title: Sesame Street

text: Starting in 2006, the Workshop expanded its outreach by creating a series of PBS specials and DVDs focusing on how military deployment affects the families of servicepeople. Its outreach efforts also focused on families of prisoners, health and wellness, and safety. In 2013, SW started Sesame Street in Communities, to help families dealing with difficult issues.


title: Sesame Street

text: As a result of Cooney's initial proposal in 1968, the Carnegie Institute awarded her an $1 million grant to create a new children's television program and establish the CTW, renamed in June 2000 to Sesame Workshop (SW).


title: Sesame Street

text: Nixon administration offials argued: we can get Sesame Street to reach poor kids by spending sixty-five cents. Why would we spend thousands of Dollars for Head Start?"


title: Sesame Street

text: Cooney and Morrisett procured additional multimillion-dollar grants from the U.S. federal government, The Arthur Vining Davis Foundations, CPB, and the Ford Foundation. Davis reported that Cooney and Morrisett decided that if they did not procure full funding from the beginning, they would drop the idea of producing the show. As Lesser reported, funds gained from a combination of government agencies and private foundations protected them from the economic pressures experienced by commercial broadcast television networks, but created challenges in procuring future funding.


title: Sesame Street

text: After "Sesame Street"s initial success, its producers began to think about its survival beyond its development and first season and decided to explore other funding sources. From the first season, they understood that the source of their funding, which they considered "seed" money, would need to be replaced. The 1970s were marked by conflicts between the CTW and the federal government; in 1978, the U.S. Department of Education refused to deliver a $2 million check until the last day of CTW's fiscal year. As a result, the CTW decided to depend upon licensing arrangements with toy companies and other manufacturers, publishing, and international sales for their funding.


title: Sesame Street

text: In 1998, the CTW accepted corporate sponsorship to raise funds for "Sesame Street" and other projects. For the first time, they allowed short advertisements by indoor playground manufacturer Discovery Zone, their first corporate sponsor, to air before and after each episode. Consumer advocate Ralph Nader, who had previously appeared on "Sesame Street", called for a boycott of the show, saying that the CTW was "exploiting impressionable children." In 2015, in response to funding challenges, it was announced that premium television service HBO would air first-run episodes of "Sesame Street". Steve Youngwood, SW's Chief Operating Officer, called the move "one of the toughest decisions we ever made." According to "The New York Times", the move "drew an immediate backlash." Critics claimed that it favored privileged children over less-advantaged children and their families, the original focus of the show. They also criticized choosing to air first-run episodes on HBO, a network with adult dramas and comedies.


title: Sesame Street

text: In 1967, when she and her team began planning the show's development, combining research with television production was, as she put it, "positively heretical." Its producers soon began developing what came to be called the CTW Model, a system of planning, production and evaluation that did not fully emerge until the end of the show's first season. According to Morrow, the Model consisted of four parts: "the interaction of receptive television producers and child science experts, the creation of a specific and age-appropriate curriculum, research to shape the program directly, and independent measurement of viewers' learning."


title: Sesame Street

text: Cooney credited the show's high standard in research procedures to Harvard professors Gerald S. Lesser, whom CTW hired to design its educational objectives; and Edward L. Palmer, who conducted the show's formative research and bridged the gap between producers and researchers. CTW conducted research in two ways: in-house formative research that informed and improved production; and independent summative evaluations, conducted by the Educational Testing Service (ETS) during the first two seasons, which measured its educational effectiveness. Cooney said, "From the beginning, we—the planners of the project—designed the show as an experimental research project with educational advisers, researchers, and television producers collaborating as equal partners." She characterized the collaboration as an "arranged marriage."


title: Sesame Street

text: "Sesame Street" has used many writers in its long history. As Peter Hellman wrote in his 1987 article in "New York Magazine", "The show, of course, depends upon its writers, and it isn't easy to find adults who could identify the interest level of a pre-schooler." Fifteen writers a year worked on the show's scripts, but very few lasted longer than one season. Norman Stiles, head writer in 1987, reported that most writers would "burn out" after writing about a dozen scripts. According to Gikow, "Sesame Street" went against the convention of hiring teachers to write for the show, as most educational television programs did at the time. Instead, Cooney and the producers felt that it would be easier to teach writers how to interpret curriculum than to teach educators how to write comedy. As Stone stated, "Writing for children is not so easy." Long-time writer Tony Geiss agreed, stating in 2009, "It's not an easy show to write. You have to know the characters and the format and how to teach and be funny at the same time, which is a big, ambidextrous stunt."


title: Sesame Street

text: The show's research team developed an annotated document, or "Writer's Notebook," which served as a bridge between the show's curriculum goals and script development. The notebook was a compilation of programming ideas designed to teach specific curriculum points, provided extended definitions of curriculum goals, and assisted the writers and producers in translating the goals into televised material. Suggestions in the notebook were free of references to specific characters and contexts on the show so that they could be implemented as openly and flexibly as possible.


title: Sesame Street

text: The research team, in a series of meetings with the writers, also developed "a curriculum sheet" that described the show's goals and priorities for each season. After receiving the curriculum focus and goals for the season, the writers met to discuss ideas and story arcs for the characters, and an "assignment sheet" was created that suggested how much time was allotted for each goal and topic. When a script was completed, the show's research team analyzed it to ensure that the goals were met. Then each production department met to determine what each episode needed in terms of costumes, lights, and sets. The writers were present during the show's taping, which for the first twenty-four years of the show took place in Manhattan, and after 1992, at the Kaufman Astoria Studios in Queens to make last-minute revisions when necessary.


title: Sesame Street

text: Early in their history "Sesame Street" and the CTW began to look for alternative funding sources and turned to creating products and writing licensing agreements. They became, as Cooney put it, "a multiple-media institution." In 1970, the CTW created a "non-broadcast" division responsible for creating and publishing books and "Sesame Street Magazine". By 2019, the Sesame Workshop had published over 6,500 book titles. The Workshop decided from the start that all materials their licensing program created would "underscore and amplify" the show's curriculum. In 2004, over 68% of "Sesame Street"s revenue came from licenses and products such as toys and clothing. By 2008, the "Sesame Street" Muppets accounted for between $15 million and $17 million per year in licensing and merchandising fees, split between the Sesame Workshop and The Jim Henson Company. By 2019, the Sesame Workshop had over 500 licensing agreements and had produced over 200 hours of home video. There have been two theatrically released "Sesame Street" movies, "Follow That Bird", released in 1985, and "Elmo in Grouchland", released in 1999. In early 2019, it was announced that a third film, a musical co-starring Anne Hathaway and written and directed by Jonathan Krisel, would be produced. In November 2019, Sesame Street announced a family friendly augmented reality application produced by Weyo in partnership with Sesame Workshop in honor of the show's 50th anniversary.


title: Sesame Street

text: Jim Henson, the creator of the Muppets, owned the trademarks to those characters, and was reluctant to market them at first. He agreed when the CTW promised that the profits from toys, books, computer games, and other products were to be used exclusively to fund the CTW and its outreach efforts. Even though Cooney and the CTW had very little experience with marketing, they demanded complete control over all products and product decisions. Any product line associated with the show had to be educational and inexpensive, and could not be advertised during the show's airings. As Davis reported, "Cooney stressed restraint, prudence, and caution" in their marketing and licensing efforts.


title: Sesame Street

text: Director Jon Stone, talking about the music of "Sesame Street", said: "There was no other sound like it on television." For the first time in children's television, the show's songs fulfilled a specific purpose and supported its curriculum. In order to attract the best composers and lyricists, the CTW allowed songwriters like Joe Raposo, "Sesame Street"s first musical director, to retain the rights to the songs they wrote, which earned them lucrative profits and helped the show sustain public interest. By 2019, there were 180 albums of "Sesame Street" music produced, and its songwriters had received 11 Grammys. In late 2018, the SW announced a multi-year agreement with Warner Music Group to re-launch Sesame Street Records in the U.S. and Canada. For the first time in 20 years, "an extensive catalog of "Sesame Street" recordings" was made available to the public in a variety of formats, including CD and vinyl compilations, digital streaming, and downloads.


title: Sesame Street

text: "Sesame Street" used animations and short films commissioned from outside studios, interspersed throughout each episode, to help teach their viewers basic concepts like numbers and letters. Jim Henson was one of the many producers to create short films for the show. Shortly after "Sesame Street" debuted in the United States, the CTW was approached independently by producers from several countries to produce versions of the show at home. These versions came to be called "co-productions." By 2001 there were over 120 million viewers of all international versions of "Sesame Street", and in 2006, there were twenty co-productions around the world. By its 50th anniversary in 2019, 190 million children viewed over 160 versions of "Sesame Street" in 70 languages. In 2005, Doreen Carvajal of "The New York Times" reported that income from the co-productions and international licensing accounted for $96 million.


title: Sesame Street

text: "Sesame Street the Musical" opened at Theatre Row off Broadway on September 8, 2022 and will run through to November 27, 2022.


title: Sesame Street

text: Shortly after the CTW was created in 1968, Joan Ganz Cooney was named its first executive director. She was one of the first female executives in American television. Her appointment was called "one of the most important television developments of the decade." She assembled a team of producers, all of whom had previously worked on "Captain Kangaroo". Jon Stone was responsible for writing, casting, and format; Dave Connell took over animation; and Sam Gibbon served as the show's chief liaison between the production staff and the research team. Cameraman Frankie Biondo has worked on "Sesame Street" from its first episode in 1969.


title: Sesame Street

text: Jim Henson and the Muppets' involvement in "Sesame Street" began when he and Cooney met at one of the curriculum planning seminars in Boston. Author Christopher Finch reported that Stone, who had worked with Henson previously, felt that if they could not bring him on board, they should "make do without puppets." Henson was initially reluctant, but he agreed to join "Sesame Street" to meet his own social goals. He also agreed to waive his performance fee for full ownership of the "Sesame Street" Muppets and to split any revenue they generated with the CTW. As Morrow stated, Henson's puppets were a crucial part of the show's popularity and it brought Henson national attention. Davis reported that Henson was able to take "arcane academic goals" and translate them to "effective and pleasurable viewing." In early research, the Muppet segments of the show scored high, and more Muppets were added during the first few seasons. Morrow reported that the Muppets were effective teaching tools because children easily recognized them, they were stereotypical and predictable, and they appealed to adults and older siblings.


