Plasmodium falciparum malaria patients in Thailand, and the risk factors for gametocyte carriage have not been fully explored.The incidence of malaria in Thailand has dramatically declined over the past two decades, and the goal is to eliminate malaria by 2025. Despite significant progress, one of the key challenges to malaria elimination are undetected gametocyte carriers. Human migration adds complexity to the malaria situation, as it not only sustains local transmission but also poses the risk of spreading drug-resistant parasites. Currently, no study has assessed the prevalence of gametocytes across multiple years in P. falciparum malaria patients admitted from January 1, 2001 to December 31, 2020 at the Hospital for Tropical Diseases, Thailand, were retrospectively examined and a total of 1962 records were included for analysis. Both P. falciparum parasites and gametocytes were diagnosed by microscopy. A regression model was used to evaluate predictors of gametocyte carriage.Medical records of all The study demonstrated gametocyte prevalence in low malaria transmission areas. Nine risk factors for gametocyte carriage were identified: age between 15 and 24 years , Karen ethnicity , preadmission duration of fever > 7 days , fever on admission (> 37.5 °C) , haemoglobin ≤ 8 g/dL , asexual parasite density > 5000−25,000/µL , asexual parasite density > 25,000−100,000/µL , asexual parasite density > 100,000/µL , platelet count ≤ 100,000/µL  and dry season . An increasing incidence of imported transnational malaria cases was observed over the past two decades.P. falciparum malaria, identify the risk factors for gametocyte carriage, and potential gametocyte carriers in Thailand. Blocking transmission is one of the key strategies for eliminating malaria in these areas. The results might provide important information for targeting gametocyte carriers and improving the allocation of resources for malaria control in Thailand. This study supports the already nationally recommended use of a single dose of primaquine in symptomatic P. falciparum malaria patients to clear gametocytes.This is the first study to determine the prevalence of gametocytes among patients with symptomatic The online version contains supplementary material available at 10.1186/s12936-023-04728-7. The World Health Organization (WHO) has considered Thailand as one of the countries in the Greater Mekong Subregion (GMS) that can potentially eliminate malaria by the year 2025 . While mPlasmodium falciparum in communities in western Thailand [. demonstrated that P. falciparum was mainly imported among Thai-Myanmar immigrants [P. falciparum that was resistant to chloroquine and pyrimethamine migrated from the GMS to Africa [P. falciparum genotypes have been identified in Africa [Gametocyte carriage has posed a significant challenge to malaria control in Thailand. A recent study found that the gametocyte rate measured by qRT‒PCR was very high 72%) among asymptomatic patients infected with Thailand . As thesThailand . Cross-bThailand  and inte2% among migrants , and sevmigrants , 10. Givmigrants . In the o Africa , 12. Curn Africa , 14.P. falciparum gametocytes occurs over a long period, unlike other Plasmodium species, typically at 7 to 15 days after the initial wave of asexual parasites exit into bloodstream from the liver [P. falciparum malaria was 163 h (with a range of 12–806 h) following the administration of artemisinin-based combination therapy (ACT) [Gametocytaemia is essential for the onward transmission of malaria infection to mosquitoes, and it does not cause any clinical symptoms. The development of he liver . Once thhe liver . A studyhe liver . In contpy (ACT) .Several risk factors were found to be associated with gametocyte carriage, including age –27, gendP. falciparum infection to reduce transmission in low-intensity malaria areas such as in GMS [Several studies demonstrated that a single or low dose of primaquine effectively reduces malaria transmission by shortening gametocyte circulation time or reducing infectivity of gametocytes to mosquitoes –40. Artes in GMS . Likewiss in GMS , 44.P, falciparum malaria, the objective of this study was to investigate the gametocyte prevalence among patients with P. falciparum mono-infection in Thailand. The study sought to identify risk factors and describe the epidemiology of gametocyte carriages in this population.To successfully implement a transmission-blocking strategy, it is necessary to determine the gametocyte burden in Thailand and identify the factors that predict gametocyte carriage. No previous studies have assessed the trend of gametocyte prevalence in this area; in addition, there are a limited number of research studies on gametocyte carriage risk factors. Due to the potential severity and life threatening nature of P. falciparum patients admitted from January 1, 2001, to December 31, 2020, were retrospectively studied. The study population included adult patients aged 15 years or older who were infected with P. falciparum malaria mono-infection confirmed by microscopy. All patients in the study were symptomatic, which was defined as a history of fever prior to admission. The history of fever was not limited by any specific timeframe. The duration of fever was defined as the duration of pre-admission fever. The definitions remained consistent throughout the study period. The exclusion criteria was a history of anti-malarial medication before admission for the current episode, except for malaria chemoprophylaxis. In addition, medical records with important missing data, such as malaria count charts, were excluded. Demographic data, travel details, and clinical and laboratory data were collected. The authors retrospectively reviewed medical charts and diagnosed severe malaria in accordance with the WHO criteria [The Hospital for Tropical Diseases is a university and tertiary referral hospital located in Bangkok, Thailand. Medical records of criteria .Giemsa-stained thick and thin films were prepared from finger-prick blood samples. Thick blood films were examined under a microscope at 100 × magnification, with 10–15 white blood cells per microscopic field considered an indicator of satisfactory thickness. The parasites were counted per 200 white blood cells in the thick film. A minimum of 200 high-power fields had to be examined before declaring the absence of malaria parasites. The number of asexual parasites and gametocytes in 1000 red blood cells was counted in the thin film, and all malaria species and stages were recorded. The parasite and gametocyte density were calculated using actual red blood cell and white blood cell counts from the automated complete blood count result. The asexual parasites and gametocytes were counted every 12 h by WHO-certified microscopists until asexual parasites were absent for three consecutive counts. These quantification methods remained unchanged throughout the study period.P. falciparum malaria cases were prescribed parenteral artesunate followed by oral ACTs for three days. Uncomplicated P. falciparum malaria cases received oral ACTs or atovaquone/proguanil. Patients enrolled in drug trials received medications according to the specific trial protocol. However, since this study focuses on analysing asexual parasites and gametocytes on admission prior to the initiation of anti-malarial drugs, the treatment administered will not affect the results. In general, patients were discharged after three consecutive negative tests for asexual parasites and a demonstrated clinical improvement. Patients enrolled in drug trials were hospitalised for 28 days prior to discharge.Regarding treatment, severe 10 transformation and were presented as geometric means per µL blood. Categorical data were presented as numbers and percentages. Crude odds ratios (ORs) or Chi-square tests were used to compare proportions as appropriate, while t-tests were used for continuous data. Binary logistic regression was used to evaluate the risk factors associated with gametocyte carriage on admission. Pearson’s correlation coefficient (r) was used to assess the linear correlation between two continuous variables. Data were analysed using SPSS version 23 . Statistical significance was set at 0.05.Gametocyte prevalence was calculated as the proportion of patients with positive gametocytes detected by brightfield microscopy on admission. Border malaria was defined as malaria transmission that took place along land borders, whereas transnational malaria was defined as malaria acquired from a country across an international border and did not involve the border per se . ContinuP. falciparum malaria cases were admitted to the Hospital for Tropical Diseases between 2001 and 2020. Of these, 379 records were excluded due to mixed infection, age less than 15 years old, missing laboratory data or a history of treatment with anti-malaria drugs. Thus, 1962 medical records were included for analysis.A total of 2341 Approximately 80% of patients were male and the median age was 24 years IQR 