Malaria elimination programs have also encountered numerous challenges, such as widespread asymptomatic carriers in endemic areas, which should be taken into account in malaria‐control programs for effective transmission interruption. The purpose of this research was to determine the prevalence of symptomatic and asymptomatic malaria infections and associated factors, in pastoral communities.Plasmodium species were detected using light microscopy and a rapid diagnostic test. Data entry and analysis were carried out using SPSS version 26 software. The association between dependent and independent variables was explored by using multivariable logistic regression analyses. A statistically significant association was declared at a p‐value of <0.05.A community‐based cross‐sectional study was conducted among selected districts in the Waghemra Zone, Northeast Ethiopia, from September to December 2022. A structured questionnaire was employed to collect sociodemographic data and associated risk factors. Plasmodium falciparum infections accounting for 67.8% (87/134). Among asymptomatic participants, 7.5% (34/451) and 10.2% (46/451) were diagnosed by rapid diagnostic test and light microscopy, respectively. On the other hand, the prevalence of symptomatic malaria was 44.5% (81/182) and 48.4% (88/182) as diagnosed by rapid diagnostic test and light microscopy, respectively. The presence of stagnant water near the houses, the utilization of insecticide‐treated mosquito nets, the number of insecticide‐treated mosquito nets, and outdoor stays at night were all positively linked with the prevalence of malaria.The overall prevalence of malaria was 21.2% (134/633), with the predominant The overall prevalence estimate for symptomatic and asymptomatic malaria was high. Malaria is still a public health problem in the study area. Malaria infection was associated with the presence of stagnant water near the houses, the utilization of insecticide‐treated mosquito nets, the number of insecticide‐treated mosquito nets, and outdoor stays at night. Improved access to all malaria interventions is needed to interrupt the transmission at the community level. Healthcare institutions are overburdened with patients during epidemics, and many resources are diverted to deal with the situation. This places a major financial burden on poverty alleviation.Plasmodium species, and a lack of long‐term and stable financing are among the challenges.Anopheles mosquito and serve as a major source of gametocytes for local mosquito vectors, which helps to maintain malaria spread.Malaria control and elimination are becoming increasingly difficult in many nations, including Ethiopia. The prevalence of asymptomatic carriers, the evolution of insecticide‐resistant vectors and drug‐resistant In high‐endemic areas, asymptomatic malaria infection is more prevalent.Despite the fact that some research on asymptomatic or symptomatic both types of malaria are conducted in various locations of Ethiopia, they often focus on health institution‐based studies and pregnant women. As a result, understanding the present prevalence of symptomatic and asymptomatic malaria, as well as the risk factors linked with it, in communities is critical for scaling up intervention programs. In the study area, there has been no research on the prevalence of symptomatic and asymptomatic malaria. As a result, the purpose of this study was to determine the prevalence of symptomatic and asymptomatic malaria, as well as associated factors, among pastoral communities in the Waghemra Zone.22.1Anopheles mosquitoes. Furthermore, the Tekeze, Bargba, and Tela Rivers have several irrigation and construction dams that are used for mosquito reproduction. Therefore, malaria is one of the leading causes of morbidity and mortality in those districts. The main occupations in the districts are subsistence farming, livestock rearing, and fishing.A community‐based cross‐sectional study was conducted from September to December 2022 among selected districts in the Waghemra Zone. Waghemra Zone is one of the 11 zones in Amhara region, Ethiopia. It is located at the following latitude and longitude coordinates: 12° 45′ 54″ N, 38° 50′ 35″ E. This zone is divided into eight districts with a total population of 536,129 people. Three districts in the Waghemra zone are highly malarious but differ in magnitude. The area's average yearly temperature and rainfall are 26°C and 786 mL, respectively. The climate and topography of the locations are ideal for the breeding of 2.2Z(α/2)2P (1−P)/d2, (1.96)2 *0.221 (1–0.221)/(0.05)2 = 384. Accounting for a 10% nonresponse rate and implementing design effect of 1.5, the final sample size was 633.The sample size was calculated using a single population proportion formula, the 95% confidence interval (CI) (Zα/2 = 1:96), and 5% margin of error (d) with a maximum proportion of 50%. Sample size = 2.3A stratified sampling method was used to select the representative sample size. The total households for each village were available at their nearest health post, which is stored as a family card folder, to determine the proportional sample size for each selected kebele. Based on this, the total sample size was proportionally allocated as 146, 104, 127, 81, 114, and 61 households to Tsitsika, Netsawork, Silazge, Meharit, Saka, and Debre‐brihan kebeles, respectively. Each household was selected using a systematic random sampling technique. Finally, one of the selected household members was chosen at random using a lottery method.2.4Individuals with and without clinical malaria symptoms who are permanent residents of the districts were included in the study. On the other hand, individuals who had taken antimalarial medications in the 4 weeks before the research period were excluded.2.52.5.1A structured questionnaire was used to collect information from each participant, including associated factors such as background characteristics, behavioral, environmental, and other factors relevant to malaria infection. Selected adult participants were interviewed directly; for children, parents were involved in the interview process. After the selection of the study participants in the households, body temperature and other