title: Sesame Street

text: Although the producers decided against depending upon a single host for "Sesame Street", instead casting a group of ethnically diverse actors, they realized that a children's television program needed to have, as Lesser put it, "a variety of distinctive and reliable personalities," both human and Muppet. Jon Stone, whose goal was to cast white actors in the minority, was responsible for hiring the show's first cast. He did not audition actors until Spring 1969, a few weeks before the five test shows were due to be filmed. Stone videotaped the auditions, and Ed Palmer took them out into the field to test children's reactions. The actors who received the "most enthusiastic thumbs up" were cast. For example, Loretta Long was chosen to play Susan when the children who saw her audition stood up and sang along with her rendition of "I'm a Little Teapot." Stone stated that casting was the only aspect of the show that was "just completely haphazard." Most of the cast and crew found jobs on "Sesame Street" through personal relationships with Stone and the other producers. According to puppeteer Marty Robinson in 2019, longevity was common among the show's cast and crew.


title: Sesame Street

text: According to the CTW's research, children preferred watching and listening to other children more than to puppets and adults, so they included children in many scenes. Dave Connell insisted that no child actors be used, so these children were non-professionals, unscripted, and spontaneous. Many of their reactions were unpredictable and difficult to control, but the adult cast learned to handle the children's spontaneity flexibly, even when it resulted in departures from the planned script or lesson. CTW research also revealed that the children's hesitations and on-air mistakes served as models for viewers. According to Morrow, this resulted in the show having a "fresh quality," especially in its early years.


title: Sesame Street

text: When "Sesame Street" premiered on November 10, 1969, it aired on only 67.6% of American televisions, but it earned a 3.3 Nielsen rating, which totaled 1.9 million households. By the show's tenth anniversary in 1979, nine million American children under the age of 6 were watching "Sesame Street" daily. According to a 1993 survey conducted by the U.S. Department of Education, out of the show's 6.6 million viewers, 2.4 million kindergartners regularly watched it. 77% of preschoolers watched it once a week, and 86% of kindergartners and first- and second-grade students had watched it once a week before starting school. The show reached most young children in almost all demographic groups.


title: Sesame Street

text: The show's ratings significantly decreased in the early 1990s, due to changes in children's viewing habits and in the television marketplace. The producers responded by making large-scale structural changes to the show. By 2006, "Sesame Street" had become "the most widely viewed children's television show in the world," with 20 international independent versions and broadcasts in over 120 countries. A 1996 survey found that 95% of all American preschoolers had watched the show by the time they were three years old. In 2008, it was estimated that 77 million Americans had watched the series as children. By the show's 40th anniversary in 2009, it was ranked the fifteenth-most-popular children's show on television, and by its 50th anniversary in 2019, the show had 100% brand awareness globally. In 2018, the show was the second-highest-rated program on PBS Kids. In 2021, however, the Sesame Street documentary "50 Years of Sunny Days," which was broadcast nationally on ABC, did not fare well in the ratings, scoring only approximately 2.3 million viewers.


title: Sesame Street

text: , there were over 1,000 research studies regarding "Sesame Street"s efficacy, impact, and effect on American culture. The CTW solicited the Educational Testing Service (ETS) to conduct summative research on the show. ETS's two "landmark" summative evaluations, conducted in 1970 and 1971, demonstrated that the show had a significant educational impact on its viewers. These studies have been cited in other studies of the effects of television on young children. Additional studies conducted throughout "Sesame Street"s history demonstrated that the show continued to have a positive effect on its young viewers.


title: Sesame Street

text: Lesser believed that "Sesame Street" research "may have conferred a new respectability upon the studies of the effects of visual media upon children." He also believed that the show had the same effect on the prestige of producing shows for children in the television industry. Historian Robert Morrow, in his book "Sesame Street and the Reform of Children's Television", which chronicled the show's influence on children's television and on the television industry as a whole, reported that many critics of commercial television saw "Sesame Street" as a "straightforward illustration for reform." Les Brown, a writer for "Variety", saw in "Sesame Street" "a hope for a more substantial future" for television.


title: Sesame Street

text: Morrow reported that the networks responded by creating more high-quality television programs, but that many critics saw them as "appeasement gestures." According to Morrow, despite the CTW Model's effectiveness in creating a popular show, commercial television "made only a limited effort to emulate CTW's methods," and did not use a curriculum or evaluate what children learned from them. By the mid-1970s commercial television had abandoned their experiments with creating better children's programming. Other critics hoped that "Sesame Street", with its depiction of a functioning, multicultural community, would nurture racial tolerance in its young viewers. It was not until the mid-1990s that another children's television educational program, "Blue's Clues", used the CTW's methods to create and modify their content. The creators of "Blue's Clues" were influenced by "Sesame Street", but wanted to use research conducted in the 30 years since its debut. Angela Santomero, one of its producers, said, "We wanted to learn from "Sesame Street" and take it one step further."


title: Sesame Street

text: Critic Richard Roeper said that perhaps one of the strongest indicators of the influence of "Sesame Street" has been the enduring rumors and urban legends surrounding the show and its characters, especially speculation concerning the sexuality of Bert and Ernie.


title: Sesame Street

text: "Sesame Street" was praised from its debut in 1969. "Newsday" reported that several newspapers and magazines had written "glowing" reports about the CTW and Cooney. The press overwhelmingly praised the new show; several popular magazines and niche magazines lauded it. In 1970, "Sesame Street" won twenty awards, including a Peabody Award, three Emmys, an award from the Public Relations Society of America, a Clio, and a Prix Jeunesse. By 1995, the show had won two Peabody Awards and four Parents' Choice Awards. It was the subject of a traveling exhibition by the Smithsonian Institution, and a film exhibition at the Museum of Modern Art.


title: Sesame Street

text: "Sesame Street" was not without its detractors, however. The state commission in Mississippi, where Henson was from, operated the state's PBS member station; in May 1970 it voted to not air "Sesame Street" because of its "highly [racially] integrated cast of children" which "the commission members felt ... Mississippi was not yet ready for." According to "", Lesser's account of the development and early years of "Sesame Street", there was little criticism of the show in the months following its premiere, but it increased at the end of its first season and beginning of the second season. Historian Robert W. Morrow speculated that much of the early criticism, which he called "surprisingly intense," stemmed from cultural and historical reasons in regards to, as he put it, "the place of children in American society and the controversies about television's effects on them."


title: Sesame Street

text: According to Morrow, the "most important" studies finding negative effects of "Sesame Street" were conducted by educator Herbert A. Sprigle and psychologist Thomas D. Cook during its first two seasons. Social scientist and Head Start founder Urie Bronfenbrenner criticized the show for being too wholesome. Psychologist Leon Eisenberg saw "Sesame Street"s urban setting as "superficial" and having little to do with the problems confronted by the inner-city child. Head Start director Edward Zigler was probably "Sesame Street"s most vocal critic in the show's early years.


title: Sesame Street

text: In spite of their commitment to multiculturalism, the CTW experienced conflicts with the leadership of minority groups, especially Latino groups and feminists, who objected to "Sesame Street"s depiction of Latinos and women. The CTW took steps to address their objections. By 1971, the CTW hired Hispanic actors, production staff, and researchers, and by the mid-1970s, Morrow reported that "the show included Chicano and Puerto Rican cast members, films about Mexican holidays and foods, and cartoons that taught Spanish words." As "The New York Times" has stated, creating strong female characters "that make kids laugh, but not...as female stereotypes" has been a challenge for the producers of "Sesame Street". According to Morrow, change regarding how women and girls were depicted on "Sesame Street" occurred slowly. As more female Muppet performers like Camille Bonora, Fran Brill, Pam Arciero, Carmen Osbahr, Stephanie D'Abruzzo, Jennifer Barnhart, and Leslie Carrara-Rudolph were hired and trained, stronger female characters like Rosita and Abby Cadabby were created.


title: Sesame Street

text: In 2002, "Sesame Street" was ranked number 27 on TV Guide's 50 Greatest TV Shows of All Time. Sesame Workshop won a Peabody Award in 2009 for its website, sesamestreet.org, and the show was given Peabody's Institutional Award in 2019 for 50 years of educating and entertaining children globally. In 2013, "TV Guide" ranked the show number 30 on its list of the 60 best TV series. As of 2021, "Sesame Street" has received 205 Emmy Awards, more than any other television series.


title: Anne of Cleves

text: Anne of Cleves (; 1515 – 16 July 1557) was Queen of England from 6 January to 12 July 1540 as the fourth wife of King Henry VIII. Not much is known about Anne before 1527, when she became betrothed to Francis, Duke of Bar, son and heir of Antoine, Duke of Lorraine, although their marriage did not proceed. In March 1539, negotiations for Anne's marriage to Henry began, as Henry believed that he needed to form a political alliance with her brother, William, who was a leader of the Protestants of western Germany, to strengthen his position against potential attacks from Catholic France and the Holy Roman Empire.


title: Anne of Cleves

text: Anne arrived in England on 27 December 1539 and married Henry on 6 January 1540, but after six months, the marriage was declared unconsummated and, as a result, she was not crowned queen consort. Following the annulment, Henry gave her a generous settlement, and she was thereafter known as "the King's Beloved Sister". Remaining in England, she lived to see the reign of Edward VI, and the coronation of Mary I, outliving the rest of Henry's wives.


title: Anne of Cleves

text: Anne was born in 1515, on either 22 September, or more probably 28 June. She was born in Düsseldorf, the second daughter of John III of the House of La Marck, Duke of Jülich "jure uxoris", Cleves, Berg "jure uxoris", Count of Mark, also known as de la Marck and Ravensberg "jure uxoris" (often referred to as Duke of Cleves) who died in 1538, and his wife Maria, Duchess of Jülich-Berg (1491–1543). She grew up in Schloss Burg on the edge of Solingen.


