The Economic Burden of Malaria: Revisiting the Evidence

Can malaria be eliminated? 15 years on

This commentary reflects on the ongoing challenges and strategies in malaria elimination, built on insights from Greenwood's 2009 commentary, alongside more recent publications and developments up to 2024. Many of the challenges and strategies discussed by Greenwood remain relevant today. Furthermore, several of Greenwood's predictions have proven accurate 15 years on. Despite significant global progress, malaria elimination faces its toughest challenge, particularly in high-transmission areas. As we confront tougher challenges in malaria elimination, it becomes clear that we must go beyond mere reliance on any single solution.

Acceptance and affordability of malaria vaccines: issues relating to hesitancy and willingness to pay amongst Nigerian parents of under-five children

BACKGROUND

With the recent approval of the malaria vaccine by the World Health Organization, it is expected that global acceptance and subsequent uptake of the intervention can help to reduce the burden of the disease in Africa. This study adopted a proactive approach in assessing parents' acceptance of the malaria vaccine, alongside their willingness to pay for the novel public health intervention.

METHODS

A national cross-sectional survey was undertaken in Nigeria using a questionnaire as the data collection instrument. The study tool was administered to parents of child-bearing age. Descriptive and inferential statistical analyses were performed using the Statistical Package for Social Sciences (SPSS) software version 25.

RESULTS

A total of 1413 valid responses were received with male (49.5%) and female (50.5%) participants represented by similar proportions. Close to two-thirds (62.5%) of the participants were between the ages of 31 and 40 years, and 47.4% of the participants were educated up to national diploma level. More than two-thirds (69.6%) of the participants indicated that they were worried about side effects that may be associated with the malaria vaccine. A strong majority (90%) of the participants indicated that the vaccine should be administered at no cost to citizens, while 46.7% of the respondents were willing to pay for the malaria vaccination. Levels of education attained by the respondents influenced their willingness to pay for malaria vaccination. This variable also underpinned participants'  reasons for non-acceptance of the vaccine. Those who attained only primary and secondary levels of education were significantly more likely to reject the malaria vaccine because they were against vaccines in general (AOR = 6.63; 95% CI = 1.33 - 39.25; p = 0.021).

CONCLUSION

This study provides critical novel insights which could influence vaccination efforts aimed at reducing the burden of malaria in Nigeria, as well as similar settings.

Who pays to treat malaria and how much? Analysis of the cost of illness, equity and economic burden of malaria in Uganda

Case management of malaria in Africa has evolved markedly over the past 20 years and updated cost estimates are needed to guide malaria control policies. We estimated the cost of malaria illness to households and the public health service and assessed the equity of these costs in Uganda. From December 2021 to May 2022, we conducted a costing exercise in eight government-run health centres covering seven sub-regions, collecting health service costs from patient observations, records review and a time-and-motion study. From November 2021 to January 2022, we gathered data on households' cost of illness from randomly selected households for 614 residents with suspected malaria. Societal costs of illness were estimated and combined with secondary data sources to estimate the total economic burden of malaria in Uganda. We used regression analyses and concentration curves to assess the equity of household costs across age, geographic location and socio-economic status. The mean societal economic cost of treating suspected malaria was $15.12 [95% confidence interval (CI): 12.83-17.14] per outpatient and $27.21 (95% CI: 20.43-33.99) per inpatient case. Households incurred 81% of outpatient and 72% of inpatient costs. Households bore nearly equal costs of illness, regardless of socio-economic status. A case of malaria cost households in the lowest quintile 26% of per capita monthly consumption, while a malaria case only cost households in the highest quintile 8%. We estimated the societal cost of malaria treatment in Uganda was $577 million (range: $302 million-1.09 billion) in 2021. The cost of malaria remains high in Uganda. Households bear the major burden of these costs. Poorer and richer households incur the same costs per case; this distribution is equal, but not equitable. These results can be applied to parameterize future economic evaluations of malaria control interventions and to evaluate the impact of malaria on Ugandan society, informing resource allocations in malaria prevention.

Malaria pervasiveness in Sub-Saharan Africa: Overcoming the scuffle

Malaria has posed a momentous health and economic burden to the Sub-Saharan African region. The Sub-Saharan African region accounts for more than 90% of global malaria-related mortality and morbidity. Pregnant women and children under 5 years old are the most vulnerable. Mosquitoes transmit the plasmodium which is the parasite responsible for malaria. The climatic conditions, poverty, and poor healthcare system of the Sub-Saharan African region are some factors fueling this menace. There have been concerted efforts to annihilate malaria but the scuffle has been a tedious one. Malarial eradication campaigns have been focused on mosquito control through the use of insecticide-treated bed nets, use of indoor insecticide sprays, and use of larvicides. The use of artemisinin in combination with other drugs has been effective to some extent. Despite the aforementioned strategies, the pervasiveness of malaria infection in the Sub-Saharan African region is worrisome. Thus, strengthening the already existing control measures, finding novel measures through intensive research, and embracing malaria vaccination could help accelerate the overcoming of this scuffle. In this review, we utilized relevant published data from various databases to reexamine the factors fueling malaria pervasiveness in this region and spelled out point-by-point intervention protocols to end malaria scuffle.

Cost of the national malaria control program and cost-effectiveness of indoor residual spraying and insecticide-treated bed net interventions in two districts of Madagascar

BACKGROUND

Madagascar has made significant progress in the fight against malaria. However, the number of malaria cases yearly increased since 2012. ITNs and IRS are key interventions for reducing malaria in Madagascar. Given the increasing number of cases and limited resources, understanding the cost-effectiveness of these strategies is essential for policy development and resource allocation.

METHODS

Using a societal perspective, this study aims to estimate the cost of the National Malaria Control Program (NMCP) through the first national malaria strategic plan (implemented over the period 2009-2013) and to assess the cost-effectiveness of two individually implemented malaria control interventions (ITNs and IRS) in two districts, Ankazobe and Brickaville. The cost-effectiveness ratio (CER) of ITN intervention was then compared to the CER of IRS intervention to identify the most cost-effective intervention. The cost of the NMCP and the costs incurred in the implementation of each intervention at the district level were initially estimated. On the basis of two results, the CERs of ITN or IRS correspond to the total cost of ITN or IRS divided by the number of people protected or the number of disability-adjusted life years (DALYs) averted. A deterministic univariate sensitivity analysis was conducted to assess the robustness of the results with a discount rate of 2.5% (0-5%) (costs and DALYs) and a 95% CI (person protected).