20–31)  had documented fever on admission. The majority of patients  had a fever duration of less than seven days, with a median duration of four days , were more likely to be afebrile on admission (p < 0.001) and had a lower maximum geometric mean asexual parasite density during admission (p = 0.045).Regarding malaria characteristics between these two groups, three parameters were significantly different Table . PatientP. falciparum malaria cases admitted in the hospital. From 2001 to 2012, the gametocyte prevalence recorded at the Hospital for Tropical Diseases, Thailand, ranged from 32 to 52%. Between 2013 and 2020, there was a decreasing trend in gametocyte prevalence  had higher odds of gametocytaemia compared with the older age groups. Regarding occupation, those who were unemployed had the highest risk of carrying gametocytes compared to other occupations . Karen, Mon and Burmese ethnicities demonstrated two to three times higher the odds of gametocytaemia than Thai citizens. Underweight individuals (BMI < 18.5 kg/m2)  and immigrants were risk factors for gametocyte carriage on admission.Univariate analysis revealed five demographic risk factors for gametocytaemia on admission: age, occupation, ethnicity, body mass index (BMI) and population group. The younger age group of 15–24 years  1.57–3.64, 2)  and travellers , overweight individuals (BMI > 25 kg/mp < 0.001), haemoglobin ≤ 8 g/dL  and severe malaria . However, the correlation between fever duration and gametocyte density was weak, despite a statistically significant p value , fever on admission (axillary temperature (> 37.5 °C) , asexual parasite density > 5000−25,000/µL , asexual parasite density > 25,000−100,000/µL , asexual parasite density > 100,000/µL , and thrombocytopenia  . There was no significant correlation between gametocyte density and asexual parasite density among different ethnicities . The risk of gametocyte carriage was approximately 1.5 times higher in cases of border malaria than cases of indigenous malaria  whereas transnational malaria showed a low risk of gametocyte carriage .In Thailand, the rainy season is between May and October, and the dry season is between September and April . A higheAll factors except gender and population group were included in the multivariable analysis. The reason was that gender showed a non-significant result (p > 0.1) and the population group had collinearity with ethnicity. Multivariable analysis revealed nine factors that had significantly higher risks of carrying gametocytes: (1) age between 15 and 24 years old, (2) being Burmese, Karen or Mon, (3) fever duration > 3 days, (4) afebrile on admission (≤ 37.5 °C), (5) haemoglobin ≤ 8 g/dL, (6) asexual parasite density ≤ 5000/µL (7) platelet count > 100,000/µL (8) clinical features of severe malaria and (9) dry season. There was no statistically significant difference in gametocyte carriage among occupations, BMI, a history of malaria and imported malaria  [This study aimed to demonstrate the gametocyte prevalence of . 3−12%) . Likewis. 3−12%) , 30, 48.. 3−12%) , possibl. 3−12%)  might co. 3−12%) . AdditioP. falciparum gametocytes, namely Pfs48/45 and Pfs230 [Nine independent factors were identified, showing a statistically significant association with gametocytaemia on admission. A younger age group 15–24 years) was an important predictor of gametocyte carriage in the study population. Many studies have associated young age with a higher risk of gametocytaemia , 23–26. –24 yearsd Pfs230 . Howeverd Pfs230 , 53. TheP. falciparum malaria than Thai citizens. This is the first study to demonstrate the association between ethnicity and gametocyte carriage. The odds of gametocytaemia in Karen, Mon, and Burmese individuals were two to three times higher than in Thai citizens. Ethnicity may not be directly associated with gametocyte development but rather related to the ecology and socio-economic structure of these populations. Difficulty in accessing healthcare system, including low-risk perception, language barriers, geographical remoteness, poor logistics and limited health coverage may lead to delayed treatment, placing this subpopulation at risk for developing gametocytes. Thus, to reduce transmission and help contain the spread of artemisinin-resistant P. falciparum malaria, it is imperative to administer a single dose of primaquine as a gametocytocidal drug, particularly to migrants who were identified with higher gametocyte prevalence.Burmese migrants , 9 or KaP. falciparum malaria compared with Thai patients, suggesting that most P. falciparum cases were imported [Unemployed status was shown to be a risk factor for gametocytaemia in the univariate analysis but not in the multivariable analysis. Political and economic crises might have driven these individuals to migrate cross-border in search for work . It has imported . Therefoimported . InteresThere were discrepancies in outcomes between studies as to whether gender , 28, 31,A higher rate of gametocyte carriers in the dry season was demonstrated in this study. Unlike previous findings, there was no association between gametocyte prevalence and seasonality , 31, 53.P. falciparum malaria in low-transmission settings [P. falciparum cases, as recommended in the Thai malaria treatment guideline, does not address the asymptomatic carriers with gametocytes who do not seek medical care. These carriers, often submicroscopic, pose a hidden threat to malaria elimination. Several studies confirmed the presence of asymptomatic and submicroscopic malaria infections in Thailand [The use of primaquine holds great potential for reducing transmission of settings . Availabsettings , 63. HowThailand , 64, 65.Thailand –68. FurtInterestingly, an increasing proportion of imported malaria cases transnationally, mainly from the African region was found. Similar situations have occurred in China, Sri Lanka and Kyrgyzstan, where imported malaria threatened malaria resurgence and reintroduction as these countries approached the elimination phase . Since TP. falciparum malaria cases admitted during the past several years was small due to the majority of cases being treated at the border area and the recent travel restriction from the COVID-19 pandemic. However, the decrease in the number of malaria cases reflected the real-life situation. Second, submicroscopic and asymptomatic malaria cases were not included in the study; thus, the gametocyte prevalence might be underestimated. Nevertheless, microscopy remains the standard diagnostic tool and can be applied in the field studies. Third, detailed data on the timing of past malaria infections could not be obtained due to the nature of retrospective study, so the gametocytes detected on admission could also result from recent infection. Furthermore, the precise geolocation may be obscured from the constant movement of human population. As a result, considering the history of malaria and border malaria as a risk factor for gametocytaemia should be interpreted with caution. Despite these limitations, the advantages of this study include a large sample size with comprehensive data on gametocyte carriage over multiple years.There were some limitations in the current study. First, the number of P. falciparum cases and gametocyte risk factors in Thailand. The results revealed that younger age groups, non-Thai citizens , afebrile on admission, individuals with a longer duration of fever and those with severe clinical features had at a higher risk of gametocyte carriage. Implementing targeted transmission-blocking interventions in this population might facilitate malaria elimination efforts in Thailand. Additionally, raising awareness of transnational malaria, particularly regarding gametocyte carriers, would be useful in preventing onward transmission and the risk of artemisinin-resistant spread. These findings highlight the need for the bidirectional efforts in malaria control.This study is the first to demonstrate gametocyte prevalence of Additional file 1: Ethnicity of P. falciparum malaria cases admitted to the Hospital for Tropical Diseases, Thailand, between 2001 and 2020.Additional file 2: Malaria contraction sites of P. falciparum malaria cases admitted to the Hospital for Tropical Diseases, Thailand, between 2001 and 2020.Additional file 3: Forest plot based on univariate analysis of demographic, clinical, parasitological, haematological, and other risk factors for gametocyte carriage.Additional file 4: Forest plot based on multivariable analysis of demographic, clinical, parasitological, haematological, and other risk factors for gametocyte carriage.Additional file 5: Scatter plot showing the association between duration of fever and gametocyte density.Additional file 6: Scatter plot showing the association between asexual parasite density and gametocyte density stratified by ethnicity.Additional file 7: Gametocyte prevalence and total number of P. falciparum malaria cases admitted to the Hospital for Tropical Diseases, Thailand recorded monthly during 2001–2020.