title: Anne of Cleves

text: Anne's father was influenced by Erasmus and followed a moderate path within the Reformation. He decided to side with the Schmalkaldic League and opposed Emperor Charles V. After John's death, Anne's brother William became Duke of Jülich-Cleves-Berg, bearing the promising epithet "The Rich". In 1526, her elder sister Sibylle was married to John Frederick, Elector of Saxony, head of the Protestant Confederation of Germany and considered the "Champion of the Reformation."


title: Anne of Cleves

text: In 1527, at the age of 11, Anne was betrothed to Francis, the 9-year-old son and heir of Antoine, Duke of Lorraine. The betrothal was considered unofficial and was cancelled in 1535. Her brother William was a Lutheran but the family was unaligned religiously, with her mother, the Duchess Maria, described as a "strict Catholic". Her father's ongoing dispute over Gelderland with Charles V made the family suitable allies for England's King Henry VIII in the wake of the Truce of Nice. The match with Anne was urged on the king by his chief minister, Thomas Cromwell.


title: Anne of Cleves

text: The artist Hans Holbein the Younger was dispatched to Düren to paint portraits of Anne and her younger sister, Amalia, each of whom Henry was considering as his fourth wife. Henry required the artist to be as accurate as possible, not to flatter the sisters. The portraits are now located in the Musée du Louvre in Paris and the Victoria and Albert Museum in London. Another 1539 portrait, by the school of Barthel Bruyn the Elder, is in the collection of Trinity College, Cambridge.


title: Anne of Cleves

text: Negotiations to arrange the marriage were in full swing by March 1539. Thomas Cromwell oversaw the talks and a marriage treaty was signed on 4 October of that year. The King agreed to pay a dowry of 100,000 florins to the bride's brother.


title: Anne of Cleves

text: Henry valued education and cultural sophistication in women, but Anne lacked these traits. She had received no formal education but was skilled in needlework and liked playing card games. She could read and write, but only in German. Nevertheless, Anne was considered gentle, virtuous and docile, which is why she was recommended as a suitable candidate for Henry.


title: Anne of Cleves

text: Anne was described by French ambassador Charles de Marillac as tall and slim, "of middling beauty and of very assured and resolute countenance." She was fair-haired and was said to have had a lovely face. In the words of the chronicler Edward Hall, "Her hair hanging down, which was fair, yellow and long ... she was apparelled after the English fashion, with a French hood, which so set forth her beauty and good visage, that every creature rejoiced to behold her." She appeared rather solemn by English standards, and looked old for her age. Holbein painted her with a high forehead, heavy-lidded eyes and a pointed chin.


title: Anne of Cleves

text: Henry met her privately on New Year's Day 1540 at Rochester Abbey in Rochester on her journey from Dover. Henry and some of his courtiers, following a courtly-love tradition, went disguised into the room where Anne was staying. Eustace Chapuys reported:


title: Anne of Cleves

text: [The King] so went up into the chamber where the said Lady Anne was looking out of a window to see the bull-baiting which was going on in the courtyard, and suddenly he embraced and kissed her, and showed her a token which the king had sent her for New Year’s gift, and she being abashed and not knowing who it was thanked him, and so he spoke with her. But she regarded him little, but always looked out the window ... and when the king saw that she took so little notice of his coming he went into another chamber and took off his cloak and came in again in a coat of purple velvet. And when the lords and knights saw his grace they did him reverence.


title: Anne of Cleves

text: According to the testimony of Henry's companions, he was disappointed with Anne, feeling that she was not as described. According to the chronicler Charles Wriothesley, Anne "regarded him little", though it is unknown whether she knew this was the king. Henry then revealed his true identity to Anne, although he is said to have been put off the marriage from then on. Henry and Anne then met officially on 3 January on Blackheath outside the gates of Greenwich Park, where a grand reception was laid out.


title: Anne of Cleves

text: Most historians believe that Henry's misgivings about the marriage were blamed on Anne's alleged unsatisfactory appearance and her failure to inspire him to consummate the marriage. He felt that he had been misled after his advisors had praised Anne's beauty: "She is nothing so fair as she hath been reported", he complained. Cromwell received some blame for the Holbein portrait, which Henry believed had not been an accurate representation of Anne, and for some of the exaggerated reports of her beauty. When the king finally met Anne, he was reportedly shocked by her plain appearance, and the marriage was never consummated.


title: Anne of Cleves

text: Henry urged Cromwell to find a legal way to avoid the marriage but, by this point, doing so was impossible without endangering the vital alliance with the Germans. In his anger and frustration, the King turned on Cromwell, to his subsequent regret.


title: Anne of Cleves

text: Despite Henry's very vocal misgivings, the two were married on 6 January 1540 at the royal Palace of Placentia in Greenwich, London, by Archbishop Thomas Cranmer. The phrase "God send me well to keep" was engraved around Anne's wedding ring. Immediately after arriving in England, Anne conformed to the Anglican form of worship, which Henry expected. The couple's first night as husband and wife was not a successful one. Henry confided to Cromwell that he had not consummated the marriage, saying, "I liked her before not well, but now I like her much worse".


title: Anne of Cleves

text: In February 1540, speaking to the Countess of Rutland, Anne praised the King as a kind husband, saying: "When he comes to bed he kisseth me, and he taketh me by the hand, and biddeth me 'Good night, sweetheart'; and in the morning kisseth me and biddeth 'Farewell, darling. Lady Rutland responded: "Madam, there must be more than this, or it will be long ere we have a duke of York, which all this realm most desireth."


title: Anne of Cleves

text: Anne was commanded to leave the Court on 24 June, and on 6 July she was informed of her husband's decision to reconsider the marriage. Witness statements were taken from a number of courtiers and two physicians which register the king's disappointment at her appearance. Henry had also commented to Thomas Heneage and Anthony Denny that he could not believe she was a virgin.


title: Anne of Cleves

text: Shortly afterwards, Anne was asked for her consent to an annulment, to which she agreed. Cromwell, the moving force behind the marriage, was attainted for treason. The marriage was annulled on 12 July 1540, on the grounds of non-consummation and her pre-contract to Francis of Lorraine. Henry VIII's physician stated that after the wedding night, Henry said he was not impotent because he experienced """" (two nocturnal pollutions while in sleep).


title: Anne of Cleves

text: Anne had been given dower lands in January 1540 to fund her household, including manors in Hampshire formerly owned by Breamore Priory and Southwick Priory. As former queen, she received a generous settlement, including Richmond Palace, and Hever Castle, home of Henry's former in-laws, the Boleyns. Anne of Cleves House, in Lewes, East Sussex, is just one of many properties she owned, though she never lived there. Henry and Anne became good friends—she was an honorary member of the king's family and was referred to as "the King's Beloved Sister". She was invited to court often and, out of gratitude for her not contesting the annulment, Henry decreed that she would be given precedence over all women in England save his own wife and daughters.


title: Anne of Cleves

text: After Catherine Howard was beheaded, Anne and her brother, William, Duke of Jülich-Cleves-Berg, pressed the king to remarry Anne. Henry quickly refused to do so. She seems to have disliked Catherine Parr, and reportedly reacted to the news of Henry's sixth marriage with the remark "Madam Parr is taking a great burden on herself."


title: Anne of Cleves

text: In March 1547, Edward VI's Privy Council asked her to move out of Bletchingley Palace, her usual residence, to Penshurst Place to make way for Thomas Cawarden, Master of Revels. They pointed out that Penshurst was nearer to Hever and the move had been Henry VIII's will.


title: Anne of Cleves

text: On 4 August 1553, Anne wrote to Mary I to congratulate her on her marriage to Philip of Spain. On 28 September 1553, when Mary left St James's Palace for Whitehall, she was accompanied by her sister Elizabeth and Anne of Cleves. Anne also took part in Mary I's coronation procession, and may have been present at her coronation at Westminster Abbey. These were her last public appearances. As the new queen was a strict Catholic, Anne yet again changed religion, now becoming a Roman Catholic.


title: Anne of Cleves

text: After a brief return to prominence, she lost royal favour in 1554, following Wyatt's rebellion. According to Simon Renard, the imperial ambassador, Anne's close association with Elizabeth had convinced the Queen that "the Lady [Anne] of Cleves was of the plot and intrigued with the Duke of Cleves to obtain help for Elizabeth: matters in which the king of France was the prime mover". There is no evidence that Anne was invited back to court after 1554. She was compelled to live a quiet and obscure life on her estates. After her arrival as the King's bride, Anne never left England. Despite occasional feelings of homesickness, Anne was generally content in England and was described by Holinshed as "a ladie of right commendable regards, courteous, gentle, a good housekeeper and verie bountifull to her servants."


title: Anne of Cleves

text: When Anne's health began to fail, Mary allowed her to live at Chelsea Old Manor, where Henry's last wife, Catherine Parr, had lived after her remarriage. Here, in the middle of July 1557, Anne dictated her last will. In it, she mentions her brother, sister, and sister-in-law, as well as the future Queen Elizabeth, the Duchess of Suffolk, and the Countess of Arundel. She left some money to her servants and asked Mary and Elizabeth to employ them in their households. She was remembered by everyone who served her as a particularly generous and easy-going mistress.


title: Anne of Cleves

text: Anne died at Chelsea Old Manor on 16 July 1557. The most likely cause of her death was cancer. She was buried in Westminster Abbey, on 3 August, in what has been described as a "somewhat hard-to-find tomb" on the opposite side of Edward the Confessor's shrine and slightly above eye level for a person of average height.


title: Malaria

text: Malaria is a mosquito-borne infectious disease that affects humans and other animals. Malaria causes symptoms that typically include fever, tiredness, vomiting, and headaches. In severe cases, it can cause jaundice, seizures, coma, or death. Symptoms usually begin ten to fifteen days after being bitten by an infected mosquito. If not properly treated, people may have recurrences of the disease months later. In those who have recently survived an infection, reinfection usually causes milder symptoms. This partial resistance disappears over months to years if the person has no continuing exposure to malaria.