clinical manifestations were examined by senior BSc nurses to identify symptomatic and asymptomatic individuals.2.5.2In addition to sociodemographic and other variables, blood samples were taken aseptically from each subject via a finger prick with a disposable sterile lancet. Rapid diagnostic test (RDT) and blood films were used to screen the samples for malaria parasites.After the bag was opened, the capillary sample was wiped onto the sample pad of the test kit for instant use. After about two drops of buffer were placed in the buffer pad, the result was read after 20 min.Plasmodium spp. The thin blood smear was fixed after drying by delicately dripping methanol with a Pasteur pipette. The methanol‐fixed thin smears were permitted to dry completely in the air by placing the slides on a level surface (about 2 min). The blood smears were transported to nearby health facilities in a slide box for giemsa staining. At least 100 high‐power fields (100 objectives) were assessed before reporting a negative result.For each participant, thin and thick blood films were produced on the same slide and labeled with a unique code for the microscopic study of 2.5.3The questionnaire was pretested, and the data collectors received training. The expiration dates of the RDT kits were examined. The manufacturer's instructions were strictly followed for the RDTs. Positive and negative blood films were run to ensure the quality and integrity of the giemsa staining. Two experienced laboratory technologists individually examined the microscopic slides. Hundred microscopic fields of the thick smear were examined before concluding as negative. The discrepancy between the first and second readings was settled by a third senior laboratory technologist. Blood smear microscopy readers was blinded to the results of RDTs. Houses that were absent during the first visit were revisited again in the following day to ensure maximum involvement. All test methods and results were interpreted in accordance with standard operating procedures.2.5.4p‐value of less than or equal to 0.25 were included in the multivariable logistic regression analysis. The 95% CI was used to determine the odds ratio (OR), and a p‐value of less than 0.05 was considered statistically significant. Finally, the study's findings were presented in text and tables as appropriate.Following data collection, SPSS version 26 was used to enter and analyze the data. Descriptive statistics were used to assess the prevalence rate and determining factors. To assess an association of factors with malaria infection, bivariable and multivariable logistic regression models were utilized. In the bivariable analysis, variables having a 33.1In this study a total of 633 asymptomatic and symptomatic patients, with a 100% response rate were included. In terms of age category, 43.4% (275/633) of participants were between the ages of 15 and 45. Of the overall study participants, 48.5% (307/633) were farmers, and 79.3% (502/633) had a family size of 4−6 people  of symptomatic and asymptomatic subjects in the Waghemra Zone (95% CI = 18.0−25.0). Of these, 56.0% (75/134) were males and 44.0% (59/134) were females. Similarly, the prevalence of malaria was greater in the age groups of 15−45 and 5−14 years, with prevalence rates of 35.1% (47/134) and 30.6% (41/134), respectively  were asymptomatic and the remaining 182 (28.8%) were symptomatic. Overall, the prevalence of malaria diagnosed by RDT and microscopy was 18.2% (115/633) (95% CI: 14.6−22.4) and 21.2% (134/633) (95% CI: 18.0−25.0), respectively. Malaria prevalence among asymptomatic and symptomatic individuals was 10.2% (46/451) and 48.4% (88/182), respectively  reported having slept under ITNs on a regular basis during the previous 2 weeks. IRS coverage and frequency were assessed during the survey, but none of the households were sprayed. In bivariable logistic regression, previous history of malaria infection, stagnant water near the house, ITN utilization, number of ITNs, outdoor stay at night, presence of a hole on the wall of the house, and knowledge of malaria transmission and prevention were chosen and entered into the forward stepwise multivariable logistic regression model.In multivariable logistic regression analysis, the presence of stagnant water near the house, ITN utilization, number of ITNs, and outdoor stay at night were found to have a statistically significant association with malaria infection. People who were living near a mosquito breeding site at a distance of ~1 km were nearly seven times more at risk of getting malaria infection than their counterparts . Similarly, those respondents who did not use ITNs regularly were at about four times higher risk of developing malaria compared to regularly used . Likewise, the odds of contracting malaria among respondents who lived in households with an inadequate number of ITNs per family size were about three times higher than their counterparts . Moreover, individuals who stayed outside at night had an almost twofold greater risk of acquiring malaria compared to those who did not  . It was comparable to a study conducted in the East Shewa Zone, Central Ethiopia (25%),Lower malaria prevalence rates have been reported from various parts of Ethiopia, including Debre Elias district, Northwest Ethiopia (5.0%),The present study showed that the prevalence of asymptomatic malaria in the Waghemra Zone was 10.2% (95% CI = 8.1−12.4). This finding was comparable with the study conducted in Jawi district, Northwest Ethiopia (11.2%),The prevalence rate of asymptomatic malaria in this study was higher than the study done in Raya Kobo district, Northeast Ethiopia (7.0%),This study showed that the prevalence of symptomatic malaria in pastoral communities of Waghemra Zone was 48.4% (95% CI = 44.2−53.0). The prevalence of this study was lower than a study done in Ibadan, Nigeria (55.0%).In general, the prevalence of malaria differed between symptomatic and asymptomatic individuals in this study. This disparity could be attributed to the fact that we used various sample sizes and that the diagnosis was performed using low‐sensitivity techniques, particularly for the diagnosis of asymptomatic malaria.Plasmodium species