Plasmodium falciparum is distinguished from the rest of the Plasmodia by its high level of parasitaemia. They infect liver cells (hepatocytes), and multiply into merozoites and rupture liver cells in the process, prior to infection of red blood cells. This study sought to estimate the extent to which P. falciparum parasitaemia correlates with hepatocellular dysfunction among Ghanaian children suffering from acute malaria in three malaria endemic districts in Ashanti Region and to predict liver dysfunction from the estimation of haemoglobin (HB) levels. A prospective uncontrolled before- and after study was conducted among under five years children with acute malaria (n = 300) and a control group (n = 20) within the same age brackets. The serum activities of liver enzymes such as aspartate transaminase (AST), alanine transaminase (ALT), alkaline phosphatase (ALP) and gamma glutamyl transferase (GGT) were measured in patients and control subjects. The study observed an inverse relationship between mean HB and parasitaemia . The mean levels of AST, ALT, ALP and GGT were higher (p < 0.0001) in the serum of the infected children before treatment compared with post treatment. Moreover, the receiver operating characteristics (ROC) curve was applied to establish that HB level at 10.9 g/dL predicted liver dysfunction with the area under the curve (AUC) being 0.75 ± 0.03 (P < 0.0001). The parasitaemia estimation and prediction of hepatocellular dysfunction in Ghanaian children with acute malaria could be done via HB levels.Malaria is an important global health disease which puts individuals, particularly children, at a greater risk of mortality.  Plasmodium falciparum parasitaemia, Malaria hepatopathy, Hepatocellular dysfunction, Aspartate transaminase, Alanine transaminase.Parasite density,  The dishan five , 3. The han five . It has han five . Liver chan five , 9. P. f density . The liv density . In this density . Thus, l density . Current22.1This prospective uncontrolled before-and after study was carried out between March and October, 2013 at three districts hospitals in the Ashanti Region, Ghana. These were St. Patrick's hospital at Offinso Municipal, Mankranso Government hospital at Ahafo Ano South district and St. Martin's hospital at Agroyesum, Amansie West district. The study zone was located within the forest-savannah and transitional ecological zone in Ghana. Studies in the area showed 50% prevalence of malaria parasitaemia among children less than 10 years of age (symptomatic/asymptomatic) with the transmission being perennial, and entomological inoculation rate of 269 infective bites per person per year [Three hundred (300) under five years’ Ghanaian children with acute malaria were recruited for the ten-month study. The control group were twenty  with sim2.2Written informed consent was obtained from all the caregivers of the participants. The ethical approval was granted by the local ethical committee on Human Research Publications and Ethics (CHRPE/KNUST/KATH/AP/022/13) and permission to conduct the clinical examination of subjects was obtained from the institution authorities. World Medical Association Declaration of Helsinki principles for Medical Research involving human subjects were followed to maintain the ethics.2.3The eligible subjects were Ghanaian children aged below five years with clinical signs of malaria who were accessing health care at the outpatient department (OPD) of the three hospitals for the very first time.2.4The exclusion criteria were any of the following; children on any form of medication and those that have viral hepatitis as well as being malnourished.2.5A structure questionnaire was used to obtain information about the children's age, gender, and risk of infection, chemotherapy along with the signs and symptoms of infection.2.6Plasmodium species before samples for analyses were obtained from the study participants. Venous blood samples were taken from the children recruited on their first visit at the hospital after they met the inclusion criteria as stipulated by the study protocols at the three major malaria-endemic districts. Venous blood was taken again from the participants after treatment. Standard operating procedures (SOPs) for venipuncture developed by BD® Diagnostics (REF: CLSI H3-A6) was adhered to by the phlebotomists. Four [2EDTA-BD, USA), while 2 mL venous blood samples were also collected into clot activator tubes and the sera were later separated for storage. The samples were transported to the clinical laboratory of St. Patrick's Hospital, Offinso for analysis.Malaria rapid diagnostic test (RDT) kits were used for field confirmation of ts. Four  mL venou2.72.7.1Two blood slides were prepared for each sample that came to the laboratory. Slightly modified World Health Organisation (WHO) guideline was utilised for smearing and staining technique as stated elsewhere . Each sl2.7.2P. falciparum parasites were counted per 200 or 500 leukocytes, which were used to estimate the parasite density per microliter of blood. Thin films were examined to confirm the species identification on the thick film. A blood slide was declared positive when a concordant result was produced by two competent microscopists.The entire smear was first screened at a low magnification (10X × 40X objective lens) to detect suitable fields with even distribution of white blood cells  , 16. Sme2.7.3Plasmodium parasites were counted against 200 WBC on the thick film. Five hundred WBC were counted where less than nine parasites were counted after counting against 200 WBC. Where microscopists did the parasite counts in the thin film  as a result of heavy parasitaemia , counted parasites were recalculated with 200 WBC. Next, parasite densities (parasite/μL of whole blood) were calculated as follows: = (Number of parasites counted/WBC counted) × WBC count/μL of participant. Also, parasite densities for all participants were calculated using assumed WBC of 5,000, 6,000, 8,000 and 10,000 μL of blood; all set by WHO to be used conveniently in facilities which lack the tools to determine patients’ absolute WBC values. Of note, 10,000 μL was adopted for the estimation of parasite density in subsequent studies because other WBC counts underestimated parasite burden during the preliminary analysis.Parasite densities were recorded as a ratio of parasites to WBC in thick films. 2.7.4As part of the exclusion criteria, participant qualification was based on the assumption that there was no indication of any hepatitis of viral origin. Therefore, all the samples collected were first subjected to screening tests to rule out hepatitis of viral origin.2.7.5CareStartTM brand by ACCESSBIO. The antigen was expressed only by P. falciparum trophozoites [P. falciparum when a concordant result was produced by the histidine-rich protein II (HPR-2) test kits.All the positives slides were set aside and blood samples in the corresponding tubes were used to test for the speciation double confirmation in the laboratory. The kits utilised were the hozoites . Blood s2.7.6The full blood counts (FBC) analysis for each participant's sample was analysed using the KX-21N Sysmex Haematology Analyzer . Daily internal quality controls and scheduled external quality assessment programme were adhered to as a quality measure. Printout result for each participant was kept for documentation and statistical purposes. The parameters of interest to this study were HB and WBC counts.2.7.7Samples for liver function test were obtained from EDTA anti-coagulated blood after centrifugation for 3 min at 1000 revolution per minute. The plasma was transferred into clean plain tubes. The samples were frozen at -20 °C and batches were run weekly. The analysis was performed using Selectra Pro S Chemistry . Samples were thawed and placed in paediatric cups. Results displayed on the monitor of this equipment included; ALT, AST, ALP, gamma-glutamyl transpeptidase (GGT), total protein (TP), albumin (ALB), globulin (GLOB), direct (DBIL) and indirect bilirubin (IND) as well as total bilirubin (TBIL).2.8www.graphpad.com) and Statistical Package for the Social Sciences (SPSS) version 20.00 for windows . Normality of all variables was ascertained before being subjected to the statistical analyses using the D′ Agostino-Pearson procedure. Continuous variables were expressed as their mean ± SEM, while categorical variables were expressed as proportion. Comparisons of the general characteristics of children under five years with acute malaria before treatment against the treated group were performed using paired t tests, Chi-square or Fischer exact tests where appropriate. However, the general characteristics of the controls were compared with the untreated group using unpaired t-test or Chi-square or Fischer exact tests. Correlation was assessed by the Pearson's method. Areas under the Curve (AUC) for the haematological marker was measured through receiver operating characteristic (ROC) curve analysis for the diagnosis of anaemia amongst before treatment and post treatment group. The diagnostic performance characteristic in terms of sensitivity and specificity was calculated at different cut-offs for HB which showed higher AUC. One-way analysis of variance (ANOVA) followed by Turkey's multiple tests was performed to compare biochemical and haematological markers among control and treated subjects. The relationships between the various liver and haematological markers were assessed via linear regression.Data was checked for completeness and consistency and all queries resolved after double data entry using Microsoft Office Excel 2007® . Statistical analyses were performed using GraphPad Prism version 6.00  among children with acute malaria before treatment (BT) in comparison with the normal and post treatment (AT) groups. However, the levels of TP, ALB, GLOB and HB were significantly raised  in AT groups than their BT cohorts. Likewise, ALP and TP were significantly higher (p < 0.05 for both) among the BT subjects than the normal groups . Most of the females had parasite density less than 10,000 μL (62.30%) and ≥10,000 μL (57.40%). The under listed liver markers; AST, ALT, ALP, GGT, TBIL, DBIL, IND and WBC significantly (P < 0.0001) increased in the serum of the BT cohorts when the falciparum parasitaemia was greater or equal to 10,000 parasites/μL. However, AST/ALT ratio and HB levels decreased significantly (P < 0.0001) when the falciparum parasitaemia was greater or equal to 10,000 parasites/μL  of HB which showed significant prediction of liver dysfunction is shown in 2 = 0.1293; p<0.0001), ALT  and AST/ALT ratio . Nevertheless, HB showed linear relationship with only ALT  in the AT group.The linear regression graphs of AST, ALT and AST/ALT ratio against HB for BT and AT groups are presented in Figures 4P. falciparum malarial infection confers a measure of hepatic compromise [falciparum malaria. Similarly, Abro et al. [Acute mpromise . This stmpromise  which deo et al. , observefalciparum parasitaemia did not have any effect on the levels of liver proteins . A similar study by Kochar et al. [The r et al. , in Indir et al. .P. falciparum parasitaemia increased with elevations of serum bilirubins   . Ramacha , at a HB level below 10.9 g/dl, there is 86.9% chance that liver dysfunction can be predicted . This, oet al. , low HB 5falciparum parasitaemia. Low HB level could predict hepatocellular dysfunction in Ghanaian children under five years. The use of HB level to predict hepatocellular dysfunction may provide useful information which physicians cannot overlook in the management of acute malaria considering the high mortality rate of this disease in Ghana.It was observed in this study that malarial infection could cause an increase in liver enzyme concentrations in serum of Ghanaian children under five years. Also, marked increase in plasma levels of liver enzymes and decrease in HB concentrations were observed in children with high Raymond Charles Ehiem: Performed the experiments; Wrote the paper.Fareed Arthur Kow Nanse: Conceived and designed the experiments.Michael Adu-Frimpong: Analysed and interpreted the data; Wrote the paper.Felix Charles Mills-Robertson: Contributed reagents, materials, analysis tools or data.This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.Data will be made available on request.The authors declare no conflict of interest.No additional information is available for this paper.