RESULTS

From 2009 to 2013, the NMCP cost USD 45.4 million (USD 43.5-47.5, r = 0-5%) per year, equivalent to USD 2.0 per capita per year. IRS implementation costs were four times higher than those of ITNs. The CER of IRS per case protected (USD 295.1 [285.1-306.1], r = 0-5%) was higher than the CER of ITNs (USD 48.6 [USD 46.0-51.5, r = 0-5%] in Ankazobe and USD 26.5 [USD 24.8-28.4, r = 0-5%] in Brickaville). The CERs per DALY averted of IRS was USD 427.6 [USD 413.0-546.3, r = 0-5%] in Ankazobe and, for ITNs, it was USD 85.4 [USD 80.8-90.5, r = 0-5%] in Ankazobe and USD 45.3 [USD 42.2-48.4, r = 0-5%] in Brickaville. Compared to the country GDP per capita (USD PPP 1494.6 in 2013), ITN intervention was "highly cost-effective" while the CER for IRS interventions was sensitive to parameter variation (CI, 95% of persons protected), which ranges from highly cost-effective to only cost-effective (USD 291.5-2004, r = 2.5%).

CONCLUSION

In the Malagasy context, IRS intervention cost more and was less effective than ITN intervention. Willingness to pay for IRS is questioned. A relevant budget impact analysis should be conducted before a potential extension of this intervention.

Genetic diversity of Plasmodium vivax and Plasmodium falciparum field isolates from Honduras in the malaria elimination phase

Malaria continues to be a major threat to public health in tropical regions, primarily affecting sub-Saharan Africa but also Asia, the Middle East, and Latin America. Malaria cases in Honduras have seen a significant decline and the country aims to eliminate the disease by 2030. This study examines the genetic diversity of Plasmodium falciparum and Plasmodium vivax in Honduras using four molecular markers (Pfama1, Pfglurp, Pvmsp3α, and Pvmsp3β), and the chloroquine resistance marker pfcrt in the context of the elimination phase. Our findings indicate that P. falciparum populations in Honduras are more homogeneous compared to P. vivax. The multilocus sequence typing (MLST) approach, using four loci from Pvmsp3α and Pvmsp3β, proved more effective in assessing the genetic diversity of P. vivax than individual marker analyses. No geographical clustering was observed for P. vivax haplotypes, either within Honduras or globally. In Honduras, P. falciparum appears to be under more effective control, while P. vivax presents a greater challenge due to its higher genetic diversity. This requires enhanced surveillance, targeted control strategies, and measures to prevent the reintroduction of variants. The isolates of P. falciparum also displayed a wild-type Pfcrt phenotype, suggesting susceptibility to chloroquine.

The economic cost of malaria in Brazil from the perspective of the public health system

This paper presents an economic evaluation aimed at estimating malaria-related health care expenditures in Brazil from the perspective of the public health system. Comprehensive estimates of the costs of malaria remain scarce, in part because of limited data. Brazil has a universal health system (Sistema Único de Saúde-SUS) in which all cases of malaria are diagnosed and treated. In addition, antimalarial drugs are only available through the SUS. We compiled comprehensive data from multiple administrative sources. Expenditure indicators were calculated for municipalities and states in the Brazilian Amazon, a region where more than 99% of the country's malaria cases are concentrated. We also developed a digital platform that allows interactive visualization of the malaria cost indicators, disaggregated by cost type and geography. Our results show that control and prevention activities are the primary cost in all states, followed by human resources and disease treatment. Expenditures per malaria notification in the Amazon ranged from PPP (purchasing power parity)-US$59.00 (2017) to PPP-US$77.00 (2016), while per capita expenditures remained relatively stable at around PPP-US$3.50. The malaria cost estimates presented here contribute to a better negotiation of the financial resources needed by the NMCP and are one of the critical pieces of information for a strategic plan of activities needed to achieve the elimination goal.

Plant-based nanoparticles targeting malaria management

Malaria is one of the most devastating diseases across the globe, particularly in low-income countries in Sub-Saharan Africa. The increasing incidence of malaria morbidity is mainly due to the shortcomings of preventative measures such as the lack of vaccines and inappropriate control over the parasite vector. Additionally, high mortality rates arise from therapeutic failures due to poor patient adherence and drug resistance development. Although the causative pathogen (Plasmodium spp.) is an intracellular parasite, the recommended antimalarial drugs show large volumes of distribution and low-to no-specificity towards the host cell. This leads to severe side effects that hamper patient compliance and promote the emergence of drug-resistant strains. Recent research efforts are promising to enable the discovery of new antimalarial agents; however, the lack of efficient means to achieve targeted delivery remains a concern, given the risk of further resistance development. New strategies based on green nanotechnologies are a promising avenue for malaria management due to their potential to eliminate malaria vectors (Anopheles sp.) and to encapsulate existing and emerging antimalarial agents and deliver them to different target sites. In this review we summarized studies on the use of plant-derived nanoparticles as cost-effective preventative measures against malaria parasites, starting from the vector stage. We also reviewed plant-based nanoengineering strategies to target malaria parasites, and further discussed the site-specific delivery of natural products using ligand-decorated nanoparticles that act through receptors on the host cells or malaria parasites. The exploration of traditionally established plant medicines, surface-engineered nanoparticles and the molecular targets of parasite/host cells may provide valuable insights for future discovery of antimalarial drugs and open new avenues for advancing science toward the goal of malaria eradication.

Influence of environmental, geographic, socio-demographic, and epidemiological factors on presence of malaria at the community level in two continents

The interactions of environmental, geographic, socio-demographic, and epidemiological factors in shaping mosquito-borne disease transmission dynamics are complex and changeable, influencing the abundance and distribution of vectors and the pathogens they transmit. In this study, 27 years of cross-sectional malaria survey data (1990-2017) were used to examine the effects of these factors on Plasmodium falciparum and Plasmodium vivax malaria presence at the community level in Africa and Asia. Monthly long-term, open-source data for each factor were compiled and analyzed using generalized linear models and classification and regression trees. Both temperature and precipitation exhibited unimodal relationships with malaria, with a positive effect up to a point after which a negative effect was observed as temperature and precipitation increased. Overall decline in malaria from 2000 to 2012 was well captured by the models, as was the resurgence after that. The models also indicated higher malaria in regions with lower economic and development indicators. Malaria is driven by a combination of environmental, geographic, socioeconomic, and epidemiological factors, and in this study, we demonstrated two approaches to capturing this complexity of drivers within models. Identifying these key drivers, and describing their associations with malaria, provides key information to inform planning and prevention strategies and interventions to reduce malaria burden.