detected was P. falciparum (65.0%), followed by P. vivax (31.3%). This was in agreement with other previous studies done in the Argoba district, Northeast EthiopiaP. falciparum and P. vivax accounted for 60% and 40% of the malaria cases in the country, respectively. This variation could be due to the fact that this study was limited to a small malaria‐endemic setting in the country, which could have caused the species prevalence to vary. Furthermore, because P. falciparum is a common species in the lowlands, there is the possibility of recrudescence.This study revealed that the predominant In the present study, the presence of stagnant water, ITN utilization, number of ITNs and outdoor stay at night were found to have a statistically significant association with malaria infection. Furthermore, people who live near stagnant water are more likely to be exposed to the malaria parasite than those who do not live near stagnant water. There are numerous freshwater collections that formed during the rainy season, which were ideal for mosquito breeding. A similar finding was reported from a study done in Simada district, Northwest Ethiopia.This study also found that households that did not regularly use ITNs were 4.39 times more likely than those who used regularly to be infected with the malaria parasite. This result supported by similar previous studies conducted in South Gondar and Arbaminch Zuria districts, Ethiopia's.Respondents who lived in households with an inadequate number of ITNs were 3.23 times more likely to develop malaria. Inadequate ITNs in households might enforce the community to utilize the ITNs infrequently. It is recommended that at least one ITN for every 2 persons in the household. Similarly, people who stayed outside at night were approximately five times more likely to be infected with malaria than those who did not. This finding was supported by a report from the Ziquala, Armachiho, and Dembia districts of the Amhara region of Ethiopia.4.1This study maintained its strength by using larger samples and sampling approaches to reduce selection bias and assure internal and external validity. Confounding factors were also eliminated with the help of binary logistic regression analysis. In this study, like any cross‐sectional study, it is difficult to establish a causal association. Furthermore, due to a shortage of resources, this study was unable to apply the molecular tool PCR for detecting malaria to support RDT and microscopic investigation.5Plasmodium species, P. falciparum was found to be the most prevalent in the study area. Due to internal conflict, for the last year of the study, none of the houses were sprayed by the IRS. Regarding associated factors, the presence of stagnant water near the houses, the utilization of ITNs, the number of ITNs, and outdoor stays at night were significantly associated with malaria infection.In this study, the overall prevalence estimate of symptomatic and asymptomatic malaria was high. Among The following recommendations are made based on the findings. Because ITN and IRS have potential protection gaps, their combination with environmental management interventions should be applied in the study area. Therefore, community awareness regarding ITN utilization and malaria prevention and control mechanism, and removal of potential mosquito breeding sites should be conducted regularly. Further prevalence studies should be conducted using highly sensitive and specific molecular methods. Both asymptomatic and symptomatic malaria should be considered during community malaria screening in the implementation of the prevention and control program so that the efficacy of control strategies can be assessed using reliable metrics.Habtu Debash: Conceptualization; data curation; formal analysis; funding acquisition; investigation; methodology; project administration; resources; software; supervision; validation; visualization; writing—original draft; writing—review and editing. Gebru Tesfaw: Conceptualization; data curation; formal analysis; funding acquisition; investigation; methodology; project administration; resources; software; supervision; validation; visualization; writing—review and editing. Hussen Ebrahim: Conceptualization; data curation; formal analysis; funding acquisition; investigation; methodology; project administration; resources; software; supervision; validation; visualization. Agumas Shibabaw: Conceptualization; data curation; formal analysis; funding acquisition; investigation; methodology; resources; software; supervision; validation; visualization; writing—review and editing. Yimer Melese: Conceptualization; data curation; formal analysis; funding acquisition; investigation; methodology; resources; software; supervision; validation; visualization; writing—review and editing. Mihret Tilahun: Conceptualization; data curation; formal analysis; funding acquisition; investigation; methodology; project administration; resources; software; supervision; validation; visualization. Ermiyas Alemayehu: Conceptualization; data curation; formal analysis; funding acquisition; investigation; methodology; resources; software; supervision; validation; visualization. Ousman Mohammed: Conceptualization; data curation; formal analysis; funding acquisition; investigation; methodology; resources; software; supervision; validation; visualization. Melkam Tesfaye: Conceptualization; data curation; formal analysis; funding acquisition; investigation; methodology; resources; software; supervision; validation; visualization. Mengistu Abate: Conceptualization; data curation; formal analysis; funding acquisition; investigation; methodology; project administration; resources; software; supervision; validation; visualization.The authors declare no conflict of interest.Plasmodium parasite received antimalarial treatment according to the national malaria treatment guidelines.Ethical clearance was obtained from the ethical review committee of College of Medicine and Health Sciences, Wollo University on the date 16/8/2022 with a protocol number of CMHS/201/2022. Permission was obtained from Waghemra Zone Health Office and each district health office where the study was conducted. This study was conducted in accordance with the Declaration of Helsinki. After briefly describing the significance of the study, the participants or children's parents or guardians signed informed written consent. Confidentiality of the data was maintained. Finally, children who were infected with the The lead author Habtu Debash affirms that this manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned  have been explained.