title: Malaria

text: Malaria is caused by single-celled microorganisms of the "Plasmodium" group. It is spread exclusively through bites of infected "Anopheles" mosquitoes. The mosquito bite introduces the parasites from the mosquito's saliva into a person's blood. The parasites travel to the liver where they mature and reproduce. Five species of "Plasmodium" can infect and be spread by humans. Most deaths are caused by "P. falciparum", whereas "P. vivax", "P. ovale", and "P. malariae" generally cause a milder form of malaria. The species "P. knowlesi" rarely causes disease in humans. Malaria is typically diagnosed by the microscopic examination of blood using blood films, or with antigen-based rapid diagnostic tests. Methods that use the polymerase chain reaction to detect the parasite's DNA have been developed, but they are not widely used in areas where malaria is common, due to their cost and complexity.


title: Malaria

text: The risk of disease can be reduced by preventing mosquito bites through the use of mosquito nets and insect repellents or with mosquito-control measures such as spraying insecticides and draining standing water. Several medications are available to prevent malaria for travellers in areas where the disease is common. Occasional doses of the combination medication sulfadoxine/pyrimethamine are recommended in infants and after the first trimester of pregnancy in areas with high rates of malaria. As of 2020, there is one vaccine which has been shown to reduce the risk of malaria by about 40% in children in Africa. A pre-print study of another vaccine has shown 77% vaccine efficacy, but this study has not yet passed peer review. Efforts to develop more effective vaccines are ongoing. The recommended treatment for malaria is a combination of antimalarial medications that includes artemisinin. The second medication may be either mefloquine, lumefantrine, or sulfadoxine/pyrimethamine. Quinine, along with doxycycline, may be used if artemisinin is not available. It is recommended that in areas where the disease is common, malaria is confirmed if possible before treatment is started due to concerns of increasing drug resistance. Resistance among the parasites has developed to several antimalarial medications; for example, chloroquine-resistant "P. falciparum" has spread to most malarial areas, and resistance to artemisinin has become a problem in some parts of Southeast Asia.


title: Malaria

text: The disease is widespread in the tropical and subtropical regions that exist in a broad band around the equator. This includes much of sub-Saharan Africa, Asia, and Latin America. In 2020 there were 241 million cases of malaria worldwide resulting in an estimated 627,000 deaths. Approximately 95% of the cases and deaths occurred in sub-Saharan Africa. Rates of disease have decreased from 2010 to 2014 but increased from 2015 to 2020. Malaria is commonly associated with poverty and has a significant negative effect on economic development. In Africa, it is estimated to result in losses of US$12 billion a year due to increased healthcare costs, lost ability to work, and adverse effects on tourism.


title: Malaria

text: Adults with malaria tend to experience chills and fever – classically in periodic intense bouts lasting around six hours, followed by a period of sweating and fever relief – as well as headache, fatigue, abdominal discomfort, and muscle pain. Children tend to have more general symptoms: fever, cough, vomiting, and diarrhea.


title: Malaria

text: Initial manifestations of the disease—common to all malaria species—are similar to flu-like symptoms, and can resemble other conditions such as sepsis, gastroenteritis, and viral diseases. The presentation may include headache, fever, shivering, joint pain, vomiting, hemolytic anemia, jaundice, hemoglobin in the urine, retinal damage, and convulsions.


title: Malaria

text: The classic symptom of malaria is paroxysm—a cyclical occurrence of sudden coldness followed by shivering and then fever and sweating, occurring every two days (tertian fever) in "P. vivax" and "P. ovale" infections, and every three days (quartan fever) for "P. malariae". "P. falciparum" infection can cause recurrent fever every 36–48 hours, or a less pronounced and almost continuous fever.


title: Malaria

text: Symptoms typically begin 10–15 days after the initial mosquito bite, but can occur as late as several months after infection with some "P. vivax" strains. Travellers taking preventative malaria medications may develop symptoms once they stop taking the drugs.


title: Malaria

text: Severe malaria is usually caused by "P. falciparum" (often referred to as falciparum malaria). Symptoms of falciparum malaria arise 9–30 days after infection. Individuals with cerebral malaria frequently exhibit neurological symptoms, including abnormal posturing, nystagmus, conjugate gaze palsy (failure of the eyes to turn together in the same direction), opisthotonus, seizures, or coma.


title: Malaria

text: Malaria has several serious complications. Among these is the development of respiratory distress, which occurs in up to 25% of adults and 40% of children with severe "P. falciparum" malaria. Possible causes include respiratory compensation of metabolic acidosis, noncardiogenic pulmonary oedema, concomitant pneumonia, and severe anaemia. Although rare in young children with severe malaria, acute respiratory distress syndrome occurs in 5–25% of adults and up to 29% of pregnant women. Coinfection of HIV with malaria increases mortality. Kidney failure is a feature of blackwater fever, where haemoglobin from lysed red blood cells leaks into the urine.


title: Malaria

text: Infection with "P. falciparum" may result in cerebral malaria, a form of severe malaria that involves encephalopathy. It is associated with retinal whitening, which may be a useful clinical sign in distinguishing malaria from other causes of fever. An enlarged spleen, enlarged liver or both of these, severe headache, low blood sugar, and haemoglobin in the urine with kidney failure may occur. Complications may include spontaneous bleeding, coagulopathy, and shock.


title: Malaria

text: Malaria in pregnant women is an important cause of stillbirths, infant mortality, miscarriage and low birth weight, particularly in "P. falciparum" infection, but also with "P. vivax".


title: Malaria

text: Malaria is caused by infection with parasites in the genus "Plasmodium". In humans, malaria is caused by six "Plasmodium" species: "P. falciparum", "P. malariae", "P. ovale curtisi", "P. ovale wallikeri", "P. vivax" and "P. knowlesi". Among those infected, "P. falciparum" is the most common species identified (~75%) followed by "P. vivax" (~20%). Although "P. falciparum" traditionally accounts for the majority of deaths, recent evidence suggests that "P. vivax" malaria is associated with potentially life-threatening conditions about as often as with a diagnosis of "P. falciparum" infection. "P. vivax" proportionally is more common outside Africa. There have been documented human infections with several species of "Plasmodium" from higher apes; however, except for "P. knowlesi"—a zoonotic species that causes malaria in macaques—these are mostly of limited public health importance.


title: Malaria

text: Parasites are typically introduced by the bite of an infected "Anopheles" mosquito. What these inoculated parasites, called "sporozoites", do in the skin and lymphatics, exactly, has yet to be accurately determined. However, a percentage of sporozoites follow the bloodstream to the liver, where they invade hepatocytes. They grow and divide in the liver for 2–10 days, with each infected hepatocyte eventually harboring up to 40,000 parasites. The infected hepatocytes break down, releasing this invasive form of "Plasmodium" cells, called "merozoites" into the bloodstream. In the blood, the merozoites rapidly invade individual red blood cells, replicating over 24–72 hours to form 16–32 new merozoites. The infected red blood cell lyses, and the new merozoites infect new red blood cells, resulting in a cycle that continuously amplifies the number of parasites in an infected person. However, most of the "P. vivax" replicating merozoite biomass is now (since 2021) known to be hidden in the spleen and bone marrow (perhaps elsewhere too), thereby supporting the astute, long-standing (since 2011) but previously ignored theory that non-circulating merozoites are the source many "P. vivax" malarial recurrences (see “Recurrent malaria” section below). Over rounds of this red blood cell infection cycle in the bloodstream and elsewhere, a small portion of parasites do not replicate, but instead develop into early sexual stage parasites called male and female "gametocytes". These gametocytes develop in the bone marrow for 11 days, then return to the blood circulation to await uptake by the bite of another mosquito. Once inside a mosquito, the gametocytes undergo sexual reproduction, and eventually form daughter sporozoites that migrate to the mosquito's salivary glands to be injected into a new host when the mosquito bites.


title: Malaria

text: The liver infection causes no symptoms; all symptoms of malaria result from the infection of red blood cells. Symptoms develop once there are more than around 100,000 parasites per milliliter of blood. Many of the symptoms associated with severe malaria are caused by the tendency of "P. falciparum" to bind to blood vessel walls, resulting in damage to the affected vessels and surrounding tissue. Parasites sequestered in the blood vessels of the lung contribute to respiratory failure. In the brain, they contribute to coma. In the placenta they contribute to low birthweight and preterm labor, and increase the risk of abortion and stillbirth. The destruction of red blood cells during infection often results in anemia, exacerbated by reduced production of new red blood cells during infection.


title: Malaria

text: Only female mosquitoes feed on blood; male mosquitoes feed on plant nectar and do not transmit the disease. Females of the mosquito genus "Anopheles" prefer to feed at night. They usually start searching for a meal at dusk, and continue through the night until they succeed. Malaria parasites can also be transmitted by blood transfusions, although this is rare.


title: Malaria

text: Symptoms of malaria can recur after varying symptom-free periods. Depending upon the cause, recurrence can be classified as recrudescence, relapse, or reinfection. Recrudescence is when symptoms return after a symptom-free period and the origin is parasites that survived in the blood as a result of inadequate or ineffective treatment. Relapse is when symptoms reappear after the parasites have been eliminated from the blood and the recurrence source is activated parasites which had persisted as dormant hypnozoites in liver cells. Relapse commonly occurs after 8–24 weeks and is often seen in "P. vivax" and "P. ovale" infections. However, relapse-like "P. vivax" recurrences are probably being over-attributed to hypnozoite activation. Some of them might have an extra-vascular or sequestered merozoite origin, making those recurrences recrudescences, not relapses. Newly recognised, non-hypnozoite, possible contributing sources to recurrent peripheral "P. vivax" parasitemia are erythrocytic forms in the bone marrow and spleen. "P. vivax" malaria cases in temperate areas often involve overwintering by hypnozoites, with relapses beginning the year after the mosquito bite. Reinfection means that the parasites responsible for the past infection were eliminated from the body but a new parasite(s) was introduced. Reinfection cannot readily be distinguished from relapse and recrudescence, although recurrence of infection within two weeks of treatment for the initial malarial manifestations is typically attributed to treatment failure. But doing this is not necessarily correct. People may develop some immunity when exposed to frequent infections.