Pulse wave velocity is a commonly used parameter for evaluating arterial stiffness and the overall condition of the cardiovascular system. The main goal of this study was to establish a methodology to test and validate multichannel bioimpedance as a suitable method for whole-body evaluations of pulse waves. We set the proximal location over the left carotid artery and eight distal locations on both the upper and lower limbs. In this way, it was possible to simultaneously evaluate pulse wave velocity (PWV) in the upper and lower limbs and in the limbs via four extra PWV measurements. Data were acquired from a statistical group of 220 healthy subjects who were divided into three age groups. The data were then analysed. We found a significant dependency of aortic PWV on age in those values measured using the left carotid as the proximal. PWV values in the upper and lower limbs were found to have no significant dependency on age. In addition, the PWV in the left femoral artery shows comparable values to published already carotid-femoral values. Those findings prove the reliability of whole-body multichannel bioimpedance for pulse wave velocity evaluation and provide reference values for whole-body PWV measurement. The arterial system’s main function is to satisfy the needs of tissues and absorb pulsation blood flow from the left ventricle and convert it into a continuous flow. This enables continuous tissue oxygenation and lower heart strain. Greater arterial stiffness leads to an increase in pulse wave propagation, a decrease in blood volume accumulation during systole, an increase in systolic pressure, and a decrease in diastolic pressure. It gives rise to increased heart strain and lower tissue supply during diastole ,2,3. Becp-d) and time delay (Δt) that the pulse wave needs to move from the proximal to the distal site:Many techniques and parameters are used to evaluate arterial stiffness, including pulse wave analysis (PWA) ,6,7, pulThe distance is commonly measured superficially between the proximal and distal sites ,10,11. DThe situation surrounding time delay, or pulse transit time, is slightly more complicated. There are many techniques that can be used to acquire it, and each has some limitations. The most widely used approaches are applanation tonometry and Doppler ultrasound. Applanation tonometry allows for the measurement of the pressure wave only at those locations where the arteries are superficially palpated. This typically means the carotid, femoral, radial, or brachial arteries ,14,15,16As an alternative, it is possible to use other methods such as oscillometric ,17,18, pThe main goal of this study was to introduce a methodology, test, and validate multichannel bioimpedance as a suitable method for whole-body evaluations of pulse wave velocity in a group of 200 volunteers. Moreover, reference values for whole-body PWV are presented.The study was based on a group of 220 normal healthy subjects who had no history of disease with major impact on PWV values and took no related medications. Prior to the experiment, they completed a questionnaire about their health state and medication. The normal subjects were recruited from the general public based on their interest. The study group was composed of a similar proportion of men and women. The measurements were performed at a special laboratory with constant environmental conditions. For this study, a rest phase was used with spontaneous breathing lasting two minutes in the supine position on an examination bed while the subjects were awake.The study was approved by the ethics committee at St. Anne’s University Hospital in Brno. All individual participants were fully informed and signed informed consent forms.Data were acquired with a Multichannel Bioimpedance Monitor  with up to 18 bioimpedance channels, a standard 12-lead ECG monitor , a Finometer Pro  for continuous blood pressure monitoring, and a phonocardiograph  for heart sound recording. All signals were recorded with a sampling frequency of 500 Hz. In addition, blood pressure was acquired via a patient monitor  at the beginning and the end of each measurement.i1), 50 (Gi2), and 51 kHz (Gi3). The first current source (Gi1) was placed between the left part of the neck and the left ankle, the second (Gi2) was placed between the right neck and the right ankle, and the last (Gi3) was placed between the left and right wrists, as shown in We focused on whole-body pulse wave velocity monitoring based on bioimpedance. Bioimpedance is measured indirectly using Ohm’s law; thus, the investigated body part is connected to an alternate current source and a voltage drop is observed. The study was based on the Multichannel Bioimpedance Monitor (MBM), which is able to measure blood flow properties in up to 18 channels using 3 current sources with different frequencies ,30,35,36In this way, the bioimpedance channels placed on the left and right body parts were separated vertically, as well as the channels placed between hands horizontally. Individual bioimpedance channels were localized by their position and the frequency selectivity of the voltage detectors. Placement of the channels and matching current sources are shown in The best proximal position was identified as the channel located over the left carotid (left neck) .Pulse wave velocity is defined as the ratio between distance and the corresponding time delay, as shown in Equation (1). The distance was measured directly from the sternum (at the level of second rib) to each proximal location, specifically to the center of the voltage electrode pairs. To determine the time delay, the pulsation component (ΔZ) of the bioimpedance signal was employed. Thus, for stroke volume, −dZ/dt max peak was chosen as the reference point to acquire the time delay. −dZ/dt max represents maximal axial blood acceleration . The pulThe time delay between proximal and distal locations, more precisely between the −dZ/dt max of those channels, could have thus been determined. An example of time delay determination is shown in Finally, twelve pulse wave velocity values were acquired using Equation (1).The statistical analysis focused on the relationship between age and PWV.a represents the slope of the line and b is a constant referred to as the y intercept. In order to simplify and make it more transparent, only two locations with the highest dependence of PWV on age were analyzed. The strongest dependence can be described by the slope of the line: parameter a in Equation (2). To select the best possible locations, the bootstrap function with one hundred repetitions was used. Thus, the polynomial equation was calculated one hundred times for a random sample of the studied group. After that, the mean value and standard deviation were computed based on the one hundred a constants of the polynomial equation. The two channels with the highest mean constants were selected for the next regression analysis as the representative.First, the study group was divided into three subgroups based on age, namely 20–40, 40–60, and 60–80 years, and described by mean and standard deviations . Next, rt-test was carried out to compare the difference between the age groups with the null hypothesis that two independent samples would have identical average values.In addition, a two-sided The data processing was performed using Python 5.Eight subjects had to be excluded because of the poor quality of their acquired signals. In addition, inappropriate subjects were excluded based on the well-known relationship between pulse wave velocity values and blood pressure ,38,39. TThe results are based on 200 normal healthy subjects with adequate signal quality. The subjects’ characteristics are presented in Hemodynamic parameters such as heart rate, systolic, and diastolic blood pressure for statistical groups are presented in Representative pulse wave velocity values for the statistical group to the lower limbs are listed in a represents the slope of the line described by Equation (2). Moreover, the p-value of the two-sided t-test compares the PWV values between the age groups.a value from Based on the highest parameter Based on previous findings, the bioimpedance method appears to be suitable for evaluating pulse wave velocity ,25,26,27The distance measurement methodology was assumed from commonly used PWV measurement methods. Thus, it was measured directly on the body surface ,6,15,27.p-value, it is evident that pulse wave velocity changes with aging are more evident (p < 0.05) in those cases where the proximal location is set at the left carotid. Those segments include a number of large elastic arteries that lose compliance with aging. PWV in the upper and lower limbs showed no significant (0.081 < p < 0.900) changes with age in the case of normal healthy subjects.The statistical analysis was based on the fact that arterial wall properties, such as elasticity, change with age; loss of elasticity results in an increase in PWV. This mainly appears in aortic PWV as the aorta is the most elastic human artery. The influence of aging on PWV values can be described by regression analysis. This is based on the highest slope of the regression line for channels 2 and 3, which were placed on the left and right thighs as being representative. The left thigh, or rather the left femoral artery, is commonly used for aortic PWV determination . A stronIt is well-known that arterial stiffness has an impact on blood pressure. Arterial elasticity loss leads to an increase in systolic pressure, a decrease in diastolic pressure, and a resulting increase in pulse pressure. However, an increase in pulse pressure is influenced by additional factors such as ventricular ejection, for example . DiastolComparing PWV values in the various age groups was more complicated. As was mentioned, the carotid-femoral PWV is considered the gold standard for evaluating central (aortic) pulse wave velocity. The pulse wave velocity at bioimpedance channel 2  has a similar predictive value as the carotid-femoral PWV. The values detected by bioimpedance were 5.86 ± 0.81 m/s for the 20–40 years group, 8.44 ± 1.68 m/s for those 40–60 years, and 10.79 ± 1.95 m/s for those 60–80 years. There are many studies with different statistical groups and different ways of dividing the subjects into groups ,45,46,47The absence of internal validation can be marked as a study limitation as well as the relatively small sample size. It would be more accurate to compare simultaneously measured bioimpedance and tonometry-based PWVs in the same subjects rather than performing a comparison with data from other studies.Whole-body multichannel bioimpedance was used to take simultaneous measurements of pulse wave velocity. Based on an analysis, linear dependence exists between age and pulse wave velocity measured from the neck to the lower limbs for normal healthy subjects.We suppose that a corresponding analysis of PWV may be used as a simple marker of arterial aging. Future perspectives include the acquisition and analysis of patients with specific diseases impacting PWV, such as hypertension and diabetes.The whole-body multichannel bioimpedance allows for taking simultaneous measurements of proximal and distal sites to eliminate possible distortion. Moreover, it enables the evaluation of both central and peripheral PWV simultaneously without the need for highly skilled medical staff.