Association between indoor residual spraying and the malaria burden in Zambia and factors associated with IRS refusals: a case-control study in Vubwi District

BACKGROUND

Indoor residual spraying (IRS) has been implemented to prevent malaria in Zambia for several decades, but its effectiveness has not been evaluated long term and in Vubwi District yet. This study aimed to assess the association between IRS and the malaria burden in Zambia and Vubwi District and to explore the factors associated with refusing IRS.

METHODS

A retrospective study was used to analyze the association between IRS and malaria incidence in Zambia in 2001-2020 and in Vubwi District in 2014-2020 by Spearman correlation analysis. A case-control study was used to explore the factors associated with IRS refusals by households in Vubwi District in 2021. A logistic regression model was performed to identify factors associated with IRS refusals.

RESULTS

The malaria incidence reached its peak (391/1000) in 2001 and dropped to the lowest (154/1000) in 2019. The annual percentage change in 2001-2003, 2003-2008, 2008-2014, 2014-2018 and 2018-2020 was - 6.54%, - 13.24%, 5.04%, - 10.28% and 18.61%, respectively. A significantly negative correlation between the percentage of population protected by the IRS against the total population in Zambia (coverage) and the average malaria incidence in the whole population was observed in 2005-2020 (r = - 0.685, P = 0.003) and 2005-2019 (r = - 0.818, P < 0.001). Among 264 participants (59 in the refuser group and 205 in the acceptor group), participants with specific occupations (self-employed: OR 0.089, 95% CI 0.022-0.364; gold panning: OR 0.113, 95% CI 0.022-0.574; housewives: OR 0.129, 95% CI 0.026-0.628 and farmers: OR 0.135, 95% CI 0.030-0.608 compared to employees) and no malaria case among household members (OR 0.167; 95% CI 0.071-0.394) had a lower risk of refusing IRS implementation, while those with a secondary education level (OR 3.690, 95% CI 1.245-10.989) had a higher risk of refusing IRS implementation compared to those who had never been to school.

CONCLUSIONS

Increasing coverage with IRS was associated with decreasing incidence of malaria in Zambia, though this was not observed in Vubwi District, possibly because of the special geographical location of Vubwi District. Interpersonal communication and targeted health education should be implemented at full scale to ensure household awareness and gain community trust.

Modeling the synergistic interplay between malaria dynamics and economic growth

The mosquito-borne disease (malaria) imposes significant challenges on human health, healthcare systems, and economic growth/productivity in many countries. This study develops and analyzes a model to understand the interplay between malaria dynamics, economic growth, and transient events. It uncovers varied effects of malaria and economic parameters on model outcomes, highlighting the interdependence of the reproduction number (R0) on both malaria and economic factors, and a reciprocal relationship where malaria diminishes economic productivity, while higher economic output is associated with reduced malaria prevalence. This emphasizes the intricate interplay between malaria dynamics and socio-economic factors. The study offers insights into malaria control and underscores the significance of optimizing external aid allocation, especially favoring an even distribution strategy, with the most significant reduction observed in an equal monthly distribution strategy compared to longer distribution intervals. Furthermore, the study shows that controlling malaria in high mosquito biting areas with limited aid, low technology, inadequate treatment, or low economic investment is challenging. The model exhibits a backward bifurcation implying that sustainability of control and mitigation measures is essential even when R0 is slightly less than one. Additionally, there is a parameter regime for which long transients are feasible. Long transients are critical for predicting the behavior of dynamic systems and identifying factors influencing transitions; they reveal reservoirs of infection, vital for disease control. Policy recommendations for effective malaria control from the study include prioritizing sustained control measures, optimizing external aid allocation, and reducing mosquito biting.

Occupational exposure to malaria, leishmaniasis and arbovirus vectors in endemic regions: A systematic review

Vector-borne diseases, including dengue, leishmaniasis and malaria, may be more common among individuals whose occupations or behaviours bring them into frequent contact with these disease vectors outside of their homes. A systematic review was conducted to ascertain at-risk occupations and situations that put individuals at increased risk of exposure to these disease vectors in endemic regions and identify the most suitable interventions for each exposure. The review was conducted in accordance with PRISMA guidelines on articles published between 1945 and October 2021, searched in 16 online databases. The primary outcome was incidence or prevalence of dengue, leishmaniasis or malaria. The review excluded ecological and qualitative studies, abstracts only, letters, commentaries, reviews, and studies of laboratory-acquired infections. Studies were appraised, data extracted, and a descriptive analysis conducted. Bite interventions for each risk group were assessed. A total of 1170 articles were screened and 99 included. Malaria, leishmaniasis and dengue were presented in 47, 41 and 24 articles, respectively; some articles presented multiple conditions. The most represented populations were soldiers, 38% (43 of 112 studies); refugees and travellers, 15% (17) each; migrant workers, 12.5% (14); miners, 9% (10); farmers, 5% (6); rubber tappers and missionaries, 1.8% (2) each; and forest workers, 0.9% (1). Risk of exposure was categorised into round-the-clock or specific times of day/night dependent on occupation. Exposure to these vectors presents a critical and understudied concern for outdoor workers and mobile populations. When devising interventions to provide round-the-clock vector bite protection, two populations are considered. First, mobile populations, characterized by their high mobility, may find potential benefits in insecticide-treated clothing, though more research and optimization are essential. Treated clothing offers personal vector protection and holds promise for economically disadvantaged individuals, especially when enabling them to self-treat their clothing to repel vectors. Secondly, semi-permanent and permanent settlement populations can receive a combination of interventions that offer both personal and community protection, including spatial repellents, suitable for extended stays. Existing research is heavily biased towards tourism and the military, diverting attention and resources from vulnerable populations where these interventions are most required like refugee populations as well as those residing in sub-Saharan Africa.

