Placental malaria (PM) poses life-threatening complications to pregnant women as they are at increased risk of maternal and perinatal morbidity and mortality associated with malaria. This study examined the factors associated with placental malaria in the Upper West Regional Hospital (UWR).A cross-sectional hospital-based study was carried out among pregnant women delivering at Upper West Regional Hospital. A cross-sectional screening survey was conducted from January 2019 to April 2019. Three hundred eligible mothers were consecutively recruited. A record review of their maternal and child history was assessed using a checklist. Placental blood samples were taken for microscopy to determine placental malaria parasitemia. Logistic regression analysis was done to determine the factors associated with placental malaria at 95 % confidence level.Plasmodium falciparum was the only species identified in those with PM. Majority of the women 66.7 % (14/21) with placental malaria had parasite density in the range 501 to 5,000 parasites/µL. Obstetric and health service factors that were significantly associated with placental malaria were gravidity and antenatal care (ANC) attendance. Primigravida  and having less than 4 ANC attendance  were found to be significantly associated with placental malaria.The proportion of mothers with placental malaria was 7 % (21/300), . The proportion of women with PM was relatively low. Primigravid mothers reporting less than 4 ANC visits had the highest risk of placental malaria. Expectant mothers should be encouraged to attend at least 4 ANC visits prior to delivery. Malaria in pregnancy is a serious public health issue globally as it poses life-threatening complications to both the mother and the fetus. Globally, over 50 million pregnant women are at risk of malaria in pregnancy annually . The burPlasmodium falciparum species [Placental malaria in sub-Saharan Africa is usually from infection with  species . FollowiP. falciparum, nulliparity poses a greater risk compared with multiparity [P. falciparum erythrocyte membrane binding protein (PFEMP1) known as Variant2 chondroitin sulfate antigen (VAR2CSA) which is peculiar to pregnant women only. The expression of this antigen enables parasitized red blood cells (RBC) bind to oncofetal chondroitin sulfate receptor in the placenta, resulting in sequestration of the parasites in the placenta [Among the many documented factors that contribute to a high risk of placental malaria with tiparity . This isplacenta . ImmunitThe prevalence of placental malaria varies across geographical settings in Africa, ranging from 8 %  to 65 % Specifically in Ghana, malaria in pregnancy accounts for 14 % of Out Patients Department (OPD) attendance, 11 % of hospitalized admission and 9 % of maternal deaths  to 52 % We assessed the proportion of mothers with placental malaria and the associated factors among pregnant women reporting to the maternity ward of Upper West Regional Hospital in Ghana. While similar studies have been conducted elsewhere, area-specific studies such as the current one are key to informing appropriate area specific interventions based on the scope and peculiar associated factors of the problem of placental malaria in the defined area. The study was a hospital based cross-sectional study with a quantitative approach conducted between January 2019 to April 2019 who were recruited at the Upper West Regional Hospital.This study involved pregnant women who presented at the labor unit of the Regional Hospital for delivery. All pregnant women who delivered at the Upper West (Wa) Regional Hospital during the study period and consented to the study were included. Pregnant women who were Glucose 6 phosphate dehydrogenase (G6PD) deficient, less than 28 weeks at the time of delivery and those requiring specialized care for conditions such renal failure and heart disease in pregnancy were excluded from the study due to higher vulnerabilities during delivery and associated limitations in obtaining informed consent. The study was conducted at the Maternity Unit labor ward of the Upper West Regional Hospital, a 196 bed-capacity hospital with 49 beds for obstetrics and gynecology that serves as the major referral center for the region and neighboring Burkina-Faso. The labor ward conducts a monthly average of 200 deliveries.oC and to as high as 40.0oC during the year. The total population of the region is 786,050 of which women in the fertile age (WIFA) forms 24 % [The Upper West region has a tropical climate with temperatures ranging from as low as 22.6rms 24 % .The sample size was estimated with a PM prevalence of 52 %  reportedA structured interview guide was designed and used to interview mothers after delivery. The questions included socio-demographics , the use of insecticide treated bed nets and indoor residual spraying (IRS) exposure among others. A checklist (designed with Enketo software) was used to collect maternal data from the maternal and child health records booklet of respondents. The variables included obstetric variables (Number of pregnancies - Gravidity and ANC attendance), medical history  and health service factors . The maternal records data were cross checked by asking the mothers the same questions, and any discrepancies reconciled or participants dropped if discrepancies could not be reconciled. A total of 4 research assistants (Midwives) were trained to administer the screening survey.Eligible participants had their placental blood taken immediately after delivery of the placenta. The delivered placenta was placed in a wide kidney dish with the maternal side facing upwards. A sterile soaked gauze with savlon was used to clean the maternal site of the placenta. An incision of about 1.5 cm deep was made in the mother’s part of the placenta through the intervillous space with a scalpel blade and a 5 cc syringe used to collect 3mls of placental blood from the pool of blood into ethylenediaminetetraacetic acid (EDTA) bottle.Thick and thin stains were prepared using 3 % Giemsa stain following standard protocol. The slides were read by a biomedical scientist under light microscope and those that were positive for malaria parasites were recorded in terms of parasite density (counts). For quality control purposes, the slides were read by two biomedical scientists. Where there were discrepancies, a third reading by an independent biomedical scientist was taken as the result. The placental malaria parasite density was also estimated. The determined malaria parasite density was further categorized into low parasite density, moderate parasite density and high parasite density according to the WHO classification. Low parasite density was malaria parasite density ≤ 500 parasites/µl, moderate parasite density was from 501 parasites/µl to 5,000 parasites/µl and high parasite density was > 5,000 parasites/µl. Those samData cleaning was done in Microsoft Excel and later imported into STATA version 15 software  for analysis. Descriptive statistics was performed for all variables and expressed as frequencies and proportions. The quantitative variables were expressed as medians and interquartile range. The proportion of mothers with placental malaria was estimated via proportion of those respondents who tested positive for placental malaria. Using simple logistic regression, we tested the association between Placental Malaria (PM) and IPTp-SP intake, maternal age, gravidity and ITN use which we reported as crude odds ratios. Multivariable logistics regression models were fitted using backward stepwise approach to assess the effect of multiple factors on placental malaria. Independent Factors which yielded statistical significance were included in the model to generate adjusted odds ratio (AOR) with significance considered at 95 % CI.A description of the respondents is given in Table Table Plasmodium falciparum species. The parasite density ranged from 237 parasites/ µl to 70,821 parasites/ µl. The median parasite density was 2,315 . Figure The proportion of placental malaria parasites among women delivering at the Upper West Regional Hospital was 7 % 21/300), . All the placental malaria cases were /300,  between socio-demographic factors and placental malaria are presented in Table The association  between obstetric and health service factors and placental malaria are presented in Table The predictors  of placental malaria are presented in Table The study revealed a low proportion of mothers with placental malaria delivering at the Upper West Regional Hospital. In contrast, a high percentage (52 %) was recorded in a prospective study conducted by van Spronsen et al.,  in the nIn this study, majority of the women (67 %) with placental malaria had parasite density in the range of 501 to 5000 parasites/µl. This is similar to a study conducted by Babalola et al., (2015) where microscopy technique was used to detect placental malaria with about 60 % of the positive samples having parasite density in the range of 501 to 5000 parasite/µl .This study has shown that primigravida has a threefold increase in odds of placental malaria compared with multigravid women. This finding is consistent with several studies detailing the significant association between women who become pregnant for the first time and placental malaria compared with their counterparts entering their second or more pregnancy. A prospective cohort study on women delivering at a hospital in Papua New Guinea documented a two times increased in odds of placenta malaria in primigravid mothers compared with multigravida counterparts . NdeseruPlasmodium parasite exposure. Placental malaria occurs when the Plasmodium infested red blood cell bind to chondroitin sulfate A (CSA) in the intervillous regions of the placenta leading to sequestration [Plasmodium infection resulted in the production of antibodies that will bind to chondroitin sulfate A (CSA) in subsequent pregnancies thereby interfering with adhesion of infected Plasmodium red blood cells to CSA [It is a consensus from several researches that primigravid or nulliparous women are more susceptible to placental malaria. This stems from the fact that the immune system of primigravid women is being primed for the first time in the pregnancy in relation to stration . In secus to CSA . This phFrom this study, statistically significant association was found between women attending less than four antenatal visits and placental malaria. These women had 9 times increased odds of having placental malaria compared with women who met the WHO recommended visits. A study conducted in Sudan also reported 11 times increased odds of placental malaria among women who did not meet the recommended WHO ANC visits , 22. ThiSuperior diagnostic method such as histopathology of placental tissue could improve the diagnostic capabilities and possibly increase the number of positive cases of placental malaria, hence giving a better picture of the prevalence.We also recognize that while the overall study sample size of 300 participants was based on appropriate sample size estimations, the small yield of 21 PM cases (7 % of study participants), which was not within our control, may nevertheless limit the rigorousness of our inferential statistical analysis.Additionally, while an alternative study design such as Case-Control study may have been better suited for this study, the lack of sufficient appropriate controls in the study area during the study period did not allow for such a design to be utilized.The study revealed a relatively low proportion of mothers with placental malaria among mothers who delivered at the Upper West Regional Hospital. Low ANC attendance as well as primigravida were strong predictors of placental malaria. This suggests improved ANC attendance may be beneficial in preventing placental malaria.