title: Malaria

text: Malaria infection develops via two phases: one that involves the liver (exoerythrocytic phase), and one that involves red blood cells, or erythrocytes (erythrocytic phase). When an infected mosquito pierces a person's skin to take a blood meal, sporozoites in the mosquito's saliva enter the bloodstream and migrate to the liver where they infect hepatocytes, multiplying asexually and asymptomatically for a period of 8–30 days.


title: Malaria

text: After a potential dormant period in the liver, these organisms differentiate to yield thousands of merozoites, which, following rupture of their host cells, escape into the blood and infect red blood cells to begin the erythrocytic stage of the life cycle. The parasite escapes from the liver undetected by wrapping itself in the cell membrane of the infected host liver cell.


title: Malaria

text: Within the red blood cells, the parasites multiply further, again asexually, periodically breaking out of their host cells to invade fresh red blood cells. Several such amplification cycles occur. Thus, classical descriptions of waves of fever arise from simultaneous waves of merozoites escaping and infecting red blood cells.


title: Malaria

text: Some "P. vivax" sporozoites do not immediately develop into exoerythrocytic-phase merozoites, but instead, produce hypnozoites that remain dormant for periods ranging from several months (7–10 months is typical) to several years. After a period of dormancy, they reactivate and produce merozoites. Hypnozoites are responsible for long incubation and late relapses in "P. vivax" infections, although their existence in "P. ovale" is uncertain.


title: Malaria

text: The parasite is relatively protected from attack by the body's immune system because for most of its human life cycle it resides within the liver and blood cells and is relatively invisible to immune surveillance. However, circulating infected blood cells are destroyed in the spleen. To avoid this fate, the "P. falciparum" parasite displays adhesive proteins on the surface of the infected blood cells, causing the blood cells to stick to the walls of small blood vessels, thereby sequestering the parasite from passage through the general circulation and the spleen. The blockage of the microvasculature causes symptoms such as those in placental malaria. Sequestered red blood cells can breach the blood–brain barrier and cause cerebral malaria.


title: Malaria

text: According to a 2005 review, due to the high levels of mortality and morbidity caused by malaria—especially the "P. falciparum" species—it has placed the greatest selective pressure on the human genome in recent history. Several genetic factors provide some resistance to it including sickle cell trait, thalassaemia traits, glucose-6-phosphate dehydrogenase deficiency, and the absence of Duffy antigens on red blood cells.


title: Malaria

text: The impact of sickle cell trait on malaria immunity illustrates some evolutionary trade-offs that have occurred because of endemic malaria. Sickle cell trait causes a change in the haemoglobin molecule in the blood. Normally, red blood cells have a very flexible, biconcave shape that allows them to move through narrow capillaries; however, when the modified haemoglobin S molecules are exposed to low amounts of oxygen, or crowd together due to dehydration, they can stick together forming strands that cause the cell to distort into a curved sickle shape. In these strands, the molecule is not as effective in taking or releasing oxygen, and the cell is not flexible enough to circulate freely. In the early stages of malaria, the parasite can cause infected red cells to sickle, and so they are removed from circulation sooner. This reduces the frequency with which malaria parasites complete their life cycle in the cell. Individuals who are homozygous (with two copies of the abnormal haemoglobin beta allele) have sickle-cell anaemia, while those who are heterozygous (with one abnormal allele and one normal allele) experience resistance to malaria without severe anaemia. Although the shorter life expectancy for those with the homozygous condition would tend to disfavour the trait's survival, the trait is preserved in malaria-prone regions because of the benefits provided by the heterozygous form.


title: Malaria

text: Liver dysfunction as a result of malaria is uncommon and usually only occurs in those with another liver condition such as viral hepatitis or chronic liver disease. The syndrome is sometimes called "malarial hepatitis". While it has been considered a rare occurrence, malarial hepatopathy has seen an increase, particularly in Southeast Asia and India. Liver compromise in people with malaria correlates with a greater likelihood of complications and death.


title: Malaria

text: Due to the non-specific nature of malaria symptoms, diagnosis is typically suspected based on symptoms and travel history, then confirmed with a parasitological test. In areas where malaria is common, the World Health Organization (WHO) recommends clinicians suspect malaria in any person who reports having fevers, or who has a current temperature above 37.5 °C without any other obvious cause. Malaria should similarly be suspected in children with signs of anemia: pale palms or a laboratory test showing hemoglobin levels below 8 grams per deciliter of blood. In areas with little to no malaria, the WHO recommends only testing people with possible exposure to malaria (typically travel to a malaria-endemic area) and unexplained fever.


title: Malaria

text: Malaria is usually confirmed by the microscopic examination of blood films or by antigen-based rapid diagnostic tests (RDT). Microscopy – i.e. examining Giemsa-stained blood with a light microscope – is the gold standard for malaria diagnosis. Microscopists typically examine both a "thick film" of blood, allowing them to scan many blood cells in a short time, and a "thin film" of blood, allowing them to clearly see individual parasites and identify the infecting "Plasmodium" species. Under typical field laboratory conditions, a microscopist can detect parasites when there are at least 100 parasites per microliter of blood, which is around the lower range of symptomatic infection. Microscopic diagnosis is relatively resource intensive, requiring trained personnel, specific equipment, electricity, and a consistent supply of microscopy slides and stains.


title: Malaria

text: In places where microscopy is unavailable, malaria is diagnosed with RDTs, rapid antigen tests that detect parasite proteins in a fingerstick blood sample. A variety of RDTs are commercially available, targeting the parasite proteins histidine rich protein 2 (HRP2, detects "P. falciparum" only), lactate dehydrogenase, or aldolase. The HRP2 test is widely used in Africa, where "P. falciparum" predominates. However, since HRP2 persists in the blood for up to five weeks after an infection is treated, an HRP2 test sometimes cannot distinguish whether someone currently has malaria or previously had it. Additionally, some "P. falciparum" parasites in the Amazon region lack the "HRP2" gene, complicating detection. RDTs are fast and easily deployed to places without full diagnostic laboratories. However they give considerably less information than microscopy, and sometimes vary in quality from producer to producer and lot to lot.


title: Malaria

text: Serological tests to detect antibodies against "Plasmodium" from the blood have been developed, but are not used for malaria diagnosis due to their relatively poor sensitivity and specificity. Highly sensitive nucleic acid amplification tests have been developed, but are not used clinically due to their relatively high cost, and poor specificity for active infections.


title: Malaria

text: Malaria is classified into either "severe" or "uncomplicated" by the World Health Organization (WHO). It is deemed severe when "any" of the following criteria are present, otherwise it is considered uncomplicated.


title: Malaria

text: Cerebral malaria is defined as a severe "P. falciparum"-malaria presenting with neurological symptoms, including coma (with a Glasgow coma scale less than 11, or a Blantyre coma scale less than 3), or with a coma that lasts longer than 30 minutes after a seizure.


title: Malaria

text: Methods used to prevent malaria include medications, mosquito elimination and the prevention of bites. As of 2020, there is one vaccine for malaria (known as RTS,S) which is licensed for use. The presence of malaria in an area requires a combination of high human population density, high "Anopheles" mosquito population density and high rates of transmission from humans to mosquitoes and from mosquitoes to humans. If any of these is lowered sufficiently, the parasite eventually disappears from that area, as happened in North America, Europe, and parts of the Middle East. However, unless the parasite is eliminated from the whole world, it could re-establish if conditions revert to a combination that favors the parasite's reproduction. Furthermore, the cost per person of eliminating anopheles mosquitoes rises with decreasing population density, making it economically unfeasible in some areas.


title: Malaria

text: Prevention of malaria may be more cost-effective than treatment of the disease in the long run, but the initial costs required are out of reach of many of the world's poorest people. There is a wide difference in the costs of control (i.e. maintenance of low endemicity) and elimination programs between countries. For example, in China—whose government in 2010 announced a strategy to pursue malaria elimination in the Chinese provinces—the required investment is a small proportion of public expenditure on health. In contrast, a similar programme in Tanzania would cost an estimated one-fifth of the public health budget. In 2021, the World Health Organization confirms that China has eliminated malaria.


title: Malaria

text: In areas where malaria is common, children under five years old often have anaemia, which is sometimes due to malaria. Giving children with anaemia in these areas preventive antimalarial medication improves red blood cell levels slightly but does not affect the risk of death or need for hospitalisation.


title: Malaria

text: Vector control refers to methods used to decrease malaria by reducing the levels of transmission by mosquitoes. For individual protection, the most effective insect repellents are based on DEET or picaridin. However, there is insufficient evidence that mosquito repellents can prevent malaria infection. Insecticide-treated nets (ITNs) and indoor residual spraying (IRS) are effective, have been commonly used to prevent malaria, and their use has contributed significantly to the decrease in malaria in the 21st century. ITNs and IRS may not be sufficient to eliminate the disease, as these interventions depend on how many people use nets, how many gaps in insecticide there are (low coverage areas), if people are not protected when outside of the home, and an increase in mosquitoes that are resistant to insecticides. Modifications to people's houses to prevent mosquito exposure may be an important long term prevention measure.


title: Malaria

text: Mosquito nets help keep mosquitoes away from people and reduce infection rates and transmission of malaria. Nets are not a perfect barrier and are often treated with an insecticide designed to kill the mosquito before it has time to find a way past the net. Insecticide-treated nets (ITNs) are estimated to be twice as effective as untreated nets and offer greater than 70% protection compared with no net. Between 2000 and 2008, the use of ITNs saved the lives of an estimated 250,000 infants in Sub-Saharan Africa. About 13% of households in Sub-Saharan countries owned ITNs in 2007 and 31% of African households were estimated to own at least one ITN in 2008. In 2000, 1.7 million (1.8%) African children living in areas of the world where malaria is common were protected by an ITN. That number increased to 20.3 million (18.5%) African children using ITNs in 2007, leaving 89.6 million children unprotected and to 68% African children using mosquito nets in 2015. Most nets are impregnated with pyrethroids, a class of insecticides with low toxicity. They are most effective when used from dusk to dawn. It is recommended to hang a large "bed net" above the center of a bed and either tuck the edges under the mattress or make sure it is large enough such that it touches the ground. ITNs are beneficial towards pregnancy outcomes in malaria-endemic regions in Africa but more data is needed in Asia and Latin America.


