Methodology. A hospital-based prospective cross-sectional descriptive and analytic study of children with severe malaria was carried out at Kiryandongo General Hospital. The study involved 350 children with severe malaria attending the study site from August to October 2021. Questionnaires were administered to caretakers to obtain sociodemographic characteristics. Medical data were obtained through physical examination followed by laboratory tests. Blood samples were tested for creatinine and blood smear for malaria. Data were analyzed using binary logistic regression (bivariate and multivariate) to assess for the factors associated with AKI. A p value < 0.05 was considered statistically significant.  Malaria remains one of the leading health problems of the developing world, and acute kidney injury (AKI) is a well-recognized complication of severe malaria in adults; but the clinical importance of AKI in paediatric severe malaria is not well documented. Knowledge of the prevalence and factors associated with AKI among children with severe malaria is among the key strategies, which can help to reduce the burden of AKI among this vulnerable group. p = 0.018), caretaker with primary education level , age of child < 5 years , history of receiving NSAIDs , moderate anemia , and severe anemia .  The mean age of children with severe malaria was 7.0 ± 3.8 years, and 54.3% of them were male. Of the 350 children enrolled, 167 had AKI, giving an overall AKI prevalence of 47.7% (95% CI: 42.5-53.0). The factors that were significantly associated with AKI among children with severe malaria included caretaker with no formal education (aOR = 21.0, 95% CI: 1.68–261.18,  The prevalence of AKI was high among children with severe malaria in Kiryandongo General Hospital. Acute kidney injury among children with severe malaria was associated with low level of education of caretakers, age of children less than 5 years, history of receiving NSAIDs, and anemia. The management of severe malaria should include screening for AKI especially in children under five years of age, anemic, and those who have received NSAIDs. Acute kidney injury has become increasingly prevalent in both developed and developing countries and is associated with severe mortality and morbidity especially in children. Acute kidney injury (AKI) in developed countries occurs predominantly in urban area (intensive care unit), and it is associated with multiorgan failure and sepsis with high mortality in older population, while AKI in rural region commonly develops in response to a single disease like malaria and in younger healthy children . In UganIn tropical regions, malaria was the first parasitic infection to be clearly associated with glomerular diseases . SeveralThe prevalence and clinical importance of AKI among children with severe malaria (SM) are not well documented in some high malaria endemic areas. There is evidence that even small changes in kidney function are associated with increased morbidity, mortality, and the risk of developing chronic kidney disease (CKD) in children with severe malaria . PreviouKiryandongo is among districts with a high prevalence of malaria in Uganda with 214/1000 confirmed malaria cases despite the effort of the government and the sensitization from the local authority on the use of mosquito nets . AccordiThis was a prospective hospital-based cross-sectional descriptive and analytical study to determine the prevalence and factors associated with AKI among children with severe malaria in Kiryandongo General Hospital.The study was conducted at Kiryandongo General Hospital which is located in Kikube Parish, Kiryandongo subcounty, Kibanda County, in Kiryandongo District, about 50 kilometers (31 miles), northeast of Masindi General Hospital. This is approximately 211 kilometers (131 miles) north of the Mulago National Referral Hospital. Kiryandongo General Hospital is a 109-bed government-owned hospital. It serves Kiryandongo District and parts of the districts of Masindi, Nakasongola, Oyam, Apac, Amuru, and Nwoya. The paediatric department has 50 beds. The hospital has a laboratory which can make the diagnosis of acute kidney injury and other chemistry investigations.The study population included all children from 2 months to 12 years admitted with severe malaria at Kiryandongo General Hospital both in paediatric ward and emergency department. This study included all children aged 2 months to 12 years and admitted with severe malaria after obtaining informed consent from caretaker and assent from children above 8 years. Children with malnutrition, preexisting kidney diseases, and conditions that cause chronic kidney injury such as hypertension, sickle cell disease, and chronic glomerulonephritis were excluded. The sample size was 350 and was calculated using the Kish Leslie formula  based on2. The physical examination was conducted to assess the presence of the following signs: alteration of the level of consciousness, jaundice, pallor, degree of dehydration, cyanosis, temperature and respiratory rate, oxygen saturation, and organomegaly, to mention but a few. Full blood count was analyzed using Sysmex Automated Hematology Analyser at Kiryandongo GH. Blood glucose was measured using FreeStyle Optium Glucometer by the principal investigator at admission. Thick blood smears for malaria parasites were done using the Field stains A and B and examined by a laboratory technician using the microscope in the main hospital laboratory. Serum creatinine was done for the diagnosis of acute kidney injury. Blood sample was drawn during insertion of intravenous cannula for measurement of full blood count, blood glucose, and blood creatinine. Prior to drawing of blood, the area was swabbed with cotton dipped in ethyl alcohol 70% to prevent contamination. Five milliliters of blood was drawn for determination of full blood count, blood glucose, and serum creatinine on admission. The red vacutainer was used to collect 3 mL of blood for serum creatinine test, and 2 mL of blood was collected in the purple vacutainer for CBC and BS test. These laboratory investigations were done on admission in the private laboratory of Kiryandongo Referral Hospital. Severe malaria was confirming by thick field smear of 1-10 parasites per thick field (+3) or of 10 or more parasites per thick field (+4).A structured questionnaire was administered by the investigator using English or Runyoro according to the preference of the participant. It was a face-to-face interview which allowed clarification. The questions were open and close ended. Variables included sociodemographic, medical, and laboratory factors. Sociodemographic factors included caretakers' sociodemographic factors (age and level of education) and child's sociodemographic factors (age and sex). Medical factors included impaired consciousness or unarousable coma, generalized body weakness, prostration or lethargy , multiple convulsions (more than 2 episodes in 24 h), respiratory distress (acidotic breathing), clinical jaundice plus evidence of other vital organ dysfunction, dehydration, and previous medication. Dehydration was classified as no dehydration, some dehydration, and severe dehydration. The laboratory factors included hypoglycemia (blood glucose < 2.2 mmol/L or <40 mg/dL). Anemia was defined as a Hb < 11 g/dL and was further classified as mild anemia (11 g/dL), moderate anemia (Hb < 8 g/dL), and severe anemia (Hb < 5 g/dL) . HyperpaMalaria was defined by the presence of malaria parasites on blood smear. Severe malaria was defined as malaria plus any of the following complications: impaired consciousness  or coma  ≤ 2) where no other cause other than malaria could be identified), multiple convulsions, acidosis, hypoglycemia, severe anemia, oliguria, jaundice, pulmonary edema, spontaneous bleeding, hemoglobinuria, shock, and hyperparasitemia .p values was reported. A variable was considered significant if it has a p value < 0.05. All factors with a p value < 0.05 or with a borderline p value < 0.2 and those which were biologically plausible with AKI among children with severe malaria were considered in the multivariate analysis which was performed to control confounding. The factors in the final multivariate model were reported together with their adjusted odd ratios and 95% CI with their respective p values. A variable was considered significant in this analysis if it had a p value < 0.05.All statistical analyses were performed with STATA version 14.2. Continuous data are presented as the mean ± standard deviation (SD), and categorical variables are summarized as frequency and percentage. The proportion of AKI among children with severe malaria was summarized as frequencies and percentage. The outcome of children with AKI was determined as a proportion of mortality/discharge among all children with AKI. Factors associated with AKI among children with severe malaria were determined using logistic regression. In bivariate analysis, based on both chi-square test and logistic regression, repeated analysis comparing each independent variable with AKI was done. Crude odd ratio (cOR) with their corresponding 95% CI and During the study period, 797 children were seen in KGH. Among 469 who had a positive blood smear for malaria, 358 had severe malaria. Eight children were excluded, and the rest were consecutively enrolled. Among the excluded, four refused to consent, three died before full assessment, and one was discharged against medical advice. Among the 350 children with severe malaria, 167 (47.7%) had AKI.The enrolled children had a mean age of 7.0 years (SD: 3.8), with majority aged between 5 and 12 years (68.9%). There were slightly more males (54.3%) than females. The mean age of their caretaker was 28.8 years (SD: 7.4) with majority at least 20 years (84.3%) and with primary education (92.3%). The children had a mean duration of illness of 3.1 ± 0.93 days before admission with majority reporting to hospital after at least 3 days of illness (82.0%), with hyperparasitemia (76.3%) and with about half having moderate to severe anemia (51.7%) .The commonest symptoms of children with severe malaria were convulsions (38.9%), vomiting (35.5%), and diarrhea (19.4%) .Of the 350 children enrolled in the study with severe malaria, 167 had AKI, giving an overall AKI prevalence of 47.7% (95% CI: 42.5-53.0). Of these, 99 (59.3%), 57 (34.1%), and 11 (6.6%) had grade 1, 2, and 3 AKI, respectively .p = 0.025). The odds of AKI were 5.6 times higher among children with history of receiving NSAIDS as compared to those with negative history of NSAIDS. The odds of AKI were 3.1 and 3.8 times higher among children with moderate and severe anemia as compared to those with normal hemoglobin , history of receiving NSAIDs, and anemia (moderate and severe).The cutoff used in this study to define renal impairment (Cr > 3 mg/dL) was chosen in accordance with the WHO recommendations for the definition of AKI in children with severe malaria . HoweverDue to high prevalence of AKI among children with severe malaria, creatinine test should be added among routine investigation of children with severe malaria. The management of severe malaria should include screening for AKI especially in children under five years of age, anemic, and those who have received NSAIDs.


