDT negatives were referred to the nearest health facility for further treatment.

In the current study, CHVs correctly handled malaria febrile illness, using RDT for malaria, and uncomplicated malaria prescriptions well. This included the understanding of malaria as well as community awareness of disease control and prevention. The CHVs administered AL to all febrile residents who tested positive for malaria by RDT. Residents who tested negative for RDT were referred to the health facility for further treatment. Similar to the current study in western Kenya, the evaluation of the effectiveness of CHV active case detection and management of malaria found that CHVs detected a high proportion of malaria cases by being able to accurately identify and treat malaria cases using RDTs and appropriately treated them with artemether-lumefantrine as well as effectively refer severe cases to higher-level facilities [ 25 , 26 ]. Furthermore, the use of CHVs in malaria control and management resulted in a significant reduction in malaria prevalence [ 24 ].

The goal of community malaria case management is to reach a larger proportion of the population, particularly the poorer segments of society, with primary health care [ 13 ]. Despite the fact that approximately 80% of missed malaria cases in the community do not seek treatment at a health facility, bringing care into the community may remove barriers to seeking care in health facilities, such as distance, transportation costs, travel time, and fixed operating hours. With the majority of febrile residents not seeking treatment at a health facility, as reported in this and another study [ 4 ], infrastructure support for CHVs will result in a reduction in anti-malarial misuse without a confirmed laboratory test and the missed out underreported malaria cases.

CHVs with more years of experience in diagnosing and treating malaria may have a higher level of expertise and knowledge, which resulted in higher quality of service as observed in the current study. The ability of CHVs to build and maintain trust with the communities they serve is critical to their success in providing healthcare services. More experienced CHVs may have a better understanding of the community's needs, preferences, and cultural beliefs. As a result, they may be more effective in providing community members with relevant health promotion information, advice, and support on malaria prevention and treatment activities [ 24 ]. Their knowledge can also assist them in identifying high-risk groups and tailoring interventions to their specific needs. This level of tailored intervention can help the CHV and the community build trust. According to a study conducted in western Kenya, CHVs with more years of experience had better knowledge of malaria prevention and treatment, were more trusted by the community, and had better communication skills, which resulted in increased community participation in malaria prevention and treatment activities [ 27 ]. A study in western Kenya showed that CHVs with more years of experience in malaria diagnosis and treatment were more accurate in diagnosing and treating malaria than those with less experience [ 28 ]. Experienced CHVs were more likely to use RDTs and adhere to treatment guidelines [ 29 ]. The current study also found that the more experienced the CHV, the more likely the febrile residents were to be referred to a health facility for further medical attention, and the less experienced the CHV, the more likely the febrile cases in their clusters were to use traditional medication and do nothing when they had a fever.

The current study discovered that CHVs in the study area performed proper malaria diagnostics, treated febrile residents, and followed RDT interpretation of results, and that this was related to the CHV's education. CHVs with higher levels of education may have better understanding of health concepts and be able to communicate more effectively with the community. This can lead to improved health outcomes, greater satisfaction with their services, more accurate diagnosis and treatment of malaria, as well as better management of any associated symptoms. The CHVs with at least a secondary education are more likely to provide appropriate treatment for malaria and refer severe cases to formal healthcare facilities [ 30 ].

CHVs who receive regular and comprehensive training on health topics, such as disease prevention and health promotion, may be more effective in their role. Comprehensive training on malaria diagnosis and treatment, how to use RDTs and how to properly administer anti-malarial drugs may be more effective in providing accurate and appropriate treatment to febrile patients by the CHVs. Better trainings will equip the CHV with confident in their ability to provide quality services in the CCMm. CHVs who had received adequate malaria diagnosis and treatment training were more likely to diagnose and treat malaria correctly, and those who received regular supportive supervision were more likely to adhere to treatment guidelines [ 31 ].

CHVs of different ages and genders may have varying levels of community trust and credibility, which can affect their ability to effectively diagnose and treat malaria. Older CHVs may be perceived as having more life experience and wisdom, which can contribute to their community credibility and trustworthiness. Older people are treated with more respect and are thought to be more reliable and trustworthy than younger people. These older CHVs have improved communication skills, more knowledgeable about the community’s social and economic context, and have built strong trusting relationships with community members [ 32 ]. As a result, older CHVs may be more effective at building community trust, which may lead to increased adherence to malaria prevention and treatment recommendations. Furthermore, older the CHV, the more experience they have and thus febrile residents could take malaria information and knowledge from them seriously.