Malaria remains a major public health concern in the Democratic Republic of Congo (DRC), and school-age children are relatively neglected in malaria prevalence surveys and may constitute a significant reservoir of transmission. This study aimed to understand the burden of malaria infections in school-age children in Kinshasa/DRC.A total of 634 (427 asymptomatic and 207 symptomatic) blood samples collected from school-age children aged 6 to 14 years were analysed by microscopy, RDT and Nested-PCR.Plasmodium spp. by microscopy, RDT and PCR was 33%, 42% and 62% among asymptomatic children and 59%, 64% and 95% in symptomatic children, respectively. The prevalence of Plasmodium falciparum, Plasmodium malariae and Plasmodium ovale spp. by PCR was 58%, 20% and 11% among asymptomatic and 93%, 13% and 16% in symptomatic children, respectively. Among P. ovale spp., P. ovale curtisi, P. ovale wallikeri and mixed P. ovale curtisi + P. ovale wallikeri accounted for 75%, 24% and 1% of infections, respectively. All Plasmodium species infections were significantly more prevalent in the rural area compared to the urban area in asymptomatic infections (p < 0.001). Living in a rural as opposed to an urban area was associated with a five-fold greater risk of asymptomatic malaria parasite carriage (p < 0.001). Amongst asymptomatic malaria parasite carriers, 43% and 16% of children harboured mixed Plasmodium with P. falciparum infections in the rural and the urban areas, respectively, whereas in symptomatic malaria infections, it was 22% and 26%, respectively. Few children carried single infections of P. malariae (2.2%) and P. ovale spp. (1.9%).The overall prevalence of School-age children are at significant risk from both asymptomatic and symptomatic malaria infections. Continuous systematic screening and treatment of school-age children in high-transmission settings is needed.The online version contains supplementary material available at 10.1186/s12936-021-03919-4. Despite a widespread reduction in malaria-associated morbidity and mortality in the past decade, malaria remains a major public health problem in sub-Saharan Africa. In 2018, an estimated 228 million cases of malaria resulting in 405,000 deaths occurred worldwide, of which 93% of cases and 94% of deaths occurred in Africa  were used as references. From the sequence data sets, a phylogenetic tree was generated using the NJ method. According to the phylogenetic tree, the samples were assigned species designations based on clustering with the reference sequences.Seventy one out of 79 Plasmodium spp. infection prevalence. Odds ratios (ORs) and 95% confidence intervals (CIs) were derived. Significance was set at p < 0.05.Data was double-entered and validated in EPI INFO version 3.5.1 and analysed using STATA version 14.2 . Descriptive variables were analysed as proportions  or by median/mean (continuous variables). Chi-square tests (or Fisher’s exact tests when appropriate) and logistic regression analysis were used to assess associations between independent variables and The study was approved by the Ethics committees of the School of Public Health, Kinshasa University, DRC  and the Institute of Tropical Medicine, Nagasaki University . Written informed consent was obtained from children’s parents/guardians and assent from children ≥ 7 years old were sought. The written informed consent document was provided either in French  or Lingala  depending on the parent’s educational background. All malaria positive cases with RDTs were treated according to national malaria diagnosis and treatment guidelines.A total of 634  children aged 6 to 14 years old were included in this study.Their median (interquartile range) age was 9 7–11)  in the rural area, and 9 (7–10)  in the urban area. Children aged 6 to 9 years accounted for 59.7% (188/315)  in the rural area, and 63.3% (202/319)  in the urban setting; 49.5% (156/315)  in the rural area, and 51.4% (164/319)  in the urban setting were females  asymptomatic school-age children who were interviewed, most of children (≥ 80%) lived together with their parents in both rural and urban areas, 60% had at least one mosquito bed net and 31% slept under a mosquito net the night before the interview in the rural area whereas 28% had at least one mosquito bed net and 25% slept under a mosquito net the night before in the urban area  went to a health centre. Forty-four percent of children reported having self-medicated (of which 33% had used sulfadoxine/pyrimethamine (SP) and 11% artemisinin-based combination therapy) given by their parents without a confirmed malaria diagnosis. Fifty-two percent of children missed classes and among these, 39% missed five days or more  went to a health centre. Seventeen percent of children reported having self-medicated with anti-malarial drugs  given by their parents without a confirmed malaria diagnosis. Forty-four percent of children missed classes and among these, 38% missed five days or more , fatigue (50%), lack of appetite (49%) and abdominal pain (48%) in the urban setting as major symptoms  attending health facilities had fever symptoms (100%), followed by vomiting (37%), fatigue (28%) and diarrhoea (23%) in the rural area Plasmodium spp. was 33%, 42% and 62% among asymptomatic children and 59%, 64% and 94% in symptomatic children by microscopy, RDT and PCR, respectively . No P. vivax infections were observed , whereas in symptomatic infections, ed Table .Table 2CP. ovale spp., 53 (75%), 17 (24%) and 1 (1%) harboured P. ovale curtisi, P. ovale wallikeri and mixed P. ovale curtisi + P. ovale wallikeri infections, respectively. Plasmodium ovale curtisi was more frequent than P. ovale wallikeri in the rural area (86.0 vs 14.0%) while they were equally distributed in urban area (48% vs 48%) with one child (5%) harbouring a mixed P. ovale curtisi + P. ovale wallikeri infection  resided in the rural area and 192 (98 asymptomatic and 94 symptomatic) in the urban setting.P. falciparum, 73 (27%) [66 (39%) asymptomatic and 7 (7%) symptomatic] carried P. malariae, and 54 (20%) [35 (21%) asymptomatic and 19 (19%) symptomatic) carried P. ovale spp. parasites  [161 (96%) asymptomatic and 100 (98%) symptomatic] carried P. falciparum, 37 (19%) [19 (19%) asymptomatic and 18 (19%) symptomatic] carried P. malariae, and 25 (13.0%) [11 (11.2%) asymptomatic and 14 (18%) symptomatic] carried P. ovale spp. parasites  [87 (89%) asymptomatic and 92 (98%) symptomatic] carried P. falciparum, P. malariae and P. ovale spp., in asymptomatic participants in the rural area , 3 (1.8%) and 4 2.4%) single infections of .4% singlP. malariae and P. ovale spp. in asymptomatic children compared to symptomatic children in the rural area  [72 (43%) asymptomatic and 22 (22%) symptomatic]  and P. ovale spp.  than those aged 6 to 9 years. In the urban area, however, older children were more likely to carry P. falciparum than younger children   . Other investigated factors were not associated with increased risk of asymptomatic malaria infection . Table S4. Symptoms of outpatient school-age children at admission (N = 207). Table S5a. Association between age and gender with asymptomatic malaria infection in rural and urban areas. Table S5b. Association between age and gender with symptomatic malaria infection in rural and urban areas. Table S6a. Association between age / gender with asymptomatic malaria single and mixed infection in rural and urban areas. Table S6b. Association between age / gender with symptomatic malaria single and mixed infections in rural and urban areas. Table S7. Predictors of asymptomatic malaria infection . Note: COR: Crude odds ratio; CI: Confidence interval; AOR: Adjusted odds ratioAdditional file 2: Figure S1. Species composition of Plasmodium infections in 98 asymptomatic  and 94 symptomatic  children in the urban Selembao health zone (HZ), and 168 asymptomatic  and 102 symptomatic  children in the rural Mont-Ngafula 2 HZ. The urban Selembao HZ: Single and mixed infections in asymptomatic (A) and symptomatic (B) children. Malaria parasite species composition in asymptomatic (E & I) and symptomatic (F & J) children. The rural Mont-Ngafula 2 HZ: Single and mixed infections in asymptomatic (C) and symptomatic (D) children. Malaria parasite species composition in asymptomatic (G & K) and symptomatic (H & L). Pf = Plasmodium falciparum, Pm = Plasmodium malariae, Po = P. ovale wallikeri and P. ovale curtisi .