P. falciparum protein marker (PSSP17), appraising its utility in the field—particularly with respect to its adoption potential with children and adults in high risk, endemic regions—is necessary to warrant its continued development.The reliance on blood for thin and thick blood smear microscopy—using a relatively invasive procedure has presented challenges to the use of reliable diagnostic tests in non-clinical settings at the point-of-need (PON). To improve the capacity of non-blood-based rapid diagnostic tests to confirm subclinical infections, and thereby identify and quantify the human reservoir at the PON, a cross-sectoral collaboration between university researchers and commercial partners produced an innovative, non-invasive saliva-based RDT capable of identifying novel, non-hrp2/3 parasite biomarkers. While this new saliva-based malaria asymptomatic and asexual rapid test (SMAART-1) shows increased detection sensitivity and precision potential by identifying a new The purpose of this study was to assess the acceptability and adoption potential of the SMAART-1 at select PON sites in the Kinshasa Province. Teachers, community health workers, nurses, and laboratory technicians participated in data collection at three distinct community sites in Kinshasa Province, Democratic Republic of the Congo. Three data collection methods were utilized in this mixed methods study to provide an overarching acceptability evaluation of the SMAART-1 at PON field sites: observation checklists of SMAART-1 implementation, focus group discussions, and surveys with local health care practitioners—particularly teachers and community health workers.Findings indicate participants were interested in and supportive of the SMAART-1 protocol, with approximately 99% of the participants surveyed indicating that they either “agreed” or “strongly agreed” with the statement that they “would use the saliva-based malaria asymptomatic rapid test as part of a community malaria detection and treatment programme.” Data also suggest that the protocol was broadly appealing for its testing sensitivity and ease of use.The SMAART-1 protocol’s clinically reliable results demonstrate a promising new level of sensitivity and precision for detecting parasite biomarkers. This study’s mixed-methods assessment of the protocol’s utility and adoption potential in the field, with a target user audience, advances its development and points to opportunities to formalize and expand evaluation efforts. Plasmodium parasite species; the parasite is transmitted in endemic countries through the bite of infected female Anopheles mosquitoes. Despite substantial progress in malaria control due to advances in prevention and treatment interventions such as insecticide-treated nets (ITNs), indoor residual spraying (IRS), preventative chemotherapies, and anti-malarial vaccines [Malaria is an acute febrile disease principally caused by vaccines , malariavaccines . Accordivaccines . An estivaccines . The WHOvaccines . The newvaccines .Plasmodium falciparum mutant populations have emerged around the globe, which no longer express the histidine-rich protein 2 (hrp2) biomarker for current blood-based RDTs, and subsequently go undetected by the majority of RDTs [Despite the concerning COVID-related service disruptions addressed above, the documented persistence if not resurgence of malaria suggests a waning efficacy of critical prevention, diagnostic, and treatment interventions. These impacts also call into question the achievability of the malaria mitigation targets established in the WHO’s Global technical strategy for malaria 2016–2030 framework (GTS), such as reducing both malaria case incidence and mortality by at least 90% by 2030 . One ave of RDTs .P. falciparum, which have been identified as concerning portions of ongoing malaria transmission and potential factors in the stalling of malaria elimination progress over recent years [hrp2/3 parasite bio-markers [P. falciparum protein marker (PSSP17), appraising its acceptability to end-users in the field—particularly with respect to its adoption potential with children and adults in regions with high endemicity—is necessary to warrant its continued commercial development. Although, SMAART-1 is currently in commercial development, and gauging acceptability and stakeholder input presently informs the refinement of the commercial product [Both microscopy and blood-based RDTs are limited in their capacity to detect extremely low-density subclinical  infections of nt years –12. The  product .The purpose of this study was therefore to assess the acceptability and adoption potential of the SMAART-1 at three PON sites in the Kinshasa Province of the Democratic Republic of the Congo (DRC). By leveraging field data  collected from all individuals involved in malaria surveillance and control in the DRC, including National Malaria Control Programme (NMCP)-trained teachers and health professionals, such as community health workers (CHWs), nurses, and laboratory technicians, the implementation and adoption potential of the SMAART-1 was assessed as a commercially viable RDT alternative to prevailing diagnostic tests that currently struggle to reliably detect subclinical malaria infection.Tenants of Rogers’ (2003) Diffusion of Innovation (DOI) theory were leveraged to apply evaluative benchmarks for the adoption potential of SMAART-1 relative to established diagnostic tests. The DOI has long been applied across sectors to both explain and predict how certain innovations  “diffuse”  throughout a population over time , 15. ConThe DOI advances five attributes that can be used to better understand how a population perceives the favourability of an innovation, under the assumption that successfully meeting an audience’s expectations for these conditions results in the innovation’s rapid adoption: relative advantage, compatibility, complexity, observability, and trialability . RelativThree data collection methods were utilized in this study to provide an overarching acceptability evaluation of the SMAART-1 at PON field sites: observation checklist assessments, surveys, and focus group discussions (FGDs). This study, therefore, applied a convergent mixed methods design in which multiple forms of data—pertaining to the same topic—are collected simultaneously and then are analysed by integrating, comparing, and contrasting common and unique findings from the different sources .n = 158) from the three sites that were trained in the use of the SMAART-1 protocol served as the sampling frame for the elicitation of inclusion in the survey and FGDs.National staff members from the Kinshasa School of Public Health (KSPH) conducted primary data collection for this study in Kinshasa Province, DRC see Fig.  in SepteThree data collection methods were utilized in this study to provide an overarching acceptability evaluation of the SMAART-1 at PON field sites: observation checklist assessments, surveys, and FGDs. All consent-affirming language, study instructions, and instrument questions were provided in either French or Lingala, whichever language was preferred by the participant. Pilot testing of the tools was conducted among the KSPH team, which allowed for refinement of phrasing to ensure effective translations in French and Lingala. Initial data collection was paper-based and subsequently entered into EpiInfo 7.n = 158), whereby KSPH study monitors referenced a targeted evaluative checklist to guide their appraisals of participants’ use of a mock SMAART-1 test and two saliva collection methods: passive saliva collection into a cup and the SUPER-SAL saliva collection device. The participants observed were those that were trained on the SMAART-1 test across the study sites. The checklist for the study monitors mirrored the instructional pamphlet given to study participants, with each step representing an item on the checklist  demographics and attitudes about the test and saliva collection methods. The survey consisted of nine Likert-type items related to three DOI constructs, one Likert-type question regarding participants’ perceived likelihood of adopting the SMAART-1 protocol, and standard demographic questions to collect data related to participants’ sex, age, education, occupation, and years of experience. The occupation was was originally coded as 0 to 5 . To create additional opportunities for analysis, the occupation variable was transformed into a new dichotomous variable that organized the respondents as “health professionals” that were coded as 1 and “non-health professionals” that were coded as 2 to understand if there were any relationships based on this re-classification of occupation types.KSPH enumerators conducted individual surveys following the observational assessment to record participants’ Using the saliva-based malaria asymptomatic rapid test will improve the ability to treat malaria quickly (Relative Advantage)The saliva-based malaria asymptomatic rapid test is better  than the malaria detection tests I have used in the past. (Relative Advantage)Overall, there are benefits to using the saliva-based malaria asymptomatic rapid test (Relative Advantage)The saliva-based malaria asymptomatic rapid test is complicated (Complexity)The saliva-based malaria asymptomatic rapid test would be difficult to use (Complexity)It would be easy for me to become skillful at using the saliva-based malaria asymptomatic rapid test (Complexity)It would be easy to test adults using the saliva-based malaria asymptomatic rapid test (Complexity)It would be easy to test children using the saliva-based malaria asymptomatic rapid test (Complexity)The Likert-type DOI-related items included in this inquiry are listed below:strongly disagree) to 4 (strongly agree). An average value from the nine items was subsequently calculated for each individuals to create a Technology Perception Index (TPI) that signified the extent to which a respondent had a positive or negative perception of the technology. A mean TPI value approaching 0 therefore represented a highly negative perception of the technology while a mean TPI value approaching 4 represented a highly positive perception of the technology. In addition to the items that make up the TPI, there was an additional item that used the same likert-type agreement scale to understand if participants would use the technology, “I would use the saliva-based malaria asymptomatic rapid test as part of a community malaria detection and treatment programme.”Respondents were asked to rate their level of agreement with each item on a five-point Likert-type scale of agreement where 1 = strongly disagree and 5 = strongly agree. Items with negative connotations of the technology were reverse coded for analysis. The Cronbach’s Alpha score for these items was 0.74, denoting an acceptable reliability coefficient for a social science construct . ResponsFinally, KSPH study facilitators conducted a total of six recorded FGDs engaging six to seven participants  from each of two core participant segments under consideration: health professionals  and highly educated and trained teachers with broad experience with malaria testing in their respective communities. These participants were selected from the individuals that were trained on and observed using the SMAART-1 protocol. Three focus group sessions were conducted with each participant group, and two sessions—one per occupational group—were conducted per study site . Each of the six FGDs was informed by a semi-structured topic guide focusing on participants’ previous experience with malaria detection and testing, perceptions of new saliva-based technology, and considerations for use and broader adoption of the SMAART-1 protocol. The KSPH study facilitators generated direct-language transcriptions and English translations of each FGD, removing any names or identifying information in the process to ensure participant anonymity and confidentiality. These transcript files  were uploaded to a secure  remote-sharing folder only accessible to study staff.Observation checklist assessment data were analuzed using IBM SPSS Statistics version 26.0 primarily applying descriptive statistics to examine the frequencies/percentages of participants who were able to effectively carry out each step of the protocol. Relatedly, measures of central tendency for participants’ observation efficacy scores were determined in terms of median, range, mode and interquartile range. Nonparameteric correlations were conducted using Pearson correlation coefficient including the efficacy score and demographic variables to understand if there were relationships in scores based on age, education, occupation and years of professional