Mid-upper arm circumference (MUAC) is a potentially credible alternative method for body mass index (BMI) to assess nutritional status. We aimed to assess the correlation between MUAC and BMI- Z-score and to identify a reliable MUAC cut-off point to detect underweight (BMI- Z-score of < −2 standard deviation) Sudanese adolescents.A cross-sectional study was conducted in eastern Sudan. After obtaining adolescents’ age and sex, their weight, height, and MUAC were measured using the standard procedures. The MUAC (cm) cut-off corresponding to underweight was calculated using receiver operating characteristic (ROC) curve analysis.r = 0.534, p < 0.001), in females , and in males . Of the 390 enrolled adolescents, 61(15.6%) were underweight. The MUAC cut-off for underweight was ≤21.2 cm in all participants , in females , and in males .In total, 390 adolescents were enrolled in the study and 205 (52.6%) of them were females. The median  age was 15.1 (14.0–16.3) years. The medians (IQR) of MUAC and BMI- Z-score were 22.0 (20.0–24.0) cm and − 0.62 (−1.5–0.3), respectively. MUAC was positively correlated with BMI Z-score in all participants (MUAC has good accuracy results and can be adopted for community-based screening of underweight adolescents. Adolescence is defined by “The World Health Organization (WHO)” as an age between 10 and 19 years. Adolescents constitute 16% of the global population and the majority (90%) live in low-and middle-income countries . AdolescSeveral anthropometric measurements such as weight, height, weight for height, head circumference, body mass index (BMI), mid-upper arm circumference (MUAC), and triceps skinfold thickness have been proposed to assess nutritional status . BMI mayZ-score and to identify a reliable MUAC cut-off point to detect underweight (BMI- Z-score of < −2 standard deviation) Sudanese adolescents.Malnutrition is a significant health problem in Sudan and it has economic, educational, and productivity impacts . There aThe Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) standard checklists were followed . The metApparently healthy adolescent males and females who were residents in the area of the study, whose age was (≥10 years – ≤19 years), and who had signed consent by their guardians for participation.Age below 10 years and above 19 years; adolescent pregnant women; adolescents with chronic diseases such as diabetes, thyroid diseases, and heart failure; critically ill patients with severe acute illness; athletes; those on hormonal medication; those who had any apparent congenital dysmorphism; adolescents on chronic medications; and those who refused to participate.2 (The eligible adolescents were interviewed and their sex and birth dates (confirmed from identity cards) were recorded. Anthropometric measures  were taken twice and the mean of measurements was taken. The measurements followed the standard procedures using calibrated instruments. A third measurement was performed in case of considerable variation between the first two readings . After taking off their shoes and removing heavy clothing and objects from their pockets, the participants were then weighed (to the nearest 10.0 g). Their standing height was measured (to the nearest 1 mm) by a stadiometer with their feet positioned together at the heels with the back of the heels. MUAC was measured (to the nearest 1 mm) in sitting or standing posture using a non-stretchable MUAC measuring tape which was placed at mid between the olecranon process of the left ulna and the acromion process of the left scapula. BMI was computed as weight in kg/height in m2 . Thereaf2 .r = 0.15) between BMI Z-scores and MUAC. The sample (390 adolescents) had an 80% power and a difference of 5% at α = 0.05 . Scatterplots with fitted linear regression lines were computed to evaluate the association between MUAC and BMI z-score for all adolescents and for each sex separately. The sensitivity and the specificity were computed and Youden’s Index (YI) was calculated as YI = sensitivity + specificity-1. The MUAC cut-off with the highest YI-value represented the optimal statistically-derived cut-off  of them were females. The median (IQR) age was 15.1 (14.0–16.3) years. The medians (IQR) of MUAC and BMI- Z-score were 22.0 (20.0–24.0) cm and − 0.62 (−1.5–0.3), respectively. Compared with males, females were significantly older, taller, and had higher MAUC and BMI Z-scores .r = 0.534 (p < 0.001) in all participants, in females [r = 0.715 (p < 0.001)], and in males    and in T 0.459)] .The best statistically derived MUAC cut-off for underweight adolescents in this study was ≤21.2 cm which showed similar results in females and males separately. The MUAC cut-off observed in our results to detect underweight adolescents was almost similar to that obtained in Tanzania in adolescents  aged 15–17 years old . In TanzOur study is a community-based study and enrolled both males and females and these are strengths of this study. One limitation of the present study is that the data for MUAC cut-off from this area might be different from other areas in Sudan. Moreover, height, weight, and MUAC are all measurements that are subjected to measurement error due to inter-observer differences in measurement or miscalculation error . A largeOur study proposes the cut-offs based on MUAC (≤22.5 cm) as an alternative for BMI for community-based screening of underweight adolescents.The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author.The studies involving humans were approved by this study complies with the Declaration of Helsinki. Ethics approval was obtained from the Ethics Committee of the Faculty of Medicine of Gadarif University, Sudan (Reference number #2021.03). Written informed consent was collected from each participant. The studies were conducted in accordance with the local legislation and institutional requirements. The participants provided their written informed consent to participate in this study.IM and SO conceived the study and supervised data collection. AA, AA-N, and IA supervised the work, guided the analysis, critically reviewed the manuscript, prepared the analysis plan, performed the data analysis, and wrote the first draft of the paper. All authors reviewed and approved the final manuscript.