Malaria and anaemia jointly remain a public health problem in developing countries of which Malawi is one. Although there is an improvement along with intervention strategies in fighting against malaria and anaemia in Malawi, the two diseases remain significant problems, especially in children 6–59 months of age. The main objective of this study was to examine the association between malaria and anaemia. Moreover, the study investigated whether socio-economic, geographic, and demographic factors had a significant impact on malaria and anaemia.The present study used a secondary cross-sectional data set from the 2017 Malawi Malaria Indicator Survey (MMIS) with a total number of 2 724 children 6–9 months of age. The study utilized a multivariate joint model within the ambit of the generalized linear mixed model (GLMM) to analyse the data. The two response variables for this study were: the child has either malaria or anaemia.The prevalence of malaria was 37.2% of the total number of children who were tested using an RDT, while 56.9% were anaemic. The results from the multivariate joint model under GLMM indicated a positive association between anaemia and malaria. Furthermore, the same results showed that mother's education level, child's age, the altitude of the place of residence, place of residence, toilet facility, access to electricity and children who slept under a mosquito bed net the night before the survey had a significant effect on malaria and anaemia.The study indicated that there is a strong association between anaemia and malaria. This is interpreted to indicate that controlling for malaria can result in a reduction of anaemia. The socio-economic, geographical and demographic variables have a significant effect on improving malaria and anaemia. Thus, improving health care, toilet facilities, access to electricity, especially in rural areas, educating the mothers of children and increasing mosquito bed nets would contribute in the reduction of malaria and anaemia in Malawi. Malaria, Anaemia, Correlation, Children under five years of age, Multivariate joint model, MMIS 2017, Public health, Infection disease, Nutrition. MalariaPlasmodium parasites, such as P. falciparum, P. vivax, P. ovale, P. malariae and P. knowlesi, with P. falciparum the most prevalent parasite in the African region  estimated approximately 219 million cases of malaria in 2017, with 200 million from Africa . In addiThe World Health Organization defines anaemia as a reduction of hemoglobin in blood cells, which causes the body tissues to not have enough oxygen. In women, men or children, anaemia can be categorized as mild, moderate, and severe. In children 6–59 months of age, when the hemoglobin concentration level is less than 11 g/dl, the child is considered anaemic . HoweverGlobally, approximately 1.62 billion people are affected by anaemia and this accounts for more than 24.8% of the world population, around 43% from developing countries, and 47.4% of these are children . In MalaThe main causes of anaemia are nutritional deficiencies and infection diseases such as HIV, intestinal worms, intake of iron, folate, vitamin B12, malaria and other parasitic infections . HoweverThere are very few studies on modelling both childhood anaemia and malaria simultaneously as many studies showed that the young children are more vulnerable to both . In addiRelevant literature reveals that numerous researchers proposed different statistical models to analyze the association between malaria and anaemia in children .In Malawi, the study by Therefore, the current study aimed to simultaneously model the association between malaria and anaemia and identify factors associated with the two diseases by utilizing the joint model for a multivariate generalized linear mixed model (GLMM) using the 2017 MMIS.22.1Malawi is one of the African countries and is among the Sub-Saharan African nations located south of the equator and surrounded by Tanzania in the North and Northeast; by Mozambique toward the East and Southwest; and Zambia toward the West and Northwest . Malawi Anopheles mosquitos and the mosquitos increase in the rainy season from November to April. The climate is cool and dry from May to August during which the transmission of malaria reduces compared to the rainy season . The data was gathered between 15 April and June 2017 and executed by the Malawi National Malaria Control Program (NMCP) through help from the President's Malaria Initiative (PMI). The United States Agency for International Development (USAID) offered money related help through the President's Malaria Initiative (PMI). They likewise supported the undertaking by offering specialized help with the administration of community and wellbeing studies as they do in nations around the world . The overseeing group of Malawi gave staff office space, and key assistance. From there on, the ICF offered specialized help through the Demographic and Health Survey (DHS) program. The ethical approval was evaluated and granted by the Malawian Ministry of Health Research and Ethics Committee with the support of the Institutional Review Board of ICF International.2.3Women between 15-49 years of age and children from 6-59 months who stayed in or visited the selected households the night before the survey were included in the interview. The 2017 MMIS was a population based on a household cluster survey and the sampling survey followed the two-stage sample design. Furthermore, the 2017 survey enables assessments of key malaria indicators for the nation as a whole, for urban and rural areas independently, and for all of the three administrative territories in Malawi: Northern, Central, and Southern.The first stage of sampling comprised a selection of 150 clusters from the enumeration areas (EAs) outlined in the 2008 Population and Housing Census. Among the 150 clusters, 60 were from urban and 90 from rural areas. The second stage of sampling involved the systematic selection of a sample of 3 750 households. Of these households, 25 households were selected from each enumeration area (EA) .The study used a total weighted number of 2 724 children 6–59 months of age to establish a national-level portrait . The stu2.4Children aged 6–59 months were tested for both anaemia and malaria with the parents' or guardians’ consent. Trained nurses were responsible for the testing and the children who tested positive were given medication on the spot, according to the national rules.2.4.1Blood samples were collected from each child aged 6–59 months using a spring-loaded, sterile lancet to make a finger- or heel-prick. The drop of blood was collected in a microcuvette, and the Haemoglobin level analysed using a portable HemoCue analyzer. The results were available within 10 min and were given to the child's parent or guardian verbally and in writing . Parents2.4.2The blood sample was collected from children's finger- or heel-prick using the SD Biolne Malaria Ag P.f/P, a rapid diagnostic test (RDT). Malaria testing can be done using microscopy or rapid diagnostic test; however, in this study the RDT was considered.Microscopic diagnosis is helpful in testing malaria, although it does have some limitations; these include inadequately trained microscopists, lack of quality control, the chance of misdiagnosis because of low parasitemia or blended diseases, and in some cases it is hard to determine the types of plasmodium. Moreover, microscopy services are not accessible, for example, in a remote area or after standard laboratory hours . Thus, f33.1The present study considered two response variables or dependent variables. The first one was anaemia status for children 6–59 months of age. The anaemia status in children is determined based on the hemoglobin concentration level in the blood measured in grams per deciliter (g/dl). When the hemoglobin concentration level adjusted for altitude is less than 11 g/dl, the child is reviewed as anaemic, otherwise not anaemic . The sec3.2The exploratory covariate or independent variables used in this study were also used in previous literature and involved a number of socio-economic, demographic, and geographic factors . The pre4The present study used Statistical Package for the Social Sciences (SPSS) to clean the data. In addition, the analysis of bivariate method was done in SPSS, with the application of cross-tabulation techniques. Pearson's chi-square test and p-values were used to investigate whether the independent variables were associated with each one of the responses variables or not. To summarize the data, the frequencies and percentages were used, and p-values to check the relationship between exploratory variables and response variables. Any exploratory variables with a p-value of less than 0.2 were included in the multivariate generalized linear mixed model (GLMM) . Then an4.1i and i. In this way, the binary generalized linear model can be written as:The study considered two response variables, which were malaria and the anaemic status of a child. Suppose the response variable te model .4.24.2.1The results from The results from The results from 4.2.2The analysis of multivariate used SAS 9.4 PROC GLIMMIX procedure to assess the correlation between anaemia and malaria and any other covariates factors which might be associated with the two diseases. In addition, we checked all possible interaction effects between the exploratory variables and none was statistically significant, hence these were not included in the results.The results from The results from The same results showed that children from mothers with post-primary levels were 0.505  times less likely to have malaria compared to those from the mother with no education. The children from mothers with primary school were 0.710  times less likely to have anaemia compared with those in the reference category group. The results revealed that the odds of testing positive malaria in an RDT for children from households with no access to electricity were 2.296  times more likely than those from households with access to electricity. The same results indicated that children from households with no access to electricity were 1.279  times more likely to have anaemia compared to those from households with access to electricity.The study also revealed that children from a household with pit latrines were 0.625  times less likely to test positive for malaria than those with no toilet facilities, while those from households with flush toilet were 0.470  times less likely to have malaria compare to those with no toilet facilities. Furthermore, children from households with flush toilets were 0.580  times less likely to have anaemia, compared to those with no toilet facilities.The results indicated that the odds of testing positive malaria in an RDT was 1.586  times more likely in households with no children slept under a mosquito bed net the night before the survey, compared to households with all children slept under a mosquito bed net.However, the odds of having anaemia in some children who slept under a mosquito bed net the night before the survey, were 1.439  times more likely than all children who slept under a mosquito bed net.However, the children living in rural and altitude residence areas were not statistically significant to anaemia, hence we did not interpret the results.The overall fitted model was highly significant as the coefficient of covariance parameter indicated the p-value = 0.000. Hence, including the random cluster effect in the model was necessary .The pseudo-likelihood test rejected the null hypothesis of zero correlation with Pearson chi-squared test = 4591.22 and the ratio of Pearson and degree of freedom of 0.91 with p-value = 0.000. This revealed that there is a good variability in the dataset and there was no residual over dispersion . Further5The present study utilized the joint model for a multivariate generalized linear mixed model (GLMM) to simultaneously model the association between malaria and anaemia and identify factors associated with the two diseases. The study indicated that anaemia and malaria are highly associated. This means that malaria and anaemia move in the same direction, where any increase of malaria in children, will also result in an increase of anaemia. This finding is consistent with existing literature . The samThe findings from this study revealed that children from mothers with primary and post-primary education level were less likely to have both malaria and anaemia compared to those from mothers with no education. This shows that the risk of having malaria or anaemia reduces as the education levels of their mothers increases. The findings from this study are aligned with the studies by The results indicated that children from households with no access to electricity have more risk of having malaria and anaemia. Furthermore, households with no toilet facilities are more likely to increase the rates of positive malaria RDT and anaemia. Access to electricity and toilet facilities are indicators of socio-economics. Therefore, households with access to socio-economics can easily access healthcare, are able to eat healthy food and can easily afford the treatment .Anopheles mosquitoes which is the cause of malaria .This work was supported by the The data that has been used is confidential.The authors declare no conflict of interest.No additional information is available for this paper.