experience. Relatedly, efficacy scores based on age were analysed using descriptive statistics, as a result of the dichotomous nature of the variable, and presented qualitatively. Though the core analysis of checklist data was conducted quantitatively , notations generated by protocol checklist observers/moderators provided textual data that was incorporated into the qualitive analysis of FGDs discussed below.For the survey data, descriptive statistics were applied to calculate frequencies/percentages of participants per demographic characteristics. Descriptive statistics were also used to determine the mean and standard deviation of the likert-type items and the TPI. Multiple Pearson non-parametric correlations were run to identify potential relationship between the TPI, the efficacy score, agreement to use the technology variable, and demographic characteristics. Table Analysing FGDs first required the translated transcriptions of both Lingala and French-based session recordings into English—a process facilitated by KSPH staff members fluent in each language. Translated transcription files were accessed from a secure shared folder, whereby a qualitative analyst on the study team uploaded the files into the qualitative data analysis software program NVivo (Version 12). Transcript files were analysed using thematic analysis, whereby emergent categories and themes were inductively generated from the data using open coding . After aTo meet qualitative evaluation criteria identified by Lincoln and Guba , select Table p = 0.043. There was also a weak, positive correlation between efficacy score and years of professional experience, r (125) = 0.201, p = 0.024. This means that there is a weak relationship with older respondents with more professional years of experience and higher efficacy scores. With the original coding of the occupation variable, there was not a significant relationship between occupation and efficacy but the recoded variable is used, a significant relationship is identified. There is a weak, negative relationship between recoded occupation and efficacy scores, r (130) =  − 0.272, p = 0.002. This means that the health professionals scored marginally higher efficacy scores than the non-health professionals, which is not surprising. When looking at sex, females and males exhibited the same median (21) and iterquartile range (1) as the entire sample.Table Overall, approximately 99% of the participants surveyed indicated that they either “agreed” or “strongly agreed” with the statement that they “would use the saliva-based malaria asymptomatic rapid test as part of a community malaria detection and treatment programme.” Only one individual in the sample of 144 (0.689%) indicated that they “disagreed” with the statement. Table p = 0.017. When using the transformed occupation variable, the correlation coefficient increased but the relationship remained weak. There was a weak positive correlation between the dependent variable and the recoded occupation variable, r (138) = 0.217, p = 0.003. So, those that were not classified as health professionals rated there agreement higher than health professionals. There was strong correlation between the dependent variable and the TPI, r (144) = 0.740, p < 0.001. This means the more positive the perceptions of the technology based on the tenets of the DOI theory, the more someone agreed to use the saliva-based system in their community malaria detection and treatment programme. Relatedly, there was a weak positive correlation between occupation and TPI, r (137) = 278, p = 0.001. Meaning, those higher coded occupations  had somewhat of a higher TPI than the CHWs, nurses, and doctors. When using the transformed occupation variable, the correlation coefficient again increased but the relationship remained week. There was a weak positive correlation between occupation and TPI, r (137) = 0.326, p < 0.001. This means that non-health professionals rated the technology more favourably in the TPI than the health professionals.When correlational analysis of the TPI, the efficacy score, demographic characteristics and the dependent variable was executed, multiple significant relationships were found. There was a weak positive correlation between the dependent variable and occupation, r (138) = 0.204, p < 0.001.There was a moderate, positive correlation between the dependent variable and item 2, r (145) = 0.628, p < 0.001.There was a moderate, positive correlation between the dependent variable and item 3, r (145) = 0.622, p < 0.001.There was a moderate, positive correlation between the dependent variable and item 4, r (145) = 0.588, p < 0.001.There was a moderate, positive correlation between the dependent variable and item 5, r (145) = 0.617, p < 0.001.There was a moderate, positive correlation between the dependent variable and item 7, r (145) = 0.485, p < 0.001.There was a moderate, positive correlation between the dependent variable and item 8, r (145) = 0.621, p < 0.001.There was a moderate, positive correlation between the dependent variable and item 9, r (145) = 0.655, Because the TPI exhibited a strong relationship with the agreement to use SMAART-1 in community malaria detection and management programs, additional Pearson non-parametric correlations were executed between the individuals items of the TPI and the dependent variable. All but two items  analysis of FGDs—coupled with analysis of select observation checklist notations—ultimately generated five first-tier thematic categories: “Disadvantages of Blood RDT,” “Advantages of Saliva RDT,” “Disadvantages of Saliva RDT,” “Overarching Testing Considerations,” and “Diffusion Considerations”. These thematic  labels served to cluster and thematically organize broadly related segments of data, encompassing more specific themes  within them. The first category—“Disadvantages of Blood RDT”—encompassed participants’ considerations towards traditional blood-based rapid diagnostic methods for assessing the presence of malaria infection. Five discrete codes were generated from our thematic analysis of participant responses within this category. These codes are represented in Table Teacher and health professional  respondents from each community site that were previously trained and observed were subsequently prompted to discuss their perspectives—based on prior engagement and experience—of the use of saliva-based RDTs. In assessing the accessibility and overall efficacy of saliva-based testing protocols, participants provided a wide array of feedback, ultimately generating two overarching thematic categories: “Advantages of Saliva RDT,” and “Disadvantages of Saliva RDT”. “Advantages of Saliva RDT”—illustrated in Table Table Focus group participants were prompted to consider additional factors in diagnostic testing service, adoption, testing execution, etc. “Overall Testing Considerations” and its six constituent codes are presented in Table Finally, FGD participants provided critical feedback regarding diffusion-related considerations—factors related to the communication, promotion, and public sensitization of saliva RDTs, including which media channels and stakeholder groups are best-suited to advance SMAART-1 adoption. Table P. falciparum infection [The recognition of pervasive diagnostic capacity limitations of established malaria RDTs at PON and POC sites in malaria endemic regions—particularly throughout sub-Saharan Africa—presented a significant need to develop a diagnostic technology and testing protocol sufficiently sensitive to low-density/subclinical nfection . This nenfection , 12. Then = 158) adoption of a mock SMAART-1 protocol and two saliva collection methods was assessed by KSPH study monitors—indicate that participants were generally able to administer the SMAART-1 without significant obstacles. With a median efficacy score of 21 and an interquartile range of 1, checklist results demonstrate a relatively uniform proficiency for use across our participant types. Because only weak relationships existed between the efficacy scores and a participants occupation and years of professional experience, this reinforces the above statement and demonstrates the relative ease of use across experts and non-experts.In this study, the adoption potential of the SMAART-1 was appraised through three data collection methods at target PON sites in Kinshasa Province, DRC: surveys, observation checklist assessments, and FGDs. Observational checklist data—whereby trained teacher and health professional participants’  demonstrates a weak relationship not only with actual use of the technology but also intended use and technology perceptions  suggests that there may exist opportunities for health professionals and non-health professionals alike to champion and administer the technology with comparable efficacy. According to DOI theory, these extant perceptions can be influenced by targeted sensitization and educational efforts implemented to familiarize potential users with a target innovation and reduce uncertainty . FollowiFGDs with teachers and CHWs generated several salient findings—some previously corroborated in prior malaria prevention and treatment studies, others emergent and seemingly novel to this study. One salient theme that emerged from the FGDs was that SMAART-1 and other saliva-based RDTs carry a distinct advantage over conventional blood-based RDTs given they do not require finger pricks or the use of a needle. In their systematic review of qualitative studies examining malaria prevention and treatment barriers throughout Africa, Maslove et al.  found thAnother recurring theme concerning blood-based RDT disadvantages was primarily identified by lab technicians within the health professional FGDs and related to detection inaccuracies—namely the frequency of false negatives due to blood-based RDT’s extremely limited detection capacities when assessing asymptomatic or subclinical infections. According to Owusu et al. , NMCP reSeveral other FGD themes emerged as salient considerations for health care practitioners in Kinshasa province, including opportunities for modifying elements of the SMAART-1 protocol to improve its use for children, recognizing potential issues with administering the test with unconscious, convulsing, or otherwise infirm individuals, promoting the protocol based on recognized accessibility and ease of use, and leveraging the expertise and trusted status of teachers, CHWs, and other key stakeholders in these target communities to help promote SMAART-1 and sensitize community members to the ease, utility, and importance of taking the test—both as a preventative measure and to ensure effective treatment. These and other themes presented in this study warrant further exploration in comparable study settings.Limitations are present in this study. One previously addressed limitation pertains to the truncated operationalization of Roger’s DOI framework . While tIn recent years, the achievability of key 2030 malaria elimination and mitigation goals set by the WHO have been called into question, prompted by the observed persistence—and in some regions, documented increases—of malaria infection and mortality. In response to concerns that subclinical infections may be a salient contributing factor to this stalling out of progress, a cross-sectoral partnership produced a saliva-based RDT sensitive and precise enough to successfully detect subclinical infections. While SMAART-1 proved clinically successful, its utility at PON and POC community sites in high-risk, malaria endemic regions was indeterminate. The purpose of this study, therefore, was to assess the acceptabilityand adoption potential of the SMAART-1 at targeted community sites in Kinshasa province, DRC through observation checklist assessments of SMAART-1 implementation, FGDs, and surveys with local health care practitioners. Primary findings indicate participants were interested in and supportive of the SMAART-1 protocol, with approximately 99% of the participants surveyed indicating that they either “agreed” or “strongly agreed” with the statement that they “would use the saliva-based malaria asymptomatic rapid test as part of a community malaria detection and treatment program.” Additional findings suggest that while the protocol was broadly appealing for its testing sensitivity and ease of use, a suite of opportunities remain to be pursued, including: addressing perceptional biases through community-based communication and sensitization campaigns, considering targeted design modifications for children and impaired individuals, and expanding research-based evaluation efforts in different countries and/or endemic regions to gauge the generalizability of the present study’s results.