The impact of health on economic growth: A narrative literature review

The nexus between health and economic growth is a dynamic and complex relationship. This article reviews the empirical evidence that has sought to assess the causal impact of health on growth, understood as growth in GDP per capita, and focusing on cross-country and selected single country studies. The review largely provides evidence in favour of a positive effect of population health on economic growth. However, the multitude of the factors at play and the possible bidirectional relationship between health and growth pose a challenge for the quantification of the effect and for the relative importance of the underlying mechanisms. There is notable heterogeneity between studies in the magnitude and, in some cases, even in the sign of the effect. The evidence suggests that the health-growth relationship may depend on three main factors: the sample composition (i.e. a country's demographic stage or GDP per capita); the health dimension considered (e.g. health improvements at different life stages may affect productivity differently); and the model specification (e.g. whether or not initial life expectancy is controlled for in the analysis or the quality of the instrument). These findings advocate for a policy approach that integrates health considerations into economic strategies and emphasizes intersectoral collaboration to maximize the economic returns from improved health outcomes.

Landscape and Socioeconomic Factors Determine Malaria Incidence in Tropical Forest Countries

Deforestation, landscape dynamics, and socioeconomic factors within the tropical Americas, Africa, and Asia may have different impacts on malaria incidence. To evaluate how these drivers affect malaria incidence at the global and regional scale, we collected malaria incidence rates from 2000 to 2019 from 67 tropical countries, along with forest loss, land use change types, and socioeconomic elements. LASSO regression, linear mixed effect modeling, and k-fold cross validation were used to create and evaluate the models. Regionality plays a role in the significance of varying risk factors. The Tropical Americas model had the highest coefficient of determination (marginal R2 = 0.369), while the Africa model showed the highest predictive accuracy with only a 17.4% error rate. Strong associations between tree cover loss (β = -4037.73, p < 0.001) and percentage forest area (β = 5373.18, p = 0.012) in Africa, and percent of key biodiversity areas under protection (β = 496.71, p < 0.001; β = 1679.20, p < 0.001) in the tropical Americas and Asia with malaria incidence indicates that malaria risk should be considered during conservation policy development, and recommends that individual approaches to policy and investment be considered when implementing malaria interventions on different spatial scales.

miR-306-5p is involved in chitin metabolism in Aedes albopictus pupae via linc8338-miR-306-5p-XM_019678125.2 axis

Aedes albopictus can transmit several lethal arboviruses. This mosquito has become a sever public health threat due to its rapidly changing global distribution. Chitin, which is the major component of the cuticle and peritrophic membrane (PM), is crucial for the growth and development of insect. microRNAs (miRNAs) play important roles in the posttranscriptional level regulation of gene expression, thereby influencing many biological processes in insects. In this study, an attempt was made to evaluate the role of miR-306-5p in regulating chitin metabolism in Ae. albopictus pupae. Overexpression of miR-306-5p resulted in a significantly reduced survival rate in pupae and an increased malformation rate in adults. Both in vivo and in vitro evidence confirmed the presence of the competing endogenous RNA (ceRNA) regulatory axis (linc8338-miR-306-5p-XM_019678125.2). RNAi of linc8338 and XM_019678125.2 had effects on pupae similar to those of miR-306-5p. The highest expression level of miR-306-5p was found in the midgut, and alteration in the expression of miR-306-5p, XM_019678125.2 and linc8338 induced increased transcript levels of chitin synthase 2 (AaCHS2) and decreased chitinase 10 (AaCht10); as well as increased thickness of the midgut and enlarged midgut epithelial cells. The results of this study highlight the potential of miR-306-5p as a prospective target in mosquito control and confirm that the ceRNA mechanism is involved in chitin metabolism. These findings will provide a basis for further studies to uncover the molecular mechanisms through which ncRNAs regulate chitin metabolism.

Assessing the Implementation Determinants of Pilot Malaria Vaccination Programs in Ghana, Kenya, and Malawi through a Complexity Lens: A Rapid Review Using a Consolidated Framework for Implementation Research

In 2019, national immunization programs in Ghana, Kenya, and Malawi commenced the implementation of RTS,S/AS01 vaccination in large-scale pilot schemes. Understanding the implementation context of this malaria vaccination in the pilot countries can provide useful insights for enhancing implementation outcomes in new countries. There has not yet been a proper synthesis of the implementation determinants of malaria vaccination programs. A rapid review was conducted to identify the implementation determinants of the pilot malaria vaccination programs in Ghana, Kenya, and Malawi, and describe the mechanism by which these determinants interact with each other. A literature search was conducted in November 2023 in PubMed and Google Scholar to identify those studies that described the factors affecting malaria vaccine implementation in Ghana, Kenya, and Malawi. Thirteen studies conducted between 2021 and 2023 were included. A total of 62 implementation determinants of malaria vaccination across all five domains of the consolidated framework for implementation research (CFIR) were identified. A causal loop diagram showed that these factors are interconnected and interrelated, identifying nine reinforcing loops and two balancing loops. As additional countries in Africa prepare for a malaria vaccine roll-out, it is pertinent to ensure that they have access to adequate information about the implementation context of countries that are already implementing malaria vaccination programs so that they understand the potential barriers and facilitators. This information can be used to inform context-specific systems enhancement to maximize implementation success. Going forward, primary implementation studies that incorporate the causal loop diagram should be integrated into the malaria vaccine implementation program to enable immunization program managers and other key stakeholders to identify and respond to emerging implementation barriers in a timely and systematic manner, to improve overall implementation performance.

Malaria Prevalence and Macroeconomic Output in Ghana, 1990 to 2019

In Ghana, malaria remains the number 1 reason for outpatient department visits, making it a major public health problem. Thus, there could be significant lost productivity days as a result of malaria morbidity and mortality, which could negatively affect economic output at the macrolevel. Nonetheless, there is a dearth of empirical evidence of the effect of malaria on macroeconomic output in Ghana. This study therefore aims to provide the foremost empirical evidence regarding the effect of malaria prevalence on macroeconomic output in Ghana using a time series design with data spanning the period 1990 to 2019. Gross Domestic Product (GDP), serving as a proxy for macroeconomic output, is the dependent variable, while the prevalence of malaria (overall, among only males and among only females) serves as the main independent variable. The Ordinary Least Square (OLS) regression is used as the baseline estimation technique and the Instrumental Variable Two-Stage Least Square (IV2SLS) regression is employed as the robustness check estimator due to its ability to deal with endogeneity. The IV2SLS regression results show that a percentage increase in the overall prevalence of malaria is associated with a 1.16% decrease in macroeconomic output at 1% significance level. We also find that the effect of malaria in males on macroeconomic output is slightly higher relative to females. The findings from the OLS regression are not qualitatively different from the IV2SLS regression estimates. There is therefore the need to strengthen efforts such as quality case management, larval source management, mass distribution of long-lasting insecticide-treated bed nets, social behavior change, surveillance (both epidemiological and entomological), intermittent preventive treatment of malaria in pregnancy, research among others, which are important toward eliminating malaria.