Plasmodium vivax and Plasmodium falciparum cases every year. This study describes the clinical–epidemiological characteristics of clinical malaria patients in this high-transmission area.Venezuela accounted for 55% of the cases and 73% of the malaria deaths in the Americas in 2019. Bolivar state, in the southeast, contributes > 60% of the country's A prospective study was conducted on patients seeking medical attention in three medical centres in the state capital, Ciudad Bolivar, between June and October 2018. Malaria diagnosis was carried out using microscopy following national standards. Malaria-positive patients were examined for clinical symptoms, and haematological tests were performed at the time of diagnosis. Patients were followed up by telephone to evaluate malaria recurrences.P. vivax, 69 (24%) for P. falciparum, and 18 (6.3%) had mixed  infections. Patients' median age was 33 years (IQR 20), 168 (69%) were men, and 40% practiced gold mining as the main occupation. Fever (96.5%), chills (91.3%), and headaches (90.6%) were the most frequent symptoms. At least one symptom associated with severe malaria was observed in 69 out of 161 patients with complete clinical evaluation (42.9%). Plasmodium vivax infections were found in 42 out of 69 (60.9%) severe cases; by contrast, P. falciparum and mixed malaria caused 34.8% (24/69) and 4.4% (3/69) of infections, respectively. Two patients died of cerebral malaria. Mean hemoglobin was lower in the patients infected with P. falciparum than those infected with  P. vivax. Regardless of the parasite causing the infection, patients presented high levels of total bilirubin, aminotransferases , and lactate dehydrogenase (LDH). Out of the 142 patients followed up by phone for three months (49.5% of the 287 patients), 35 (24.7%) reported recurrences.Out of 287 patients, 200 (69.7%) were positive for P. vivax patients with at least one criteria of severe clinical disease is a matter of concern. Whether it is the result of a lack of timely diagnosis and effective treatment should be explored.The high malaria prevalence among young male adults practicing gold mining suggests that this occupation is a significant risk factor. The unexpected high prevalence of  Malaria remains a significant public health problem worldwide . There wHistorically, Venezuela had the highest malaria incidence rate in Latin America by 1931. The situation changed dramatically in 1961. After intensive control efforts, this nation became the first World Health Organization-certified (WHO) country that eliminated malaria in almost 70% of its territory . Due to Plasmodium vivax accounted for 77.3% of reported cases, followed by Plasmodium falciparum (16.2%), and mixed  malaria (6.5%) [P. falciparum seems to remain the same regardless of the dramatic increase in transmission during the last decade [The reported data from Venezuela in 2019 indicate that, like in other countries from the Americas –11, Plasciparum 1.2%, and 2, corresponding to 26.2% of the national territory, with an approximate population of 1,837,485 inhabitants projected by 2018 [Plasmodium vivax is the most prevalent parasite, with 70–80% of malaria cases, whereas P. falciparum causes the remaining 20–30% of cases annually [El Perú" and "La Sabanita"); these are centres without hospitalization areas attended by a general or family doctor with experience in public health administration. The third was a type IV Hospital , the main hospitalization centre for malaria patients in Ciudad Bolivar.Bolivar state is in the country's south, bordering Brazil and Guyana; it has 240,528 km by 2018 . Plasmodannually . Three mThe study protocol was reviewed and approved by the Bioethics and Health Biosecurity Committee of "Ruíz y Páez" University Hospital Complex (CHRRP-CBBS-001-2018). The study was carried out according to the ethical principles for medical research in humans of the Declaration of Helsinki and the Venezuelan regulations for this type of research, with all patients' corresponding signed informed consent."Ministerio del Poder Popular para la Salud" of Venezuela criteria [P. vivax malaria received chloroquine and primaquine (daily over 14 days) (n = 198). Given the changing conditions during the malaria epidemic, patients infected with P. falciparum received one of the following treatments: (a) artemether plus lumefantrine and primaquine (single dose) (n = 58) or (b) artesunate plus mefloquine and primaquine (single dose) (n = 5). Patients with mixed infections were treated with one of the following options: (a) artemether plus lumefantrine and primaquine (daily over 14 days) (n = 16) or (b) artesunate plus mefloquine and primaquine (daily over 14 days) (n = 2). Patients with severe malaria cases received (a) injectable artesunate (n = 6) or (b) injectable artemether (n = 2).A prospective study was conducted during the period June–October 2018. Patients positive for a malaria infection confirmed by microscopy were invited to participate. These patients sought malaria diagnosis and treatment at any of the three study sites. Trained physicians at each site performed a standard clinical evaluation and detailed physical examination of all subjects in this study. Patients were classified as non-severe or severe malaria cases according to the WHO  and "Mincriteria , regardlcriteria . PatientAlthough a total of 287 patients diagnosed with malaria accepted to participate in the study, blood samples (8 ml) by venipuncture were collected only from 161 patients due to limitations in resources. The blood samples were aliquoted into three fractions: 3 ml were preserved with sodium citrate to study coagulation , 3 ml were collected with ethylenediaminetetraacetic acid to study haematology, and 2 ml without anticoagulant were used to study blood chemistry . In this study, malaria recurrences were defined following WHO standards in terms of reappearance of parasitaemia after treatment, due to recrudescence, relapse or a new infection . To estiParametric tests were used, and when the assumption of normality was rejected, the data were analysed using non-parametric tests. The distribution of the parameters was statistically evaluated using Kolmogorov–Smirnov. Fisher's exact was used when necessary for variables with low frequencies. The analyses were carried out in the statistical software Statistical Package for the Social Sciences . Maps were performed using ArcGIS software .P. vivax, 69 (24%) P. falciparum, and 18 (6.3%) had mixed  malaria infections. The total numbers of cases by locality of origin are shown in Fig. P. vivax, P. falciparum, and mixed malaria infections (p = 0.12). Table n = 8), diabetes (n = 3) and others.Out of the 287 patients diagnosed with malaria who accepted participating in the study, 200 (69.7%) had P. falciparum malaria and Sifontes' municipality's provenance (p = 0.01)  were from the Bolivar state. Of these, 103 (35.9%) and 94 (32.8%) came from the Sifontes and Heres municipalities, respectively. The rest of the patients were from other municipalities, such as Angostura, El Callao, Sucre, Piar, Cedeño, Caroni, and Gran Sabana , chills (91.3%), and headache (90.6%). Low back pain was present in almost half of the patients evaluated. The less frequent clinical manifestations were epistaxis (2.4%) and gingivorrhagia (1.7%). Paleness (59.2%) and choluria (38.3%) were also frequent in these patients regardless of the parasite species causing malaria. Twenty-nine (10.1%) patients presented hepatomegaly; it was more frequent in patients infected with P. falciparum than with P. vivax, although without significant differences between both species . Splenomegaly (p = 0.02) and somnolence (p = 0.03) were associated with P. falciparum infection. Seizures and stupor only occurred in patients with P. falciparum infection . Leukopenia was associated with P. falciparum infection (p < 0.05). Severe thrombocytopenia was more frequently observed in patients with P. falciparum . However, the average platelet values were within the range of moderate thrombocytopenia in all malaria patients, and no significant differences were observed between parasite species (p = 0.93). The mean glycaemia was lower in patients with P. vivax infection (p < 0.05), showing significant hypoglycaemia linked to P. vivax infection (p < 0.05). There were no differences between P. vivax and P. falciparum patients in their total bilirubin, aminotransferases (AST and ALT), and lactate dehydrogenase values (Table Laboratory results are presented in Table Plasmodium vivax infections caused 60.8% (42/69) of cases with at least one disease severity criteria. Plasmodium falciparum infection and mixed malaria infection caused 24/69 (34.7%) and 4.34% (3/69) severe cases, respectively. Proportionally, patients with P. falciparum infection were more likely to develop severe symptoms than P. vivax and mixed malaria infections . Although most severe malaria (88.4%) had one clinical complication, eight patients simultaneously presented two or more complications. The most frequent complication in patients with P. vivax was hyperbilirubinaemia (plasma or serum bilirubin > 3 mg/dL), and 38 of 42 patients (90.4%) presented it as the only criterion of severe malaria. In addition, there were four patients with two criteria: one with cerebral malaria and pulmonary oedema, one with kidney failure and severe anaemia, one with cerebral malaria and hyperbilirubinaemia, and one presenting severe anaemia and hyperbilirubinaemia. Similarly, the most frequent complication in patients with P. falciparum was hyperbilirubinaemia; 14 of 24 patients (58.3%) as the only criterion of severe malaria. However, six of the 24 patients (25%) presented cerebral malaria, and three (12.5%) had severe anaemia. Less frequent were spontaneous bleeding  and renal dysfunction . Among the patients with mixed infection, two presented hyperbilirubinaemia and one pulmonary oedema as criteria of severity. One patient with P. vivax and another with P. falciparum died due to cerebral malaria.According to the local and the WHO , 14 guidP. vivax , P. falciparum , and mixed malaria  infections.A total of 285 (99.3%) patients were followed up by telephone; however, only 49.8% (142/285) completed the follow-up for three months. Thirty-five patients (24.7%) had a recurrence. Of these, 31 had only one new episode, and four had two new episodes during follow-up; most (65.7%) recurrences occurred one month after infection. The proportion of recurrences was similar in patients with P. vivax as a single infection determined by microscopy. However, 76% of the enrolled patients have P. vivax if mixed malaria infections are included. Gold mining has been associated with malaria in the Bolivar state [The dramatic increase in malaria transmission in Venezuela has changed the regional epidemiological landscape , 5. Stilar state , 19; conar state . Those ear state .P. falciparum malaria and Sifontes; this is consistent with the importance of this area with gold mining in this parasite incidence [It has been hypothesized that human mobility to and from the mining areas has been a critical factor in the current malaria epidemic , 21–23. ncidence .P. falciparum infections , whereas others reported this sign most frequently in P. vivax infected patients [Malaria symptoms  , 25 werepatients .P. falciparum infection (p = 0.03) [P. falciparum infection in previous reports [P. vivax infections in this study. A significant finding is that 69 of the 161 patients with complete clinical evaluations (42.9%) met at least one criterion for severe malaria as defined by the WHO. A similar result was reported in a small study in Merida state (western Venezuela) that registered 13 of 33 (39.3%) patients with some form