Plasmodium falciparum monoinfection were assessed for clearing parasites after starting artemisinin combination therapy (ACT). The median (range) time to clear half of the initial parasites was 5.6 (1.5 to 9.6) h, with 20% of patients showing a median of 8 h. There was no correlation between parasite clearance and initial parasitemia, blood cell counts, or mutations of P. falciparum gene Pfkelch13 (the molecular marker of artemisinin resistance [AR]). The in vitro ring-stage survival assay (RSA) revealed one (of four) culture-adapted strains with a quantifiable resistance of 2.01% ± 0.1% (mean ± standard error of the mean [SEM]). Regression analyses of in vivo and in vitro measurements of the four CHT strains and WHO-validated K13 resistance mutations yielded good correlation , strengthening evaluation of emerging AR with small sample sizes, a challenge in many low/moderate-prevalence sites. There is an urgent need to deploy multiple, complementary approaches to understand the evolutionary dynamics of the emergence of P. falciparum resistant to artemisinin derivatives in countries where malaria is endemic.Emerging resistance to artemisinin drugs threatens the elimination of malaria. Resistance is widespread in South East Asia (SEA) and Myanmar. Neighboring Bangladesh, where 90% of infections occur in the Chittagong Hill Tracts (CHTs), lacks recent assessment. We undertook a prospective study in the sole district-level hospital in Bandarban, a CHT district with low population densities but 60% of reported malaria cases. Thirty patients presented with malaria in 2018. An increase to 68 patients in 2019 correlated with the district-level rise in malaria, rainfall, humidity, and temperature. Twenty-four patients (7 in 2018 and 17 in 2019) with uncomplicated  Plasmodium falciparum, the most virulent of human malaria parasites responsible for the major burden of disease. Yet, over 400,000 deaths and 228 million worldwide cases of malaria occurred in 2018 (https://nmcp.gov.bd). Over 90% of malaria cases occur in the Chittagong Hill Tracts (CHTs) in three districts, Khagrachhari, Rangamati, and Bandarban, which border Myanmar , spreading from South Asia with devastating effects for malaria morbidity/mortality in Africa 30 years ago –6. Artem–7–P. falciparumkelch13 (K13) as a molecular and major causal marker of AR in P. falciparum malaria  infection from patient circulation, in response to drug treatment , 12. Sub malaria . Reports malaria . But, in malaria , 16. Pol malaria , an in vsistance , 19 as wsistance .in vivo parasite clearance in the CHTs have not been done. A major challenge is that CHTs are remote and rural  by application of PCR-based technologies to infected blood from patients is well established and widely utilized in Bangladesh , 22 Howend rural . Here, wIn vivo parasite clearance studies in Bandarban Sadar Hospital were undertaken over 2 years, from 2018 to 2019  negative (as found for one patient in 2018) despite having malaria symptoms  studies. The remaining 5 showed initial parasitemias below 1,000 parasites/μL, the threshold level for inclusion in PCT measurements. However, all 14 were subjected to K13 marker analyses and hematological assessments. Four were evaluated in the RSA. In 2019, all 68 patients who presented with malaria symptoms were RDT positive, and 27 met inclusion criteria of P. falciparum monoinfection without additional factors. Eighteen who showed an initial parasitemia of ≥1,000 parasites/μL were enrolled in PCT studies . to 2019 . In 2018P. falciparum infections were dominant, only about a third could be utilized for PCT studies due to other complications of presentations or insufficient threshold parasitemia. One unexpected observation was that the number of malaria patients presenting at the clinic increased by ∼2-fold from 2018 to 2019 (P < 0.0001), which in turn showed significant correlation to rainfall  (P < 0.0001) (P = 0.0001)  , humidit 0.0001) , and min 0.0001) . This stParticipants enrolled in PCT studies were young adults, with 67% males . At the 10.1128/mbio.03444-21.1DATA SET S1Data Set S1, PDF file, 1.9 MB.All patient parameters associated with clinical studies. Download Copyright © 2022 Nima et al.2022Nima et al.https://creativecommons.org/licenses/by/4.0/Creative Commons Attribution 4.0 International license.This content is distributed under the terms of the 10.1128/mbio.03444-21.2TABLE S1Table S1, PDF file, 0.3 MB.Participant baseline parameters at time of enrollment in the study in Bandarban District Hospital, Sadar, 2018 to 2019. Age, gender, febrile status, parasite density (per μL), parasitemia (%), and hemoglobin (g/dL) data are shown. Download Copyright © 2022 Nima et al.2022Nima et al.https://creativecommons.org/licenses/by/4.0/Creative Commons Attribution 4.0 International license.This content is distributed under the terms of the 1/2) between 6 and 24 h. For the majority of patients (15 of 24), the time to clear half the parasites was substantially less than 5 h; two examples of such clearance curves are shown in 50, PC90, and PC95, respectively) are summarized in Enrollment parasite densities were moderate in each year . Over 2 10.1128/mbio.03444-21.5FIG S1in vivo over time (h) in 2018 (A) and 2019 (B). The cumulative proportion of parasitemic participants and their clearance over a 30-day period  are shown for 2018 (C) and 2019 (D). The cumulative proportion of parasitemic participants and their clearance over 72 h after administration of the first dose of ACT are shown for 2018 (E) and 2019 (F). The proportion distribution of participants with time (h) of first negative microscopy slide after administration of first dose of ACT is shown for samples collected in 2018 (G) and 2019 (H). Download FIG S1, TIF file, 0.07 MB.Parasite clearance data, cumulative proportion of parasitemic patients and their clearance over time, clearance rate, and associated 50% clearance values in patients enrolled in 2018 and 2019. The parasite clearance curve shows linear regression of percent parasite density Copyright © 2022 Nima et al.2022Nima et al.https://creativecommons.org/licenses/by/4.0/Creative Commons Attribution 4.0 International license.This content is distributed under the terms of the 10.1128/mbio.03444-21.6FIG S2P = 0.02, R2 = 0.04) (A), mean corpuscular volume (MCV)  (B), mean corpuscular hemoglobin (MCH)  (C), mean corpuscular hemoglobin concentration (MCHC)  (D), white blood cell–total count (WBC-TC)  (E), lymphocytes  (F), neutrophils  (G), mixed cell count (MXD), including monocytes, basophils, and eosinophils  (H). Download FIG S2, TIF file, 0.09 MB.Associations between initial parasite density and hematological parameters of study participants from Bandarban District Hospital, Sadar. Linear regression and correlation analyses between initial parasite density (parasites/μL) and platelets  also supported a bimodal distribution  h in 2019. Together, these data suggest that an in vivo delay in reducing the initial P. falciparum parasitemia by 50% was reliably detected in two consecutive years, 2018 and 2019. Moreover, although the number of P. falciparum infections increased ∼2 fold, the fraction showing slower clearance to half of the initial parasites in 2019 was comparable to that in 2018. Nonetheless, all infections were cured, indicating that there was no failure of the ACT artemether-lumefantrine.Since the numbers of participants were different in 2018 and 2019, we examined the proportion of participants as a function of the time in hours to a “slide-negative” state to confirm that clearance was achieved by 60 h . While mribution  and G. T50 , mean corpuscular hemoglobin concentration (MCHC), mean corpuscular hemoglobin (MCH), white blood cells–total count (WBC-TC), mixed cell count (MXD) , and platelets , platelets (per μL), mean corpuscular volume (fL), mean corpuscular hemoglobin (pg), mean corpuscular hemoglobin concentration (g/dL), and immune cell characteristics , lymphocytes (%), neutrophils (%), and monocytes-basophils-eosinophils (%) are shown. Download Copyright © 2022 Nima et al.2022Nima et al.https://creativecommons.org/licenses/by/4.0/Creative Commons Attribution 4.0 International license.This content is distributed under the terms of the 10.1128/mbio.03444-21.7FIG S350) and baseline parameters. (A) Age of study participants ; (B) Mann-Whitney test of PC50 between male and female participants (P= 0.17); (C) initial parasite density, samples collected in 2018 ; (D) initial parasite density, samples collected in 2019 ; (E) initial parasite density, samples collected in 2018 and 2019 . Download FIG S3, TIF file, 0.04 MB.Associations between 50% parasite clearance  and hematological parameters. (A) Hemoglobin % (g/dL) ; (B) platelets (μl) ; (C) mean corpuscular volume (MCV) (fL) ; (D) mean corpuscular hemoglobin (MCH) (pg) ; (E) mean corpuscular hemoglobin concentration (MCHC) (g/dL) ; (F) white blood cells–total count (WBC-TC) (μl) ; (G) lymphocytes (%) ; (H) neutrophils (%) ; (I) mixed cell count (MXD), including monocytes, basophils, and eosinophils (%) . Download FIG S4, TIF file, 0.06 MB.Associations between 50% parasite clearance  was more than 10-fold higher than that in Bandarban Sadar.P. falciparum monoinfection in the absence of severe manifestation who were enrolled at Alikadam. Participants ranged from pediatric individuals to young adults. Sixty-three percent and 75% were males in 2019 and 2020, respectively. Parasite densities were moderate , and patients were not anemic (Hb < 9 g/dL). Since K13 polymorphisms associated with AR are invariably associated with the β-propeller domain, we restricted analyses to this region. As shown in in vivo delay in clearance of 50% of the initial parasitemia cannot be explained by resistance mutations in the β-propeller domain of K13.As summarized in 10.1128/mbio.03444-21.9FIG S5Pf3D7) is provided in FIG S5, TIF file, 0.09 MB.Study flow chart of Alikadam, baseline characteristics, and K13 polymorphism at all study sites. (A) Alikadam study flow chart. (B) Baseline characteristics, parasite clearance, and incidence parameters in participants enrolled in Alikadam Upazila Health Complex (UHC) in 2019 and 2020. (C) K13 polymorphisms in Bandarban Sadar and Alikadam Upazila. The sequence of the Bangladesh strain I-003 K13 gene  Flow chart of laboratory culture adaptation attempts in 2018 and 2019. (B) Isolates and their initial parasitemias and days taken to reach at least 2% parasitemia. Patient isolates I-001, I-003, I-004, and I-011 were forwarded to RSA. I-002 parameters could not be analyzed by the WWARN PCE. For outpatient O-012, there were no WWARN PCE data. Isolate I-017 could not be expanded in Copyright © 2022 Nima et al.2022Nima et al.https://creativecommons.org/licenses/by/4.0/Creative Commons Attribution 4.0 International license.This content is distributed under the terms of the in vitro RSA measurements to the artemisinin derivative, dihydroartemisinin (DHA). As shown in C580Y, showed significant survival in the presence of DHA, with a mean RSA value of 9.55%. Of the Bangladesh strains, I-004 showed no ring-stage survival. I-001 and I-011 showed RSA values greater than zero but less than 1%, suggesting the absence of AR. However, I-003 displayed RSA values of 2.007% ± 0.119% (mean ± SEM). Since an RSA value of >1% is recognized to signify resistance, our data suggest that I-003 presents a low (compared to NF54K13C580Y) but measurable level of AR.Of the 6 culture-adapted isolates of 2018, isolate O-012 could not be further expanded for RSA studies. Due to insufficient data points, I-002 could not be analyzed by the WWARN PCE tool. Thus, the remaining four isolates, I-001, I-003, I-004, and I-011, were successfully expanded for 10.1128/mbio.03444-21.4TABLE S3P value, unpaired two-tailed t tests; ns, nonsignificant. Download Table S3, PDF file, 0.3 MB.Ring-stage survival assay (RSA) data for Bangladesh isolates and control strains. RSA %, percentage parasite survival at 0 to 3 hpi of Bangladeshi isolates treated for 6 h with 700 nM DHA relative to DMSO-treated controls; parasitemia was estimated by microscopy 66 h later. N, number of independent biological