Plasmodium falciparum infection. Through bioinformatics approaches, we selected expression quantitative trait loci (eQTL) for FCGR2A, FCGR2B, FCGR2C, FCGR3A, and FCGR3B genes encoding FcγRs (FCGR), in whole blood. We prioritized two regulatory variants, rs2099684 and rs1771575, located in open genomic regions. These variants were identified using RegVar, ImmuNexUT, and transcription factor annotations specific to immune cells. In addition to these, we genotyped the coding variants FCGR2A/rs1801274 and FCGR2B/rs1050501 in 234 individuals from a malaria-endemic area in Burkina Faso. We conducted age and family-based analyses to evaluate associations with the prevalence of malarial infection in both children and adults. The analysis revealed that the regulatory rs1771575-CC genotype was predicted to influence FCGR2B/FCGR2C/FCGR3A transcripts in immune cells and was the sole variant associated with a higher prevalence of malarial infection in children. In conclusion, this study identifies the rs1771575 cis-regulatory variant affecting several FcγRs in myeloid and neutrophil cells and associates it with the inter-individual capacity of children living in Burkina Faso to control malarial infection.Antibodies play a crucial role in activating protective immunity against malaria by interacting with Fc-gamma receptors (FcγRs). Genetic variations in genes encoding FcγRs can affect immune cell responses to the parasite. In this study, our aim was to investigate whether non-coding variants that regulate FcγR expression could influence the prevalence of  Plasmodium falciparum (Pf) remains a significant global health burden, particularly for children living in endemic regions  *40 cycles]. The specificity and accuracy of the TaqMan assays were validated by confirming a perfect match (100%) with the genotypes obtained by Sanger sequencing in 20 randomly selected human subjects. In each TaqMan assay, positive controls included two homozygous FCG2B alleles (TT and CC) and one heterozygous TC FCG2B allele.Blood samples were collected using venipuncture, and DNA was extracted from mononuclear cells separated by a Ficoll-Hypaque density gradient following the described procedure (27). Before genotyping, the samples underwent whole-genome amplification using the primer extension pre-amplification method. The genotyping of the 2O, and 1 μL of DNA (10–15 ng/μL).For the genotyping of variations at rs1771575, rs2099684, and rs1801274. TaqMan genotyping assays  with IDs C_26275257_10, C_16118535_20, and C_9077561_20, respectively, were used. PCR amplification was performed on the QuantStudio 6 Flex Real-Time PCR Systems  in a final volume of 5 μL, containing 2.1 μL of Master Mix , 0.06 μL of TaqMan probe, 1.84 μL of HPfI across genotypes. A simple linear regression was carried out to calculate the residual for PrevPfI when including age in the model. The residuals were used as phenotypes for some association analyses. As age was shown to influence the prevalence of P. falciparum infection, the age effect was further taken into account. Multiple linear regression was carried out to test the effect on the outcome variable PrevPfI, taking into account age and rs1771575. CC:0, CT:1, TT:2, (additive model) or CC:1 vs. CT/TT 0 (recessive model) are the explanatory variables.Univariate analyses were carried out using Graphpad Prism to assess the association between malaria-related phenotypes and genotypes. Non-parametric Mann-Whitney tests were used to compare median values of PrevLinear mixed models and transmission/disequilibrium (QTDT 2.6.0 program) approaches based on the standard variance components method were used to take into account the family effect . VariancFCGR gene expression and the prevalence of malaria infection in children residing in Burkina Faso. By highlighting the crucial role of non-coding genetic regulatory variants in controlling FCGR expression, this research sheds light on the intricate interactions governing immune responses and disease susceptibility. It also acts as a catalyst for further investigations into the functional implications of these regulatory variants, thereby advancing our understanding of the genetic mechanisms influencing the highly variable capacity of individuals to resist P. falciparum infection in African populations.In conclusion, our study presents preliminary evidence of an association between an intergenic variant that selectively regulates This work holds significant promise for contributing to a broader understanding of the specific genetic and epigenetic factors that influence immune responses. Consequently, it may guide the development of personalized treatments and vaccine strategies tailored to the diverse host responses to infectious diseases like malaria.


P<0.05 for all). Community maps identified many unimproved water sources in all three villages that were used by humans, cattle, or both. We found that children primarily fetched water, and that unprotected wells were dedicated for drinking water whereas ponds were dedicated for other domestic uses and cattle. Although not identified in the community maps, we found hand pumps in all three villages were not in use because of unpleasant taste and high cost. This study improves our understanding of individual, social and environmental factors that are associated with malaria, schistosomiasis, and co-infection, which can inform potential entry points for integrated disease prevention and control.Malaria and schistosomiasis are two major parasitic vector-borne diseases that are a particular threat to young children in Sub-Saharan Africa. In the present study, we investigated factors that are associated with malaria, schistosomiasis, and co-infection among school-aged children, using an explanatory sequential mixed-methods approach. A cross-sectional study was conducted in January 2022 in Misungwi, Tanzania, that sampled 1,122 children aged 5 to 14 years old for malaria and schistosomiasis infection. Mixed-effect logistic regression models were used to assess the association between infection prevalence or seroprevalence, and environmental determinants that create favorable conditions for vectors and parasites and social determinants that relate to disease exposure. Community mapping combined with direct field observations were conducted in August 2022 in three selected villages from the cross-sectional study to understand specific water use behaviors and to identify potential malaria mosquito larval breeding sites and freshwater snail habitat. The prevalence of malaria, seroprevalence of schistosomiasis, and co-infection in this study were 40.4%, 94.3%, and 38.1%, respectively. Individual-level factors emerged as the primary determinants driving the association with infection, with age (every one-year increase in age) and sex (boys vs girls) being statistically and positively associated with malaria, schistosomiasis, and co-infection ( Anopheles mosquitoes, Biomphalaria and Bulinus snails), parasites , biological susceptibility, and adaptive capabilities  [Eighty percent of the world’s population are at risk of one or more vector-borne diseases . Malariaeatment) –5.Plasmodium parasites, with P. falciparum being the predominant species in SSA [Anopheles (An.) vector mosquitoes in Africa include An. arabiensis, An. gambiae sensu stricto (s.s.), and An. funestus, all with their own unique ecological niches [An. funestus and An. gambiae s.s. share similar feeding and biting habits as they are both anthropophilic, endophagic, and bite from dusk till dawn [Human malaria is caused by five different s in SSA . The doml niches , 8. An. ill dawn , 10.Several important tools to control and prevent malaria have been introduced in the past two decades, including long lasting insecticidal nets (LLIN), early diagnosis with rapid diagnostic tests, and treatment with artemisinin-based combination therapy , with LLSchistosoma species each with their respective snail intermediate host–S. mansoni that infects Biomphalaria snails and causes intestinal schistosomiasis, and S. haematobium that infects Bulinus snails and causes urogenital schistosomiasis [Schistosoma species, snail intermediate hosts, and the transmission of