Plasmodium spp., alternative diagnostic sampling methods that are effective and non-invasive are needed, particularly for long-term studies. Saliva and stool samples from malaria-infected individuals contain trace amounts of Plasmodium DNA and therefore could be used as alternatives. Malaria was screened using rapid diagnosis tests and confirmed via microscopy. Nested PCR tests targeting the Plasmodium falciparum-specific STEVOR gene were performed for blood, saliva and stool samples that were positive for malaria. Three hundred sixty-seven (367) children were enrolled and eighty (22.22%) were confirmed to be positive for malaria. Matched blood, saliva and stool samples were available for 35 children. By using blood smears as the gold standard for the diagnosis of malaria, our study indicates that Plasmodium DNA was more detectable in blood (100%) than in saliva (22.86%) and stools (14.29%). Applying qPCR to the STEVOR gene to detect Plasmodium falciparum DNA in saliva and stool samples cannot be considered as an alternative to the current malaria detection processes using blood specimens.Due to the difficulty of obtaining blood samples, which is the invasive method that is currently used for the detection of  Plasmodium infection, which, if left untreated, can progress from asymptomatic parasitaemia to uncomplicated malaria, and then to severe malaria, and finally, death. Practically in all endemic countries, a significant decline in disease rates has been demonstrated, which is probably due to the large-scale bed net program and the improvement in case management such as enhanced diagnostic tests and the implementation of highly effective anti-malarial drugs. Clinical malaria is characterised by the presence of a malaria parasite in the blood, and is associated with other symptoms such as intermittent fever, malaise, shaking, chills, arthralgia, myalgia, vomiting, etc. [Malaria continues to pose a huge public health threat globally. In 2020, malaria accounted for 627,000 deaths in the world, and 95% of the deaths occurred in sub-Saharan Africa . MalariaP. falciparum, P. malariae and P. ovale, have been reported, and P. falciparum represents 95% of the encountered isolates [Plasmodium infection, severe malaria represents 20% of P. falciparum infections [In Gabon, a Central African country, the malaria transmission rate is stable throughout the year, with a mean prevalence of 22.3%  due to its warm and humid equatorial climate, which favours the proliferation of mosquitos [isolates . In Gaboisolates . In Franfections ,8.Plasmodium parasites) relies on demonstrating the presence of asexual erythrocytic stages from peripheral blood. Light microscopy requires blood obtained from a finger prick or via venipuncture. However, this technique (i) presents various risks and limitations in the course of repeated measurements, (ii) it is invasive, (iv) it requires strict aseptic precaution and (v) it can be tedious when patients fail to cooperate, especially in cases in which infants and children are involved [Currently, malaria diagnostic methods are based on the identification of plasmodium or plasmodium proteins in the blood using rapid diagnostic tests (RDTs) and microscopy. RDTs are widely used in the field, with a similar or lower sensitivity compared to microscopy ,10. RDTsinvolved .P. falciparum-infected patients contain traces of parasite DNA, which can be amplified with polymerase chain reaction (PCR) [Plasmodium DNA using real-time PCR analyses of ethanol-preserved faeces showed satisfactory diagnostic performance in the estimation of malaria prevalence compared to the use of dried blood spot samples [P. falciparum infection showed that stored saliva DNA in combination with ultra-sensitive qPCR assays based on the detection of the P. falciparum mitochondrial cox3 gene could potentially enhance the routine testing of P. falciparum during disease surveillance, monitoring and evaluation of interventions for malaria elimination [P. falciparum infection in saliva has a sensibility of more than 90%. [STEVOR) gene is a powerful tool to detect P. falciparum infection only, with a sensitivity and specificity rate of 100% in both symptomatic and asymptomatic individuals [STEVOR gene is encoded in 40 copies in the subtelomeric region of the P. falciparum genome. This study compares the ability to detect P. falciparum infections in blood, saliva and stool samples using highly sensitive qPCR assays targeting the STEVOR gene.An alternative method of diagnosis using samples such as stools and saliva will be of immense importance to properly investigate malaria using molecular tools. These bodily fluids can be non-invasively obtained from patients. Indeed, studies suggest that saliva and stool samples from on (PCR) ,14. In a samples . Anothermination . The useividuals ,17,18. TP. falciparum malaria is highly endemic with a perennial mode of transmission and some seasonal fluctuations [®  and analysed in a laboratory. All samples were coded with alphanumerical identifier to protect the identity of each participant. Only children with (i) uncomplicated malaria, (ii) monospecific P. falciparum infection and (iii) written informed consent from their parents or tutors were included in this study. This study was approved by the National Ethics Committee of Gabon (PROT 0020/2015/SG/CNE). This cross-sectional descriptive study was conducted at the paediatric ward of the “Hôpital de l’Amitié Sino-Gabonaise de Franceville” from 15th March to 31st December 2021. Franceville is a semi-urban region of southeast Gabon  where tuations . During ®-Biorad” following the manufacturer’s instructions. Optimal-IT® is a direct test that detects the presence of the pLDH enzyme, and it also allows for the differentiation of specific infections by P. falciparum from infections with other Plasmodium species such as P. vivax, P. ovale and P. malariae. All results were confirmed via microscopy by two experienced microscopists. The parasite load was, therefore, determined and expressed as the number of parasites  per microliter of blood using Lambaréné’s method [P. falciparum malaria infection were asked to provide saliva and stool samples. The diagnosis of malaria was performed using the Rapid Diagnosis Test (RDT) “Optimal-ITs method . Consequ®, QIAGEN) [® Lonart; Cipla, Mumbai, India). Saliva was collected using sterile swabs (~200 µL), and a few milligrams of stool was collected in sterile pots containing a conservation medium (RNALater QIAGEN)  and stor® kit (Omega Bio-Tek), Inc.400 Pinnacle Way, Suite 450, Norcross, GA 30071, USA) (ii) saliva using the Qiagen® saliva DNA extraction kit  and (iii) stool using the Qiagen® stool DNA extraction kit  following the manufacturer’s instructions. Due to the difficulty in obtaining DNA in stool samples and in order to check the quality of the extracted DNA, we quantified the DNA template with nanodrops only in the stool samples.DNA template was extracted from (i) blood using the DNA Blood Omega Bio-Tek E.Z.NAIn order to check the presence of DNA and quantify it in all matched samples, we amplified the human GAPDH housekeeping gene using quantitative real-time PCR (qPCR). qPCR was performed using the following primers: GAPDH_F: 5′-GAAGGTGAAGGTCGGAGT-3′; GAPDH_R: 5′-GAAGATGGTGATGGGATTTC-3′. The probe was 5′-rox-CAAGCTTCCCGTTCTCAGCC-BHQ2-3′, and the conditions were 94 °C for 10 min, 94 °C for 30 s, 55 °C for 30 s and 72 °C for 30 s for 40 cycles in the presence of the Universal PCR Master mix kit (Apply Biosystems). Nested real-time PCR assay targeting a conserved fragment of STEVOR gene was used. Only blood, saliva and stools from infected children (with written informed consent) were tested.Nested qPCR of saliva, nested qPCR of stools and nested qPCR of blood were performed in the same conditions. A total of 2.5 µL of DNA template  were amplified using a Perkin Elmer thermal cycler. The total volume of reaction was 25 µL containing 1× PCR buffer as supplied by the manufacturer; 17 µM each of dATP, dCTP, dGTP and dTTP; 0.75 pM of each primer, P5, P18, P19 and P20  and a 0.All the amplifications were performed in 96-well optical PCR plates using an Applied Biosystems 7900 HT Fast Real-Time PCR system and under the following conditions: 93 °C for 3 min and 35 cycles of 93 °C for 50 s, 50 °C for 50 s and 72 °C for 50 s.t-test was used for comparison of two means, and non-parametric Kruskal–Wallis test was used when the numbers were insufficient. The level of significance was assumed at p < 0.05.Data were analysed using R software version 3.5.3 (manufacturer) . QualitaDuring this study, there were 367 children aged 1 to 180 months who were screened for malaria infections. The febrile patients included in the analysis are shown in The numbers of males and females were 201 (54.7%) and 166 (45.23%), respectively. The mean temperature was 38.18 ± 1.17 °C. P. falciparum was responsible for 100% of the infections. The prevalence of malaria calculated via microscopy was 21.80% , with a mean parasitaemia of 26,512.23 ± 4687.12 parasites/µL . A total of 35 patients agreed to participate in the study, and each patient provided a stool and saliva sample. The mean values of their haemoglobin and temperature were 9.03 ± 1.75 g/dl  and 37.1 ± 6.54 °C , respectively. To validate the quality of the extracted DNA, the GAPDH gene was amplified. The results show that DNA was detectable in all of the samples. p < 0.001). To determine the performance of the nested qPCR of saliva, the nested qPCR of stools and the nested qPCR of blood, thick blood smears were used as the gold standard. We found that the sensitivity of the qPCR of blood was the highest compared with the qPCR of saliva and the qPCR of stools  when stools were used. False negative results were observed in all ranges of parasitaemia , and the−5 and 5.2 × 10−6). There was no statistical difference between the CT values of the faeces and saliva samples (p > 0.06). We found that the Cycle Threshold (Ct) value of the blood samples’ amplifications was significantly lower than the stool and saliva samples’ Ct values . This extremely low sensitivity, compared to the one obtained from the blood samples (100%), could be explained by the large amount of degraded parasite DNA in the stool. Indeed, the literature states that infected erythrocytes are degraded in both the spleen and liver during the course of infection and a large amount of degraded parasite constituents including DNA are produced in the liver. The degraded constituents are excreted from the liver (via the bile) into the faeces [Plasmodium DNA detection. Indeed, in another study led in Uganda, they kept stools in alcohol prior to performing DNA extraction [The majority of studies investigating the detection of plasmodium DNA in stools are focused on monkeys ,29,30. Olanation . Our rese faeces . Furthertraction . In thistraction . This diFor some faecal samples, a qPCR assay was at the limit of detection (≥40 Ct), and the Ct value of blood was statistically lower than the saliva and faeces values, which means that there is more parasite DNA in blood than in saliva and stools. This last result is obvious because the parasite infects red blood cells, and it is more abundant in blood than in any other fluid.Plasmodium falciparum DNA is detectable in saliva and stools using nested PCR targeting the STEVOR gene, although the sensitivity is considerably reduced when compared to the results obtained from blood samples. However, the small sample size of this study means that it is not possible to draw any firm conclusions about the suitability of these non-invasive samples in detecting malaria parasite DNA in saliva and stools. Further studies are needed to improve the detection of Plasmodium DNA in these fluids.