replicates. Each biological replicate was performed in technical duplicate. Copyright © 2022 Nima et al.2022Nima et al.https://creativecommons.org/licenses/by/4.0/Creative Commons Attribution 4.0 International license.This content is distributed under the terms of the in vivo infections . Since the PC1/2 values for Bangladesh strains were below 5.5 h (Tables S4 and S5), we used as comparators published data for PC1/2 of <5.5 h of well-established K13 resistance mutations. As shown in P value of 0.0014, with an R2 of 0.71, suggesting that metadata comparisons may flag early stages of emergence of resistance that may otherwise escape standard surveillance.Since RSAs were designed to mimic the plasma exposure seen during fections , we examfections . As showfections . This isP. falciparum strains resistant to artemisinins. This needs to be accomplished in addition to interrupting local transmissions and preventing reestablishment of infection. Measurement of in vivo clearance of parasites in response to ACT treatment in malaria patients and establishment of culture-adapted Bangladesh strains to determine parasite-intrinsic resistance using RSA are both critically important to guide strategies and interventions to achieve and sustain elimination. It is imperative to understand whether one or both expand over time. Hence, this study fills an important gap in knowledge and provides approaches for identifying the emergence of AR in the CHTs, where >90% of malaria occurs in Bangladesh.The goal of Bangladesh’s National Strategic Plan for Malaria Elimination 2017–2021 is to eliminate the disease by 2030 . A key cP. falciparum caused ∼80% to 90% of infections in Bandarban, consistent with prior reports . From 2018 to 2019, malaria had an average of 60% resurgence across Bandarban. Infections rose in the low-API subdistrict of Bandarban Sadar as well as in Alikadam, which has a high API. The increase was well correlated with climatic factors, suggesting that it may be due to increasing local transmission, which is a malaria control priority that must be considered in conjunction with emerging AR  and initial parasitemia or blood cell counts. Although platelet levels were significantly reduced relative to parasitemia (not shown), they showed no correlation with PC50. In the case of initial Hb, lymphocytes, and neutrophils, although the correlation coefficient was low (<0.6), the P values were <0.05, suggesting that there may be weak correlation that needs further evaluation in subsequent studies. In prior work, correlates of immunity have been inversely correlated with delayed clearance  of 2.5 (0.7 to 5.4) between 6 and 24 h after administration. Unlike many studies that report K13 polymorphism with either RSA or parasite clearance data , an API much higher than that of Bandarban (21.4 compared to 0.8 in 2018 and 32.1 compared to 1.6 in 2019), and a closer location to the border with Myanmar, where K13 resistance mutations have been reported and work there enabled rapid collection of infected blood samples for analyses of K13 polymorphisms. Building the requisite clinical capacity will render Alikadam a superior subdistrict site for in vivo delayed clearance studies to broaden the comprehensive assessment of AR across remote rural, forested regions with low population density, which present frontiers of malaria in Bangladesh, and other countries where malaria is endemic.Since the Alikadam subdistrict clinic facility lacks facilities for overnight stay, in vivo parasite clearance to determine the presence of clinical AR and its quantitative correlation with parasitemia, comprehensive blood count parameters, and AR molecular markers as well as laboratory adaptation of patient isolates to conduct further in vitro and genetic studies of P. falciparum parasite populations in Bandarban. In 2018, we established the clinical capacity to measure in vivo AR in Bandarban Sadar Hospital. The site was chosen because it is the only hospital in the CHTs where it is possible to undertake a protocol for in vivo delayed P. falciparum clearance, as recommended by the WWARN , in 2019 we added collection of parasite isolates at Alikadam Upazila Health Complex because of its higher annual parasitological index  .in vivo clearance in Bangladesh limited the local information on which to base power calculations, we used findings from neighboring Myanmar, which reports a 20% prevalence rate of the F446I mutation  or 2,000 red blood cells  , prior to administration of the first dose of artemether-lumefantrine (A-L) combination therapy (ACT) . The smear results were counted in duplicate by two independent microscopists and then averaged. Parasite density/mL was calculated by dividing the number of asexual parasites by the number of WBC counted (200) and multiplying by an assumed WBC count of 8,000/μL in thick film . Smears were considered negative when no asexual parasites were found after counting 200 WBC.The admitted indoor patient department (IPD) patients were treated by the hospital staff as described in the protocol of the National Malaria Elimination Program. Briefly, one to four tablets (depending on the patient’s body weight) of A-L (20 mg artemether and 120 mg lumefantrine) was administered at each of the following six time points: 0, 8, 24, 36, 48, 60, and 72 h. Blood draws were planned at 6, 12, 24, 36, and 48 h after the first drug administration . Due to Patients were confirmed to be free of parasites and fever for at least 1 day and up to 72 h before being released from the clinic. Smears were considered negative when no asexual parasites were found after counting 200 WBC or 2,000 RBC. Patients were subsequently followed up for fever, pulse, and blood pressure and malarial infection (by RDT and slides) up to 30 days at home weekly, on days 9, 16, 23, and 30. No abnormalities were found. The study had no influence on the treatment decisions made by the hospital physicians.1/2), estimated time in hours it takes for the parasitemia to decrease by half (50%), independent of initial parasite density; PC50, PC90, PC95, and PC99, estimated time in hours for parasitemia to be reduced by 50%, 90%, 95%, and 99% of its initial value , respectively.Parasite clearance times (PCTs) were determined for each patient using the WWARN parasite clearance estimator (PCE) tool . The parAll definitions above follow WWARN methodology for calculating parasite clearance , 35.A Sysmex XP-300 hematology analyzer  was used to provide a full blood cell count, including differential white blood cell counts, prior to administration of the ACT.2EDTA vacutainers  . For culture adaptation, washed infected blood was adjusted to 4% hematocrit in 5 mL RPMI 1640 medium containing l-glutamine, 50 mg/L hypoxanthine, 25 mM HEPES, 2 g/L glucose, 20 μg/mL gentamicin, 0.225% NaHCO3, and 15% human pooled plasma with 0.5% Albumax, and cultures were placed in a candle jar  at 37°C. Cultures were fed and monitored daily: at 2% rings, they were frozen for storage. An adaptation was considered unsuccessful if no parasites emerged up to 60 days.Ten milliliters of venous blood was drawn, before administration of ACT, from adults (≥18 years of age) and 7 mL from adolescents (ages 11 to 17 years) using K0–3h was performed as previously described  after culture adaptation. The RSAescribed . BrieflyGenomic DNA was extracted from 200 μl whole blood using a QiaAmp blood minikit .Plasmodium species was confirmed by using a nested PCR in accordance with a previously published method with minor modifications  using CLC Sequence Viewer 8 (Qiagen Aarhus A/S). The sequence of the Bangladesh strain I-003 K13 gene (compared to Pf3D7) is provided in The sequence of the propeller domain of the ocedures . An 849-Weather data for 2018 and 2019 were obtained from the Soil Resource Development Institute (SRDI), Bandarban, Bangladesh.This study was approved by the Ethical Review Committee of icddr,b (protocol no. PR-17078) and the Institutional Review Board of the University of Notre Dame (protocol no. 17-10-4146).ArcGIS 10.4.1  was used to generate the malaria incidence map for 2019 .Associations between two variables were assessed using Spearman correlation and Mann-Whitney analysis. All statistical analyses were performed using GraphPad Prism 7 .All data are available in the supplemental material.


Malaria was eliminated from Sri Lanka in 2012, and since then 50–60 imported malaria cases have been reported yearly. The country has remained malaria-free since, except for a single case of indigenous malaria in 2018. Blood donors are routinely screened for malaria, and transfusion malaria has not been reported in the country since 1966.Plasmodium falciparum malaria infection following a blood transfusion 18 days earlier. The blood donor was an armed forces personnel who returned from South Sudan following a United Nations peace-keeping mission. The blood recipient’s malaria infection took a complicated clinical course with elevated liver enzymes, lowered blood pressure and a prolonged parasite clearance time of 7 days but he recovered fully after two courses of artemether-lumefantrine interrupted by a course of intravenous artesunate. The prolonged parasite clearance is likely due to lack of splenic clearance of dead or damaged intra-erythrocytic parasites (due to a splenectomy) rather than to the parasite strain being resistant to artemisinin or the partner drug. This is corroborated by the fact that the blood donor’s infection responded to artemether-lumefantrine with parasites being cleared on day 3. The blood donor who had not displayed signs or symptoms of malaria, had been screened for malaria on arrival in Sri Lanka and was negative on both microscopy and RDT. At the point of blood donation a blood smear examined microscopically was also reported negative for malaria, but retrospectively, the preserved smear of the donor’s blood was found to contain P. falciparum parasites at a very low density. The donor when tested after the transfusion-induced case was diagnosed, also tested positive for malaria and was treated.A 17-year-old splenectomized beta thalassaemia patient developed a transfusion-induced After malaria elimination, transfusion-induced malaria from blood donors returning from malaria endemic countries poses a threat to preventing the re-establishment of the disease. Improved surveillance of arrivals in Sri Lanka from malaria endemic countries using more sensitive methods for screening than microscopy may be required to reduce this risk. More stringent criteria for selecting blood donors, and more effective methods of screening donors for malaria than microscopy may also be necessary.The online version contains supplementary material available at 10.1186/s12936-021-03881-1. Since being certified by the World Health Organization (WHO) as a malaria-free country in 2016, Sri Lanka reports 50–60 imported malaria cases a year [Plasmodium malariae and two Plasmodium falciparum infections [Sri Lanka has reported 16 transfusion-induced malaria cases between 1960 and 1966 when malaria was endemic in the country leading to 14 fections , but nonP. falciparum by microscopy . The diagnosis was also confirmed by polymerase chain reaction testing.The recipient of the blood transfusion was a 16-year-old Sri Lankan boy who has beta thalassaemia major with a co-morbidity of blood transfusion-induced cardiomyopathy. Thalassaemia is the commonest monogenic disease in Sri Lanka . The pat3. The patient was treated with artemisinin-based combination therapy (ACT), artemether-lumefantrine, the first-line treatment for P. falciparum malaria in Sri Lanka, for 3 days at the standard recommended dosage under supervision, based on national malaria treatment guidelines [The day after admission, when the malaria diagnosis was confirmed the patient was febrile (37.8 °C), had a blood pressure of 90/60 Hgmm and a normal heart rate. Laboratory investigations revealed a haemoglobin (Hb) of 5.4 mg/dl, WBC count of 31,300/μl and a platelet count of 378,000/mm3. He still had irregular spikes of fever. The liver enzymes increased  over 3 days. Serum C-Reactive Protein was elevated above 100 mg/L. The patient was managed with