Malaria remains a significant public health problem in sub-Saharan Africa. Child mortality due to severe malaria remains high in developing countries despite improvements in malaria management and a better understanding of its pathophysiology. To address the lack of epidemiological studies on severe malaria in Gabon, this study describes the epidemiological aspects of severe malaria in rural, semi-rural, and urban areas of southeast Gabon.P falciparum malaria diagnosed by microscopy with at least one of the malaria severity criteria.Demographic, clinical, and laboratory data for children and adolescents aged 0–18 years were collected in 2019 from hospital records at three health facilities in southeastern Gabon. The patients included in the study were positive for Severe malaria accounted for 18.8% (667/3552) of malaria cases. Children aged 0–5 years accounted for 71.8% (479/667) of all severe malaria cases. Adolescents over 15 years of age were the least affected by severe malaria with 4.2% (28/667). Across the study, severe anemia , convulsions , respiratory distress , and altered consciousness  were the most frequent clinical signs of severe malaria in children. Franceville was the locality most affected by severe malaria with 49.2% (328/667), followed by Koulamoutou with 42.0% (280/667) and Lastourville with 8.8% (59/667). Convulsions  and coma  were more frequent in children living in urban areas. In contrast, severe anemia  and jaundice  were more common in children living in semi-rural areas.Severe malaria is more prevalent in urban areas in regions with a high malaria transmission intensity. However, in this study, the epidemiological characteristics of severe malaria were similar in the three settings  despite different levels of urbanization. Nevertheless, the various signs of severity were more frequent in Franceville, an urban area. Children under 5 years of age remain the most vulnerable age group. Plasmodium. The clinical presentations of malaria may vary and include asymptomatic malaria, uncomplicated malaria, or severe malaria . The species Plasmodium falciparum is most often responsible for severe forms of malaria [Plasmodium falciparum in the blood and is associated with one or more clinical signs [Despite control efforts, malaria remains a significant public health problem in sub-Saharan Africa. According to the World Health Organization (WHO), in 2020, 241 million cases of malaria and 627,000 deaths were recorded worldwide, 77% of which affected children under 5 years of age. That same year, 96% of all malaria cases were recorded in sub-Saharan Africa [al signs . These ifemale anopheles per person [In Gabon, a Central African country composed of 9 provinces, there is a high intensity of malaria transmission throughout the year. The entomological inoculation rate can reach approximately 1,000 bites of infected r person , 8, 10. r person –13.In Gabon, the main signs of severe malaria in children are severe anemia, neurological complications, hypoglycemia and respiratory distress. In children under 5 years of age, severe anemia is the most frequent clinical sign in severe forms , 14–16. This retrospective study was conducted in three localities in southeastern Gabon in 2019. Franceville is the administrative capital of the Haut-Ogooué province (1°37′15″S and 13°34′58″E). It is an urban area and the third largest city in the country. Koulamoutou, the administrative capital of the Ogooué-Lolo province , is a semi-urban area. Finally, Lastourville is the capital of the Mulundu department and a rural region of Gabon . The records used in this study came from the Amissa Bongo Regional Hospital of Franceville, the Paul Moukambi Hospital of Koulamoutou, and the outpatient department of the medical center of Lastourville.This retrospective study targeted patients aged 0 to 18 with severe malaria. Data collection was conducted in the same manner in the three health facilities. A standardized sheet was use for data collection from the hospital registers. All socio-demographic, biological and clinical information have been collected.P. falciparum parasitaemia by microscopy with at least one of the criteria for severe malaria according to the WHO definition : Altered consciousness (GCS score 9–14 or Blantyre score 3–4 in children under 5 years of age), coma (with a Blantyre score < 3 in children under 5 years of age and a GCS score < 9 in older children), respiratory distress ), Multiple convulsions (More than one seizure in 24 h), Prostration , shock (PAS < 70 mm Hg in children or < 80 mm Hg in adults), pulmonary edema (Radiologic diagnosis), abnormal bleeding , jaundice (bilirubinemia > 50 µmol (3 mg / dl) with a parasite count > 100 000 / µl), severe anemia (Hb < 5 g/dl or Ht < 15% in children < 12 years and Hb < 7 g/dl or Ht < 20% in children > 12 years and adults), hypoglycemia (Blood glucose or plasma glucose < 2. 