Plasmodium falciparum infection accounts for most severe cases of the disease in humans. The mechanisms of cerebral malaria pathogenesis have been studied extensively in humans and animal malaria models; however, it is far from being fully understood. Recent discoveries indicate a potential role of bradykinin and the kallikrein kinin system in the pathogenesis of cerebral malaria. The aim of this review is to highlight how bradykinin is formed in cerebral malaria and how it may impact cerebral blood-brain barrier function. Areas of interest in this context include Plasmodium parasite enzymes that directly generate bradykinin from plasma protein precursors, cytoadhesion of P. falciparum infected red blood cells to brain endothelial cells, and endothelial cell blood-brain barrier disruption.Malaria is a parasitic disease of global health significance and a leading cause of death in children living in endemic regions. Although various Plasmodium species are responsible for the disease,  Plasmodium falciparum (Pf) infection. In 2021 there was an estimated 619,000 malaria deaths world-wide; 593,000 of these deaths occurred in sub-Saharan Africa  infection are due to cerebral malaria.Malaria continues to be a major cause of morbidity and mortality in tropical and sub-tropical areas of the world. Life-threatening clinical malaria syndromes – severe anemia, respiratory distress accompanied by metabolic acidosis, cerebral malaria (CM) and combinations therein – primarily affect children and pregnant women with n Africa . ChildrePf blood stage infection. The World Health Organization has defined 3 clinical criteria for the diagnosis of CM: i) a peripheral blood smear or rapid diagnostic test positive for asexual stage Pf parasites; ii) exclusion of any other etiology of neurologic dysfunction; and iii) coma and seizures (Pf infected red blood cells (iRBCs) to brain vascular endothelium are collectively thought to initiate the breakdown of the BBB  on the iRBC surface that bind to intercellular adhesion molecule 1 (ICAM-1) and endothelial protein C receptor (EPCR) on the brain endothelial cell (EC) luminal surface , and CD8 T cells . Immunos is a 9 amino acid peptide (RPPGFSPFR) liberated by cleavage of high or low molecular weight kininogen (HK and LK) by plasma kallikrein (PKa), tissue kallikrein, and/or activated factor XII (FXIIa). The  peptide . Relatedptidases . Lys BK ptidases   is a serine protease that also hydrolyzes PK to PKa when bound to HK on the cells to liberate BK  Figure. FXII bi9BK and LysDesArg9BK, respectively, and are ligands for the BK G-protein coupled B2 receptor (B2R) and B1 receptor (B1R), respectively (Angiotensin converting enzyme (ACE) is the major BK degrading enzyme in the intravascular compartment. In total, there are 13 plasma and tissue BK peptidases . Carboxyectively Figure 1The archetype contact activation system disease state is hereditary angioedema, an inflammatory disorder manifested by localized edema in skin, soft tissue, bowel, and the larynx. This condition has been associated with defects or deficiency of C1 inhibitor, FXII, plasminogen, angiopoietin 1, HK, heparan sulfate, and myoferlin . Since Bth century suggested that increased vascular permeability and capillary leakage contribute to the pathogenesis of severe malaria. Estimated changes in intravascular versus extravascular plasma distribution in patients undergoing malaria-induced “fever therapy” for the treatment of neurosyphilis were among the first to suggest that Pf blood stage infection leads to vascular leakiness  infected with P. knowlesi relative to uninfected controls , decreased in plasma of rhesus monkeys   . Plasma esponses . These cPlasmodium falciparum iRBCs internalize plasma HK and actively process it through cysteine proteases to liberate BK and its analogs to the extracellular space  and B1R (DALBK). The same results were observed when cells were treated with BK alone. Bradykinin or conditioned medium of Pf cultures stimulation of brain EC monolayers impaired tight junctions with loss of ZO-1 and β-catenin expression on cell surface, resulting in changes in EC function that allowed for increased permeability of bovine serum albumin tracer ] and, independently, E64 protease. In other studies, both falcipain-2 and falcipain-3 generated BK (2. BK formed by any means stimulates nitric oxide production, induces vasodilatation, activates EC, enhances microvascular permeability, and modulates cellular metabolism.Kininogens such as HK have been known to be substrates and inhibitors of cysteine proteases for over 40 years. We showed that HK inhibits platelet calpain 2 with high affinity, and molar excess calpain 2 destroys HK . Furtherlyzes BK . PlasmodesArg9BK . Furtherrated BK . Both enPlasmodium species involved. Bradykinin has been reported to have anti-plasmodial activity against P. gallinaceum, a malarial strain that infects chickens (The role of BK in malaria depends on its local or systemic production, the correlate BK receptor to which it binds and signals, and chickens .P. falciparum schizont cultures inhibited parasite growth similarly to captopril, an ACE inhibitor (In other studies, the addition of BK to nhibitor . ACE connhibitor  levels. nhibitor .Published data reviewed here suggest that BK may be generated and contribute to the pathogenesis of vasogenic edema in CM in several ways Figure 2All authors contributed to the manuscript. AP wrote the first draft. The other authors worked together to complete the manuscript. All authors have seen the final version of the manuscript.