intravenous inotropes  because of the poor response of blood pressure to fluid therapy. With parasites persisting in peripheral blood on completion of the ACT course at 72 h, and deterioration of the patient’s clinical condition, further anti-malarial treatment options were considered. The second-line anti-malarial medicine in Sri Lanka, dihydroartemisinin-piperaquine (DHAPPQ) could not be used in this patient because it is contraindicated in cardiomyopathies which the patient suffered from. Treatment with the next option, intravenous artesunate 2.4 mg/kg was, therefore, commenced immediately  and given for a further 3 days while the patient was managed in the Coronary Care Unit of the hospital. Following the last dose of IV artesunate, he was started on a 3-day course of oral artemether-lumefantrine as the recommended practice after parenteral artesunate. By day seven of commencement of treatment, asexual malaria parasites were no longer seen in blood smears, but gametocytes  were present at a density of 270/μl. The patient had improved clinically by then and had a stable blood pressure after withdrawal of inotropes, and liver function test had returned to normal levels (AST- 48.7 U/L and ALT- 25.5 U/L). The gametocyte count decreased gradually to 152 parasites/µl on completion of oral ACT on day 9. A stat dose of primaquine (0.75 mg/ kg−3 tablets) was given on day 10 for its anti-gametocyte activity. The patient was completely cleared of parasites including gametocytes by day 15. Following the transfusion of three units of blood the patient was discharged from hospital on day seventeen (post transfusion Hb was 9.8 mg/dl (27th April 2021). Data on beta thalassaemia patient diagnosed with malaria is provided in Additional file The patient’s clinical condition deteriorated over the first 3 days of treatment. The peripheral blood parasitaemia declined very slowly from a starting density of 51,015 parasites/μl on admission. After 72 h of commencement of anti-malarial treatment the parasitaemia was 7147 parasites/μl, blood pressure remained below normal at 90/50 mmHg, haemoglobin (Hb) level fell to 7.6 mg/dl and the WBC count was 47,430/mmP. falciparum parasites . On testing the asymptomatic donor for malaria on 10th May 2021, soon after the recipient was diagnosed, he was found to be positive for malaria by microscopy at a very low density of 32 parasites/ μl with ring and gametocyte stages of P. falciparum. On admission his Hb was 15.2 g/dl. He was admitted to the same hospital ward as the blood recipient a day later, and was treated with an oral ACT artemether-lumefantrine and a single dose of primaquine [Upon diagnosis of malaria in the recipient, information on the blood donor of the last transfusion given to the recipient on the 21st of April 2021 was traced, based on the records maintained by the National Blood Transfusion Service. The donor was a member of the armed forces who had returned to Sri Lanka on the 9th of December 2020 after spending 16 months in South Sudan on a United Nations peacekeeping mission. He was also traced in the AMC database as a person who was being kept under surveillance. While in South Sudan he had taken mefloquine and doxycycline as antimalarial prophylaxis, but reportedly, not on a regular basis. As per guidelines of the AMC, and through the close collaboration that exists with the armed forces, their members arriving from malaria endemic countries are screened for malaria by microscopy and Rapid Diagnostic Tests (RDT) at the airport, or, due to the current COVID-19 pandemic, at COVID quarantine centers where they are kept for 14 days. The first malaria screening of the group of 51 armed forces personnel of whom the blood donor was one, was performed at the airport on the 9th of December 2020 and he and the rest of the group were reported as negative for malaria by microscopy and RDT. He was asymptomatic on arrival and gave no history of malaria while in South Sudan. He had donated blood four months after his return, on the 9th of April 2021 and this blood donation was used on the beta thalassaemia patient. Prior to transfusion the blood product was screened for malaria by microscopy as a routine procedure but was reported as negative. However, when the stored blood smear was examined retrospectively after the incident of transfusion-malaria, it showed Reactive parasitological and entomological surveillance activities commenced the same day as the diagnosis of malaria was made in the blood recipient and donor respectively in accordance with AMC’s prevention of re-establishment strategy. Primary and secondary case surveillance was carried out covering all residents of houses within a radius of 1 km of residencies of both the recipient and the donor . A totalAnopheles culicifacies, the primary vector of malaria in Sri Lanka, larval source management, space spraying and distribution of long-lasting insecticidal nets (LLINs) were carried out. Entomological surveillance was also carried out around all sites where, the blood donor had stayed night over the past 14 days from blood donation up to diagnosis, and larvae of primary vector was found in two locations. The same vector control methods mentioned above were applied at these sites as well.Entomological surveillance was conducted within a radius of 1 km of the residence of the blood recipient. With the reporting of larvae of P. falciparum malaria. This was established as a case of blood transfusion-induced malaria by the fact that his last transfusion of blood was found to be infected with P. falciparum. The blood donor was a returnee from South Sudan having been on a mission there for a year and four months. Although microscopy at the time of blood donation was reported as malaria-negative, retrospective re-examination of the donor’s blood smear at the time of donation, as well as when he was tested after the recipient was diagnosed with malaria revealed that he had a P. falciparum malaria infection throughout, although he had remained free of signs and symptoms of malaria ever since he returned to Sri Lanka.This is the first case of transfusion-induced malaria reported in Sri Lanka in five decades, and the first during the prevention of reintroduction (POR) phase of malaria. The recipient, who suffered from beta thalassaemia major and gave no history of overseas travel but of receiving a recent blood transfusion, was diagnosed with The beta thalassaemia patient had a clinically complicated malaria infection with co-morbidities, and prolonged parasite clearance. The possibility that this malaria infection imported from South Sudan was a drug-resistant strain, or even one with a reduced sensitivity to artemisinin or the partner drug lumefantrine was considered, but was dismissed on the grounds that the infection in the blood donor responded well, both clinically and parasitologically to the same medication. The prolonged parasite clearance is likely, instead, to have been due to the absence of the spleen. Such slow responses of malaria infections to treatment have been reported previously in splenectomized patients –9. IntraDelays in the diagnosis of malaria has been a frequent feature during the POR phase in Sri Lanka , 11, as P. falciparum [Plasmodium vivax and Plasmodium ovale infections can remain dormant as hypnozoites in the liver, but it appears that even P. falciparum parasites can persist in a “dormant” state in the blood to manifest as clinical infections later. The asymptomatic blood donor, by the fact that he was not even anaemic, whilst harbouring a P. falciparum infection over several months, must have developed a partial clinical and parasitological immunity to P. falciparum while in South Sudan through repeat parasite inoculations, aided by his intermittent recourse to prophylactic anti-malarial medicines which may have led to a persistent low-grade malaria infection.This case is a reminder that the risk of transfusion-induced malaria in the country persists even after elimination because of imported malaria from overseas. It demonstrates that even the current very rigorous POR strategies being implemented in Sri Lanka are not infallible, due, not to flaws in the strategy itself, but due to lapses in operations and implementation. The blood donor was duly screened for malaria on entry to the country but was found to be negative by both microscopy and RDT. This could have been due to a very low parasite density, below the microscopic threshold of detection, which is corroborated by the fact that the person was asymptomatic and was even well enough to have considered donating blood 4 months later. There have been numerous incidents in the past 9 years since malaria elimination, of arrivals in Sri Lanka from malaria endemic countries being screened on entry to the country and found negative, but who, weeks to months later developed a clinically patent malaria infection, even with lciparum . ClearlyPlasmodium parasites can survive in whole blood and plasma when stored at 4 °C for up to approximately 18 days, and parasites can be detectable even up to 28 days when frozen, although with diminished infectivity [ectivity , 16. Conectivity ) may havectivity . A Natioalbeit at a very low parasitaemia for at least 18 days, and possibly longer, had presented a daunting risk for the re-establishment of malaria in Sri Lanka had his infection been transmitted to mosquitoes. This case has now led to the AMC greatly strengthening its surveillance on armed forces returnees from malaria endemic countries, they being a high-risk group for imported malaria including considering the routine use of more sensitive malaria detection methods than microscopy, such as the polymerase chain reaction tests to screen returnees from high malaria risk destinations.The blood donor, a member of the armed forces and a returnee from South Sudan was duly screened for malaria at the airport on his return together with 51 members of the same contingent, and all were negative on microscopy and RDT. It is standard practice that all such groups of armed service personnel returnees are kept under surveillance for a period of one year for the possibility of developing malaria. If they reside in a malaria receptive area, they are each provided with a LLIN as a precautionary measure to minimize the risk of their transmitting malaria, in the event that they develop an asymptomatic malaria infection. He was traced on the AMC database even before details emerged from the Blood Bank, as a member of the group that was under surveillance. However, a lapse in the follow-up procedure led to this person who was asymptomatic, to donate blood. The prevailing COVID 19 epidemic which led to several restrictions being imposed on routine follow-up work of the AMC might have contributed to this unfortunate breach in procedure . The facThis case report illustrates the importance of effective blood donor screening for malaria during the POR phase of malaria using more sensitive and objective methods than microscopy, such as antigen and antibody detecting immunochemical methods. It also reaffirms the importance of proactive case detection and follow-up, particularly in armed forces personnel returning from high malaria risk destinations, here too, using molecularly methods rather than microscopy, and emphasizes the need for stringent implementation of the strategies that are in place including reactive entomological surveillance and vector control.Transfusion-induced malaria is among the risk factors for re-establishment of malaria after elimination. Screening of blood donors for malaria by microscopy can be low in sensitivity even in the hands of expert microscopists because the test positivity rate is extremely low. Population groups who are at high risk of imported malaria such as armed forces personnel returning from malarious countries must be screened using more sensitive methods than microscopy and kept under close surveillance for at least a year, for the possibility of their developing malaria infections, even if they are negative for malaria on arrival in the country.Additional file 1: Table S1. Data on beta thalassaemia patient diagnosed with malaria.