2 mmol (< 40 mg / dl)), Hyperparasitemia , hyperlactatemia (lactate > 5 mmol/l), Renal failure (Creatininemia > 265 µmol (3 mg/dl) or blood urea > 20 mmol), metabolic acidosis (Base deficit > 8 mEq / l or plasma bicarbonate < 15 mmol or venous plasma lactate > 5 mmol), identified by WHO.Severe malaria was defined by the detection of asexual Data were collected from medical and hospital records dating from 2016 to 2018. This study analyzed records of minor patients who consulted for malaria in emergency and outpatient departments. Adult, non-malarial patients were not included. Clinical and demographic data (age and sex) of patients were collected from the emergency department records of each health facility. In addition, patients’ biological data were collected from laboratory records.Plasmodium have been observed by at least two microscopists and the parasitemia is expressed qualitatively, as follow: low (+) 1–10/100 fields, light (++) 11–100/100 fields, moderate (+++) 1–10/one field, and high parasitemia (++++) > 10/one field [In the health facilities of the region, malaria is diagnosed by optical microscopy. The thick drop examination is positive if asexual forms of ne field . These sne field .All collected data were initially recorded on a spreadsheet and analyzed using the Stata software .Variables were described using proportions for qualitative variables, means and standard deviation for quantitative variables. Proportions were compared using the Chi2 test or Fisher’s exact test. The significance level was set at α = 5% for all analyses. All patients with missing data were excluded from the analysis.The consultation of laboratory records was performed in accordance with the Declaration of Helsinki 2000. This study was approved by the National Research Ethics Committee of Gabon (N°001/PR/SG/CNER/2018) which waives the informed consent of the patient in the framework of a retrospective study and by the management of the CHRAB of Franceville, CHRPM of Koulamoutou and CM of Lastourville, guarantor of the hospital data. The data were collected anonymously as part of the routine analyses carried out in the laboratories of these health structures. These facilities are under the supervision of a Director.Plasmodium falciparum by microscopy (thick drop) and 18.8% (667/3552) had severe malaria. Table In total, 6114 febrile children and adolescents consulted the different study sites. Among these, 58.1% (3552) patients tested positive for In this study, severe anaemia (49.0%), convulsions (43.0%), respiratory distress (5.1%) and altered consciousness (4.8%) were the most frequently observed clinical signs of severe malaria. Jaundice (3.7%), coma (3.4%), hypoglycaemia (0.6%) and renal failure (0.4%) were the least severe forms observed Table .Table In 3.7% of severe cases, we observed an association between at least one neurological sign and severe anaemia (haemoglobin level < 5 g/dL in children and haemoglobin level < 7 g/dL in minors over 12 years of age).Table The distribution of severe forms of malaria in Franceville (328 severe cases), Koulamoutou (280 severe cases) and Lastourville (59 severe cases) is presented in Table Severe malaria was divided between urban (328 severe cases observed) and semi-rural (339 severe cases) settings. Table There is a lack of data on severe forms of malaria in sub-Saharan Africa, a form of the disease which is responsible for important morbi-mortalities, especially in children. The objective of this study was to describe the epidemiological aspects of severe malaria in children and adolescents in southeast Gabon. The choice of the study period was motivated by the observation of a rebound in malaria prevalence in Gabon after 2010 . The retSevere anemia, convulsions, coma and respiratory distress were the most severe forms observed. These results are similar to those observed in other studies , 28, 29.In our study, the majority of children had a parasitaemia of more than 10,000 parasites/µl of blood. The severe form hyperparasitaemia was not observed. This result could be explained by the fact that the parasite load was estimated qualitatively and not quantitatively. However, although hyperparasitaemia is considered a severity criterion for malaria, the presence of P. falciparum parasitemia associated with at least one severity criterion is considered severe malaria, according to the WHO , 34. Morp < 0.05), except for altered consciousness, respiratory distress, hypoglycemia, and renal failure. The low proportion of patients in Lastourville could be at the origin of this difference observed between sites. The difference in the prevalence of these severe forms between sites  could be explained by the fact that hospital facilities are more accessible in Franceville than in the other sites. Moreover, there is also a difference in the density of the resident child population in each site associated with economic hardship which restricts prompt access of patients and families to a health facility. Similar results were found in other studies conducted in Gabon [However, Franceville had the highest prevalence of severe malaria compared to the other sites. These severe forms of malaria infection were significantly different between the three areas . In addition, the prevalence of severe anemia and jaundice were significantly higher in semi-rural areas than in urban areas (p < 0.05). This result is similar to that observed in Equatorial Guinea . HoweverIn this study, the mortality rate was 2.7%. This rate was close to that observed by Isoufou et al. in Lambaréné (center of Gabon) and by Andreas Chiabi and colleagues (3.8%) in Cameroon , 39.p > 0.05). This result could be explained by the existence of road infrastructures between a large number of villages and localities with a hospital structure, facilitating access to hospitals. In addition, malaria control measures across the country could explain this lack of difference in the fatality rates. The various severe forms associated with death were: altered consciousness, followed by respiratory distress and coma. These results are similar to those observed in other studies where the occurrence of coma, altered consciousness and respiratory distress were associated with death [This could be explained by the fact that the Koulamoutou CHRPM is the reference hospital in the Ogooué-Lolo province. Cases of severe malaria from other health facilities in the region are systematically transferred to the CHRPM. For example, serious cases of malaria from the Lastourville Medical Center, a secondary health establishment within the same health region, are transferred to the Koulamoutou CHRPM, which is better equipped to treat serious cases. This result could also be explained by the practice of self-medication by parents , 21, 40.th death , 41, 42.This retrospective study has a few limitations. This retrospective study did not allow us to find in the registers all the criteria of the definition of severe malaria, in particular, shock, pulmonary edema, abnormal bleeding, metabolic acidosis and hyperlactatemia . The BlaThe epidemiological characteristics of severe malaria