of severe malaria [Although clinical manifestations commonly associated with malaria in the region were found , 31, som = 0.03) , 32. Hyp reports –35, but  malaria . This hi malaria , 36 and  malaria  and are  malaria  and Indo13 of 33 .3% patieP. falciparum than P. vivax and mixed malaria cases. It is worth mentioning that because P. vivax infections are higher in prevalence, infections by this parasite are linked to the majority of severe cases in terms of absolute numbers. Thus, this study adds new evidence that P. vivax infections –considered benign malaria– can also result in severe disease [The high number of severe malaria cases could result from bias when studying patients seeking treatment in the city's main clinical centres. It can be speculated that, on average, the patients could have been suffering from more severe disease, forcing them to seek treatment in a major health centre. Nevertheless, as expected , 41, the disease –49.Even considering the bias introduced by studying solely clinical cases, the observed high frequency of patients with at least one criterion of severe malaria is a matter of concern. Determining whether this pattern results from inadequate access to timely and effective treatment requires longitudinal studies with proper controls.P. vivax patients with at least one severe malaria criterion also showed, on average, more complex infections. In particular, samples from 91 P. vivax infections were genotyped using nine microsatellite loci as part of another study [P. vivax using a Fisher exact test . A similar analysis was not significant in 57 P. falciparum-infected patients with their samples genotyped with eight microsatellite loci. This pattern is consistent with a study conducted in Colombia [P. vivax and P. falciparum. Although preliminary, given the limited number of samples with complete clinical evaluations, the finding suggests that this association should be further investigated in the region.It is important to note that er study . An infeColombia , with P.P. vivax malaria due to treatment failure) from reinfection  or relapse  in the absence of genomics tools [The patient's follow-up in this study relayed on self-reporting; still, the proportion of recurrences (24.7%) was similar to those reported elsewhere . Althougcs tools , 58. FinP. vivax infections. However, the study has limitations imposed by the circumstances where the data was collected. First, it only included clinical patients passively diagnosed with malaria when they were seeking treatment. Thus, subclinical and submicroscopic infections were not included, and the study was likely biased toward patients with severe symptoms seeking attention in the primary diagnostic centres. Second, the study covered loosely defined endemic areas, so there is no accurate estimate of prevalence per location. Given the limited number of individuals from some localities, the data was aggregated. Third, only 161 out of 287 patients had clinical laboratory tests due to limited resources. Fourth, thick smears were used to diagnose malaria, as is the standard in Venezuela [P. vivax, should be a matter of concern.The information reported here depicts a scenario where severe malaria seems relatively high, including several with enezuela ; howeverenezuela . Even whP. vivax malaria was observed. This finding should prompt comprehensive studies to identify the factors leading to this pattern. Whether severe disease could be avoided or diminished with timely diagnosis and effective treatment is a matter that needs to be explored in the context of longitudinal studies, which should use active detection to characterize subclinical infections. Such prospective studies should include genotyping tools to allow exploring the factors driving recurrences.Malaria infections were more prevalent in young male adults practicing illegal gold mining in Bolivar State. Thus, like other studies in the region, the data presented here indicate that transmission in mining areas requires immediate attention in terms of research and policies. A high number of severe malaria cases with


Plasmodium falciparum foci and the hidden burden of Plasmodium vivax in pregnancy. Maternal malaria and fetal health outcomes were investigated with a perinatal surveillance study in the municipality of Cruzeiro do Sul, Acre state, Brazilian Amazon. The research questions are: what are the causal effects of low birth weight on low Apgar at 5-min and of perinatal anaemia on stillbirth?Malaria elimination in Brazil poses several challenges, including the control of From November 2018 to October 2019, pregnant women of ≥ 22 weeks or puerperal mothers, who delivered at the referral maternity hospital , were recruited to participate in a malaria surveillance study. Clinical information was obtained from a questionnaire and abstracted from medical reports. Haemoglobin level and presence of malarial parasites were tested by haematology counter and light microscopy, respectively. Low Apgar at 5-min and stillbirth were the outcomes analysed in function of clinical data and epidemiologic risk factors for maternal malaria infection using both a model of additive and independent effects and a causal model with control of confounders and use of mediation.N = 2807) women had malaria during pregnancy. Nearly half of malaria infections during pregnancy (n = 94) were P. falciparum. A total of 27 women  had perinatal malaria . Perinatal anaemia was demonstrated in 1144 women  and low birth weight occurred in 212 newborns . A total of 75 newborns  had low (< 7) Apgar scores at 5-min., and stillbirth occurred in 23 instances . Low birth weight resulted in 7.1 higher odds of low Apgar at 5-min  modulated by living in rural conditions, malaria during pregnancy, perinatal malaria, and perinatal anaemia. Stillbirth was associated with perinatal anaemia  modulated by living in rural conditions, falciparum malaria during pregnancy, perinatal malaria, and perinatal fever.In total, 202 (7.2%; While Brazil continues its path towards malaria elimination, the population still faces major structural problems, including substandard living conditions. Here malaria infections on pregnant women were observed having indirect effects on fetal outcomes, contributing to low Apgar at 5-min and stillbirth. Finally, the utility of employing multiple statistical analysis methods to validate consistent trends is vital to ensure optimal public health intervention designs.The online version contains supplementary material available at 10.1186/s12936-021-03981-y. Plasmodium parasites and transmitted by Anopheles mosquitoes. In 2019, 229 million clinical cases occurred worldwide with 409,000 deaths P. falcip 2.6% 4/13 in the  2.6% 4/13 in the  2.6% 4/13 in the Anopheles (Nyssorhynchus) darlingi, the main malaria vector, limits the impact that insecticide-treated mosquito bed nets could have on malaria transmission [P. falciparum infection was found. This further shows that mother’s rural residency and P. falciparum exposure may lead to recurrence of infection with this malarial parasite, independently of the use of anti-mosquito interventions. This escape effect of anophelines from mosquito intervention was proposed in a mathematical modelling study [Plasmodium-infected mosquito biting is skewed towards the night hours from 00:00 to 03:00 when the density of mosquitoes is lowest and therefore higher biting tolerance occurs in human hosts [Nearly 60% of the surveyed mothers used insecticide treated bed nets 1729/2807) and chemical repellent (2123/2807) in the three trimesters of pregnancy. In 2019 52% of pregnant women in malaria-endemic regions in the world slept under the protection of an insecticide-treated mosquito bed net [729/2807 smission . Here nong study . According study –41, 43, p = 0.0136) if the mother was diagnosed with perinatal malaria  if the mother had P. falciparum infection during pregnancy . The odds of perinatal anaemia are 2.61 times higher  [It is noteworthy that several studies have shown that  anaemia , 8. The  anaemia , 44. In  anaemia . Anotheranaemia) .OR = 1.42; 95% CI 1.12–1.80; p = 0.0028). This association is consistent with the literature [P. falciparum detected by light microscopy [P. falciparum [OR = 35.5; 95% CI 25.11–50.22; p < 0.001) and have lower head circumferences .Maternal anaemia was here associated with significantly greater odds of having low birth weight   Fig. A. The ApP. falciparum and P. vivax malaria increase the risk of stillbirth, with the former responsible for 12–20% of stillbirths every year in sub-Saharan Africa [Plasmodium vivax, prevalent in Latin America, Southeast Asia, and Western Pacific, increases the risk of stillbirths by almost three times [OR = 12.56; 95% CI 5.1–31.02; p < 0.001). Perinatal fever was both associated with maternal perinatal malaria  and diagnosis of P. falciparum during pregnancy  .Both n Africa . Naturaln Africa . Plasmodee times . Here a ee times . Figure n = 564; 20.1%) did not undergo examination of parasites by light microscopy during pregnancy, thus missing the opportunity to diagnose asymptomatic infection. Among health professionals involved in prenatal care, malaria in pregnancy is still not a priority [OR = 0.41; 95% CI 0.23–0.74; p = 0.003; Table OR = 0.19; 95% CI 0.04–0.93; p = 0.041; Table One fifth of the surveyed mothers  who did not undergo malaria tests were not at risk of malaria exposure. If this is correct, the assumption they would get negative results if they had been tested is reasonable. Thus, pooling them together with those 2243 mothers who received malaria testing in the analysis can be justified  can become biased to be high. With overfitting, a model can erroneously predict the magnitude or even direction of an association [Here a multivariable regression model based on a stepwise variable selection method was applied. Although this approach has been widely used in public health studies and beyond, it suffers from a few issues . A commoociation . Alternavivax and/or falciparum) during pregnancy might lead to a newborn having low Apgar at 5-min (Model B1). An association between P. falciparum (single or mixed) in pregnancy and stillbirth was seen (Model B2). This association might be related to P. falciparum inducement of intrauterine subdevelopment [In the analysis of causation paths Fig. , any parelopment .n = 564) of mothers in this survey did not receive testing for malaria during pregnancy, it was assumed that if testing had been done, they would result negative. Missing data listed in Table This large-scale surveillance study adds important information about the web of causation contributing to maternal–fetal outcomes in pregnant women with malaria, however it does have some limitations. Nutritional status, alcoholism, or smoking—which should be important factors modulating anaemia in mothers—were not assessed. These factors are unobserved variables in the proposed DAGs Fig. B. As 20.Here malaria risk factor on maternal–fetal health outcomes were assessed. Additive and independent effects only partially explained the underlying effects that maternal malaria can have on newborn outcomes. Causation of endemic malaria on the health of mothers and newborns is much more complex. The causal paths can be modulated by distal determinants in the causal framework. The conditions of mothers living environment tied to increased malaria risk can affect newborn outcomes after gestational period, including stillbirth.Additional file 1. “Research Tool” for clarification of the instrument used to obtain variables described in the manuscript from the study population.Additional file 2. “Alternative results” for showing application of the same analytical approach as in Fig. n = 2243).