schistosomiasis [In SSA, there are two forms of schistosomiasis caused by two different somiasis , 14. Liksomiasis .Bulinus in seasonal bodies of water, and Biomphalaria in permanent bodies of water) where they develop and are released back into the water as an infective form of the parasite (cercariae) [Schistosoma can then again release their eggs through the urine and feces of the host to continue the transmission cycle [Schistosoma can survive approximately 3–6 years within their human host [The transmission cycle for schistosomiasis is influenced by human behavior, specifically the practice of open defecation, where an infected person passes parasitic eggs through their urine or feces into a freshwater source  . The eggrcariae) , 15, 16.rcariae) . Once thon cycle . The lifSchistosoma species and not only treats schistosomiasis, but reduces transmission by decreasing the number of worms in the host [Prevention strategies for schistosomiasis have primarily focused on mass drug administration (MDA) campaigns that deliver Praziquantel tablets without prior diagnosis to at-risk populations in endemic areas, at a frequency that depends on the endemicity of the community to reduce worm burden , 18–20. the host , 22. Altthe host , 23, 24.Schistosomiasis does not typically result in death but can lead to long-term health challenges and chronic morbidity. Tanzania has been reported to have moderate to high prevalence of schistosomiasis (irrespective of species) with considerable geographic variation, with studies reporting a prevalence of schistosomiasis between 6% and 53% in a single region of Tanzania –27.Co-infection is likely to occur where malaria and schistosomiasis are co-endemic. This is especially likely in the Lake Victoria Zone in Tanzania where malaria and schistosomiasis are both endemic. Four studies between the years of 2010 and 2017 determined the prevalence of malaria and intestinal schistosomiasis co-infection as between 22.6% and 27.2% in the Lake Victoria Zone region –31. Co-eAn. funestus s.l. is the predominant malaria vector species, followed by An. gambiae s.l. [Biomphalaria snail species  that are present all year round in and around Lake Victoria, and for Bulinus snail species  found in seasonal water bodies and rice fields situated inland [2 and includes 27 wards, 78 villages and a population of approximately 351,000 people; this area was divided into 86 clusters according to the main study protocol of a cluster randomized trial of malaria vector control interventions, 48 of which were used for this study  [The availability of limited funds necessitated schistosomiasis testing to be conducted on a smaller sample of children—1,296 children compared to 4,200. Although we collected survey information for all 4,200 children, the analysis was restricted to the subset of children that were tested for schistosomiasis . The sample size of 1,296 children (27 children per cluster in 48 clusters instead of 50 children per cluster in 84 clusters) was determined based on hypothesized schistosomiasis seroprevalence. Using the sample size equation for two proportions in a cross-sectional survey with clustered sampling design, this sample size was sufficient to estimate the seroprevalence of schistosomiasis (as measured by IgG and IgM antibody detection) with 80% power and 5% precision, assuming a seroprevalence of 50% and an intracluster correlation of 0.23 . Under tgh risk) , 42. A dS. mansoni and S. haematobium) using immunochromatographic (ICT) IgG-IgM rapid tests (sRDTs) . When mRDTs and sRDTs were positive, free artemether-lumefantrine and Praziquantel tablets were provided, respectively. The mRDTs were kept at ambient temperature in sealed bags with desiccant packs for up to six weeks before being transferred to 4°C where they were kept until September 2022. Pictures of all complete sRDTs were taken using tablets/smartphones and classified based on the intensity of the test band with more intense bands hypothesized to reflect higher IgM antibody titers  relative to IgG antibody titers . A strong-positive test was characterized by a sRDT with a clear and distinct test band (recent infection)  , whereasfection) .The environmental data for this study  were obtained from publicly accessible satellite imagery and are defined in the . The elution procedure followed the methods outlined by Williams et al., 2009 [The performance of the sRDTs were assessed by measuring the sensitivity and specificity of the test compared to a gold standard enzyme-linked immunosorbent assay (ELISA) kit. We retrieved and eluted blood spots from 188 (15%) mRDTs from the cross-sectional to detect anti-Schistosoma l., 2009 . BrieflyThe qualitative data collection for this study was conducted in August 2022 through a community mapping activity combined with direct field observations. Two villages from the cross-sectional study (Isesa and Mwagimagi) were selected based on malaria, schistosomiasis, and co-infection prevalence , and proximity to Lake Victoria (one inland and one by the lake). At some point between the formation of the study area and the community mapping, Gukwa seceded from Mwagimagi to become a separate village–therefore, additional maps were created for Gukwa. Ten community members above the age of 18 from each village (at least 5 men and 5 women per village) were selected by village leaders to create a map of their village  to identify the location of temporary and permanent bodies of water  as well as their specific uses . We then identified the features in the community maps, along with other bodies of water that were not identified in the map, to understand water access and use behaviors.Data analysis focused on three primary outcomes: 1.1) malaria prevalence, 1.2) schistosomiasis seroprevalence, and 1.3) malaria and schistosomiasis co-infection; and two secondary outcomes: 2.1) strong-positive schistosomiasis seroprevalence (based on picture classification) and 2.2) malaria and strong-positive schistosomiasis co-infection.Candidate individual-level determinants, household-level social determinants and environmental determinants hypothesized to be associated with malaria, schistosomiasis, and co-infection are detailed below and further defined in a . The differences in study population in the two selected villages for the community mapping  were compared using chi-square, Fisher’s exact, or a Kruskal-Wallis tests. P-values less than 0.05 were considered statistically significant.Mixed effects logistic regression models accounting for a clustered sampling design were used to identify individual- and household-level social determinants, and environmental determinants that were associated with all five outcomes. The PROC GLIMMIX procedure in SAS version 9.4  was used to fit the generalized linear mixed model (GLMM) using the Laplace parameter approximation, a logit link, and random effects at the cluster level. A random effect term for the cluster in which the individual belonged was included to account for the heterogeneity in the 48 clusters–the random effect was assumed to follow a normal distribution. The models were also adjusted for the study intervention arm to account for potential biases or effects introduced by the type of LLIN assigned as part of the main trial protocol. Using SAS version 9.4 , the univariable association between all candidate explanatory variables and each outcome was assessed, and variables with a P-value of less than 0.2 were entered into a multivariable model. For models that could not accommodate all candidate explanatory variables due to low numbers of events , the “Dredge” function in the MuMIn package in RStudio version 4.1.3  was used to determine the best combination of explanatory variables from those selected using a P-value of less than 0.2 . The DreMulticollinearity between explanatory variables in the mixed effects logistic regression models for all five outcomes was assessed–a variance inflation factor of greater than 2.5 was considered substantial collinearity . Model fSpatial clusters of high and low infection at the household-level for all five outcomes were assessed using Getis-Ord-Gi* in ArcMap version 10.8.1  and further analyzed