Falciparum and endemic Burkitt lymphoma (eBL) are co-endemic in Africa, but the malaria experience in eBL patients is unknown. A lower prevalence of falciparum has been reported in eBL patients, but those results are anecdotally attributed to pre-enrollment anti-malaria treatment.Falciparum was diagnosed using thick blood film microscopy (TFM) and antigen-capture rapid diagnostic tests (RDTs). Guardians of the children answered a 40-item structured questionnaire about their child’s pre-enrollment lifetime malaria history and treatment, demographics, socioeconomics, animal exposures, fevers, and hospitalizations. We utilized exploratory factor analysis to reduce the 40 questionnaire variables into six factors, including Inpatient malaria and Outpatient malaria factors that were surrogates of pre-enrollment anti-malaria treatment. The six factors accounted for 83–90% of the variance in the questionnaire data. We calculated odds ratios and 95% confidence intervals (OR 95% CI) of association of eBL with falciparum positivity, defined as positive both on TFM or RDTs, or only RDTs (indicative of recent infection) or TFM  versus no infection, using multivariable logistic regression, controlling for group of age , sex, and study site and the afore-mentioned pre-enrollment factors.We studied 677 eBL patients and 2920 community controls aged 0–15 years enrolled in six regions in Uganda, Tanzania, and Kenya during 2010–2016. falciparum infection was 25.6% in the eBL cases and 45.7% in community controls . The results were similar for recent falciparum infection  and current falciparum infection . These aORs for any, recent and current falciparum infection did not change when we adjusted for pre-enrollment factors  were significantly lower in stratified analysis for any infection in children < 5 years  or ≥ 10 years .The prevalence of falciparum prevalence in eBL cases and open a space to consider alternative immunology-based hypotheses.Our study results reduce support for pre-enrollment antimalaria treatment as a sole explanation for the observed lower The online version contains supplementary material available at 10.1186/s13027-021-00377-0. Plasmodium falciparum with eBL, which opened the hypothesis about whether this correlation was evidence of causation [falciparum infection stimulates proliferation of polyclonal B cells in the GC, where BL originates, and activates the MYC oncogene in B cells by promoting chromosomal translocations of MYC on chromosome 8q24 into the vicinity of immunoglobulin genes [falciparum preferentially stimulates B cells infected with Epstein-Barr virus via the cysteine-rich inter-domain region 1 alpha  of the Plasmodium falciparum membrane protein 1 (PfEMP1) [Endemic Burkitt lymphoma (eBL) is an aggressive germinal-center (GC) B-cell non-Hodgkin lymphoma  first deausation . This hyausation –6, and lausation , 8. A cain genes , 10. Fur(PfEMP1) , 12.falciparum infection is associated with high malaria morbidity and mortality in children below age 3 years who lack immunity [However, as immunity –15, it iimmunity . Acquireimmunity , althougimmunity . The obsimmunity  suggestsimmunity , but thiimmunity .falciparum in eBL patients than controls in Uganda [p < 0.0001) in our study of 697 eBL cases and 2934 community controls enrolled in the Epidemiology of Burkitt lymphoma in East African children and minors (EMBLEM) study in Uganda, Tanzania, and Kenya [p < 0.0001) or by other variables that captured pre-enrollment anti-malaria treatment. These results challenged the hypothesis that the lower prevalence of falciparum infection is due to pre-enrollment treatment of malaria, while also raising the possibility that falciparum prevalence is low in children with eBL because they have robust acquired resistance to falciparum.Two studies reported a lower prevalence of n Uganda  and Kenyn Uganda . This unnd Kenya . These rIn the current study, we conducted a more comprehensive adjustment of pre-enrollment exposures by using exploratory factor analysis (EFA) to reduce 40 questionnaire variables about the child’s pre-enrollment lifetime malaria history and treatment, demographics, socioeconomics, animal exposures, fevers, and hospitalizations into a few informative factors  and usedfalciparum infection using thick blood film microscopy (TFM) and commercial antigen rapid diagnostic tests (RDTs [https://emblem.cancer.gov/resources/EMBLEM_Interview_Questionnaire.pdf) (Supplementary Table The study population has been described previously . Brieflyts (RDTs . Pre-enrhttp://www.isr.umich.edu/src/smp/ive) in SAS 9.4 [The 40 data elements analyzed in this study are shown in Supplementary Table  SAS 9.4 . Imputat SAS 9.4 .EFA was performed on the complete combined and country-specific datasets , sex, and study site, which were considered apriori as confounders. Falciparum infection was defined two ways:  First, as a two-level variable with  no infection, defined as negative on both TFM and RDT (coded 0), or infected, defined as positive either on TFM or RDT (coded 1). Second, as a three-level variable with no infection defined as before; recent infection defined as positive on RDT but negative on TFM (coded 1), or current infection defined as positive on TFM regardless of RDT result  to estimate the association of eBL with  malaria  and fromfalciparum infection and 29.6% had current falciparum infection. Uganda contributed most (41%), followed by Kenya (33%), and the least number was from Tanzania (26%).We analyzed 3631 children (692 eBL cases) enrolled in Uganda, Tanzania, and Kenya during 2010–2016 , whereas the association of falciparum infection with the Inpatient malaria factor was more consistent with a threshold . Higher scores on the Animals, Non-specific fevers, and Home factors were associated with falciparum positivity, with a pattern suggesting monotonic trend for the Animals factor  and a threshold for the Non-specific fevers (aORs were 1.29 to 1.40 for Q2 to Q4 vs. Q1) and the Home factors (aORs were 1.14 to 1.38 for Q2 to Q4 vs. Q1). The Outpatient factor was unrelated to falciparum positivity (P = 0.20). Although there were slight variations, the associations observed in the combined analyses were present in country-specific analyses  resulting in lower odds of eBL  when we further adjusted for mean platelet count, hemoglobin, and WBC count as confounders [We observed lower founders  and in sfalciparum infection  or current falciparum infection .The adjusted results were similar for recent falciparum positivity, defined as any, recent, or current falciparum infection, in eBL patients than controls in crude and adjusted analyses. The ORs did not change when we adjusted for Inpatient malaria and Outpatient malaria factors as surrogates of pre-enrollment anti-malaria treatment, for the other four factors obtained from EFA, for platelets, low hemoglobin, and elevated white cell counts, which are risk factors for eBL [falciparum positivity among eBL patients, on one hand,  and increase support for exploring alternative hypotheses, on the other hand.Our study found significantly lower prevalence of  for eBL . The res for eBL , 34 and  for eBL , 33. Ourfalciparum infection in eBL children is a surrogate of robust immunity to malaria. Immune response to falciparum spans a spectrum from lack of immunity, which is associated with severe malaria to strong age-related acquired anti-malaria and anti-parasite immunity [falciparum infection. We suggest from our results that eBL cases possess strong anti-malaria and anti-parasite immunity. Lack of immunity represents a serious risk of death from severe malaria in areas with high eBL incidence, thus, immunity against severe malaria usually develops quickly, in some estimates occurs after exposure to 1–2 falciparum infections and is usually well-developed in the first 1–3 years of life in malaria endemic countries [falciparum infection or the development of mild/moderate malaria, which are also associated with serious life-threatening morbidity and mortality from anemia, stunting, malnutrition, bacterial co-infections [falciparum infection to survive in those areas, and it is supported by our finding that eBL cases have significantly lower parasite density than controls of a similar age [One alternative hypothesis, that is usually dismissed  because it is counter-intuitive, is that lower prevalence of immunity , which iountries . Howeverfections , and seifections . The risfections . Despitefections . Becauseilar age .falciparum because lack of immunity to malaria would predispose to severe malaria and high risk of death before eBL [falciparum parasites [falciparum variants linked to severe malaria, indicating prior exposure to and immune response to such variants [falciparum parasitemia [falciparum parasitemia  and increased activity by splenic macrophages to clear parasites [falciparum antigenic load to the spleen is a risk factor for eBL [falciparum variants , but  the multiplicity of diverse variants the children are exposed to that are the risk factor for eBL [Falciparum parasites can establish  new infections in immune populations only by allelic switching of falciparum multigene families, such as PfEMP1 [falciparum variants, presumably expressing novel epitopes that are not recognized by the hosts' acquired immunity, may be related to eBL [The inferences above also suggest that there are some important differences between  malaria versus viral carcinogenesis , 38. In fore eBL . Thus, cfore eBL  as a cenarasites . Our stuvariants . Althougvariants , it doesasitemia . Childreasitemia , 18, butarasites . We sugg for eBL  in child for eBL . Falcipas PfEMP1 , to exprd to eBL , 48, 49.falciparum burden could encourage better coordination between eBL and malariologists. eBL may be a suitable sentinel condition to detect  pockets of high localized community falciparum transmission, which can be identified and targeted for investigation to suppress  reservoirs that may threaten malaria prevention and intervention programs [falciparum infection [falciparum genotypic complexity are better measures of force of falciparum infection, co-transmission and superinfection events [falciparum complexity that could also be used as an intermediate phenotype for eBL.Our results highlight potential value of establishing collaboration between malaria and eBL research to jointly address  overlapping interests. A  better appreciation of the link between eBL and exposure to high programs . In viewnfection , 48, 49 n events , close cfalciparum using two methods. Our use of EFA is novel in eBL-malaria research, which made it possible for us to rigorously control for confounding without overfitting the data. The use of two tests for falciparum allowed us to test associations of eBL with recent anti-malaria treatment, which would have detected a positive association of recent falciparum with eBL, presumably because such  children may have unreported  pre-enrollment anti-malaria treatment. We acknowledge that the case-control design is a weakness of our study because it is susceptible to reverse causality that cannot be fully addressed. Nonetheless, our results substantially increase our understanding about the relationship between eBL and falciparum infection, the role of pre-enrollment exposures, and offer support for considering novel hypotheses.The strengths of our study include having a large sample size, data from three countries, detailed data about anti-malaria treatment before study enrollment, and measurement of falciparum infection was significantly lower in eBL cases than controls in crude and adjusted analyses. The results were robust in analyses controlling for pre-enrollment factors and in analyses stratified by age. These results reduce support for pre-enrollment antimalaria treatment as a sole explanation for the observed lower falciparum prevalence in eBL cases, and open up space to consider alternative hypotheses such as the state of  immunity to falciparum infection in children before and after eBL onset.In conclusion, we show that Additional file 1: Supplementary Table 1. Questionnaire variables/data elements and how they were coded for exploratory factor analysis. Supplementary Table 2. Eigenvalue and variance explained by extracted factors shown for each imputed dataset and by study country. Supplementary Table 3. Odds ratios and 95% confidence intervals (CIs) of the association of factors with falciparum infection risk in controls, by country. Supplementary Table 4. Odds ratios and 95% confidence intervals (CIs) of the association of factors with eBL risk, by country.