were similar in the two settings , despite different levels of urbanization. However, the proportions of severe malaria cases were higher in Franceville, which is an urban area. Children aged 0–5 years were the most affected by severe malaria and deaths due to this disease. Coma, convulsions, severe anemia, jaundice, and respiratory distress were the most common severe clinical signs. Severe malaria was more common in children living in the urban area than in those living in the semi-rural area. Furthermore, the death rate in these two types of settings was similar. However, these observations may underestimate the real prevalence of severe malaria in southeastern Gabon. Indeed, the poor state of health records and the loss of medical records have largely contributed to the loss of patient information. It is therefore necessary to characterize severe malaria in all regions of the country to gain a better idea of the national prevalence of severe malaria and its characteristics in Gabon.


Malaria is a major cause of morbidity and mortality in children under the age of five worldwide. Although various malaria elimination measures have been implemented over the past decades, malaria remains a serious threat to public health, especially in tropical and subtropical areas. Ethiopia has set targets for eliminating malaria by 2030. No research has been conducted in the study area concerning malaria among children, who are the most malaria-prone segment of a community. The purpose of this study was to assess malaria prevalence and the factors associated with it among children under five years of age who attended the Sheko Health Center, Southwest Ethiopia, from June 1 to October 30, 2022.An institutional-based cross-sectional study was employed from June 1 to October 30, 2022, at the Sheko Health Center. Capillary blood samples were collected from 286 randomly selected symptomatic children. Data on socio-demographics and associated factors were collected using a pre-tested structured questionnaire, and data on parents’ and guardians’ knowledge about malaria was recorded on Excel 2016 Spreadsheets after interviewing them, and their responses were presented by a frequency table. Data were entered into Epi Data Manager (v4.0.2.101) and analyzed using the Statistical Package for Social Sciences (SPSS) version 25. Associated factors of malaria were analyzed using bivariate and multivariable logistic regression, and statistical significance was set at P < 0.05.Plasmodium falciparum, Plasmodium vivax, and mixed infections (both species) representing 52.2%, 34.3%, and 13.4% of the cases, respectively. The majority of the parents or guardians believed that malaria is transmissible but could be prevented, and 80% of them considered mosquito bites to be the main mode of malaria transmission. Insecticide-treated net (ITN) was mentioned as a malaria prevention strategy by more than half of the respondents, while indoor residual spraying (IRS) was considered only by 19.6%. Based on multivariable logistic regression analysis, a significant association was found in children between the ages of 12 and 36 months , children who lived in rural areas , and children who did not use ITN the past two weeks before sample collection .Overall, 23.4% (95% CI = 18.6–28.8%) malaria infection was recorded among the children whose blood samples were examined, with This study revealed a high malaria prevalence among children aged under five years. Attention must be paid to improving the coverage of the ITN and its use in the study area, which could help reduce the risk of mosquito bites. Health education for the guardians of the children could also help to raise awareness about the prevention and control strategies for malaria transmission and further reduce the impact of the disease. Malaria is a major public health problem that still causes disease and death. It significantly contributes to poverty in areas with few resources, particularly in tropical regions around the world. Data from 85 countries with high malaria incidence show an increase in malaria cases between 2019 and 2020 . In the Malaria remains among the top 10 diseases in the district, as evidenced by the district health department report, which adds to the remoteness of the area with low infrastructure coverage, making the study area one of the hardest-to-reach areas in the region. Investigating the malaria prevalence in such an area is of paramount importance to the community of the study area, particularly children (vulnerable groups). Malaria affects children in different ways because children typically lack acquired immunity, i.e., they are more likely to experience severe malaria, also known as cerebral malaria, which can result in coma or seizures and quickly lead to death. Moreover, the side effects of recurrent infections like anemia raise the chance of death in the early months of life and result in low birth weight when they occur during pregnancy .The national health sector transformation plan (HSTP) for Ethiopia’s four-year period of 2015/16 to 2019/20 was intended to be matched with the national malaria control strategy (NMSP) that was created by the Ethiopian government for the years 2017–2020. The suggested targets for the 2017–2020 NMSP include maintaining nearly zero malaria mortality  by 2020, a 40% decrease in malaria cases by 2020, and the elimination of malaria in Ethiopia by 2030 [Previous studies, which were carried out in areas where malaria is endemic and is a primary cause of morbidity and mortality in children under five years of age in Ethiopia, only focused on the adult population . There hAn institutional-based cross-sectional study was conducted in the Sheko district at Sheko Health Center, southwest Ethiopia, from June 1 to October 30, 2022. The district’s boundaries are Debub Bench to the south, Guraferda to the west, Sheka Zone to the north, Gambela Region to the northwest, and Semien Bench to the east. The health center was established in 1961 and is located 588 km from Addis Ababa, Ethiopia, and 20 km from Mizan Teferi, which is one of the major cities of the Southern Nations, Nationalities, and People’s Region. There is a delivery department, an outpatient department, a