using SatScan software  . Getis-OThe community mapping activity combined with direct field observations were conducted to strengthen our understanding of the risk factors and exposures to malaria and schistosomiasis. We observed and engaged with individuals fetching water to understand their water use behaviors. Along with structured visual observations , we took detailed notes on topics such as: 1) water use , 2) number of times a day the water source was frequented, and 3) the rationale for visiting a particular water source. Themes and subthemes from the community maps and field observations were used to support and explain the higher than hypothesized schistosomiasis seroprevalence in the study area–beyond what was captured by the questions in the cross-sectional survey.The protocol for this study was reviewed and approved by the institutional review boards, of the University of Ottawa (Canada) and Medical Research Coordinating Committee of the National Institute for Medical Research (Tanzania). Written informed consent forms were obtained from the HoH, adult guardian in the household, or participant prior to data collection activities. Study data did not include information that could be used to identify individual study participants. All participants were anonymized using study numbers as unique participant identifiers. Additional information regarding the ethical, cultural, and scientific considerations specific to inclusivity in global research is included in the (P<0.0001) and households in this village were further away from Lake Victoria compared to Isesa .1122 children were included in this study. The median age of selected children was 9 years old, and there were an equal number of girls  and boys  . Nearly P<0.0001), schistosomiasis , and co-infection ; while boys had higher odds of infection compared to girls for malaria , and co-infection . A limited number of household-level social determinants were found to be associated with infection status. Not having adequate LLIN access was positively associated with malaria , schistosomiasis , and co-infection  and having unimproved water sources was positively associated with malaria  and co-infection . Two environmental determinants, namely population density and distance to Lake Victoria, were key factors positively associated with malaria and co-infection, but not with schistosomiasis. Households in less densely populated areas (<100 compared to >200 people per km2) had higher odds of malaria infection  and co-infection , and households further from the lake (≥ 5km compared to <1km from the lake) had higher odds of malaria infection . The final multivariable models for malaria and co-infection had acceptable discrimination , while the model for schistosomiasis had outstanding discrimination (AUC = 0.91). There was no evidence of spatial autocorrelation for any primary model  based on Global Moran’s I test.The univariable association between all factors are included as a (P<0.0001), and strong-positive co-infection ; while boys had higher odds compared to girls for strong-positive schistosomiasis seropositivity , and strong-positive co-infection  (P = 0.0342) as well as strong-positive co-infection . The final multivariable models for the secondary analyses had acceptable discrimination . There was no evidence of spatial autocorrelation for any secondary model  based on Global Moran’s I test.Results from the primary analysis were comparable to results obtained from the secondary analysis that investigated factors associated with strong-positive schistosomiasis seropositivity and strong-positive co-infection, in terms of identified determinants and associated strength of association. Individual-level social determinants continued to be the primary determinants driving the association with strong-positive schistosomiasis seropositivity and strong-positive co-infection. Aligned with the primary analysis, older age was associated with higher prevalence for strong-positive schistosomiasis seropositivity  . DiffereP<0.001), while two significant coldspots were identified in the northern region of the study area    of children with malaria were identified in the southern region of the study area  . AlthougP<0.001) . The spaP<0.001) .P = 0.001—Cluster 2: RR = 1.53; P = 0.012)  and secondary  analysis both identified comparable factors associated with child infection status, however the spatial patterns in disease prevalence and seroprevalence exhibited notable differences between the primary and secondary analyses. There were two significant hotspots of strong-positive schistosomiasis seropositivity   in the i= 0.012) .S. mansoni Antibody IgM ELISA test, IgG ELISA test, and S. haematobium Antibody ELISA test using eluate from mRDTs collected during the cross-sectional survey, were all negative–likely reflecting the methods used to elute Schistosoma antibodies from the mRDTs.The results from the Human Six maps were created in the three selected villages  .Community maps identified many water sources, often noting ponds next to wells  Some mapOnly women in Isesa identified a hand pump as a water source in their community map. We found multiple working hand pumps sourced from either wells or boreholes in all three villages, however they were not in use because of unpleasant taste and cost. The hand pumps in both villages cost roughly 50 TSH (converted to $0.02 USD) for 20 litres of water. The quality and safety of the water sourced from the hand pumps were not assessed by the research team.Seasonality. All six community maps identified temporary and permanent water sources in their community maps  being statistically and positively associated with malaria, schistosomiasis, and co-infection outcomes. Despite efforts to examine household-level social determinants and environmental determinants, a limited number of factors were found to be associated with infection prevalence and seroprevalence which could be attributed to the high levels of exposures to mosquito larval breeding sites and snail habitats in the study area. The widespread exposure to malaria and schistosomiasis diminishes the association and distinction between social and environmental factors such as socioeconomic status or temperature with infection prevalence and seroprevalence since everyone is already exposed and vulnerable to infection. Community maps identified unimproved water sources in all three villages that were used by humans, cattle, or both. We found that children primarily fetched water, and that unprotected wells were dedicated for drinking water whereas ponds were dedicated for other domestic uses and cattle.The results from this study suggest that malaria and schistosomiasis share a common population at risk, and that older boys are particularly vulnerable to both diseases which is consistent with other studies , 29. TheNeither knowledge nor perception questions regarding malaria and schistosomiasis were found to have a significant association with infection prevalence and seroprevalence, likely reflecting exposures to both diseases. For instance, although housing structure was included in the wealth score as a proxy for household SES, we found that majority of households had unimproved housing  that could increase the risk of a child’s exposure to malaria by allowing mosquitoes to enter their home , 63. It S. haematoboum and S. bovis (the livestock Schistosome) in west Africa [Another key factor to consider regarding risk factors for malaria and schistosomiasis and the Sustainable Development Goals, are that cattle are also present in and around human water sources in this study area. Cattle are not considered to be a significant source of transmission of schistosomiasis in SSA , but there is evidence of a hybrid species of t Africa . It is cAnopheles mosquitoes, whereas LLINs target the adult stage–thereby making these effective and complementary approaches [The results of our analysis support the consideration of environmental control measures in high transmission areas like Misungwi, such as access to safe water and sanitation , larval source management , and snail control (for schistosomiasis), given the potential added benefits. Larval source