When comparing the sensitivity and specificity of mid-upper arm circumference (MUAC) versus weight-for-height z-scores (WHZ) to identify wasting in children aged 6–59 months in Nepal, our findings suggest that only using MUAC compared to WHZ to screen may exclude a large number of children who could be at risk of severe or moderate acute malnutrition. Mid-upper arm circumference (MUAC) had a lower sensitivity compared to weight-for-height z-score (WHZ), indicating it can detect only a small proportion of the total number of children aged 6–59 months who are wasted.Using sensitivity and specificity criteria, the poor performance of MUAC compared to WHZ to identify cases of severe and moderate wasting in infants and children aged 6–59 months suggests a need to further refine admission criteria, including the choice of indicators and cutoffs. In countries with a high prevalence of undernutrition, timely, accurate screening at the community level is essential to identify children with wasting. The World Health Organization recommends using either weight-for-height z-scores (WHZ) and mid-upper arm circumference (MUAC) or both measures and signs of edema to be used to identify children with severe acute malnutrition for treatment. We compared WHZ and MUAC cutoffs to identify wasting among children aged 6–59 months in Nepal, using WHZ as the reference standard.We used cross-sectional anthropometric data for 3,169 children aged 6–59 months from a 2017 cross-sectional dataset, representative of 42 of Nepal's 77 districts. We used descriptive statistics, receiver operating characteristic (ROC) curves, and kappa statistics to compare the use of MUAC and WHZ to identify wasting. The Youden index was calculated to determine the optimum MUAC cutoffs.The prevalence of wasting was 3.1% and 10.5% using MUAC and WHZ, respectively. We found 13.6% sensitivity for severe acute malnutrition (SAM) (MUAC <115 mm) and 21.0% sensitivity for moderate acute malnutrition (MAM) (MUAC ≥115 to <125 mm), with specificity of 99.7% and 91.2%, respectively. The sensitivity of MUAC for children aged 6–23 months was higher than for children aged 24–59 months. The total area of the ROC curve was 0.53 for the MUAC cutoff for SAM and 0.56 for MAM. The optimum MUAC cutoffs for SAM and MAM were 125 mm and 132 mm, respectively.Although MUAC can be used as a rapid screening tool to detect wasting in children aged 6–59 months, using the recommended MUAC cutoffs captures only a small proportion of the total number of wasted children. The poor sensitivity and specificity of MUAC compared to WHZ suggests a need to refine admission and discharge criteria for acute malnutrition management programs to ensure that wasting among infants and children in Nepal is consistently and accurately diagnosed and treated. Furthermore, undernourished children who survive have diminished learning capacity and lower productivity in adulthood.In countries with a high prevalence of undernutrition, timely, accurate screening at the community level is essential to identify children with acute malnutrition. More than 500,000 deaths annually could be prevented globally by timely and proper treatment of acute malnutrition.,,The prevalence of child undernutrition in Nepal is among the highest in the world. Among children aged under 5 years, 10% are wasted (low weight-for-height) including 2% severely wasted; this alarmingly high level has persisted for at least 2 decades.–––,Researchers have raised concern about the effectiveness of using MUAC as a wasting screening tool because of its low sensitivity compared to WHZ.Only using MUAC to screen for malnutrition globally would result in 14.4 of the 16 million children in 2016 with SAM not identified or treated.This study uses a cross-sectional dataset collected by a local survey firm in July–September 2017 across 16 of Nepal's 77 districts, including a total sample of 3,169 children aged 6–59 months. Structured questionnaires were used to interview the young child's mother and a household head  to obtain socioeconomic and demographic information, as well as to measure knowledge and practices related to nutrition, reproductive health and family planning, agriculture and food security, empowerment, and exposure to health and nutrition-related interventions.Anthropometry, including length/height, weight, and MUAC of each child, was measured by a team of 20 trained and standardized data collectors. The length of children aged 6–23 months and height of children aged 24–59 months were measured using the vertical stadiometer, following WHO guidelines.,,,,These anthropometric data were then transformed into WHZ z-scores. The prevalence of wasting was calculated by using both WHZ and MUAC. To classify children as SAM and MAM using WHZ, we used cutoffs of <-3 SD WHZ and ≥-3 to <-2 SD WHZ, respectively. To classify children as SAM and MAM using MUAC, we used cutoffs of <115 mm and ≥115 mm to <125 mm, respectively.We obtained ethical clearance from the Ministry of Health and Population, Nepal Health Research Council, Kathmandu, Nepal (NHRC #1620/2017). All respondents gave written informed consent before the interview and collection of anthropometric data. No treatment or incentive was given to the study participants.Selected background characteristics of the surveyed households and children aged 6–59 months are presented in We found 13.6% sensitivity for SAM (MUAC <115 mm) and 21.0% sensitivity for MAM (MUAC ≥115 mm to <125 mm) with specificity of 99.7% and 91.2%, respectively. The total area of the ROC curve was 0.53 for the MUAC cutoff for SAM (<115 mm). The kappa value for the SAM cutoff was 9.0%. The total area under ROC curve was 0.56 for the MAM cutoff ≥115 mm to <125 mm. The kappa value for the MAM cutoff was 17.0%.Comparison of ROC and kappa by child gender and age are shown in Among the children aged 6–23 months, 11.5% were found wasted including 8.9% with MAM and 2.6% with SAM using WHZ, but only 5.0% MAM and 0.7% SAM were identified as wasted using MUAC. Among children aged 24–59 months 9.8% were identified as wasted using WHZ including 8.2% with MAM and 1.6% with SAM, whereas using MUAC, only 0.7% and 0.2% of these children were diagnosed with MAM and SAM, respectively. The total AUC of the SAM cutoff was 0.61 and 0.51 for children aged 6–23 months and 24–59 months, respectively. The kappa value of the SAM cutoff for children aged 6–23 months was 12.0% and 6.0% for children aged 24–59 months. Likewise, the total AUC of the MAM cutoff for children aged 6–23 months and 24–59 months were 0.61 and 0.53, respectively. The kappa value of the MAM cutoff for children aged 6–23 months was 25.1% and 7.0% for children aged 24–59 months.Among the children aged 6–23 months, 8.9% with MAM and 2.6% with SAM were identified as wasted using WHZ, but only 5.0% with MAM and 0.7% with SAM were identified as wasted using MUAC.This study compares the sensitivity and specificity of MUAC versus WHZ to identify wasting in children aged 6–59 months in Nepal, to contribute to local and global debates on how to ensure the timely and accurate diagnosis of wasting, a prerequisite to identifying and treating millions of children globally suffering from undernutrition. This is the first-ever study comparing the performance of MUAC and WHZ in Nepal to identify wasted children and among the few studies globally to use population-based, rather than hospital/treatment center-based, data to explore variations in the MUAC and WHZ indicators. This study looks at discrepancies in classification overall and then separately by child age and child gender. The percentage of wasting, as measured by WHZ, was found to be almost the same as the national prevalence found in the recent demographic and health survey done in 2016 (10.5% vs. 9.8%).,–,With WHZ as the reference standard, we found MUAC only had 13.6% sensitivity for SAM (MUAC <115 mm) and 21% sensitivity for MAM (MUAC ≥115 mm to <125 mm), with a specificity of 99.7% and 91.2%, respectively. This is consistent with various studies that have reported a very wide range of sensitivity of MUAC, ranging from 17.5% to 43.5% and consistently higher specificity.,–Similarly, since MUAC >115 mm is being used in Nepal as a single criterion to discharge children with SAM from outpatient therapeutic centers, proper nutritional rehabilitation will be missed, and thousands of Nepalese children will be discharged as cured who could still be suffering from undernutrition or at increased risk of relapse. Finally, many studies to date focus on SAM, but MAM management programs, especially blanket and targeted supplementary feeding programs in Nepal, use MUAC only. These findings show that a large number of children with MAM are being missed and not provided with nutrition rehabilitation, counseling, and support because MUAC was the only anthropometric measurement used. Existing literature suggests that MUAC-only based programs tend to identify significantly more girls and younger children than those identified by WHZ.These findings show that a large number of children with MAM are being missed and not provided with nutrition rehabilitation, counseling, and support because MUAC was the only anthropometric measurement used.,,In line with previous studies,A limitation of this study is that we could not analyze relationships between the screening tools and mortality, screening tools and response to treatment such as weight gain, or time for nutrition rehabilitation/graduation from treatment. We have used a cross-sectional dataset, which could not capture information on response to treatment or recovery/survival. Furthermore, screening and exclusion of children with edema were not done in these analyses, which could offer yet another interesting perspective on the prevalence of acute malnutrition. We used WHZ as a reference standard, but WHZ itself is not without its challenges for diagnosis and treatment of wasting, including the need for all health workers to be trained and standardized to ensure accuracy of measurement and for anthropometric equipment to be maintained in good condition.This study confirms that MUAC, using WHZ as the reference standard, can detect wasting but in only a small fraction of all wasted children, leaving the majority of wasting in Nepal undetected and untreated. The poor performance in terms of sensitivity and specificity confirms the need to either increase the MUAC cutoff values or adopt both MUAC and WHZ at every health facility and in acute malnutrition management programs for early, rapid, and accurate diagnosis and treatment of wasting in Nepal. Therefore, WHZ should also be used as the admission and discharge criteria, rather than MUAC alone, as a standalone anthropometric criterion at therapeutic centers. Additionally, the Government of Nepal and development partners will need to continue to work with communities to ensure that more children are brought to the health facilities where these criteria would be used. Furthermore, while evidence-based updating is done to policies and programs for the treatment of undernutrition, governments and development partners should continue to invest in prevention efforts. Multisectoral policies and programs focused on the prevention of all forms of child malnutrition should continue so that the prevalence of wasting does not remain above 10% for another 20 years. The findings of this study can help the Government of Nepal and development partners to update screening and management approaches for acute malnutrition to enable timely and proper nutrition rehabilitation of children aged under 5 years.