In recent years, the downward trajectory of malaria transmission has slowed and, in some places, reversed. New tools are needed to further reduce malaria transmission. One approach that has received recent attention is a novel house-based intervention comprising window screening (S) and general house repairs to make the house more mosquito proof, together with EaveTubes (ET) that provide an innovative way of targeting mosquitoes with insecticides as they search for human hosts at night. The combined approach of Screening + EaveTubes (SET) essentially turns the house into a ‘lure and kill’ device.This study evaluated the impact of SET on malaria infection prevalence in Côte d’Ivoire and compares the result in the primary outcome, malaria case incidence. Malaria infection prevalence was measured in a cross-sectional survey in 40 villages, as part of a cluster-randomised trial evaluating the impact of SET on malaria case incidence.p < 0.0001). There was moderate agreement between RDT and microscopy results, with a reduction in odds of infection of 36% recorded when infection was measured by microscopy. Prevalence measured by RDT correlated strongly with incidence at a cluster level.Infection prevalence, measured by rapid diagnostic test (RDT), was 50.4% and 36.7% in the control arm and intervention arm, respectively, corresponding to an odds ratio of 0.57 (0.45–0.71), In addition to reducing malaria case incidence, house screening and EaveTubes substantially reduced malaria infection prevalence 18 months after installation. Infection prevalence may be a good metric to use for evaluating malaria interventions in areas of similar transmission levels to this setting.ISRCTN18145556, registered 1 February 2017.The online version contains supplementary material available at 10.1186/s12916-023-02871-1. Vector control has been credited with a large contribution to the decline in malaria cases and deaths in the past 15 years , 3. ThisOne such tool is the In2Care® EaveTube. EaveTubes comprise PVC tubes which are inserted into a house at eave level and are closed off using an insecticide treated netted insert. EaveTubes exploit the preference of the anopheline mosquito to enter households at eave height  and haveInitial entomological studies conducted in semi-field enclosures suggested that the combination of EaveTubes, closed eaves, and screened windows successfully reduced mosquito populations , 10. To The incidence of clinical malaria  is typically considered the gold standard measure of impact for malaria intervention trials , and it Measuring infection prevalence incurs vastly fewer cost implications for this type of evaluation compared to the measurement of incidence. Prevalence can be estimated through cross-sectional surveys at single time points which greatly reduces time, expense, and logistical burden. As part of the evaluation of the SET technology, we performed an endline cross-sectional survey to assess the impact on malaria infection prevalence in the study population 18 months post-installation of SET. This paper evaluates the impact of a vector control intervention on malaria infection prevalence using different diagnostics in a trial where SET resulted in a substantial reduction in malaria case incidence in the intervention clusters.The trial took place in 40 villages (clusters) within 50 km of the city of Bouaké, central Côte d’Ivoire. The study setting has moderate to high malaria transmission with seasonal transmission primarily occurring between May to November each year. There is a high level of pyrethroid resistance in the local anopheline vectors, as well as resistance to carbamates and organochlorides .The protocol and primary results for the trial have been previously published , 14. BriThe main epidemiological outcome of the trial was malaria case incidence. This was measured in a cohort of 50 children aged 6 months to 10 years per cluster. The cohorts were visited every 2 weeks during the transmission season (May to November) and once a month during the dry season (December to April). Febrile children were tested for malaria with an RDT and received treatment (artesunate-amodiaquine) if positive. The full analyses of the incidence data, as well as entomological and economic outcomes, have been published elsewhere .An endline cross-sectional survey took place in November 2018, 18 months after the installation of SET. In contrast to the baseline survey where households were the sampling unit, compounds (ranging from 1 to 5 households) were randomly selected from census lists of each cluster, and individuals were tested until approximately 70 people per cluster had been sampled. Anyone over the age of 6 months was invited to be part of the study. Participants were tested using RDT  and had a blood smear taken for microscopy analysis, regardless of symptoms of malaria. A short questionnaire was also administered to collect information on house structure, household assets, intervention use, and potential malaria symptoms.The prevalence survey had 80% power to detect a 40% reduction in prevalence between the control arm and the SET arm, assuming a 40% prevalence in the control arm and a coefficient of variation between clusters of 0.5.Descriptive statistics (proportions and means) and infection status associations were calculated with confidence intervals adjusting standard errors for clustering at the village level using the svy command in Stata. To assess the impact of the intervention, a mixed effect logit model with arm as a fixed effect and cluster included as a random effect was used to produce odds ratios using both the RDT and/or microscopy data. Impact was assessed separately for villages with more than 70% of houses with SET installed, compared to those with less than or equal to 70% coverage. Per protocol analyses involved comparison of children who lived in houses with SET installed with those in control clusters.To compare differences between the baseline and endline results (in children aged 6 months to 10 years only), an interaction between arm and survey was fitted to the mixed effect logistic model previously described.Incidence was calculated as described in detail in the main trial results paper . ClusterThis study is registered as an International Standard Randomised Controlled Trial, ISRCTN18145556.n = 1851) of children were infected by malaria (determined using RDT) at the time of the survey. Children aged 5–10 years were more likely to be RDT positive (76.9%), compared to 0–2 year olds (63.8%) and 2–5 year olds (72.7%). The results from the baseline survey were used for the restricted randomisation, to ensure that the two arms were balanced on infection prevalence , whilst 19% reporting never using a net. Children aged 5–10 years were more likely to report never using a net (22.6%), compared to 0–2 years (15.7%) or 2–5 years (16.5%). 73.2% . Net use was relatively high, with 72.5% of people reporting using a net the previous night, though this appeared lower in the intervention arm (68.0%) compared to the control arm (77.1%). The difference in net use across age groups was greater in the SET arm (ranging from 55% in 10–15 year olds to 76% in 50–100 year olds) compared to the control arm (ranging from 71% in 10–15 year olds to 84% in 0–5 year olds).In the endline survey, mean prevalence by cluster was 43.5% (95% CI: 23.7–66.2). Infection was highest in males  with the burden of infection highest in children aged 5–10 years (66.8%). Infection was highest in individuals living in households classified as the lowest SES category . Infection was lower in those who reported using a net the previous night (41.0% compared to 50.0%).p < 0.001)  compared to the control arm (50.4%), with 43% lower odds of infection in the SET arm compared to the control arm (odds ratio (OR) 0.57 0.45–0.71), 1) Table ; Fig. 1., 1) TablIn the intervention clusters, there was a reduction in malaria infection prevalence for all age groups compared to those living in control clusters. Individuals reporting sleeping under a net the night before had lower infection prevalence in both arms. There was no evidence for an interaction between intervention arm and bed net use, suggesting that the benefit of living in a SET village was additional (not multiplicative) to the protection conferred by a bed net. However, individuals living in SET villages but not using a bed net had lower prevalence (42.8%) than those using a net in control villages (47.5%) with the biggest difference between those living in control villages and not using a net (60.2%) and those living in SET villages and using a net (33.8%).p = 0.019). Importantly, the trial was not designed to assess the differential impact of coverage so these results should be interpreted with caution. A sensitivity analysis was performed controlling for cluster baseline prevalence and showed a similar result (OR 0.76 (95% CI: 0.59–0.98), p = 0.031).Due to the range of coverage of SET in the intervention clusters (32% to 100% of households), we assessed the impact of intervention coverage on malaria infection prevalence. Seven clusters had SET coverage of 70% or lower. At baseline, infection prevalence in the 7 lower coverage clusters was similar to infection prevalence in the 14 clusters which had > 70% coverage  in clusters with coverage ≤ 70% and infection prevalence of 70.7% (95% CI: 48.4–88.5) in clusters with > 70% coverage). In the endline survey, clusters with ≤ 70% coverage had a mean infection prevalence of 43.4% (95% CI: 32.9–52.1) compared to a prevalence of 33.0% (95% CI: 23.7–56.3) in the clusters with coverage > 70%, suggesting a stronger effect of the intervention when coverage was higher. However, when comparing the lower coverage clusters to the control clusters, there was still evidence for a drop in prevalence in the lower coverage villages (OR 0.76 (95% CI: 0.60–0.95), p = 0.003) was similar to the impact for those households with SET. This suggests a community impact of the intervention, meaning that households benefited from others in their village having SET installed, regardless of whether they lived in houses with the intervention themselves.Thirty-five (25%) of the households  sampled in the intervention arm did not have SET. Individuals living in these houses had comparable infection prevalence (37.4%) to those who did have the intervention (36.5%). When compared to individuals living in control villages, the impact of living in a SET cluster for those households without SET (OR 0.57 (0.40–0.83), p = 0.025). Prevalence in the control arm reduced from 73.9% (95% CI: 67.7–79.3) to 69.4% (95% CI: 63.5–74.6) (p = 0.254), whilst the prevalence in the intervention arm reduced from 72.4% (95% CI 66.1–77.9) to 51.0% (95% CI: 45.8–56.1), p < 0.001, corresponding to a risk difference of 21.4% (95% CI: 13.8–29.0) . 36.4% (n = 1072) of participants had a microscopically detectable infection, 98% of which were Plasmodium falciparum or mixed infections. Plasmodium malariae infections were detected in 2% of slides (n = 66), whilst Plasmodium ovale infections were detected in 0.4% of slides (n = 13). Similarly, to the RDT results, the prevalence of microscopic infections were lower in participants living in intervention clusters (31.9%) compared to those living in the control clusters (41.4%) (OR 0.64 (0.44–0.93), p = 0.019).The majority of participants in the endline survey also had a blood smear taken for microscopy  of positive RDT results were also positive by microscopy. Whilst age patterns of infection prevalence appeared similar for the two diagnostics, the agreement between the two was lowest in older participants (only 36.5% and 31.1% of positive RDT results were positive by microscopy in 25–50 year olds and 50–100 year olds respectively). Mean parasite density was also lower in infections in those age groups (< 2000 trophozoites per ml) compared to younger age groups .p < 0.001).Cluster-level infection prevalence in the endline survey was associated with malaria case incidence measured in the child cohort at the end of the two years Fig. . ClusterNew paradigms of vector control tools are urgently needed if we are to continue the downward trajectory of malaria transmission that has been achieved over the past few decades. Housing modifications are a paradigm that has rarely been explored in cluster randomised trials. In this large trial, EaveTubes combined with house screening demonstrated a strong impact on malaria case incidence in Côte d’Ivoire . The curThe endline prevalence survey took place at the end of the transmission season, 18 months after the intervention had been installed. Bed net trials in Tanzania have shown that an intervention’s impact on prevalence can differ substantially in accordance with the timing of the survey, which may be a reflection of seasonality of transmission, or the ageing of the intervention . In the Infection prevalence was highest in children aged between 5 and 10 years old in both arms at endline. Together with children aged 10–15 years, these children were the least likely to have slept under a net—a finding that has been seen elsewhere in malaria endemic settings , 19. HowThere were considerable discrepancies between the results of the RDTs and the results of the microscopy. One explanation for differences between the diagnostics could be that RDTs are still detecting circulating HRP-2 from previous infections; however, only a small proportion of participants reported receiving treatment for malaria in the previous 2 weeks, the majority of whom were either positive by RDT or both microscopy and RDT. Other potential reasons for discrepancies could be other circulating infections causing false positives in RDTs , 22 or, One of the barriers to undertaking large scale trials, such as the Screening + EaveTubes trial in Côte d’Ivoire, is the limited number of funders who are willing or able to fund large cluster randomised control trials. Malaria case incidence can be an expensive and logistically challenging metric to collect, whereas prevalence is considerably cheaper to measure than incidence, due to the nature of the data collection . To illustrate efforts involved in active case detection for the incidence measure in this trial, the team undertook over 60,000 visits to approximately 2000 children over a 2-year period . In thisEpidemiological metrics are essential for a comprehensive evaluation of interventions and for those interventions to receive a recommendation from the WHO. In this high transmission setting, malaria case incidence and infection prevalence were similarly reduced in the SET intervention clusters, highlighting the usefulness of this intervention combination to reduce malaria transmission in this setting. Whilst the incidence measures collect interesting information regarding the differential impact over season and are likely the most useful metric in low transmission settings, infection prevalence may be a good option for more cheaply evaluating new products where transmission is moderate to high.Additional file 1. Map showing the location of the study villages in Bouaké, Côte d’Ivoire. The pie charts indicate the proportion of houses in each cluster that received the intervention.Additional file 2. Graph showing the association between endline infection prevalence and malaria case incidence in children aged 6 months to 10 years.