The Macroeconomic Impact of Increasing Investments in Malaria Control in 26 High Malaria Burden Countries: An Application of the Updated EPIC Model

BACKGROUND

Malaria remains a major public health problem. While globally malaria mortality affects predominantly young children, clinical malaria affects all age groups throughout life. Malaria not only threatens health but also child education and adult productivity while burdening government budgets and economic development. Increased investments in malaria control can contribute to reduce this burden but have an opportunity cost for the economy. Quantifying the net economic value of investing in malaria can encourage political and financial commitment.

METHODS

We adapted an existing macroeconomic model to simulate the effects of reducing malaria on the gross domestic product (GDP) of 26 high burden countries while accounting for the opportunity costs of increased investments in malaria. We compared two scenarios differing in their level of malaria investment and associated burden reduction: sustaining malaria control at 2015 intervention coverage levels, time at which coverage levels reached their historic peak and scaling-up coverage to reach the 2030 global burden reduction targets. We incorporated the effects that reduced malaria in children and young adolescents may have on the productivity of working adults and on the future size of the labour force augmented by educational returns, skills, and experience. We calibrated the model using estimates from linked epidemiologic and costing models on these same scenarios and from published country-specific macroeconomic data.

RESULTS

Scaling-up malaria control could produce a dividend of US$ 152 billion in the modelled countries, equivalent to 0.17% of total GDP projected over the study period across the 26 countries. Assuming a larger share of malaria investments is paid out from domestic savings, the dividend would be smaller but still significant, ranging between 0.10% and 0.14% of total projected GDP. Annual GDP gains were estimated to increase over time. Lower income and higher burden countries would experience higher gains.

CONCLUSION

Intensified malaria control can produce a multiplied return despite the opportunity cost of greater investments.

The oral repellent - science fiction or common sense? Insects, vector-borne diseases, failing strategies, and a bold proposition

Over the last decades, unimaginable amounts of money have gone into research and development of vector control measures, repellents, treatment, and vaccines for vector borne diseases. Technological progress and scientific breakthroughs allowed for ever more sophisticated and futuristic strategies. Yet, each year, millions of people still die or suffer from potentially serious consequences of malaria or dengue to more recent infections, such as zika or chikungunya, or of debilitating consequences of neglected tropical diseases. This does not seem value for money. In addition, all current vector control strategies and personal protection methods have shortcomings, some serious, that are either destructive to non-target species or unsatisfactory in their effectiveness. On the other hand, the rapid decline in insect populations and their predators reflects decades-long aggressive and indiscriminate vector control. This major disruption of biodiversity has an impact on human life not anticipated by the well-meaning killing of invertebrates. The objective of this paper is to re-examine current control methods, their effectiveness, their impact on biodiversity, human and animal health, and to call for scientific courage in the pursuit of fresh ideas. This paper brings together topics that are usually presented in isolation, thereby missing important links that offer potential solutions to long-standing problems in global health. First, it serves as a reminder of the importance of insects to human life and discusses the few that play a role in transmitting disease. Next, it examines critically the many currently employed vector control strategies and personal protection methods. Finally, based on new insights into insect chemo-sensation and attractants, this perspective makes a case for revisiting a previously abandoned idea, the oral repellent, and its use via currently successful methods of mass-application. The call is out for focused research to provide a powerful tool for public health, tropical medicine, and travel medicine.

Mosquito Larvicidal Activity and Cytotoxicity of the Extracts of Aromatic Plants from Malaysia

Despite ongoing control efforts, the mosquito population and diseases vectored by them continue to thrive worldwide, causing major health concerns. There has been growing interest in the use of botanicals as alternatives to insecticides due to their widespread insecticidal properties, biodegradability, and adaptability to ecological conditions. In this study, we investigated the larvicidal activity and cytotoxicity effects of solvent extracts from three aromatic plants-Curcuma longa (turmeric), Ocimum americanum (hoary basil), and Petroselinum crispum (parsley)-against Aedes albopictus. Subsequently, we examined the phytochemical composition of the extracts through gas chromatography-mass spectrometry (GC-MS) analysis. Results revealed that the hexane extracts of O. americanum and P. crispum exhibited the greatest larvicidal activity with the lowest median lethal concentration (LC₅₀) values (<30 µg/mL) at 24 h post-treatment, with the former found to be significantly less toxic towards African monkey kidney (Vero) cells. The GC-MS analysis of the said extract indicated the presence of different classes of metabolites, including phenylpropanoids, very long-chain alkanes, fatty acids and their derivatives, and terpenes, with the most abundant component being methyl eugenol (55.28%), most of which, have been documented for their larvicidal activities. These findings provide valuable insights into the potential use and development of bioinsecticides, particularly from O. americanum.

The economic burden of malaria inpatients and its determinants during China's elimination stage

Background

Malaria burden is still worrisome, while empirical evidence from malaria-eliminated countries including China may provide inspiration for the world.

Objective

This study aimed to investigate China's malaria hospitalization costs and explore its determinants.

Methods

Stratified multistage sampling across provincial, municipal, and county hospitals was conducted in 2017. All the malaria medical records were retrieved from 2014 to 2016 in 70 hospitals. Parametric and non-parametric methods were employed to estimate hospitalization costs, and the non-parametric bootstrap was used to compare hospitalization costs among sample areas and assessed the uncertainty of its differences. Quantile regressions were conducted to identify the determinants of hospitalization costs.

Results

The median hospitalization costs of 1633 malaria inpatients were 628 USD. Medication and laboratory tests accounted for over 70% of total expenditure. The median reimbursement rate was 41.87%, and this number was even lower in higher-level hospitals (<35%) and among the New Rural Cooperative Medical Scheme (<40%). Finally, health insurance type, hospital tier, clinical units, unknown fever, and comorbidity were the main determinants of hospitalization costs.

Conclusion

The disparity of health protection for malaria hospitalization between rural and urban areas was noteworthy. Equivocal diagnosis and comorbidity are contributors of high cost as well. A reasonable payment system and enhanced capacities to treat malaria in a cost-effective way are suggested to reassure malaria economic burden.