We present the case of imported malaria in pregnancy to the United Kingdom (UK) from Nigeria, where a 28-year-old primigravida presented to our maternity assessment unit (MAU) with complaints of pyrexia, rigors and passing dark coloured urine. She gave a travel history of recent migration from Nigeria 10 days before presenting to our emergency department.She initially became unwell five days after her arrival with general malaise and myalgia. On day six, she developed lower abdominal pain and observed that her urine was dark in colour. This prompted her to contact her general practitioner (GP). Treatment for a urinary tract infection was initiated by the GP after a phone consultation in keeping with COVID-19 contingency guidance, and the patient was prescribed antibiotics for three days.She presented to the emergency department two days after completing the course of antibiotics where she complained of worsening pelvic pain, reduced foetal movements and passing black urine. She was treated as suspected COVID-19 and red flag sepsis. Obstetric review led to investigation and diagnosis of severe malaria in pregnancy, which was accompanied by blackwater fever (BWF). The patient recovered after three doses of artesunate. An ultrasound scan of the foetus revealed a congenital cardiac anomaly, which had not been detected in an earlier scan. There was no evidence of congenital malaria in the neonate after delivery.Plasmodium falciparum can be significantly high. Those who survive the disease in pregnancy are also known to develop several complications such as intrauterine death and preterm labour. There was also the component of blackwater fever, which is a rare event associated with severe malaria, and it also has a mortality rate. Significant in her medical history was a diagnosis of the sickle cell trait, and we postulate that this feature gave an added protection from the complications of severe malaria in pregnancy as well as blackwater fever.There are several novel aspects in this case as maternal mortality in severe  The onset of the COVID-19 pandemic has led to other infectious diseases with similar presentations, such as malaria, being underdiagnosed. Common to both are fever, headache, chills, arthralgia, vomiting and diarrhoea. Prior to the pandemic, any patient presenting with a fever from a malaria-endemic country or those with a travel history to such regions would be under high suspicion of this potentially fatal parasitic infection. With the emergence of the COVID-19, it has become the main differential for patients who present with pyrexia. This has led to the potential to overlook other causes of a patient’s presentation, such as malaria, with the potential of poorer outcomes due to a delay in diagnosis [In 2019, 1,719 cases of malaria were reported in the United Kingdom (UK) .The WHO malaria report in 2020 voiced that significant improvement has been made in the fight against the parasite over the past 20 years . HoweverAnopheles mosquito [Plasmodium falciparum is the most virulent and is responsible for 20% of mortality in pregnancy [According to the WHO, 10,000 maternal deaths occur each year from malaria. Pregnant women are 10 times more likely to contract malaria , and themosquito . Amongstregnancy . Apart fregnancy . It is aregnancy .A 28-year-old primigravida presented at 32 weeks with a five-day history of pelvic pain, lethargy and fever. She indicated that she arrived in the United Kingdom as a student 10 days earlier and developed myalgia, abdominal pain and fever that started five days after her arrival. On day six, she developed worsening lower abdominal pains and observed that her urine was a dark colour. At this time, she had a virtual phone consultation with her GP, where she complained of suprapubic pain and the passage of dark urine at each void. The GP diagnosed her with a urinary tract infection and prescribed a three-day course of antibiotics. Despite the antibiotics, she reported that her urine changed to a black colour and that the fever and lower abdominal pain persisted. She also had a one-day history of reduced foetal movements. The patient had no significant medical history, except for uterine fibroids. There was also no significant family or drug allergy history. She denied contact with any ill person.She also denied any previous infection with malaria, HIV or hepatitis. She was classified as a late booker in the United Kingdom (UK) and grouped as high risk since there was no documented evidence of previous antenatal care. The dating of the pregnancy was based on her menstrual cycle, which was regular as there was no dating scan.Clinical examination and investigationsUpon review, the patient was febrile (38°C) and tachycardic (HR: 132 bpm) with a blood pressure reading of 132/80 mmHg. The cardiovascular and respiratory examinations were unremarkable. There was localised tenderness in the suprapubic region upon abdominal palpation; however, there was no organomegaly.An antenatal foetal cardiotocography (CTG) was performed using the Dawes Redman analysis. The criteria for foetal well-being were not met due to a foetal tachyarrhythmia of 190 bpm.Treponema, and hepatitis B and C), haemoglobinopathy screen  and glucose-6-phosphate dehydrogenase (G6PD) deficiency test. There was a high suspicion of malaria based on the history of dark-coloured urine along with the patient’s travel history; hence, a rapid malaria antigen test was requested along with thick and thin films for confirmation of any parasitaemia. Initial laboratory investigations were consistent with active haemolysis , along with full booking blood , and no other life stages were seen. Parasitaemia was 3%-4%. These findings were consistent with the rapid diagnostic test and confirmed the diagnosis of severe malaria in pregnancy.On the routine haematology blood film, platelet numbers appeared low. Ring-form trophozoites were seen with morphology consistent with 6/L and no epithelial cell, hence excluding haematuria. Haptoglobin testing was not performed. Throughout admission, her renal function was preserved despite having macroscopic haemoglobinuria as her estimated glomerular filtration rate (eGFR) remained at >/90. The same trend was noted with the electrolyte balance of the patient, which remained normal throughout her sequelae. There was no evidence of any coagulopathy on admission , along with her complaint of pyrexia in the MAU triage. She also had mild conjunctival icterus, which progressively worsened as her total bilirubin increased due to haemolysis of red blood cells.The timeline on the patient’s arrival to the United Kingdom was not initially forthcoming from the patient despite her being quite unwell clinically when she arrived at the hospital. However, the differential of malaria was chosen as a high priority due to the patient’s history. The initial diagnosis of malaria was made on the background clinical presentation and findings, along with an initial rapid antigen malaria test. This included ethnicity, a recent arrival in the United Kingdom and poor/absence of antenatal care. The diagnosis was later further established by confirmation of After confirmation of the diagnosis with laboratory evidence, the patient was again approached and asked about her travel history and sick contacts. She then confided that her husband was also sick at home with a fever, and they arrived from Nigeria 10 days before.TreatmentThe patient was admitted to high-dependency unit (HDU) care, was started on intravenous artesunate 12 hours after her initial admission and made a good recovery after three doses. Twenty-four hours after the administration of the first dose of artesunate, there were no parasites in malarial blood films. She was then switched to oral therapy, where she completed a full course of artesunate.Her general care was tailored to the treatment of severe malaria in pregnancy based on guidance from the Royal College of Obstetrics and Gynaecology green top guideline . There wEven though our main differential and diagnosis was malaria in pregnancy, the patient was concomitantly treated with meropenem prophylactically to prevent gram-negative septicaemia, which is commonly seen in severe malaria infection. She received a total of 24 hours of meropenem and continued on a five-day course of oral cefuroxime after review by our infectious disease specialist. Blood cultures yielded no bacterial growth after two days and subsequent days, up to five days, post culture.The patient was discharged after a five-day admission to the hospital and with a plan to follow up in one month to ensure favourable response.Follow-up and outcomeMaternal OutcomeIn the follow-up blood film one month later, no malaria parasites were seen.Foetal OutcomeAn anomaly scan was also performed as an inpatient at 32 + 4, which concluded no obvious foetal defects. A growth scan at 37 + 2 weeks showed appropriate growth; however, there was an abnormal four-chamber heart view with a disproportion between the right and the left ventricle. A foetal echocardiogram confirmed a right ventricle/left ventricle disproportion with hypoplastic aortic arch. Prenatal microarray analysis confirmed a male foetus with no significant copy number changes detected. This was consistent with previous results from a rapid FISH, which was done previously. The growth remained appropriate, and she was offered induction of labour at 38 + 5 due to the foetal cardiac anomaly, which resulted in an emergency caesarean section. At delivery, the neonate was started on prostaglandin E1 (PGE1) and transferred to the congenital heart centre for augmentation surgery. A screen for congenital malaria on day two of life confirmed that there was no in utero transfer of any malarial parasites. Examination of the placenta showed no histological abnormality.In this case, the initial diagnosis at the emergency department was COVID-19 with a differential diagnosis of red flag sepsis. It was after review by the obstetric team that consideration for a diagnosis of malaria was made, and the patient was treated and investigated for this. Both diseases can have a similar presentation, such as fever, headache, shortness of breath and fatigue. The complications of severe malaria are also similar to COVID-19: these include acute respiratory distress syndrome (ARDS), septic shock and multiorgan failure . AlthougAlthough significant inroads have been made against malaria in the past 20 years, very few studies have been done on malaria in pregnancy due to ethical restrictions; hence, the disease remains poorly understood. It is known, however, that the most common maternal complication is anaemia along with placental sequestration of the parasite. This can trigger a pathological process that contributes to adverse outcomes such as low birth weight, intrauterine growth restriction and preterm delivery. A standard definition for severe malaria has been a longstanding problem; however, in pregnancy, a parasitaemia of greater than 2% places patients at risk of developing a severe infection, and such women should be treated with the severe malaria protocol, with HDU or intensive care unit admission ,15. As s9/L) and hyperbilirubinemia (89 umol/L). To account for this, we explore the patient factors that may have contributed to this outcome.In our case, the patient had a clinical presentation of blackwater fever (BWF), but no other features of complicated malaria. Apart from the black-coloured urine, which is due to haemoglobinuria, her diagnosis of severe malaria was confirmed by laboratory findings such as hyperparasitaemia (3%-4%), thrombocytopenia  is a rare event in severe malaria and is a representation of acute intravascular haemolysis . It is mfections . The exafections . Apart ffections ,21. Althfections .Her kidney function and electrolytes remained in the normal range, which suggested preservation of her renal function despite the passage of dark-coloured urine. We postulate here that since our patient was a carrier of the sickle cell trait, this may have offered protection against developing complications from the severe malaria infection. The literature indicated that patients with inherited haemoglobinopathies such as sickle cell trait (haemoglobin AS), thalassaemias, haemoglobin C, and G6PD deficiency have a protective component against death from falciparum malaria . The mecAt the follow-up growth scan, the discovery of a foetal cardiac defect was concerning as the previous scan reported no congenital anomaly. Consideration was given as to the cause of this diagnosis, whether it was congenital or induced from the severe malaria infection or was it from the treatment with artesunate. Careful evaluation of the drug for treatment was undertaken before deciding to treat it with artesunate. It is the recommended drug for severe malaria in pregnancy and is safe in all trimesters. From previous studies, artesunate is not associated with an increased risk of miscarriage, stillbirth or congenital anomalies ,26. TherMalaria continues to be a parasitic disease that can have devastating effects and continues to be a challenge globally. Pregnant women are more susceptible to malaria due to the immunocompromised state of pregnancy and are at greater risk of developing severe foetal and maternal complications.The omission of malaria as a possible differential in any patients who present with pyrexia from an endemic region or in those with travel history to such areas can have a consequential impact on the outcome of the patient’s well-being, including death. On the contra side, malaria is highly treatable, and when it is recognised and diagnosed in a timely manner, the outcome is favourable. Prompt diagnosis and appropriate treatment are then crucial to prevent morbidity and fatal outcomes.Although this was not a feature in our patient, it is also crucial to remember that malaria can co-exist with sepsis, and they must be distinguished from each other as not doing so can again have fatal outcomes secondary to untreated septicaemia.In conclusion, we need to be mindful of the impact the COVID-19 pandemic has on global healthcare including the lack of funding on other infectious diseases and hence a threat of a resurgence of such cases. It is therefore imperative that clinicians should remain open-minded when dealing with pyrexia in any patient and not be overshadowed by the now common COVID-19 diagnosis.