title: Malaria

text: In areas of high malaria resistance, piperonyl butoxide (PBO) combined with pyrethroids in mosquito netting is effective in reducing malaria infection rates. Questions remain concerning the durability of PBO on nets as the impact on mosquito mortality was not sustained after twenty washes in experimental trials.


title: Malaria

text: Indoor residual spraying is the spraying of insecticides on the walls inside a home. After feeding, many mosquitoes rest on a nearby surface while digesting the bloodmeal, so if the walls of houses have been coated with insecticides, the resting mosquitoes can be killed before they can bite another person and transfer the malaria parasite. As of 2006, the World Health Organization recommends 12 insecticides in IRS operations, including DDT and the pyrethroids cyfluthrin and deltamethrin. This public health use of small amounts of DDT is permitted under the Stockholm Convention, which prohibits its agricultural use. One problem with all forms of IRS is insecticide resistance. Mosquitoes affected by IRS tend to rest and live indoors, and due to the irritation caused by spraying, their descendants tend to rest and live outdoors, meaning that they are less affected by the IRS. Communities using insecticide treated nets, in addition to indoor residual spraying with 'non-pyrethroid-like' insecticides found associated reductions in malaria. Additionally, the use of 'pyrethroid-like' insecticides in addition to indoor residual spraying did not result in a detectable additional benefit in communities using insecticide treated nets.


title: Malaria

text: Housing is a risk factor for malaria and modifying the house as a prevention measure may be a sustainable strategy that does not rely on the effectiveness of insecticides such as pyrethroids. The physical environment inside and outside the home that may improve the density of mosquitoes are considerations. Examples of potential modifications include how close the home is to mosquito breeding sites, drainage and water supply near the home, availability of mosquito resting sites (vegetation around the home), the proximity to live stock and domestic animals, and physical improvements or modifications to the design of the home to prevent mosquitoes from entering.


title: Malaria

text: People have tried a number of other methods to reduce mosquito bites and slow the spread of malaria. Efforts to decrease mosquito larvae by decreasing the availability of open water where they develop, or by adding substances to decrease their development, are effective in some locations. Electronic mosquito repellent devices, which make very high-frequency sounds that are supposed to keep female mosquitoes away, have no supporting evidence of effectiveness. There is a low certainty evidence that fogging may have an effect on malaria transmission. Larviciding by hand delivery of chemical or microbial insecticides into water bodies containing low larval distribution may reduce malarial transmission. There is insufficient evidence to determine whether larvivorous fish can decrease mosquito density and transmission in the area.


title: Malaria

text: There are a number of medications that can help prevent or interrupt malaria in travellers to places where infection is common. Many of these medications are also used in treatment. In places where "Plasmodium" is resistant to one or more medications, three medications—mefloquine, doxycycline, or the combination of atovaquone/proguanil ("Malarone")—are frequently used for prevention. Doxycycline and the atovaquone/proguanil are better tolerated while mefloquine is taken once a week. Areas of the world with chloroquine-sensitive malaria are uncommon. Antimalarial mass drug administration to an entire population at the same time may reduce the risk of contracting malaria in the population, however the effectiveness of mass drug administration may vary depending on the prevalence of malaria in the area. Other factors such as drug administration plus other protective measures such as mosiquito control, the proportion of people treated in the area, and the risk of reinfection with malaria may play a role in the effectiveness of mass drug treatment approaches.


title: Malaria

text: The protective effect does not begin immediately, and people visiting areas where malaria exists usually start taking the drugs one to two weeks before they arrive, and continue taking them for four weeks after leaving (except for atovaquone/proguanil, which only needs to be started two days before and continued for seven days afterward). The use of preventive drugs is often not practical for those who live in areas where malaria exists, and their use is usually given only to pregnant women and short-term visitors. This is due to the cost of the drugs, side effects from long-term use, and the difficulty in obtaining antimalarial drugs outside of wealthy nations. During pregnancy, medication to prevent malaria has been found to improve the weight of the baby at birth and decrease the risk of anaemia in the mother. The use of preventive drugs where malaria-bearing mosquitoes are present may encourage the development of partial resistance.


title: Malaria

text: Giving antimalarial drugs to infants through intermittent preventive therapy can reduce the risk of having malaria infection, hospital admission, and anaemia.


title: Malaria

text: Mefloquine is more effective than sulfadoxine-pyrimethamine in preventing malaria for HIV-negative pregnant women. Cotrimoxazole is effective in preventing malaria infection and reduce the risk of getting anaemia in HIV-positive women. Giving sulfadoxine-pyrimethamine for three or more doses as intermittent preventive therapy is superior than two doses for HIV-positive women living in malaria-endemic areas.


title: Malaria

text: Prompt treatment of confirmed cases with artemisinin-based combination therapies (ACTs) may also reduce transmission.


title: Malaria

text: Community participation and health education strategies promoting awareness of malaria and the importance of control measures have been successfully used to reduce the incidence of malaria in some areas of the developing world. Recognising the disease in the early stages can prevent it from becoming fatal. Education can also inform people to cover over areas of stagnant, still water, such as water tanks that are ideal breeding grounds for the parasite and mosquito, thus cutting down the risk of the transmission between people. This is generally used in urban areas where there are large centers of population in a confined space and transmission would be most likely in these areas. Intermittent preventive therapy is another intervention that has been used successfully to control malaria in pregnant women and infants, and in preschool children where transmission is seasonal.


title: Malaria

text: Malaria is treated with antimalarial medications; the ones used depends on the type and severity of the disease. While medications against fever are commonly used, their effects on outcomes are not clear. Providing free antimalarial drugs to households may reduce childhood deaths when used appropriately. Programmes which presumptively treat all causes of fever with antimalarial drugs may lead to overuse of antimalarials and undertreat other causes of fever. Nevertheless, the use of malaria rapid-diagnostic kits can help to reduce over-usage of antimalarials.


title: Malaria

text: Simple or uncomplicated malaria may be treated with oral medications. Artemisinin drugs are effective and safe in treating uncomplicated malaria. Artemisinin in combination with other antimalarials (known as artemisinin-combination therapy, or ACT) is about 90% effective when used to treat uncomplicated malaria. The most effective treatment for "P. falciparum" infection is the use of ACT, which decreases resistance to any single drug component. Artemether-lumefantrine (six-dose regimen) is more effective than the artemether-lumefantrine (four-dose regimen) or other regimens not containing artemisinin derivatives in treating falciparum malaria. Another recommended combination is dihydroartemisinin and piperaquine. Artemisinin-naphthoquine combination therapy showed promising results in treating falciparum malaria. However, more research is needed to establish its efficacy as a reliable treatment. Artesunate plus mefloquine performs better than mefloquine alone in treating uncomplicated falciparum malaria in low transmission settings. Atovaquone-proguanil is effective against uncomplicated falciparum with a possible failure rate of 5% to 10%; the addition of artesunate may reduce failure rate. Azithromycin monotherapy or combination therapy has not shown effectiveness in treating plasmodium or vivax malaria. Amodiaquine plus sulfadoxine-pyrimethamine may achieve less treatment failures when compared to sulfadoxine-pyrimethamine alone in uncomplicated falciparum malaria. There is insufficient data on chlorproguanil-dapsone in treating uncomplicated falciparum malaria. The addition of primaquine with artemisinin-based combination therapy for falciparum malaria reduces its transmission at day 3-4 and day 8 of infection. Sulfadoxine-pyrimethamine plus artesunate is better than sulfadoxine-pyrimethamine plus amodiaquine in controlling treatment failure at day 28. However, the latter is better than the former in reducing gametocytes in blood at day 7.


title: Malaria

text: Infection with "P. vivax", "P. ovale" or "P. malariae" usually does not require hospitalisation. Treatment of "P. vivax" malaria requires both elimination of blood stages (using chloroquine or artemisinin-based combination therapy) and clearance of liver forms with an 8-aminoquinoline agent such as primaquine or tafenoquine.


title: Malaria

text: The view that 8-aminoquinoline drugs kill parasites in the liver is the conventional one. However, there are reasons to believe that primaquine might, to a currently unknown extent, also inactivate non-circulating, extra-hepatic merozoites (clarity in this regard is expected to be forthcoming soon).


title: Malaria

text: To treat malaria during pregnancy, the WHO recommends the use of quinine plus clindamycin early in the pregnancy (1st trimester), and ACT in later stages (2nd and 3rd trimesters). There is limited safety data on the antimalarial drugs in pregnancy.


title: Malaria

text: Cases of severe and complicated malaria are almost always caused by infection with "P. falciparum". The other species usually cause only febrile disease. Severe and complicated malaria cases are medical emergencies since mortality rates are high (10% to 50%).


title: Malaria

text: Recommended treatment for severe malaria is the intravenous use of antimalarial drugs. For severe malaria, parenteral artesunate was superior to quinine in both children and adults. In another systematic review, artemisinin derivatives (artemether and arteether) were as efficacious as quinine in the treatment of cerebral malaria in children. Treatment of severe malaria involves supportive measures that are best done in a critical care unit. This includes the management of high fevers and the seizures that may result from it. It also includes monitoring for poor breathing effort, low blood sugar, and low blood potassium. Artemisinin derivatives have the same or better efficacy than quinolones in preventing deaths in severe or complicated malaria. Quinine loading dose helps to shorten the duration of fever and increases parasite clearance from the body. There is no difference in effectiveness when using intrarectal quinine compared to intravenous or intramuscular quinine in treating uncomplicated/complicated falciparum malaria. There is insufficient evidence for intramuscular arteether to treat severe malaria. The provision of rectal artesunate before transfer to hospital may reduce the rate of death for children with severe malaria.


title: Malaria

text: Cerebral malaria is the form of severe and complicated malaria with the worst neurological symptoms. There is insufficient data on whether osmotic agents such as mannitol or urea are effective in treating cerebral malaria. Routine phenobarbitone in cerebral malaria is associated with fewer convulsions but possibly more deaths. There is no evidence that steroids would bring treatment benefits for cerebral malaria.