Prediction of malaria using deep learning models: A case study on city clusters in the state of Amazonas, Brazil, from 2003 to 2018

Background:

Malaria is curable. Nonetheless, over 229 million cases of malaria were recorded in 2019, along with 409,000 deaths. Although over 42 million Brazilians are at risk of contracting malaria, 99% percent of all malaria cases in Brazil are located in or around the Amazon rainforest. Despite declining cases and deaths, malaria remains a major public health issue in Brazil. Accurate spatiotemporal prediction of malaria propagation may enable improved resource allocation to support efforts to eradicate the disease.

Methods:

In response to calls for novel research on malaria elimination strategies that suit local conditions, in this study, we propose machine learning (ML) and deep learning (DL) models to predict the probability of malaria cases in the state of Amazonas. Using a dataset of approximately 6 million records (January 2003 to December 2018), we applied k-means clustering to group cities based on their similarity of malaria incidence. We evaluated random forest, long-short term memory (LSTM) and dated recurrent unit (GRU) models and compared their performance.

Results:

The LSTM architecture achieved better performance in clusters with less variability in the number of cases, whereas the GRU presents better results in clusters with high variability. Although Diebold-Mariano testing suggested that both the LSTM and GRU performed comparably, GRU can be trained significantly faster, which could prove advantageous in practice.

Conclusions:

All models showed satisfactory accuracy and strong performance in predicting new cases of malaria, and each could serve as a supplemental tool to support regional policies and strategies.

Governance Quality, Public Health, Education, and Innovation: Study for Novel Implications

Pandemic or worldwide disease is the greatest issue of all time that not only affects human health but also influences the economic, educational, and other activities of the countries, since malaria is among the leading health disease that disrupts the economic system of the country. Therefore, this study aimed to analyze whether educational expenditure and technological innovation influence malarial incidence in emerging economies. This study also examined the role of government effectiveness, government health expenditure, gross domestic growth, human capital, and research and development during the period 2000-2018. Employing panel data approaches, including the slope heterogeneity and cross-sectional dependence, the second-generation unit root test reveals the stationarity of all variables. The study also validated the existence of a long-run relationship between the variables. Based on the asymmetrical distribution properties, this study employed the quantile regression approach. The empirical results asserted that education and technological innovation significantly reduce malarial incidents in the panel economies. Also, government effectiveness, research and development, and human capital adversely affect incidences of malaria. In contrast, gross domestic product is the only factor found that increases malarial incidents during the selected period. Based on the empirical results, this study suggested policy measures that could benefit the governors, policymakers, and scholars.

Soluble triggering receptor expressed on myeloid cells-1 (sTREM-1) and other inflammatory mediators in malaria by Plasmodium vivax during enteroparasites coinfection

Malaria is a major health issue with more than 200 million cases occurring annually. Moreover, in Malaria endemic area are frequently observed Malaria-enteroparasite co-infections associated with the modulation of inflammatory response. In this aspect, biomarkers play an important role in the disease prognosis. This study aimed to evaluate inflammatory mediators in malaria during coinfection with enteroparasites. A subset of serum samples already collected was analyzed and divided into four groups: Malaria (n = 34), Co-infected (n = 116), Enteroparasite (n = 120) and Control (n = 95). The serum levels of sTREM-1 and IL-6 were measured by ELISA. TNF-α, and IL-10 levels were previously carried out by flow cytometry. Higher serum levels of sTREM-1 and IL-6 were showed in malaria patients compared to healthy controls. In co-infected malarial patients sTREM-1 serum levels were similar to control group. Interestingly, co-infected malaria patients showed IL-6 serum levels decreased compared to individuals only infected with P. vivax. However, in Malaria patients and co-infected there was a positive correlation between the IL-6 and IL-10 levels (P < 0.0001). This is the first report of sTREM-1 levels in P. vivax infected. Moreover, the results revealing a divergent effect of co-infection with the increased balance between pro-and anti-inflammatory cytokines and reduced IL-6 levels but increases the anemia occurrence. The results also highlight the potential use of IL-6 as a biomarker for P. vivax and enteroparasites coinfection.

Incremental cost and cost-effectiveness of the addition of indoor residual spraying with pirimiphos-methyl in sub-Saharan Africa versus standard malaria control: results of data collection and analysis in the Next Generation Indoor Residual Sprays (NgenIRS) project, an economic-evaluation

BACKGROUND

Malaria is a major cause of morbidity and mortality globally, especially in sub-Saharan Africa. Widespread resistance to pyrethroids threatens the gains achieved by vector control. To counter resistance to pyrethroids, third-generation indoor residual spraying (3GIRS) products have been developed. This study details the results of a multi-country cost and cost-effectiveness analysis of indoor residual spraying (IRS) programmes using Actellic®300CS, a 3GIRS product with pirimiphos-methyl, in sub-Saharan Africa in 2017 added to standard malaria control interventions including insecticide-treated bed nets versus standard malaria control interventions alone.

METHODS

An economic evaluation of 3GIRS using Actellic®300CS in a broad range of sub-Saharan African settings was conducted using a variety of primary data collection and evidence synthesis methods. Four IRS programmes in Ghana, Mali, Uganda, and Zambia were included in the effectiveness analysis. Cost data come from six IRS programmes: one in each of the four countries where effect was measured plus Mozambique and a separate programme conducted by AngloGold Ashanti Malaria Control in Ghana. Financial and economic costs were quantified and valued. The main indicator for the cost was cost per person targeted. Country-specific case incidence rate ratios (IRRs), estimated by comparing IRS study districts to adjacent non-IRS study districts or facilities, were used to calculate cases averted in each study area. A deterministic analysis and sensitivity analysis were conducted in each of the four countries for which effectiveness evaluations were available. Probabilistic sensitivity analysis was used to generate plausibility bounds around the incremental cost-effectiveness ratio estimates for adding IRS to other standard interventions in each study setting as well as jointly utilizing data on effect and cost across all settings.

RESULTS

Overall, IRRs from each country indicated that adding IRS with Actellic®300CS to the local standard intervention package was protective compared to the standard intervention package alone (IRR 0.67, [95% CI 0.50-0.91]). Results indicate that Actellic®300CS is expected to be a cost-effective (> 60% probability of being cost-effective in all settings) or highly cost-effective intervention across a range of transmission settings in sub-Saharan Africa.