Emanators were replaced every month for a three-month period.The spread of artemisinin resistant malaria from SE Asia to the rest of the world remains a threat that will only be ended by eliminating malaria from the region. Novel control approaches are required to mitigate this threat. Spatial repellents (SR) are one such approach. We therefore conducted a multiple cross-over experiment from April 2013 – April 2014, in which all houses in one of two villages in Mondolkiri Province, Cambodia were alternately supplied with an emanator of the spatial repellent metofluthrin per 30 mMosquito densities were simultaneously monitored in each village for two weeks every month using six CDC light-traps/night run from 18.00 to 07.00 hrs inside bedrooms and malaria prevalence, seroconversion and gSG6 protein rates assessed from prevalence surveys. After emanators were installed in the first village they were installed in the second village for a further three-month period and following that were again used in the initial village for a further three months. Surveys were undertaken before the initial installation of the emanators and at each cross-over point.Anopheles dirus densities were highest in houses closest to the forest. Transmission rates were low even before the application of the emanators. Perhaps due to the low levels of malaria transmission in Mondolkiri no significant relationships were found in Plasmodium cases or seroconversion rates between villages, surveys or by intervention. Adult males, who might spend more time unprotected in the forest at night, appeared to be at greater risk of becoming infected with P. falciparum malaria as compared to women or young children.At the malaria transmission levels present in Mondolkiri the metofluthrin emanators evaluated had no observable effect on malaria prevalence. This may be due to confounding by low prevalence rates. Proteet al.  demonstret al. . Such deet al. .Although not designed as a malaria control tool (due to their high cost) slow-release emanators made of dual layer polyethylene mesh, impregnated with 10% (w/w) metofluthrin, have recently been shown to reduce landing rates of outdoor biting of secondary vectors of malaria in Cambodia . When usAnopheles dirus, the principal malaria vector in the region, was almost absent [An. dirus mediated transmission could not be rigorously investigated. The effect of a metofluthrin spatial repellent emanator on malaria prevalence when used indoors and in peridomicilliary settings, was, therefore, examined in a cross-over study design in two isolated villages of Mondolkiri Province where autochthonous, low level, malaria transmission occurs.Previous studies in Cambodia took place in areas where there was little or no malaria transmission and t absent . Thus, tTwo villages, Ou Chra and Pu Cha, located in an area of diminishing forest in Mondolkiri Province, Cambodia, were chosen for the study. These villages, which have been previously described ,17, are At the start of the study all 34 houses in Ou Chra and the 51 houses that formed the closest hamlet of the village of Pu Cha were mapped with hand held GPS units (Supplementary file 1) and consent to participate in the study was obtained. Houses were photographed and a to-scale plan (to the nearest 10 cm) of houses drawn. The height of the roof from the floor was also determined so that the volume of air inside the different rooms could be calculated. Residents were asked about their evening activities, their use of nets and, in order to determine their relative socio-economic status, their ownership of certain goods (data not shown here). Baseline collections of mosquitoes were undertaken for six months and, at the end of this time, an initial parasitological survey was undertaken to determine malaria prevalence in the two villages. After this, a cross-over experiment in which each village acted alternately as a control, for three months, or as the intervention village. Houses in the intervention village were provided with metofluthrin emanators, supplied by Sumitomo Chemical Co. Ltd. .EZ)-(1RS)-cis-trans-2,2-dimethyl -3-prop-1-enylcyclopropanecarboxylate). According to manufacturers specification a single emanator can protect 30 m3 of space for 4 weeks. The total estimated volume of each area requiring protection (which included verandas in front of television sets) was determined according to where people stayed in the evening and to the available openings through which mosquitoes might enter. The number of emanators required to meet specifications along with their optimum location  was established. Wires or nails were put into place such that the emanator was in a location where it was potentially exposed to air movement. Locations were chosen on an ad hoc basis according to the experience of the investigators. Thus, if a room required five emanators to be fully covered the five locations used for installation were chosen to be sufficiently separated so that coverage would be complete and that locations with the largest opening were covered. They were installed above head height (circa 2.4 m) so that they did not interfere with other activities and were out of reach of children. The initial installation of the wire or nails was done before the application of the emanators. The emanator came with a plastic clip so that, once the initial wire or nails had been prepared, installation and replacement in a house was a few seconds’ work and installation (and replacement) in all houses in the intervention village could be completed in a few hours. Emanators were replaced every 4 weeks. Unfortunately, placebo products were not available so that the experiment was not blinded between villagers or project staff.The emanators were made of polyethylene dual layer (15 x 8 cm wide) 3–4 mesh held in an open plastic frame impregnated with 10% (w/w) metofluthrin benzyl in Ou Chra and during seven weeks in Pu Cha. Sentinel collections were also undertaken at the edge of what remained of the forest in Ou Chra. Collected mosquitoes were dissected to determine parous rates and the duration of the gonotrophic cycle, the results of which have been reported elsewhere [Entomological assessment was designed to estimate exposure to potential malaria vectors inside houses. CDC light-traps hung 1.5 m off the floor at the foot of the bed in which sleepers were protected by an LLIN were used to sample potential malaria vectors indoors. For 2 weeks each month, from April 2013 to March 2014, light-traps were simultaneously run from 18.00 to 06.00 hrs the following morning in each village in a random set of houses such that by the end of the two weeks all 34 houses in Ou Chra and a random set of houses from Pu Cha had been sampled. In addition, almost daily collections were undertaken during 12 of the 21 weeks from 3lsewhere . In ordeAn. dirus s.l. were identified to species using the PCR-protocol as described by Walton et al. [A sample of the mosquitoes morphologically identified as n et al. . UnfortuPlasmodium antibodies and, if positive, were given first line malaria treatment as recommended by the National Malaria Control Programme of Cambodia.During each survey, over a period of 3 days in Pu Cha and 2 days and a morning in Ou Chra, all residents were invited to attend a parasitology investigation under the house of the village leader. When attending the survey, a persons’ temperature was taken; they were asked at what time they had gone to bed the previous night, if they owned a mosquito net and if they had used it the previous night. People attending the surveys with a fever (a temperature ≥37.5°C) were tested with a Rapid Diagnostic Test (RDT)  for the presence of 19 (MSP119) and apical membrane antigen-1 (AMA1) using an indirect ELISA.Filter paper samples for subsequent PCR determination of parasite prevalence were obtained from finger prick blood. Blood was also eluted into 150 μl Eppendorf tubes containing EDTA that facilitated the separation of serum from the clot. All blood and serum samples were kept on ice and transported to Phnom Penh for storage at -20°C until shipment to the United Kingdom for processing. Serum samples were tested for antimalarial IgG antibodies against merozoite surface protein-1Samples from each dried blood spot were removed with a standard hole punch  and DNAs were extracted using a previously described chelex/boiling method . A high-19 (MSP119) and apical membrane antigen-1 (AMA1) using an indirect ELISA at 1/1000 and 1/2000 dilutions respectively.Collected sera were tested for antimalarial IgG antibodies against merozoite surface protein-119 or AMA1 at 0.1795 μg/ml and 0.5 μg/ml respectively and kept overnight at 4°C. Plates were washed using PBS plus 0.05% Tween 20 (PBS/T) and incubated for 3 hrs at room temperature (RT) with 150 μl of 1% (w/v) skimmed milk powder  in PBS/T. Plates were washed again and 50μl of samples were added in duplicate to each plate. A pool of sera from Tanzania, a highly endemic area in Africa, was titrated on each plate as a positive control. Following another overnight incubation at 4°C the plates were washed (PBS/T) and incubated  with 50 μl of horseradish peroxidase-conjugated rabbit anti-human IgG . All plates were developed using 100 μl of OPD substrate solution  and reactions were stopped with 25 μl of 2 M H2SO4. Plates were read immediately at 492 nm and optical density (OD) values recorded.High absorbance ELISA plates (Immulon 4 HX) were coated with 50 μl of MSP1Anopheles can be used as a marker of exposure to biting females [Anopheles and because of its synthetic nature reproducibility of the immunological assay is to be expected [An. gambiae bites [An. gambiae. Negative control sera were obtained from staff of the London School of Hygiene and Tropical Medicine who had not been exposed to An. gambiae bites.The prevalence of gSG6 protein, found in the saliva of  females -28. It aexpected -28. In Aae bites . For the2SO4 and the OD492 determined using a microplate reader. Results were processed as previously described [Following another overnight incubation at 4°C plates were washed and incubated  with 100 μl of polyclonal rabbit anti-human IgG/HRP antibody . After washing colorimetric development was carried out  with 100 μl of OPD. The reaction was terminated by adding 25 μl of 2M Hescribed . PositivIgG levels were expressed as final OD calculated as the mean OD value with antigen minus the OD value without antigen. The OD values for the malaria antigen were normalised using the standard curve on each plate and the results dichotomised into positive or negative using a mixture model to determine a cut off, as described previously . Cut offA reversible catalytic conversion model was used to fit age seroprevalence data and estimate seroconversion rates (SCR) . SCR canThe study was approved by the National Ethics Committee for Health Research in Phnom Penh, Cambodia . Informed consent was obtained for all respondents.A total of 145 people were registered in Ou Chra and 309 in Pu Cha. The age and sex distribution was similar between the two villages , half beAn. dirus from a colony maintained in Phnom Penh were knocked down within 15 minutes when exposed at 30cm from a random set of four similar samples in ad hoc bioassays.A total of 86 emanators (mean of 2.5 emanators per house) were installed in Ou Chra each month when it was the intervention village and 125 (mean of 2.1 per house) in Pu Cha. Two of the houses in Ou Chra, were cook houses and people did not sleep in them. Emanators were, nevertheless, installed since that was where the families ate their evening meal. No evaluation of the products integrity was undertaken during the study although caged specimens of An. dirus s.l. identified to species by PCR were An. dirus s.s.. We therefore presume that this was the only member of the complex