title: Malaria

text: Cerebral malaria usually makes a patient comatose, if the cause of the coma is in doubt, test for other locally prevalent causes of encephalopathy (bacterial, viral or fungal infection) should be carried out. In areas where there is a high prevalence of malaria infection (e.g. tropical region) treatment can start without testing first. To manage the cerebral malaria when confirmed the following can be done:


title: Malaria

text: There is insufficient evidence to show that blood transfusion is useful in either reducing deaths for children with severe anaemia or in improving their haematocrit in one month. There is insufficient evidence that iron chelating agents such as deferoxamine and deferiprone improve outcomes of those with malaria falciparum infection.


title: Malaria

text: Drug resistance poses a growing problem in 21st-century malaria treatment. In the 2000s (decade), malaria with partial resistance to artemisins emerged in Southeast Asia. Resistance is now common against all classes of antimalarial drugs apart from artemisinins. Treatment of resistant strains became increasingly dependent on this class of drugs. The cost of artemisinins limits their use in the developing world. Malaria strains found on the Cambodia–Thailand border are resistant to combination therapies that include artemisinins, and may, therefore, be untreatable. Exposure of the parasite population to artemisinin monotherapies in subtherapeutic doses for over 30 years and the availability of substandard artemisinins likely drove the selection of the resistant phenotype. Resistance to artemisinin has been detected in Cambodia, Myanmar, Thailand, and Vietnam, and there has been emerging resistance in Laos. Resistance to the combination of artemisinin and piperaquine was first detected in 2013 in Cambodia, and by 2019 had spread across Cambodia and into Laos, Thailand and Vietnam (with up to 80 percent of malaria parasites resistant in some regions).


title: Malaria

text: There is insufficient evidence in unit packaged antimalarial drugs in preventing treatment failures of malaria infection. However, if supported by training of healthcare providers and patient information, there is improvement in compliance of those receiving treatment.


title: Malaria

text: When properly treated, people with malaria can usually expect a complete recovery. However, severe malaria can progress extremely rapidly and cause death within hours or days. In the most severe cases of the disease, fatality rates can reach 20%, even with intensive care and treatment. Over the longer term, developmental impairments have been documented in children who have had episodes of severe malaria. Chronic infection without severe disease can occur in an immune-deficiency syndrome associated with a decreased responsiveness to "Salmonella" bacteria and the Epstein–Barr virus.


title: Malaria

text: During childhood, malaria causes anaemia during a period of rapid brain development, and also direct brain damage resulting from cerebral malaria. Some survivors of cerebral malaria have an increased risk of neurological and cognitive deficits, behavioural disorders, and epilepsy. Malaria prophylaxis was shown to improve cognitive function and school performance in clinical trials when compared to placebo groups.


title: Malaria

text: The WHO estimates that in 2019 there were 229 million new cases of malaria resulting in 409,000 deaths. Children under 5 years old are the most affected, accounting for 67% of malaria deaths worldwide in 2019. About 125 million pregnant women are at risk of infection each year; in Sub-Saharan Africa, maternal malaria is associated with up to 200,000 estimated infant deaths yearly. There are about 10,000 malaria cases per year in Western Europe, and 1300–1500 in the United States. The United States eradicated malaria as a major public health concern in 1951, though small outbreaks persist. About 900 people died from the disease in Europe between 1993 and 2003. Both the global incidence of disease and resulting mortality have declined in recent years. According to the WHO and UNICEF, deaths attributable to malaria in 2015 were reduced by 60% from a 2000 estimate of 985,000, largely due to the widespread use of insecticide-treated nets and artemisinin-based combination therapies. In 2012, there were 207 million cases of malaria. That year, the disease is estimated to have killed between 473,000 and 789,000 people, many of whom were children in Africa. Efforts at decreasing the disease in Africa since 2000 have been partially effective, with rates of the disease dropping by an estimated forty percent on the continent.


title: Malaria

text: Malaria is presently endemic in a broad band around the equator, in areas of the Americas, many parts of Asia, and much of Africa; in Sub-Saharan Africa, 85–90% of malaria fatalities occur. An estimate for 2009 reported that countries with the highest death rate per 100,000 of population were Ivory Coast (86.15), Angola (56.93) and Burkina Faso (50.66). A 2010 estimate indicated the deadliest countries per population were Burkina Faso, Mozambique and Mali. The Malaria Atlas Project aims to map global levels of malaria, providing a way to determine the global spatial limits of the disease and to assess disease burden. This effort led to the publication of a map of "P. falciparum" endemicity in 2010 and an update in 2019. As of 2010, about 100 countries have endemic malaria. Every year, 125 million international travellers visit these countries, and more than 30,000 contract the disease.


title: Malaria

text: The geographic distribution of malaria within large regions is complex, and malaria-afflicted and malaria-free areas are often found close to each other. Malaria is prevalent in tropical and subtropical regions because of rainfall, consistent high temperatures and high humidity, along with stagnant waters where mosquito larvae readily mature, providing them with the environment they need for continuous breeding. In drier areas, outbreaks of malaria have been predicted with reasonable accuracy by mapping rainfall. Malaria is more common in rural areas than in cities. For example, several cities in the Greater Mekong Subregion of Southeast Asia are essentially malaria-free, but the disease is prevalent in many rural regions, including along international borders and forest fringes. In contrast, malaria in Africa is present in both rural and urban areas, though the risk is lower in the larger cities.


title: Malaria

text: Climate change is likely to affect malaria transmission, but the degree of effect and the areas affected is uncertain. Greater rainfall in certain areas of India, and following an El Niño event is associated with increased mosquito numbers.


title: Malaria

text: Since 1900 there has been substantial change in temperature and rainfall over Africa. However, factors that contribute to how rainfall results in water for mosquito breeding are complex, incorporating the extent to which it is absorbed into soil and vegetation for example, or rates of runoff and evaporation. Recent research has provided a more in-depth picture of conditions across Africa, combining a malaria climatic suitability model with a continental-scale model representing real-world hydrological processes.


title: Malaria

text: Although the parasite responsible for "P. falciparum" malaria has been in existence for 50,000–100,000 years, the population size of the parasite did not increase until about 10,000 years ago, concurrently with advances in agriculture and the development of human settlements. Close relatives of the human malaria parasites remain common in chimpanzees. Some evidence suggests that the "P. falciparum" malaria may have originated in gorillas.


title: Malaria

text: References to the unique periodic fevers of malaria are found throughout history. Hippocrates described periodic fevers, labelling them tertian, quartan, subtertian and quotidian. The Roman Columella associated the disease with insects from swamps. Malaria may have contributed to the decline of the Roman Empire, and was so pervasive in Rome that it was known as the "Roman fever". Several regions in ancient Rome were considered at-risk for the disease because of the favourable conditions present for malaria vectors. This included areas such as southern Italy, the island of Sardinia, the Pontine Marshes, the lower regions of coastal Etruria and the city of Rome along the Tiber. The presence of stagnant water in these places was preferred by mosquitoes for breeding grounds. Irrigated gardens, swamp-like grounds, run-off from agriculture, and drainage problems from road construction led to the increase of standing water.


title: Malaria

text: The term malaria originates from Mediaeval —"bad air"; the disease was formerly called "ague" or "marsh fever" due to its association with swamps and marshland. The term appeared in English at least as early as 1768. Malaria was once common in most of Europe and North America, where it is no longer endemic, though imported cases do occur.


title: Malaria

text: Malaria is not referenced in the medical books of the Mayans or Aztecs. Despite this, antibodies against malaria have been detected in some South American mummies, indicating that some malaria strains in the Americas might have a pre-Columbian origin. European settlers and the West Africans they enslaved likely brought malaria to the Americas starting in the 16th century.


title: Malaria

text: Scientific studies on malaria made their first significant advance in 1880, when Charles Louis Alphonse Laveran—a French army doctor working in the military hospital of Constantine in Algeria—observed parasites inside the red blood cells of infected people for the first time. He, therefore, proposed that malaria is caused by this organism, the first time a protist was identified as causing disease. For this and later discoveries, he was awarded the 1907 Nobel Prize for Physiology or Medicine. A year later, Carlos Finlay, a Cuban doctor treating people with yellow fever in Havana, provided strong evidence that mosquitoes were transmitting disease to and from humans. This work followed earlier suggestions by Josiah C. Nott, and work by Sir Patrick Manson, the "father of tropical medicine", on the transmission of filariasis.


title: Malaria

text: In April 1894, a Scottish physician, Sir Ronald Ross, visited Sir Patrick Manson at his house on Queen Anne Street, London. This visit was the start of four years of collaboration and fervent research that culminated in 1897 when Ross, who was working in the Presidency General Hospital in Calcutta, proved the complete life-cycle of the malaria parasite in mosquitoes. He thus proved that the mosquito was the vector for malaria in humans by showing that certain mosquito species transmit malaria to birds. He isolated malaria parasites from the salivary glands of mosquitoes that had fed on infected birds. For this work, Ross received the 1902 Nobel Prize in Medicine. After resigning from the Indian Medical Service, Ross worked at the newly established Liverpool School of Tropical Medicine and directed malaria-control efforts in Egypt, Panama, Greece and Mauritius. The findings of Finlay and Ross were later confirmed by a medical board headed by Walter Reed in 1900. Its recommendations were implemented by William C. Gorgas in the health measures undertaken during construction of the Panama Canal. This public-health work saved the lives of thousands of workers and helped develop the methods used in future public-health campaigns against the disease.


title: Malaria

text: In 1896, Amico Bignami discussed the role of mosquitoes in malaria. In 1898, Bignami, Giovanni Battista Grassi and Giuseppe Bastianelli succeeded in showing experimentally the transmission of malaria in humans, using infected mosquitoes to contract malaria themselves which they presented in November 1898 to the Accademia dei Lincei.


title: Malaria

text: The first effective treatment for malaria came from the bark of cinchona tree, which contains quinine. This tree grows on the slopes of the Andes, mainly in Peru. The indigenous peoples of Peru made a tincture of cinchona to control fever. Its effectiveness against malaria was found and the Jesuits introduced the treatment to Europe around 1640; by 1677, it was included in the London Pharmacopoeia as an antimalarial treatment. It was not until 1820 that the active ingredient, quinine, was extracted from the bark, isolated and named by the French chemists Pierre Joseph Pelletier and Joseph Bienaimé Caventou.