DISCUSSION

Variations in the incremental costs and cost-effectiveness likely result from several sources including: variation in the sprayed wall surfaces and house size relative to household population, the underlying malaria burden in the communities sprayed, the effectiveness of 3GIRS in different settings, and insecticide price. Programmes should be aware that current recommendations to rotate can mean variation and uncertainty in budgets; programmes should consider this in their insecticide-resistance management strategies.

CONCLUSIONS

The optimal combination of 3GIRS delivery with other malaria control interventions will be highly context specific. 3GIRS using Actellic®300CS is expected to deliver acceptable value for money in a broad range of sub-Saharan African malaria transmission settings.

Plants used traditionally as antimalarials in Latin America: Mining the tree of life for potential new medicines

ETHNOPHARMACOLOGICAL RELEVANCE

Malaria remains a serious and challenging disease. Traditional antimalarial medicines are largely based on plants, and ethnopharmacological research has inspired the development of antimalarial pharmaceuticals such as artemisinin. Antimalarial drug resistance is an increasing problem in Plasmodium species, and new therapeutic strategies to combat malaria are needed. Although the number of malaria cases has been decreasing in Latin America, malaria remains a significant threat in many regions. Local people in Latin America have been using numerous plant species to treat malaria, some of which have been scientifically studied, but many others have not.

AIM OF THE STUDY

Our principal objective is to harness ethnobotanical data on species used traditionally to treat malaria, combined with phylogenetic approaches, to understand how ethnobotany could help identify plant genera as potential sources of new medicines.

MATERIALS AND METHODS

Plants used to treat malaria in Latin America were compiled from published and grey literature, unpublished data, and herbarium specimens. Initial assessment of potentially important species/genera/families included compiling the number of species used within the genus, the number of use reports per genus and species, and the geographic distribution of their use. The analysis of taxonomic distribution of species reported as antimalarial in Latin America (excluding the Southern Cone) was conducted, to determine which genera and families with reputed antimalarial properties are over-represented, and phylogenetic analyses were performed to identify if there was evidence for antimalarial species being dispersed/clustered throughout the tree or at its tips. This approach enabled 'hot-nodes' in certain families to be identified, to predict new genera with potential antimalarial properties.

RESULTS

Over 1000 plant species have been used to treat malaria in Latin America, of which over 600 species were cited only once. The genera with the highest number of antimalarial species were Aspidosperma, Solanum, Piper, Croton and Aristolochia. In terms of geographic distribution, the most widely used genera were Aspidosperma, Momordica, Cinchona, Senna and Stachytarpheta. Significant phylogenetic signal was detected in the distribution of native species used for malaria, analysed in a genus-level phylogenetic framework. The eudicot and magnoliidae lineages were over-represented, while monocots were not.

CONCLUSION

Analysis of ethnobotanical use reports in a phylogenetic framework reveals the existence of hot nodes for malaria across the Latin American flora. We demonstrate how species and genera currently lacking such reports could be pinpointed as of potential interest based on their evolutionary history. Extending this approach to other regions of the world and other diseases could accelerate the discovery of novel medicines and enhance healthcare in areas where new therapeutic strategies are needed.

Drug-induced hypersensitivity to artemisinin-based therapies for malaria

In the early 2000s, artemisinin-based combination therapy (ACT) was introduced as first-line treatment for uncomplicated Plasmodium falciparum malaria in virtually all endemic countries. However, despite the well-known excellent tolerability of ACTs, hypersensitivity to artemisinin derivatives remains a repeatedly documented adverse drug reaction of still unknown frequency. The clinical features of an artemisinin-induced hypersensitivity reaction range from mild to life-threatening severity, and a significant number of cases may pass unnoticed. In this review, we discuss the medical importance of hypersensitivity to artemisinin derivatives and we review data on the presumed frequency and its potential underlying mechanisms. Furthermore, we advocate to make alternative non-artemisinin-based drugs available for patients who do not tolerate artemisinin derivatives and to continue investing in the development of novel non-artemisinin-based combination regimens.

Virus-Like Particle Vaccines Against Respiratory Viruses and Protozoan Parasites

The field of vaccinology underwent massive advances over the past decades with the introduction of virus-like particles (VLPs), a supra-molecular nanoparticle vaccine platform that resembles viral structures without the ability to replicate in hosts. This innovative approach has been remarkably effective, as evidenced by its profound immunogenicity and safety. These highly desirable intrinsic properties enabled their further development as vaccines against a multitude of diseases. To date, several VLP-based vaccines have already been commercialized and many more are undergoing clinical evaluation prior to FDA approval. However, efficacious vaccines against a plethora of pathogens are still lacking, which imposes a tremendous socioeconomic burden and continues to threaten public health throughout the globe. This is especially the case for several respiratory pathogens and protozoan parasites. In this review, we briefly describe the fundamentals of VLP vaccines and the unique properties that enable these to be such valuable vaccine candidates and summarize current advances in VLP-based vaccines targeting respiratory and parasitic diseases of global importance.

Trends of the global, regional and national incidence of malaria in 204 countries from 1990 to 2019 and implications for malaria prevention

BACKGROUND

Malaria is a life-threatening disease worldwide, but lacks studies on its incidence at the global level. We aimed to describe global trends and regional diversities in incidence of malaria infection, to make global tailored implications for malaria prevention.

METHODS

We used the data from the Global Burden of Disease Study 2019. The age-standardized incidence rate (ASR) and absolute number of malaria episodes showed the epidemic status of malaria infection. The estimated annual percentage change of ASR and changes in malaria episodes quantified the malaria incidence trends. The connection between ASRs and traveller number indicated infection risk for travellers.

RESULTS

Globally, the malaria ASR decreased by an average 0.80% (95% confidence interval 0.58-1.02%) per year from 1990 to 2019; however, it slightly increased from 3195.32 per 100 000 in 2015 to 3247.02 per 100 000 in 2019. The incidence rate of children under 5 was higher than other age groups. A total of 40 countries had higher ASRs in 2019 than in 2015, with the largest expansion in Cabo Verde (from 2.02 per 100 000 to 597.00 per 100 000). After 2015, the ASRs in high-middle, middle and low-middle Socio-demographic Index regions began to rise and the uptrends remained in 2019. Central, Western and Eastern Sub-Saharan Africa had the highest ASRs since 1990, and traveller number in Eastern and Western Sub-Saharan Africa increased by 31.24 and 7.58%, respectively, from 2017 to 2018. Especially, most countries with ASR over 10 000 per 100 000 had increase in traveller number from 2017 to 2018, with the highest change by 89.56% in Mozambique.