management including mosquito larval habitat modifications, habitat manipulations, biological control, and larviciding, targets the immature stage of the proaches . Althougproaches . Similarproaches . MDA areSchistosome worms in the host [The WHO recommends that Praziquantel be available in health facilities for the treatment of schistosomiasis , 67, andthe host , 72. Stuthe host , 74. Altthe host , 75.This study was nested in an ongoing four-arm, single blinded, parallel, cluster randomized control trial assessing the efficacy of three dual active-ingredients LLIN for the control of malaria. Although the LLIN metrics may not be generalizable to the entire population of Tanzania, it highlights important limitations in the availability and behaviors surrounding the main malaria vector control tool. Usual malaria vector control prevention strategies are based on a three year LLIN campaign targeting one LLIN for every two people . In TanzAnopheles mosquitoes, coupled with their behavioral resistance, also poses a threat to current efforts aimed at controlling malaria. Current control measures for malaria (LLIN) are most effective against mosquito species that are both anthropophilic  and endophagic (feed indoors). Studies have however found that after LLIN distribution or community wide LLIN use, the mosquito vectors have the ability to alter their behavior by either feeding earlier [Insecticide resistance in  earlier  or shift earlier , 79 to f earlier . In a re earlier . CurrentSchistosoma species. This restricted our ability to evaluate the gradient of infection exposures to S. mansoni  near the lake and S. haematobium  inland [This study was subject to some limitations. We were unable to distinguish between current and past infection of schistosomiasis, which likely explains the findings of very high (94.3%) schistosomiasis seroprevalence in the study area. Children between five and fourteen were included in this study since Praziquantel tablets were not recommended for children under four years old (or under 94 cm in height) at the time of recruitment . As of F) inland , 81. The) inland . These t) inland . Symptom) inland , 22.An. funestus, the dominant Anopheles species in the study area. However, seasonality could play an important role for schistosomiasis transmission since there are many species of Biomphalaria and Bulinus snails, each with their own unique aquatic niche and breeding site preference  [Biomphalaria and Bulinus snails species can also aestivate and survive during the dry season, which increases the risk of schistosomiasis during the rainy season [Another limitation to note is that the cross-sectional survey and community mapping were both administered and conducted during the dry season in January and August, respectively. Malaria transmission in Misungwi is year-round, which is indicative of the breeding site preference  of y ponds) , 86. Somy season . The dryy season . This onThe utilization of both qualitative and quantitative data allowed us to gain a comprehensive understanding of population vulnerabilities and socio-ecological factors associated with malaria, schistosomiasis, and co-infection among school-aged children in Misungwi, Lake Victoria Zone, Tanzania. To our knowledge, this is the first study to investigate individual- and household-level social determinants, and household-level environmental determinants associated with malaria, schistosomiasis, and co-infection using a mixed-method approach in an African setting. The geographic overlap and co-infection of malaria and schistosomiasis in Misungwi, Tanzania, suggest that integrated or supplementary control strategies are necessary to reduce disease transmission. Future studies can examine the coordination between stakeholders or funding sources for malaria and schistosomiasis control programs to assess the feasibility of integrating environmental control with current strategies. This study improves our understanding of social and environmental factors that are associated with malaria, schistosomiasis, and co-infection which can inform potential entry points for integrated disease prevention and control.S1 Text(DOCX)Click here for additional data file.S2 Text(DOCX)Click here for additional data file.S3 Text(DOCX)Click here for additional data file.S4 Text(DOCX)Click here for additional data file.S5 Text(DOCX)Click here for additional data file.


Plasmodium spp. was circulating in the past in southern European populations, which are now devoid of malaria. The aim of this study was to evaluate the efficacy of immunodetection and, more particularly, rapid diagnostic tests (RDT), in order to further assess Plasmodium infections in ancient northern European populations.Paleomicrobiological data have clarified that ® + 4 OPTIMA, which is routinely used to detect malaria, was used to detect Plasmodium antigens from proteins recovered from ancient specimens extracted from 39 dental pulp samples. These samples were collected from 39 individuals who were buried in the sixth century, near the site of the current Palace of Versailles in France. Positive and negative controls were also used. Antigens detected were quantified using chemiluminescence imaging system analysis.A commercially available RDT, PALUTOPPlasmodium antigens were detected in 14/39 (35.9%) individuals, including Plasmodium vivax antigens in 11 individuals and Plasmodium falciparum antigens co-detected in two individuals, while Pan-Plasmodium antigens were detected in three individuals. Controls all yielded expected results.Plasmodium spp. antigens in ancient dental pulp samples, and demonstrated the existence of malaria in Versailles, France, in the sixth century. Plasmodium vivax, which is regarded as being responsible for an attenuated form of malaria and less deadly forms, was the most prevalent species. This illustrates, for the first time in ancient populations, co-infection with P. falciparum, bringing into question the climate-driven ecosystems prevailing at that time in the Versailles area.The data reported here showed that RDTs are a suitable tool for detecting  Plasmodium parasites and is transmitted by the bite of infected female Anopheles mosquitoes [Plasmodium falciparum, Plasmodium vivax, Plasmodium ovale wallikeri, P. ovale curtisi, Plasmodium malariae, and Plasmodium knowlesi. Malaria is no longer endemic in many developed countries and was eliminated from most Western European countries between the 1930s and 1970s. However, the disease continues to represent a challenge in terms of prevention, diagnosis, and patient management. Malaria is imported into Europe by travellers and migrants from endemic areas, as well as by visitors from endemic areas and armed forces personnel returning home after overseas operations. Among developed countries, mainland France reports the greatest number of cases of imported malaria, with 4,995 estimated cases in 2021 . The last proven autochthonous case in France was detected in 2006 in Corsica [P. vivax) in Europe occurred in 2011–2012 in Greece [Malaria is a deadly infection and a public health concern. In 2021, there were an estimated 247 million cases worldwide, resulting in 619000 deaths [Plasmodium antigens in dental pulp from teeth collected from human remains. Here, immunochromatography detection of Plasmodium specific antigens in the presence of the appropriate controls was assessed on human remains collected from a sixth century Merovingian necropolis near the site of the world-renowned Palace of Versailles , which detects three antigens of human malaria, Pf HRP-2 (histidine rich protein-2) specific to P. falciparum, pLDH (lactate dehydrogenase) specific to P. vivax, and Pan-pLDH common to all Plasmodium species (pan species). Test strips were extracted for quantitative reading using the FUSION FX chemiluminescent imaging system and the ImageQuant TL software . The possible result scenarios described by the supplier are the following: the test is considered as invalid if the internal control band remains negative. In the presence of a positive internal control band, the test result is considered as negative if all the other bands are negative. In the presence of a positive internal