title: Malaria

text: Quinine was the predominant malarial medication until the 1920s when other medications began to appear. In the 1940s, chloroquine replaced quinine as the treatment of both uncomplicated and severe malaria until resistance supervened, first in Southeast Asia and South America in the 1950s and then globally in the 1980s.


title: Malaria

text: The medicinal value of "Artemisia annua" has been used by Chinese herbalists in traditional Chinese medicines for 2,000 years. In 1596, Li Shizhen recommended tea made from qinghao specifically to treat malaria symptoms in his "Compendium of Materia Medica". Artemisinins, discovered by Chinese scientist Tu Youyou and colleagues in the 1970s from the plant "Artemisia annua", became the recommended treatment for "P. falciparum" malaria, administered in severe cases in combination with other antimalarials. Tu says she was influenced by a traditional Chinese herbal medicine source, "The Handbook of Prescriptions for Emergency Treatments", written in 340 by Ge Hong. For her work on malaria, Tu Youyou received the 2015 Nobel Prize in Physiology or Medicine.


title: Malaria

text: "Plasmodium vivax" was used between 1917 and the 1940s for malariotherapy—deliberate injection of malaria parasites to induce a fever to combat certain diseases such as tertiary syphilis. In 1927, the inventor of this technique, Julius Wagner-Jauregg, received the Nobel Prize in Physiology or Medicine for his discoveries. The technique was dangerous, killing about 15% of patients, so it is no longer in use.


title: Malaria

text: The first pesticide used for indoor residual spraying was DDT. Although it was initially used exclusively to combat malaria, its use quickly spread to agriculture. In time, pest control, rather than disease control, came to dominate DDT use, and this large-scale agricultural use led to the evolution of pesticide-resistant mosquitoes in many regions. The DDT resistance shown by "Anopheles" mosquitoes can be compared to antibiotic resistance shown by bacteria. During the 1960s, awareness of the negative consequences of its indiscriminate use increased, ultimately leading to bans on agricultural applications of DDT in many countries in the 1970s. Before DDT, malaria was successfully eliminated or controlled in tropical areas like Brazil and Egypt by removing or poisoning the breeding grounds of the mosquitoes or the aquatic habitats of the larval stages, for example by applying the highly toxic arsenic compound Paris Green to places with standing water.


title: Malaria

text: Malaria vaccines have been an elusive goal of research. The first promising studies demonstrating the potential for a malaria vaccine were performed in 1967 by immunising mice with live, radiation-attenuated sporozoites, which provided significant protection to the mice upon subsequent injection with normal, viable sporozoites. Since the 1970s, there has been a considerable effort to develop similar vaccination strategies for humans. The first vaccine, called RTS,S, was approved by European regulators in 2015.


title: Malaria

text: Malaria has been successfully eliminated or significantly reduced in certain areas, but not globally. Malaria was once common in the United States, but the US eliminated malaria from most parts of the country in the early 20th century using vector control programs, which combined the monitoring and treatment of infected humans, draining of wetland breeding grounds for agriculture and other changes in water management practices, and advances in sanitation, including greater use of glass windows and screens in dwellings. The use of the pesticide DDT and other means eliminated malaria from the remaining pockets in southern states of the US the 1950s, as part of the National Malaria Eradication Program. Most of Europe, North America, Australia, North Africa and the Caribbean, and parts of South America, Asia and Southern Africa have also eliminated malaria. The WHO defines "elimination" (or "malaria-free") as having no domestic transmission (indigenous cases) for the past three years. They also define "pre-elimination" and "elimination" stages when a country has fewer than 5 or 1, respectively, cases per 1000 people at risk per year.


title: Malaria

text: In 1955 the WHO launched the Global Malaria Eradication Program (GMEP), which supported substantial reductions in malaria cases in some countries, including India. However, due to vector and parasite resistance and other factors, the feasibility of eradicating malaria with the strategy used at the time and resources available led to waning support for the program. WHO suspended the program in 1969.


title: Malaria

text: Target 6C of the Millennium Development Goals included reversal of the global increase in malaria incidence by 2015, with specific targets for children under 5 years old. Since 2000, support for malaria eradication increased, although some actors in the global health community (including voices within the WHO) view malaria eradication as a premature goal and suggest that the establishment of strict deadlines for malaria eradication may be counterproductive as they are likely to be missed.


title: Malaria

text: In 2006, the organization Malaria No More set a public goal of eliminating malaria from Africa by 2015, and the organization claimed they planned to dissolve if that goal was accomplished. In 2007, World Malaria Day was established by the 60th session of the World Health Assembly. As of 2018, they are still functioning.


title: Malaria

text: , The Global Fund to Fight AIDS, Tuberculosis, and Malaria has distributed 230 million insecticide-treated nets intended to stop mosquito-borne transmission of malaria. The U.S.-based Clinton Foundation has worked to manage demand and stabilize prices in the artemisinin market. Other efforts, such as the Malaria Atlas Project, focus on analysing climate and weather information required to accurately predict malaria spread based on the availability of habitat of malaria-carrying parasites. The Malaria Policy Advisory Committee (MPAC) of the World Health Organization (WHO) was formed in 2012, "to provide strategic advice and technical input to WHO on all aspects of malaria control and elimination". In November 2013, WHO and the malaria vaccine funders group set a goal to develop vaccines designed to interrupt malaria transmission with malaria eradication's long-term goal.


title: Malaria

text: In 2015 the WHO targeted a 90% reduction in malaria deaths by 2030, and Bill Gates said in 2016 that he thought global eradication would be possible by 2040. According to the WHO's World Malaria Report 2015, the global mortality rate for malaria fell by 60% between 2000 and 2015. The WHO targeted a further 90% reduction between 2015 and 2030, with a 40% reduction and eradication in 10 countries by 2020. However, the 2020 goal was missed with a slight increase in cases compared to 2015.


title: Malaria

text: Before 2016, the Global Fund against HIV/AIDS, Tuberculosis and Malaria had provided 659 million ITN (insecticide treated bed nets), organise support and education to prevents malaria. The challenges are high due to the lack of funds, the fragile health structure and the remote indigenous population that could be hard to reach and educate. Most of indigenous population rely on self-diagnosis, self-treatment, healer, and traditional medicine. The WHO applied for fund to the Gates Foundation which favour the action of malaria eradication in 2007. Six countries, the United Arab Emirates, Morocco, Armenia, Turkmenistan, Kyrgyzstan, and Sri Lanka managed to have no endemic cases of malaria for three consecutive years and certified malaria-free by the WHO despite the stagnation of the funding in 2010. The funding is essential to finance the cost of medication and hospitalisation cannot be supported by the poor countries where the disease is widely spread. The goal of eradication has not been met; nevertheless, the decrease rate of the disease is considerable.


title: Malaria

text: While 31 out of 92 endemic countries were estimated to be on track with the WHO goals for 2020, 15 countries reported an increase of 40% or more between 2015 and 2020. Between 2000 and 30 June 2021, twelve countries were certified by the WHO as being malaria-free. Argentina and Algeria were declared free of malaria in 2019. El Salvador and China were declared malaria-free in the first half of 2021.


title: Malaria

text: Regional disparities were evident: Southeast Asia was on track to meet WHO's 2020 goals, while Africa, Americas, Eastern Mediterranean and West Pacific regions were off-track. The six Greater Mekong Subregion countries aim for elimination of "P. falciparum" transmitted malaria by 2025 and elimination of all malaria by 2030, having achieved a 97% and 90% reduction of cases respectively since 2000. Ahead of World Malaria Day, 25 April 2021, WHO named 25 countries in which it is working to eliminate malaria by 2025 as part of its E-2025 initiative.


title: Malaria

text: A major challenge to malaria elimination is the persistence of malaria in border regions, making international cooperation crucial.


title: Malaria

text: One of the targets of Goal 3 of the UN's Sustainable Development Goals is to end the malaria epidemic in all countries by 2030.


title: Malaria

text: In 2018, WHO announced that Paraguay was free of malaria, after a national malaria eradication effort that began in 1950.


title: Malaria

text: As of 2019, the eradication process is ongoing, but it will be difficult to achieve a world free of malaria with the current approaches and tools. Only one malaria vaccine is licensed for use, and it shows relatively low effectiveness, while several other vaccine candidates in clinical trials aim to provide protection for children in endemic areas and reduce the speed of malaria transmission. Approaches may require investing more in research and greater primary health care. Continuing surveillance will also be important to prevent the return of malaria in countries where the disease has been eliminated.


title: Malaria

text: Malaria is not just a disease commonly associated with poverty: some evidence suggests that it is also a cause of poverty and a major hindrance to economic development. Although tropical regions are most affected, malaria's furthest influence reaches into some temperate zones that have extreme seasonal changes. The disease has been associated with major negative economic effects on regions where it is widespread. During the late 19th and early 20th centuries, it was a major factor in the slow economic development of the American southern states.


title: Malaria

text: A comparison of average per capita GDP in 1995, adjusted for parity of purchasing power, between countries with malaria and countries without malaria gives a fivefold difference (US$1,526 versus US$8,268). In the period 1965 to 1990, countries where malaria was common had an average per capita GDP that increased only 0.4% per year, compared to 2.4% per year in other countries.


title: Malaria

text: Poverty can increase the risk of malaria since those in poverty do not have the financial capacities to prevent or treat the disease. In its entirety, the economic impact of malaria has been estimated to cost Africa US$12 billion every year. The economic impact includes costs of health care, working days lost due to sickness, days lost in education, decreased productivity due to brain damage from cerebral malaria, and loss of investment and tourism. The disease has a heavy burden in some countries, where it may be responsible for 30–50% of hospital admissions, up to 50% of outpatient visits, and up to 40% of public health spending.


title: Malaria

text: Cerebral malaria is one of the leading causes of neurological disabilities in African children. Studies comparing cognitive functions before and after treatment for severe malarial illness continued to show significantly impaired school performance and cognitive abilities even after recovery. Consequently, severe and cerebral malaria have far-reaching socioeconomic consequences that extend beyond the immediate effects of the disease.