laboratory department, an emergency room, an antenatal care unit (ANC), and a tuberculosis clinic at the health center. The health center has currently provided different health services for approximately 71,742 people .Children aged under 5 years who attended the Sheko district health center from June 1 to October 30, 2022, were enrolled, and the parents or guardians of the children were also considered participants for the face-to-face interview. Children aged under 5 years with malaria-related symptoms who visited the Sheko district health center during the study period and fulfilled the inclusion criteria were enrolled as study participants.Children aged ≤ 59 months who had malaria symptoms  and wereThe sample size was determined by the following formula. (0.228) , and q =297.After adding a 10% non-response rate the total sample size was calculated to be Children who visited the health center laboratory for blood film examination and met eligibility criteria were recruited by a systematic random sampling technique, considering the flow of cases in the health center the previous year. The sampling frame was obtained from the registered information from the health facilities in the area studied, and accordingly, there were approximately 1414 children aged under 5 years who received services such as immunization or vaccination at health institutions in the catchment. The kth interval was calculated as (4.76 ≈ 5). Therefore, the study participants who met the inclusion criteria were picked every fifth time after randomly selecting the first child using the lottery system. Finally, 297 children who met the inclusion criteria were included in the study.Malaria prevalence.Some of the independent variables were age, sex, residence, educational status, occupational status, family monthly income, insecticide-treated net (ITN) use, mosquito/vector breeding site, insecticidal residual spraying (IRS), and family size…Face-to-face interviews with parents or guardians of study participants (children) were used to collect sociodemographic information and related factors. A 6 μL and 2 μL capillary blood sample was taken aseptically from the children’s fingers or big toes using sterile blood lancets to prepare thick and thin blood film smears. To reduce the occurrence of any possible bias, a systematic random sampling technique was used.Frosted slides were used to make a thin and thick blood smear, and the blood films were air-dried before the thin film was fixed with absolute methanol. Following the standard operating procedure, both thin and thick blood smears were stained for 10 minutes with the Giemsa staining working solution. The blood film slides were examined by experienced laboratory technicians at the Sheko District Health Center.Data were entered into Epi Data Manager (v4.0.2.101) and analyzed using the Statistical Package for Social Sciences (SPSS) version 25. Descriptive statistics were used to summarize the demographic profile of the study participants. Bivariate and multivariable logistic regression analyses were performed, and a P-value of less than 0.05 was taken as statistical significance.A thick and thin blood film was prepared, and a thin smear was fixed with absolute methanol in the field and transported to the Mizan-Tepi University parasitology laboratory. It was stained with a 10% working solution of Giemsa for 10 minutes. The slides were examined using the oil immersion objective of the microscope by two experienced lab technicians independently. A third technician, who was unaware of the preceding results, was tasked with resolving any discrepancies. The blood film was recorded as positive or negative after examining 200 high-power fields of the thick smear , 14.The formula below was used to determine the number of malaria parasites per microliter (μL) of blood, assuming that the patient’s total leukocyte count was 8000/μL. The parasite count multiplied by 8000 WBC/ μl of blood is the parasite burden. Consequently, the malaria parasite density was classified as high parasitemia with a parasite density of , moderate with a parasite density of , and low with a parasite density of (< 1000 parasites/μL of blood) . The numIf the number of WBCs is unknown, it can be assumed to be 8000/μL.Symptomatic children: refers to children who had malaria-related symptoms  within the past 2 days and at the time of examination and the presence of malaria parasites in their blood , 17.In the test methods, a checklist, a structured questionnaire, and standard operating procedures (SOP) for malaria microscopy were employed to ensure the quality of the data. Giemsa’s working solution was prepared by filtering the crystals using Whatman filter paper. Additionally, the glass slides were labeled in such a way that the slide code matched the particular child’s file. A sterile automatic lancet was used for each child to draw the blood sample, and a microscopic examination of the blood films was performed by three experienced laboratory technicians.Ethical clearance with approval number CHS/00982/22 was obtained from the College of Health Science and Medicine at Mizan-Tepi University. The objective of the study and the procedure were explained to the study participants before blood sample collection. Verbal assent from the children and written informed consent from the parents or guardians were obtained before data collection.Plasmodium species. More than 60% of the study participants were urban dwellers; more than one-third of the study participants were in the age range of 12–59 months; and more than half of them were male [A total of 286 children aged under 5 years with malaria symptoms participated in the study, and a response rate of 96.3% was recorded from their parents or guardians. Of the children, 23.4% (95% CI = 18.6–28.8) were confirmed to be positive for ere male .Plasmodium species, Plasmodium falciparum  was comparatively more prevalent in both sexes than Plasmodium vivax (P. vivax). More than 60% of the study participants were urban dwellers, while the malaria parasite was more common among children living in rural areas [Children between the ages of 37 and 59 months and those between 12 and 36 months had a higher malaria