CONCLUSIONS

Malaria is still a public health threat for locals and travellers in Sub-Saharan Africa and other malaria-endemic areas, especially for children under 5. There were unexpected global uptrends of malaria ASRs from 2015 to 2019. More studies are needed to achieve the goal of malaria elimination.

Chemical Strategies towards the Synthesis of Betulinic Acid and Its More Potent Antiprotozoal Analogues

Betulinic acid (BA, 3β-hydroxy-lup-20(29)-en-28-oic acid) is a pentacyclic triterpene acid present predominantly in Betula ssp. (Betulaceae) and is also widely spread in many species belonging to different plant families. BA presents a wide spectrum of remarkable pharmacological properties, such as cytotoxic, anti-HIV, anti-inflammatory, antidiabetic and antimicrobial activities, including antiprotozoal effects. The present review first describes the sources of BA and discusses the chemical strategies to produce this molecule starting from betulin, its natural precursor. Next, the antiprotozoal properties of BA are briefly discussed and the chemical strategies for the synthesis of analogues displaying antiplasmodial, antileishmanial and antitrypanosomal activities are systematically presented. The antiplasmodial activity described for BA was moderate, nevertheless, some C-3 position acylated analogues showed an improvement of this activity and the hybrid models—with artesunic acid—showed the most interesting properties. Some analogues also presented more intense antileishmanial activities compared with BA, and, in addition to these, heterocycles fused to C-2/C-3 positions and amide derivatives were the most promising analogues. Regarding the antitrypanosomal activity, some interesting antitrypanosomal derivatives were prepared by amide formation at the C-28 carboxylic group of the lupane skeleton. Considering that BA can be produced either by isolation of different plant extracts or by chemical transformation of betulin, easily obtained from Betula ssp., it could be said that BA is a molecule of great interest as a starting material for the synthesis of novel antiprotozoal agents.

Novel control strategies for mosquito-borne diseases

Mosquito-borne diseases are an increasing global health challenge, threatening over 40% of the world's population. Despite major advances in malaria control since 2000, recent progress has stalled. Additionally, the risk of Aedes-borne arboviruses is rapidly growing, with the unprecedented spread of dengue and chikungunya viruses, outbreaks of yellow fever and the 2015 epidemic of Zika virus in Latin America. To counteract this growing problem, diverse and innovative mosquito control technologies are currently under development. Conceptually, these span an impressive spectrum of approaches, from invasive transgene cassettes with the potential to crash mosquito populations or reduce the vectorial capacity of a population, to low-cost alterations in housing design that restrict mosquito entry. This themed issue will present articles providing insight into the breadth of mosquito control research, while demonstrating the requirement for an interdisciplinary approach. The issue will highlight mosquito control technologies at varying stages of development and includes both opinion pieces and research articles with laboratory and field-based data on control strategy development. This article is part of the theme issue 'Novel control strategies for mosquito-borne diseases'.

Parasites and Parasitology in this SARS-CoV-2, COVID-19 World: An American Society of Parasitologists Presidential Address

The novel coronavirus disease 2019 (COVID-19) is one of the worst global health crises of this generation. The core of this pandemic is the rapid transmissibility of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus, its high morbidity and mortality, and the presence of infectious asymptomatic carriers. As a result, COVID-19 has dominated this year's headlines and commanded significant research attention. As we consider SARS-CoV-2 and the COVID-19 pandemic, it is essential that scientists, governments, the media, and the general population also come to grips with the everyday cost of parasitic diseases. Plasmodium (malaria), schistosomes, filarial worms, hookworms, Ascaris, whipworms, and other protozoan and metazoan parasites take a tremendous toll on local communities. Yet, because most of these diseases are no longer endemic to developed countries, their research and intervention are not funded at levels that are proportional to their global morbidity and mortality. The scientific and public health communities must indeed vigorously fight SARS-CoV-2 and COVID-19, but while doing so and beyond, it will be essential to demonstrate steadfast resolve toward understanding and combating the parasitic diseases that for centuries have haunted humankind.

What will studies of Fulani individuals naturally exposed to malaria teach us about protective immunity to malaria?

There are an estimated over 200 million yearly cases of malaria worldwide. Despite concerted international effort to combat the disease, it still causes approximately half a million deaths every year, the majority of which are young children with Plasmodium falciparum infection in sub‐Saharan Africa. Successes are largely attributed to malaria prevention strategies, such as insecticide‐treated mosquito nets and indoor spraying, as well as improved access to existing treatments. One important hurdle to new approaches for the treatment and prevention of malaria is our limited understanding of the biology of Plasmodium infection and its complex interaction with the immune system of its human host. Therefore, the elimination of malaria in Africa not only relies on existing tools to reduce malaria burden, but also requires fundamental research to develop innovative approaches. Here, we summarize our discoveries from investigations of ethnic groups of West Africa who have different susceptibility to malaria.

Improving Accuracy of Malaria Diagnosis in Underserved Rural and Remote Endemic Areas of Sub-Saharan Africa: A Call to Develop Multiplexing Rapid Diagnostic Tests

Clinical infection with malaria, caused by parasites of the genus Plasmodium, is considered a serious medical condition with the potential to become a life-threatening emergency. This is especially relevant to low-income countries in tropical and subtropical regions of the world where high rates of malaria-related morbidity and mortality are recorded. As a means to combat this major global public health threat, rapid and effective diagnosis remains the frontline action to initiate a timely and appropriate medical intervention. From all the approaches to parasite detection, rapid diagnostic tests, so-called RDTs, are the easiest to use and most cost-effective. However, some of the limitations inherent in this methodology could hinder effective patient treatment. A primary drawback is that the vast majority of commercially available RDTs detect only one of the five species of human malaria, P. falciparum. While this is the main cause of infection in many areas, it excludes the possibility of infection with another parasite (P. vivax, P. ovale, P. malariae, and P. knowlesi) or of mixed infections containing different species. Hence, a diagnosis of non-P. falciparum malaria is missed. In turn, in resource-constrained settings where optimal microscopy is not available, a misdiagnosis of bacterial infection based on signs and symptoms alone often results in an inappropriate prescription of antibiotics. Here, we discuss how effective diagnosis of malaria and indiscriminate use of antibiotics in sub-Saharan Africa, a hot spot for P. falciparum transmission, may both be addressed by the development of innovative multiplexing RDTs that detect two or more species of Plasmodium.