The majority of CHVs in the study site were females, 90% of which is consistent with the general trend in western Kenya [ 33 ]. Male CHVs may be more effective at engaging men in health promotion activities, while female CHVs may be more effective at engaging women and children. In contrast to the current study, a study done in Nigeria found that female CHVs were more likely than male CHVs to correctly diagnose and treat malaria, and younger CHVs were more likely to follow treatment guidelines than older ones [ 34 ].

As demonstrated in the current study, CHVs' qualifications have a significant impact on the quality of service and treatment seeking patterns of febrile residents within their clusters. Working with CHVs lowers the cost of accessing malaria diagnosis and treatment services, as evidenced by CHVs competently offering malaria diagnosis, treating uncomplicated cases, and referring complicated cases to nearby health facilities for further management. Based on the CHVs' optimal performance in classifying malaria symptoms, promptly reporting commodity stock-outs, and good ACD performance, it is possible that the CHVs could be used to address gaps in the persistence of malaria cases in both endemic and non-endemic areas with supportive supervision, more trainings, and improved supply of testing kits and drugs. Therefore, when managing malaria cases in the community, the proper training, years of experience, education level, and age of the CHVs should all be taken into account for optimal performance of CCMm.

The CHV years of experience, education level, health training received, age, and gender can all influence the quality of malaria diagnosis and treatment provided by CHVs in Western Kenya. However, other factors can influence the quality of malaria diagnosis and treatment provided by CHVs such as availability and quality of diagnostic tools and anti-malarial drugs, the support and supervision provided by healthcare professionals, and the context in which CHVs operate. To improve the quality of malaria diagnosis and treatment provided by CHVs, it is critical to consider all of these factors and design comprehensive interventions that address each community's unique challenges and opportunities, while also ensuring that CHVs are adequately trained, equipped, and supported to carry out their roles effectively.

Availability of data and materials

The dataset used in this study is available from the corresponding author upon request.

Abbreviations

Active Case Detection

Confidence Interval

Dried blood spots

Community Case Mnagement of malaria

Community Health Volunteer

International Center of Excellence for Malaria Research

Rapid diagnosis test

Real-time polymerase chain reaction

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Acknowledgements

We would like to thank the Nyakach and Muhoroni Sub-County study participants for their participation in the study. We would like to express our gratitude to all of the CHVs who worked tirelessly to complete this project. Special thanks to Charles Omboko, Nick Abwao, Dickens Atieli, Polycarp Aduogo, Victor Ocharo, Shadrack Onyango and Sally Mungoi for their efforts in coordination in data collection, preparations and processing samples as well as the ICEMR team who participated in this research study.

This research is supported by grants from the National Institutes of Health (U19 AI129326 and D43 TW001505).

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Wilfred Ouma Otambo, Kevin O. Ochwedo, Collince J. Omondi, Harrysone Atieli & John Githure

Program in Public Health, University of California Irvine, Irvine, CA, USA

Ming-Chieh Lee, Chloe Wang, Guofa Zhou & Guiyun Yan

Centre for Global Health Research, Kenya Medical Research Institute, Kisumu, Kenya

Andew K. Githeko

Department of Pathology, School of Medicine, Case Western Reserve University, Cleveland, OH, USA

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Contributions

WOO Conceptualization, designed the study, oversaw its implementation, performed laboratory assays, interpretations, analyses, drafted the original manuscript and edited and reviewed the final manuscript. KOO and CJO aided in the coordination of sample collection and reviewing the manuscript. MCL and CW helped in designing the figure. HA provided administrative support. AKG contributed to study design, editing and reviewing the manuscript. GZ contributed to study design, data analysis, editing and reviewing the manuscript. JK contributed to study design and editing and reviewed the manuscript. JG conceived the study design, administrative support, reviewed and revised the manuscript. GY contributed to study design, editing and review of the manuscript, and funded the project. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Wilfred Ouma Otambo .

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Ethics approval and consent to participate.

The study received ethical approval from Maseno University's Ethics Review Committee (reference number: MSU/DRPI/MUERC/00991/21) and the University of California, Irvine's Institutional Review Board (HS# 2017-3512). The survey was open to all community residents willing to participate in the study. Residents who declined or changed their willingness to participate in the study at any time were excluded from the data analysis. All study participants provided written informed consent. Minors provided assent with informed consent from parents or guardians.

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Supplementary Information

Additional file 1: table s1..

Categorization of Community health volunteers (CHVs) and febrile residents’ demographic information. Table S2. Association of CHVs demographics and quality of service.

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Otambo, W.O., Ochwedo, K.O., Omondi, C.J. et al. Community case management of malaria in Western Kenya: performance of community health volunteers in active malaria case surveillance. Malar J 22 , 83 (2023). https://doi.org/10.1186/s12936-023-04523-4

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DOI : https://doi.org/10.1186/s12936-023-04523-4

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