prevalence compared to children under the age of 12 months. In comparison, males had a higher malaria prevalence than females. In terms of the distribution of al areas .Moderate parasitemia predominated in terms of malaria parasite density, followed by low and high parasitemia. Nearly half of the children had parasite densities of (5000 parasites/μL of blood), 35.8% had densities of , and 14.9% had densities of (1000 parasites/μL of blood). Male study participants made up 57.6% of the total and had a greater moderate parasitemia than female participants, although there was no statistically significant difference in parasite density (p = .066). The highest parasite density in moderate parasitemia was seen in the age range of 37 to 59 months, and parasitemia was statistically significant across all age ranges (p = .002). Additionally, there were statistical differences (p = .001) between residents of rural and urban areas, with 60.6% of those in rural areas having moderate parasitemia .Plasmodium species in the country are P. falciparum and P. vivax. They accounted for 52.3% and 34.3% of the malaria prevalence recorded in this study, respectively, while the remaining 13.4% was contributed by a mixed infection of both species [The most common  species .The analysis of the parents’ or guardians’ knowledge showed that 94.1% had at least heard of malaria, the majority of the parents or guardians believed that malaria is transmissible but can be prevented, and 80% of them considered mosquito bites as the main mode of malaria transmission. Insecticide-treated nets were mentioned as a malaria prevention strategy by more than half of the respondents, while indoor residual spraying (IRS) was considered only by 19.6% .This study revealed that children who live close to a vector breeding site have a prevalence of sixty-five (22.7%) malaria infections, while children whose homes are not treated with insecticide chemicals have a high prevalence of 46 (16.1%) cases, and children whose homes have holes or cracks in the walls have a prevalence of fifty-three (18.5%). According to the findings of the study, households that had access to ITN were better protected than those that did not. Although the use of ITNs is the most important factor in malaria prevention, the number of ITNs available per family must also be considered. The more ITNs a household has, the lower its risk of developing malaria. Children who regularly slept on an ITN had a comparatively low prevalence of malaria .More than 60% of the study participants reported having access to ITN, and 59.8% of them had used IRS services in the previous year. More than half of the guardians responded that their children used an ITN during the past two weeks before blood sample collection, while only 33.6% of the children slept under an ITN regularly over the previous two weeks. The multivariable logistic regression model was fitted considering variables from binary logistic regression with P-values of ≤ 0.25. Age (12 to 36 months), residence, child who did not use ITN the past two weeks before sample collection, frequency of ITN use, and presence of vector breeding sites close to the homes of children were selected as candidates for analysis. In the multivariable logistic regression analysis, children in the 12-36-month age interval were found to be more likely to be infected with malaria  than those under 12 months and older than 3 years; similarly, children who were rural residents were more prone to malaria infection than their counterparts . Furthermore, children who did not use ITN for the past two weeks before sample collection had a 3.3 times greater chance of contracting malaria than children who did not use it . Furthermore, children who used ITN only occasionally or infrequently had a higher risk of contracting malaria than those who used ITN regularly , and children who lived near a vector breeding site had a higher risk of infection  than those who lived far away from a vector breeding site .Plasmodium that were identified in the blood of children represented 52.3% and 34.3% of infections, respectively. This result is consistent with Ethiopia’s national Plasmodium species distribution [Plasmodium infection. This could be a result of the fact that these children reside in regions where malaria transmission is stable and can build age-related protective immunity from repeated exposure to infected mosquito bites [Malaria remains a public health issue for children aged under five years in the study area. The overall prevalence of malaria was 24.3% 95% CI = 18.6–28.8) among children who visited the Sheko district health center, which is comparable to the one obtained from southern Ethiopia 22.1%, 22.8) .6–28.8 a, and Nig.1%, 22.8ribution –33. AccoPlasmodium parasite than their counterparts. This study revealed that ITN use has a significant association with malaria [Most of the malaria-positive children had moderate parasitemia, followed by low and high parasitemia levels, respectively, making up 49.3%, 35.8%, and 14.9% of the infected children. This is concurrent with previous studies conducted in northern Ethiopia , and in  malaria , which i malaria . This caThis study was carried out using the commonly used microscopy method, which could be the reason why a low prevalence of malaria was recorded. Therefore, the magnitude of the disease could be higher than the one found if high-sensitivity techniques such as polymerase chain reaction and loop-mediated isothermal amplification were used.Malaria continues to be the greatest public health problem for children aged under five years in the study area. This study revealed a high prevalence of malaria, with children in the age range of 37–59 months taking the largest share. The inability to use ITN, residence, and the presence of vector breeding grounds were among the important associated factors. Therefore, stakeholders  organizations should focus on raising the public’s awareness of the use of ITNs, IRS services, and environmental sanitation.S1 Data(SAV)Click here for additional data file.S1 File(DOCX)Click here for additional data file.S2 File(DOCX)Click here for additional data file.S1 Checklist(DOCX)Click here for additional data file.