present in the study area. Altogether 554 light traps were run in Ou Chra  and 406 in Pu Cha (a mean of 6.9 trap nights per house). Fourteen species or species complexes of anophelines were identified from light-trap collections in Ou Chra and nine from Pu Cha. Anopheles dirus was the most common anopheline caught in light-traps in Ou Chra and the second most common species in Pu Cha (where An. maculatus s.l. was the most common species) (An. dirus was only the seventh most common species collected (An. dirus per trap was more than six times the 0.275 (s.d. 0.46) per trap recorded from Pu Cha. When the houses closest to the forest were included the mean number collected in Ou Chra was 2.52 (s.d. 3.29), a nine-fold difference. An. dirus  from light trap collections in the two villages.All 102 species) . In lighollected . Even exAn. dirus . Numbers of An. dirus collected decreased only slightly with increasing house height. Mean numbers of An. dirus in Ou Chra decreased in each three-month period independent of the presence of metofluthrin. Numbers in Pu Cha, however, were lower when the metofluthrin was present but this difference was not significant  so did the number of nificant .P. falciparum  were recorded from Ou Chra and ten from Pu Cha  whilst nine cases of P. vivax were recorded from Ou Chra  and 10 from Pu Cha  . All but three of the 17 positive P. falciparum attendees were over 17 years of age whilst 7 of the 12 people with P. vivax were under 15 years of age.A total of 1180 samples were collected in the four surveys  (data not shown here). Parasitological results are given in ecorded) . Three oPlasmodium falciparum or P. vivax/P. ovale distribution between villages or between surveys. Using the data from all the surveys combined no differences in the distribution of Plasmodium cases by age group were identified.Given the low prevalence rates it is not surprising that according to the results of parametric tests there were no significant differences in P. falciparum than P. vivax antigens.Optical density (OD) values were generally low, as is expected in a region of relatively low transmission intensity. ODs followed the usual trend of increasing with age. This was more pronounced for P. falciparum and P. vivax AMA and MSP antibody responses by village and survey. The normalized ODs by village and survey showed minimal differences between either variable. There are slightly higher P. falciparum MSP119 ODs in Ou Chra than Pu Cha, otherwise very little difference was found. P. vivax MSP-119 at baseline and after the intervention. P. falciparum antigens tested. The maximum log-likelihood is the time point at which a change in transmission is most likely to have occurred. It indicates that a change in transmission occurred approximately 13 years ago. The OD values for the intervention villages shifted to the left, in other words, the OD values were lower in the villages when the intervention was present, indicating a reduction in transmission. Among 1-5 year olds there was very little difference between baseline and intervention samples . For all age groups combined, there was, however, a significant drop in P. vivax MSP119 ODs between baseline and intervention (p=0.000) and this was maintained when negative results were set to 0.001. Normalised optical densities for P. falciparum AMA1 also decreased between baseline and intervention but this was not significant (p=0.19) .Small drops in OD values from non-intervention to intervention villages were seen in the reverse cumulative distribution plots (RCDP). P. vivax the relationship was almost linear. For both villages the fit between observed and expected values for P. falciparum improved when a predicted change in seroconversion 13 years previously was included in the model  with age-specific seroprevalence data and estimate seroconversion rates (SCR). Seroconversion curves showed the usual trend with increasing seroprevalence with age . For P. he model . OverallAn. dirus collected in the two villages probably reflects the proximity of the forest to the two villages. Indeed, the houses in Ou Chra with the highest densities of An. dirus were the houses at the edge of the village or close to the rice fields near the edge of the forest. The high numbers of An. dirus collected following the rain, and the absence of any indication of aestivation in the mosquito [The eight-fold difference in the number of mosquito  indicatemosquito . The absAn. dirus between the two villages, even before the introduction of the intervention, resulted in higher initial estimated prevalence rates in Ou Chra compared to Pu Cha although these were not quite significant (4/126 compared to 2/285 Fishers exact test p = 0.08). Indeed, apart from the difference in the reverse cumulative distribution plots of P. vivax no significant relationships were found in Plasmodium cases or seroconversion rates between villages, surveys or by intervention. Thus, both serological and parasitological data indicate that the intervention had little or no effect on parasite prevalence or transmission in the two villages but this might be an effect of low parasite rate and sample size. Adult males, who might spend more time unprotected in the forest at night, appeared to be at greater risk of getting falciparum malaria than women or young children.The difference in numbers of P. falciparum transmission. It is also possible that with increasing exposure older people may tolerate the salivary gland proteins (since the antibody response against gSG6 would predominantly be from IgE). Such an effect would tend to mask any difference between age groups. The apparent change in transmission that occurred thirteen years before the survey is consistent with the arrival of many residents from non-endemic areas. Indeed, the residents in Ou Chra had generally been there for slightly longer than had residents in Pu Cha, which was also reflected in the seroconversion rates in the two villages.The gSG6 assay is a relatively underdeveloped assay and may have lacked sensitivity. Thus, OD values for gSG6 showed very little difference between villages or age groups. The more pronounced increase in seroconversion rates with age may also be because of a higher incidence of the disease with age or it might, perhaps, be because the assay was originally optimised to work in African populations with high rates of P. falciparum cases among men over 17 years of age implies that they were being infected either before they went to bed or when they were in the forest. Without controlling transmission in the forest, either by using some novel technique, or by restricting access  elimination in this region will be difficult.The elimination of malaria from the greater Mekong region is a priority concern because of the possible spread of artemisinin-resistant parasites. Thus, even in low transmission areas, such as Ou Chra and Pu Cha, suitable and effective anti-vector measures, in addition to LLINs, are required. Enhanced information on the place where people acquire their parasites is also needed. The bias in There was no indication that the wide-scale application of metofluthrin dispensers to give complete coverage of all potential sitting places in all houses in either village affected malaria prevalence, despite reducing landing rates in outdoor collections elsewhere. The lack of an observed effect might, however, be due to the low rate of transmission in the study villages and to acquisition of the disease in forested areas away from the village. Studies in areas where transmission rates are higher would seem to be worthwhile.


Malaria and malnutrition are major public health problems in developing countries. This studywas mainly focused on the prevalence, patterns, and predictors of these conditions and their associations. Z scores were computed based on the World Health Organization growth reference curves. Malaria infection was diagnosed using light-emitting diode fluorescence microscopy.  A cross-sectional community study was conducted from February to March 2018 among 281 participants living in two districts in Douala. A questionnaire was used to collect sociodemographic information and parasitological and anthropometric data of participants. Nutritional status was determined using age, weight, and height. Body mass index for age (BMIAZ), height-for-age (HAZ), weight-for-age (WAZ), and weight-for-height (WHZ) p = 0.04), age (p = 0.01), WAZ (p = 0.0049), HAZ (p = 0.03), and BMI (p = 0.02). The overall prevalence of malnutrition was 43.1%, and stunting was the main form of malnutrition recorded in children under five years of age (23.6%). The risk of being stunted in this group was about quintupled in malaria-infected participants . In those aged 5-19 years, the prevalence of underweight was significantly higher in malaria-positive individuals as compared to their negative counterparts (p = 0.02). The overall prevalence of malaria and malnutrition cooccurrence was 8.5% and varied with age (p < 0.0001) and study site (p = 0.04). Conclusion and Recommendation. Malaria was associated with malnutrition among the study participants. Early detection and treatment of these ailments would reduce morbidity and mortality. The overall prevalence of malaria was 18.9%, mostly asymptomatic cases. Malaria infection was associated with study site ( Malaria and malnutrition are both important public health problems worldwide, especially in developing countries. The African continent is seriously burdened with malaria and malnutrition as it accounts for the bulk of victims. In 2019, the World Health Organization (WHO) reported that malaria was responsible for 229 million disease cases and 409,000 deaths worldwide; sub-Saharan Africa (sSA) concentrated more than 90% of these statistics [Malnutrition is a global public health problem that mostly affects communities of developing countries under its various forms, including undernutrition , inadequate vitamins or minerals intake, overweight, obesity, and resulting diet-related noncommunicable diseases . UndernuMalaria and malnutrition are causes of concern in Cameroon. Malaria is the main cause of hospital morbidity and mortality, accounting for 40-50% of hospital consultations and 23% of hospitalizations .The relationship between both health problems is still elusive as findings are diverse and conflicting , 8. A beThe aim of this study was to determine the prevalence, patterns, and factors associated with malnutrition and malaria among individuals living in Douala, Cameroon. In addition, the eventual associations between both diseases were also studied.Bamileke, Bassa, and Duala). Ndokoti and Nyalla have tropical climate with two seasons, one dry season (October to May) and one rainy season (June to October). The humidity rate is high, with an average temperature ranging from 25°C to 30°C [The study was carried out in two districts in the city of Douala , namely Ndokoti and Nyalla . These t to 30°C –13. All N = p (1 − p) z2/d2 where N is the sample size, p is the prevalence of malaria and malnutrition cooccurrence  [z is the decision variable at confidence of 95% (z = 1.96), and d is the sampling-related error risk (d = 0.05). The minimum sample size for the study was estimated at 115 participants.The study population consisted of children, adolescents, and adults living in the town of Douala. They were enrolled using random sampling method. Sample size was calculated using the Lorentz's formula, as follows: ameroon) , z is thA cross-sectional community-based study was carried out from February to March 2018. The objectives and benefits of the study were explained to each participant , and parents/guardians of children and adolescents. After obtaining written consent from parents/guardians and adult participants along with assent from older children and