Background: Seasonal malaria chemoprevention (SMC) has been adopted and implemented in the southern regions of Senegal in children aged between three and 120 months since 2013. Scaling up this strategy requires its evaluation to assess the impact. This study was carried out to determine the dynamics ofPlasmodium falciparum carriage before and after two years of SMC implementation.Methods: Four household surveys were conducted in villages in the health district of Saraya, which is a SMC implementation area in Senegal. These villages were selected using probability proportional to size sampling. Each selected village was divided into segments containing at least 50 children. In each segment, a household questionnaire was administered to the parents or legal representatives of children aged three to 120 months. Blood smears were collected to determineP. falciparum prevalence by microscopy one month before the first round of SMC, one month after the last round of the first SMC campaign and two years after the start of the implementation.Results: A total of 2008 children were included with a mean average age of 4.81 (+/-2.73) years. Of the study population, 50.33% were more than five years old and 50.3% were male. In 2013, mosquito net ownership was 99.4 % before the SMC campaign and 97.4% after. In 2015, it was 36.6% before and 45.8% after the campaign. In 2013, the prevalence of plasmodium carriage was 11.8% before and 6.1% after the SMC campaign. In 2015, the prevalence was 4.9% before the administration of SMC and this increased up to 15.3% after. Malaria prevalence was high among children over five years old and in boys.Conclusions: The decrease inPlasmodium falciparum parasite prevalence, which subsequently increased after two years of SMC implementation in this study, suggests adding an extra cycle of the SMC or adjusting the administration period. This intervention has been shown to be effective, cost-effective, safe and feasible for malaria prevention among children under five years. This strategy has been adopted in many countries in sub-Saharan Africa for implementation in areas that meet the eligibility criteria ,. In order to optimize the fight against malaria, Senegal adopted SMC as one of malaria prevention strategies but extended the coverage to children aged between three and 120 months. This decision was based on the results from other studies conducted within the country that have shown that children aged 5–10 years old were as vulnerable as those under five years old. SMC was implemented in 2013 in the southeastern part of the country. To be more effective and performant, the door-to-door strategy was adopted, and drugs were administered by community volunteers. The effectiveness of this method has been demonstrated in studies conducted in many countries including Senegal, Gambia and Mali ,. WHO also advocated its regular surveillance based on epidemiological and biological arguments. In this context, this study was conducted to assess the dynamics ofPlasmodium carriage at the beginning and two years after the implementation of SMC in southern Senegal. The objective was to determine the prevalence of malaria before and after the first two mass distribution campaigns of SMC in order to assess the impact of this strategy.Seasonal malaria chemoprevention (SMC) is a prevention strategy for children that complements existing malaria control interventions. Previously known as intermittent preventive treatment of malaria in children (IPTc), SMC involves monthly antimalarial treatment with sulfadoxine-pyrimethamine plus amodiaquine (SPAQ) for up to four months to prevent malaria. It has been recommended by the World Health Organization (WHO) since March 2012, for children aged 3–59 months living in areas with intense and highly seasonal malaria transmission in the Sahel sub-region ,2. It is bordered in the south by the Republic of Guinea and in the east by the Republic of Mali . Therefore, Saraya district meets the eligibility criteria for the implementation of SMC as recommended by WHO.Malaria is a major public health problem because the overall incidence of malaria in the Kédougou region was 36.9% in 2019, with a proportional morbidity rate of 27% and the same proportion for the mortality rate. The latter was higher in children under five years of age (50%). Malaria is also endemic with a seasonal upsurge in transmission between July and November  where "S" is the number of segments, "int" is the integral, "N" is the total population of the village, "0.38" is the factor to be multiplied to the general population in order to get the total number of eligible children for our study, and "50" is the desired number of eligible children per segment.The villages were divided in segments, using the village maps provided by the National Agency for Statistics and Demography (NASD) and the Geography Department of University Cheikh Anta Diop de Dakar (UCAD). Based on the map and the approximate population, the village was divided into the number of segments calculated, in line with the natural boundaries (such as roads and paths). One of the segments was then drawn at random from the center of the village for the household survey and all the households in that segment were visited. If in this segment, the required number was not reached, the field team moved on to the next neighbor on the list.. A blood smear was taken to determine the prevalence of malaria using microscopy.A standardized questionnaire was administered to parents or care givers/guardians of each selected child to collect socio-demographic data and to assess the use of malaria prevention measures like the use of mosquito bed netsParasitological assessment. For each child, finger-prick blood samples were collected for thick and thin smear tests to determine malaria prevalence using microscopy. The staining and determination of the parasite density when a slide was positive was done according to the recommendations of the NMCP in its guide for the biological diagnosis of malaria . The reading was done by technicians from two different laboratories  according to the recommendations of the national guideline for the biological diagnosis of malaria . A comparison of the results of the two readings was made before selecting one. When they were identical, the given one was retained. On the other hand, when they were discordant (opposite results or a difference in parasite density greater than 25% for a positive result), a third reading was used. The final result was the one having two readings with the same result.Microsoft Excel 2019, 16.60 (22041000)(RRID:SCR_016137) file and analyzed usingEpi Info 7.1.3.3 software(RRID:SCR_021682). Quantitative variables (age) are expressed in terms of the mean with their standard deviation. Categorical variables, such as gender, age group and use of LLINs, are expressed as percentages with their confidence intervals. These different categorical variables were analyzed according to the period of the surveys, age groups and gender. Their proportions were compared using Chi-square test or Fisher exact test . The significance level of the different tests was set at 5 %. For the Chi-square, the determination of the p-value was done using the Mid-p exact proposed by the software used for the analysis.The data collected were entered into aNMCP. Epidemiological report, 2014.) and 2015  administration campaigns. The SMC coverages considered in this study were those of the latest rounds given by the NMCP after the 2013 . Written informed consent was obtained from the parents or legal representatives of potential child participant prior to enrolment in the study. To respect confidentiality, an identification code was given to each participant. Permission from the NMCP to use the SMC coverage data for the publication of this article was obtained from the coordinator who is one of the authors..Overall, 2008 children aged three to 120 months were enrolled in this study. This was made up of 498 and 491 children before and after the SMC campaign in 2013, while 547 and 472 children were enrolled before and after the 2015 campaign. Children under five years old represented 52.8% [CI 95%: 48.3–57.3%] of the children in the first survey, 43.6% [CI 95%: 38.2–48.1%] in the second, 47.3% [CI 95%: 43.1–51.6%] in the third and 51.5% [CI 95%: 46.9–56.1%] in the 2015 post-campaign survey. Young girls were predominant during the pre-campaign of 2013, 50.8% [CI 95%: 46.3–55.3%] and the two 2015 surveys, with 51.2% [CI 95%: 46.9–55.5%] for the pre-campaign and 51.91% [CI 95%: 47.3–56.5%] for the post-campaign. SMC coverage after the last round was 96.7% after the 2013 mass administration campaign and 90.4% after the 2015 campaign. Children who slept under a bed net the week before the surveys were higher in 2013: 99.4% [CI 95%: 98.1–99.8%] and 97.3% [CI 95%: 95.4–98.5%] respectively for the pre- and post-campaign compared to 2015, 36.6% [CI 95%: 32.6–40.8%] and 45.8% [CI 95%: 41.2–50.4%] 10.Plasmodium carriage rate of 11.8% in the first survey, 6.1% in the second, 4.9% in the third and 15.2% in the last.Plasmodium carriage was higher in older children (5–10 years) in all surveys. The prevalence was 7.2% in the 2013 pre-campaign, 4.7% in the 2013 post-campaign, 3.3% in the 2015 pre-campaign, and 9.1% in the 2015 post-campaign survey in older children. Among children under five years old, the prevalences were 4.6%; 1.4%; 1.6%; and 6.1% for the 2013 pre- and post-campaigns and 2015 pre- and post-campaigns, respectively. This difference in proportion between the two age groups was statistically significant for the majority of the surveys (the Chi-square gave a p= 0.01 for the pre- and post-campaign of 2013 and p= 0.02 for the 2015 post campaign) except for the 2015 pre-campaign survey where the p= 0.07.Microscopic examination of the blood smear during the different household surveys showed aPlasmodium carriage in girls was 6% and 2.6% respectively for the pre- and post-campaigns of 2013 and, 2.9% and 8.2% respectively for those of 2015. Among young boys, it was 5.8% before the campaign in 2013, and 3.5% after; 2% and 7% respectively before and after the 2015 campaign. Despite these differences, no statistical significative association was found between parasite carriage and gender in the surveys .According to gender,Plasmodium-positive slides, 16 (59.2%) had not slept under a net the night before the survey. The survey conducted one month after the 2015 campaign showed that 29 (40.3%) participants of the 72 with positive slides, had not slept under a bed net the previous night.Plasmodium falciparum was the prevalent species in this study regardless of the survey. The presence of other species such asPlasmodium malariae andPlasmodium ovale was also noted at low prevalence in the different surveys. Mixed infections withP. falciparum andP. malariae were found during the pre- and post-campaign surveys in 2015.P. falciparum gametocytes were identified on positive slides in the survey conducted in 2013 before SMC (0.6%), but also in the two surveys in 2015 (0.2% and 1.9% respectively before and after the campaigns)  had slept under a mosquito net the night before the survey. The