adolescents, anthropometric and clinical data were collected from each participant. Moreover, a few drops of blood were collected for malaria diagnosis. Finally, participants and their parents/guardians were educated on malaria and control measures.Data collection was done through 15-25-minute interviews of participants or their guardians and recording in a survey form.Axillary body temperature of each participant was measured using an electronic thermometer . Fever was defined as axillary temperature of >37.5°C .2) = BW/H2.Anthropometric measurements of each participant were collected by two trained field workers using standard methods. Height (cm) was measured to the nearest 1 cm with a stadiometer in the recumbent position and erect position for participants aged less than 24 months and those above 24 months, respectively . Body weZ scores were used to determine the nutritional status of each participant. Body mass index was used for adolescents and adults while Z scores were used for children. Malnutrition among adults was defined as BMI < 18.5 kg/m2 (undernutrition), BMI ranging 25-29.9 kg/m2 (overweight), and BMI ≥ 30 kg/m2 (obesity). BMI ranging between 18.5 and 24.9 kg/m2 was considered normal [Z score (WHZ), height-for-age Z score (HAZ), and weight-for-age Z score (WAZ) less than -2 were used to define wasting, stunting, and underweight, respectively, among those under five years old, while BMI-for-age Z (BMIAZ) and HAZ scores were used for those aged 5-19 years. Scores < −3 were indicative of a severe nutritional conditions [Z scores were computed using the WHO Anthro version 3.2.2  and WHO AnthroPlus version 1.0.4  software. Children and adolescents were diagnosed as malnourished when at least one of these Z scores was less than -2 [Anthropometric indicators including BMI and d normal , 15. Weinditions , 15. The than -2 , 15.Diagnosis of malaria was performed using light-emitting diode (LED) fluorescence microscopy (FM) . This teSymptomatic malaria was defined as the presence of malaria parasites using fluorescence microscopy (FM) associated with fever . AsymptoThe study was approved by the institutional review board (IRB) of the University of Douala (No. CEI-UD/270/09/2015/T). Administrative clearance was sought from Delegation of Public Health for Littoral Region (No. 2596/AS/MINSANTE/DRSPL/BCASS). Written consent forms were obtained from each participant or their parents/guardians before their inclusion in the study. Objectives, gains, and risks of the study were explained to each participants, parents, and guardians in the French or English language. They were informed about the confidential and voluntary aspect of the study and were free to withdraw at any time. The right of children and adolescents not to participate in the study despite parental approval was respected. Positive malaria cases were treated as per national treatment guidelines with artesunate + amodiaquine .χ2) and Fisher's exact tests were used to compare proportions upon respect of Cochran's rule. Parametric statistical tests including one-way analysis of variance (ANOVA) and unpaired sample Student's tests were used to compare mean values between groups. Their nonparametric versions  were used if data failed to respect hypotheses for using these parametric tests. Univariate and multivariate logistic regression models were used to quantify the influence of malaria on nutritional status and conversely. Multivariate logistic regression was used to identify factors associated with the risk of being both malaria infected and malnourished. The resulting odds ratio (OR) were then converted into risk ratio (RR) as described by Zhang and Yu [p value < 0.05 was considered statistically significant.All data were verified for consistency, coded, and keyed into an Excel spreadsheet  and thereafter analysed with the Statistical Package for Social Science (SPSS) v22 for Windows  and GraphPad v5.03 for Windows . Data were presented as percentage  or mean ± standard deviation (SD) where appropriate. Participants were categorized into three age groups  as per the WHO reports on growth indicators assessments . Indepeng and Yu . A p valARR = 0.59; 95% CI: 0.33-0.99; p = 0.04) and among participants above 20 years . On the other hand, the malaria prevalence was higher in malnourished individuals as compared to normal individuals (19.8% vs. 18.1%). The risk of malaria infection was higher in malnourished participants, but no association was found  (p = 0.01). Besides, most malaria infection cases were asymptomatic .In total, 53 individuals were infected with malaria parasites, thus an overall prevalence of 18.9% . Malaria infection rate was significantly lower in the Nyalla district  . Particip = 0.0049), HAZ (p = 0.03), and BMI (p = 0.02). In fact, the risk of malaria infection is reduced by 41% , 20% , and 6% , respectively, when these anthropometric indices increase by one unity. No association was found with WHZ  and BMIAS .Using univariate logistic regression model, a statistically significant association was found between malaria infection and WAZ  in those aged ≥ 20 years as compared to those less than 5 years (p < 0.0001).The overall prevalence of malnutrition was 43.1%  among participants. The risk of malnutrition was threefold higher  among children under five as presented in p = 0.0001). One participant had severe stunting while no severe underweight case was reported.Likewise, stunting (8.0%) was the main type of malnutrition in 5-19 years with a prevalence of malnutrition of 19.6%  in this group age. Prevalence of malnutrition in this age group was significantly higher in female compared to male  and was mainly represented by overweight (33.0%) and obesity grade I (25.7%). The same pattern was observed in male and females.p = 0.03) (p = 0.02)  . In thos = 0.02) . In adul = 0.02) .ARR = 4.70; 95% CI: 1.34-7.09; p = 0.02) higher in malaria-infected individuals as compared to uninfected ones. No association was found with gender , age , and study site .The risk of being stunted was fivefold (p < 0.05). Likewise, the association between malaria and forms of undernutrition was not significant although the risk for stunting  and underweight  was higher in people infected with malaria parasites. Gender and study sites were not associated with the risk for stunting and underweight among this age group.In those aged 5-20 years, no statistically significant association was found between gender, study site, and different types of undernutrition . In addition, 34.5%  and 10.3%  of the study population were suffering from either malnutrition or malaria only, respectively. The rest of persons were exempted from malaria and malnutrition.χ2 = 8.456; df = 3; ARR = 0.39; 95% CI: 0.15-0.99; p = 0.04) and children under five  compared to their counterparts living in Nyalla and those aged 5-19 years . The prevalence of malaria and malnutrition was similar between females and males .As presented in p = 0.003). Likewise, the mean BMI value was significantly lower in malaria-infected individuals . Besides, the same pattern was observed only among females for these both anthropometric indexes while among males, no statistically significant difference was found (p > 0.05).The influence of malaria and gender on nutritional index is presented in The variation of anthropometric indexes with respect to the type of malaria is summarized in This study focuses on the association between malaria and malnutrition in Douala, Cameroon. Females accounted for most of the participants, and this is consistent with national demographic data , 26. TheAsymptomatic malaria accounted for 84.9% of all malaria cases, and this is consistent with previous studies conducted in the same town , 27–29, Anopheles mosquitoes. This immunity protects individuals from nonsevere and severe malaria [Malaria prevalence significantly varied with study site. This is consistent with many reports which outlined the spatial variability of malaria risk and the importance of environmental factors on the distribution of the disease , 33. Ris malaria –36. Some malaria , 38. ThuThe prevalence of malnutrition was 43.1% in this study. This high burden of malnutrition was also reported in other studies conducted in Cameroon , 39–43. The prevalence of undernutrition was higher among less five years, and this is consistent with findings from several studies that reported highest rates of malnutrition in their youngest age categories , 10, 43.Stunting was the commonest type of undernutrition among <5 years and 5-19 years. This is in line with works by Sumbele et al. in the South West region , 45, ManObesity and overweight were mainly diagnosed in participants aged > 20 years. Our result is higher than the 4.1% found by Mandengue et al., but consistent with reports by Epacka Ewane et al. and Koanga et al. –50. ObesZ score (WAS) and BMI, as mean values of these parameters were lower in malaria-infected individuals. Malaria is known to be associated with poor nutritional outcomes [The risk of stunting was higher in malaria infected among children under five. Previous studies reported similar findings, including a case-control study conducted among children of the Adami Tulu district, Ethiopia . Conversoutcomes , 54, espoutcomes .The prevalence of participants with malnutrition and malaria was 8.5%, and this was higher in females compared to males. A meta-analysis study outlined a higher risk of low birth weight in pregnant women with malaria and malnutrition compared to those with only one of these diseases or none . This fiPlasmodium falciparum is involved in >90% of malaria cases [This study has several limitations. First, a low number of wasting and underweight precluded the ability to assess the implication of malaria as a risk factor. Second, the presence of unmeasured confounders could have explained certain association found in this study. The nature of the study  did not allow for elucidating the temporality between malnutrition and malaria. However, this study is first to address the association between malaria and malnutrition in the town of Douala, the economic capital city of Cameroon. It documents the burden of malnutrition and malaria in our setting in a context of achieving the sustainable development goals (SDGs). Details on food habits and physical activity of participants were not captured, thereby limiting more detailed analyses of the findings found in this study. A low number of malaria-infected participants were symptomatic. In this context, we were unable to do comparisons of the proportion of different types of malnutrition  between asymptomatic and symptomatic malaria cases. LED-based FM was used for malaria diagnosis. This technique does not allow for malaria species diagnosis and quantitative assessment of parasitaemia, which are major drawbacks of this technique. Parasitaemia is commonly determined to assess malaria severity . In addiia cases , 61. In ia cases .The present study showed that malaria and malnutrition are prevalent in Douala. It also pointed out the deleterious effects of malaria on nutritional status and vice versa, as well as the influence of host (gender and age) and environment factors on the association between both diseases. Early detection and treatment of these ailments would reduce morbidity and mortality due to malaria and malnutrition in Cameroon. There is also a need for more studies on the topic in the 10 regions of the country to have a clear picture of the burden due to these two public health concerns. Finally, the national malaria control programme should integrate the control of malnutrition in its guidelines in order to efficiently manage malaria in the country. The implementation and scale-up of these different strategies could achieve WHO malaria control and elimination goals, along with mitigating deleterious effects of malnutrition.