survey conducted one month after the administration of SMC in 2013 found that of the 30 positive subjects only two (6.7%) had not used net the day before the survey. In 2015, the survey conducted one month before the SMC campaign showed that of the 27 participants that hadpaigns) 10.Plasmodium carriage during the first two years of the scaling up of the SMC in a mass campaign in Senegal. It was conducted in the region of Kedougou where malaria is a real problem for public health. A variation in the number of children recruited during the four surveys was noted during this study.This study determined the variations inNMCP. Annual report of NMCP activities 2014 in Senegal, 2014.). It could also be explained by the free mass distribution of LLINs organized by the NMCP throughout the country between 2012 and 2013 . The decrease in the parasite carriage observed in the first three surveys also reflects the decrease in malaria-related morbidity and mortality noted between 2013 and 2014 . This finding was shown in a study conducted in Senegal in 2009. This study estimated a considerable decrease in prevalence over the years of SPAQ administration.A decrease in parasite carriage was observed before the start of the SMC in 2013 and the survey one month after the mass administration campaign the same year, but also during the pre-campaign survey of 2015. This decrease could be explained by the higher SMC coverage rates in 2013 (95%) and 2014 (98%) . It could also be explained by the gradual decline in net usage rates noted between 2013 and 2015 in this study. This increase was also felt by an increase of malaria morbidity and mortality in the 2015 NMCP report .The rebound in parasitemia observed during the household survey one month after the 2015 campaign, despite good SMC coverage, could be explained by an increase in rainfall compared to 2014 ,. In Niger, a study assessing the dynamics ofPlasmodium carriage after the implementation of SMC also found that children over five years of age were those with the highest prevalence. This study reported higher parasite prevalence than those found in our study.P. falciparum was the most frequent species found in the present study and this further supports the choice of this area for the implementation of the SMC as recommended by WHO in its field guide for implementation. As in this study, other species ofPlasmodium parasites such asP. malariae andP. ovale were also found in other studies conducted in the Kedougou region where our study site was located. The presence of gametocytes in children, even if it is more important to ascertain their presence in children under five years old, during the different surveys, proves that they constitute a reservoir of parasites. The addition of low dose primaquine to SMC is an option to be considered. The effect of this medication on gametocytes has been proven by numerous studies, including one from Senegal .The higher parasite carriage in children over five years of age found in our study confirms the need to broaden the SMC target in Senegal as demonstrated by previous studies conducted in the country prior to the adoption of the strategy  for malaria control/eradication in Senegal. The study evaluates the prevalence of malaria parasite carriage before and after the implementation of SMC in the Saraya health district, southern Senegal. While the authors have presented a comprehensive analysis, there are a few key points that need to be addressed to further enhance the validity and impact of their findings. Overall, the study carries significant implications for malaria eradication efforts in Senegal. Addressing the points mentioned below will strengthen the methodological aspects of the research and increase the impact of the findings.The manuscript “Malaria parasite carriage before and two years after the implementation of seasonal malaria chemoprevention: a case study of the Saraya health district, southern Senegal” by Manga Methodology:Plasmodium spp., particularly for asymptomatic malaria patients with parasitemia levels below the detection limits of microscopy. One critical aspect that requires clarification is the limit of detection for parasitemia. Given that the study aims to assess the impact of SMC on malaria parasite carriage, it is essential to specify the sensitivity threshold of the methods used for parasite detection. The introduction of ultra-sensitive PCR (uPCR) has revolutionized the detection of Minor Comments: Figure 1 Resolution: The authors should address the issue of low resolution in Figure 1, which hinders the proper display of the Senegal map in the insert. Enhancing the resolution will improve the clarity of the map and facilitate better understanding for readers.Is the work clearly and accurately presented and does it cite the current literature?YesIf applicable, is the statistical analysis and its interpretation appropriate?YesAre all the source data underlying the results available to ensure full reproducibility?YesIs the study design appropriate and is the work technically sound?YesAre the conclusions drawn adequately supported by the results?YesAre sufficient details of methods and analysis provided to allow replication by others?YesReviewer Expertise:NAI confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. Version 2 of the article appears better and and overall improves the quality of reporting done by the authors.Is the work clearly and accurately presented and does it cite the current literature?PartlyIf applicable, is the statistical analysis and its interpretation appropriate?PartlyAre all the source data underlying the results available to ensure full reproducibility?YesIs the study design appropriate and is the work technically sound?YesAre the conclusions drawn adequately supported by the results?YesAre sufficient details of methods and analysis provided to allow replication by others?YesReviewer Expertise:Malaria Molecular/Serological diagnostics, Molecular Epidemiology of Drug Resistance, Malaria MicroscopyI confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. Summary: The research report presented by Manga IA et al presents an important finding in Senegal addressing a key aspect of the impact of seasonal malaria chemoprevention strategy in Sahel regions of Africa. These findings will hopefully contribute to the growing body of literature on the widespread implementation of SMC in Africa. A few comments to improve the quality of the work are presented below. Once the comments have been addressed, the whole article should be proofread for english language.Introduction and Methods: The research work is clearly presented but lack some elements that improve the accuracy of background information. First the first paragraph of the manuscript describes SMC as a targeted strategy but does not say clearly the target of the strategy. This should be clear before the third sentence of this introduction to provide a clear context reading further.Is the study design appropriate and does the work have academic merit? Was this study conducted as ancillary to another study? If yes, this should be indicated to provide more context.Are sufficient details of methods and analysis provided to allow replication by others? The study design is appropriate for testing parasite rates in the community in the context of seasonal malaria chemoprevention.  The statistics analysis section needs to be re-written to identify what variables the authors referred to, and how they were handled. In addition, there is a need to precise what statistical tests were used to compare parasite rates and justification for the choice of statistical methods provided. The authors should proofread the manuscript/article for english language and tenses used. There needs to be consistency in language to ease reading. The section on ethical considerations should be detailed. Did the authors obtain assent for children 9-10 years old? If yes, how, if no, why not?  In addition, the authors are dealing with huge datasets. Did the authors obtain permission for potential publication of research results?Are all the source data underlying the results available to ensure full reproducibility?   Yes, this is an important criterion for reproducibility and integrity in scientific research.  In the results section table 2, the p values reflect a comparison of parasite rates between the two age groups or between the pre- and post surveys? This needs to be clearly reflected. perhaps the table title should change to clearly and specifically reflect the statistics. I will suggest that comparisons for pre- post surveys be separated from comparisons between age groups of the study population. Conclusion:Are the conclusions drawn adequately supported by the results? The conclusions are adequately supported by the results obtained. Perhaps, the Authors should formulate a recommendation for a more formal assessment superposing epidemiological and rainfall data to support the proposal to add another cycle of the SP and AQ administration.Is the work clearly and accurately presented and does it cite the current literature?PartlyIf applicable, is the statistical analysis and its interpretation appropriate?PartlyAre all the source data underlying the results available to ensure full reproducibility?YesIs the study design appropriate and is the work technically sound?YesAre the conclusions drawn adequately supported by the results?YesAre sufficient details of methods and analysis provided to allow replication by others?YesReviewer Expertise:Malaria Molecular/Serological diagnostics, Molecular Epidemiology of Drug Resistance, Malaria Microscopy,I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. Thank you for the suggestions and recommendations to improve the quality of this article. We have taken them into account in the new version resubmitted to the journal. Introduction and method  We have added the WHO recommended SMC target as you suggested. Yes, this study was also conducted to assess the impact of this strategy on the molecular markers of Plasmodium resistance to the drugs used. We think that adding it in the context could be confusing. That is why we have not added it in the new version submitted for publication. Statistical analysis We have rewritten this section to clarify the nature of some of the variables. In addition we have also given the tests used for each comparison. The p-value given in Table 2 corresponds to a comparison of the different categories of each survey as indicated at the bottom of the table. Ethical considerations We only asked for parental consent for their child's participation in this study. We thought that assent should be obtained in adolescence, i.e. at an age above 10 years. The use of other data besides the study data was done with the permission of the competent authorities. The CMS coverage data used here was only possible with the endorsement of the NMCP, some of whose members are among the authors of this article.Conclusion  The proposal to link our data with rainfall and epidemiological data is very relevant to justify the need to adapt the administration cycles. This perspective will be taken into account in the correction of the next version.