control band, the sample is considered as containing specific antigen of P. falciparum, suggesting current infection, if the Pan (Pan Plasmodium-pLDH) and Pf  bands are positive. The presence of a positive internal control band with only a positive Pf band is predictive of a P. falciparum current infection or effective post-treatment: HRP2 proteins can be found up to 45 days after effective treatment. The presence of a positive internal control band with positive Pv (P. vivax pLDH) and Pan bands suggests a vivax infection. The presence of a positive internal control band with only the Pan band is predictive of infections with P. ovale, P. malariae or P. knowlesi. If all the bands are positive, this result suggests the presence of a mixed infection with at least P. falciparum and P. vivax.The malaria RDT used in the study was PALUTOP® Malaria LAMP assay, Meridian Bioscience, Cincinnati, USA), were taken after validation of the approach by the laboratory ethics committee. Additionally, five samples infected with different Plasmodium species at different parasitaemia were used as control . Moreover, three P. falciparum parasites collected from in vitro cultures were used . These P. falciparum parasites were previously maintained in human red blood cells in RPMI 1640 medium  supplemented with 10% human serum  and buffered with 25 mM HEPES and 25 mM NaHCO3 under controlled atmospheric conditions that consisted of 10% O2, 5% CO2 and 85% N2 with a humidity of 95%.To validate the assay, three fresh negative blood samples, previously tested by a routine malaria test .All these samples (including the negative controls) were stored at room temperature (average 21 °C) for five days in ambient air  to mimic ancient blood specimens. Both fresh and derived mock-ancient blood specimens were then tested by routine laboratory diagnostic methods, the Alethia® Malaria LAMP assay , and immunochromatographic assay , part of a Merovingian necropolis dating from the sixth century was discovered. Dating was carried out using the C14 dating method and was applied to two tombs and funeral materials consisting of pearls, ceramics and metal artefacts. In total, 35 graves contained objects, including some 284 beads and 127 metal remains. Of the human remains of 109 people which were excavated, 13 were women, 15 were men and 81 were of undetermined sex, aged between one and approximately 50 years old. Thirty-nine of these individuals had at least one intact tooth available for study. This comprised 12 men, 10 women and 17 individuals of undetermined sex  individuals (Table As for the ancient specimens, the presence of P. falciparum infection, and 82.9–100% for P. vivax infection [Plasmodium Pan-pLDH antigen but not the least sensitive antigens for P. falciparum and P. vivax detection in comparison with PfHRP2 and PvLDH [P. ovale and/or P. malariae or with low density P. vivax infections.Although the size of the tested population was limited to 39 individuals, a prevalence of malaria-infected individuals of 35.9% was found, suggesting a relatively high prevalence of malaria infection in this area of Versailles, even when the sensitivity of the test used in this study was taken into account. Indeed, PALUTOP® + 4 OPTIMA performance tests demonstrated a sensitivity interval of 91–98.7% for nfection –29. In oPlasmodium spp. antigens in the sixth century remains excavated from a site near the current Palace of Versailles in northern France. In this study, dental pulp, which has been recognized as containing blood at the time of death [Plasmodium antigens. This is the first time that immunochromatographic tests and, more particularly, RDTs have been used to detect Plasmodium spp. in dental pulp. It is also the first time that the biological presence of old malaria infections has been detected in France.The results reported here, which used an immunochromatographic assay in the presence of appropriate controls, detected the presence of of death , proved P. falciparum infection, the first from bone samples dating from the sixteenth century from the Medici family of Florence [P. falciparum in two samples belonging to the same individual [Plasmodium falciparum mtDNA fragments were also detected by NGS in two individuals dating from the first and second centuries CE in southern Italy after hybridisation capture [The preservation of protein samples over time and their stability have been demonstrated by several published studies, as resistance of proteins to degradation is high and greater than that of DNA, at least in ancient human remains , 31–33. Florence , and anoFlorence . Investidividual . Plasmod capture .Pfhrp2 gene [Plasmodium spp. NGS reads, confirming the usability of immunoassays on ancient samples with preserved specificity and sensitivity similar to that achieved with modern samples [RDT sensitivity is generally greater than 90% and specificity is greater than 80% . Howeverrp2 gene . The com samples .P. vivax antigen, an observation which is in line with previous observations of P. vivax in three individual samples collected between 1942 and 1944 in the Ebro Delta in Spain, before eradication, and investigated by metagenomics 70 years later [P. vivax [P. vivax may have a South Asian origin, by modelling studies based on climatic variations [P. vivax-like malarial protozoan, with a favourable climate for mosquito development, which probably covered western and central parts of Europe, where climatic conditions were mild. These results support the continued survival of P. vivax-like parasites throughout the quaternary era in Europe [P. falciparum and P. vivax co-infection currently occurring in between 5 and 7% of all malaria cases [Anopheles mosquitoes at that time, in the absence of any retrieved published data on insects in the mediaeval period. However, some historical sources reported marshland in this part of France [Anopheles mosquitoes. Moreover, Anopheles maculipennis, Anopheles atroparvus, Anopheles sacharovi and Anopheles labranchiae, all known to be possible vectors for P. falciparum and P. vivax [Most individuals were found to be positive for the rs later , 40. FurP. vivax , 42. Oneriations . These iia cases  may furtf France , biotopeP. vivax , have beP. vivax . Taken tPlasmodium spp. in these individuals. In modern times, the detection of Plasmodium spp. in the blood is associated with a wide spectrum of medical conditions, from asymptomatic carriage in apparently healthy individuals to death.There is, however, a lack of anthropological data to further assess the morbidity of Plasmodium antigens captured from ancient specimens by RDTs, have been quantified, especially using chemiluminescence imaging system analysis. Immunochromatographic tests and, more particularly, RDTs were showed to be a suitable tool for detecting Plasmodium spp. antigens in ancient dental pulp. Immunodetection proved to be a fast, sensitive and very useful technique for screening ancient samples for infectious disease, for the purposes of carrying out an initial diagnosis directly on the excavation sites. However, the lack of validation of DNA-based detection of Plasmodium is a limit of this study.This is the first time that the Secondly, this is the first biological detection of malaria at a time of transition between the Roman Empire and the Merovingian reign, within the territory of modern-day France. The study of other sites, in particular sites that used to be marshy, would be of great interest in terms of gaining a better understanding the determinants of the current eradication of malaria in Europe.


While European healthcare systems face resource shortages as a consequence of the coronavirus pandemic, numbers of imported falciparum malaria cases increased again with re-intensifying international travel. The aim of the study was to identify malaria-specific complications associated with a prolonged intensive care unit (ICU) length of stay (ICU-LOS) in the pre-COVID-19 era and to determine targets for their prevention. This retrospective observational investigation included all the cases treated from 2001 to 2015 at the Charité University Hospital, Berlin. The association of malaria-specific complications with the ICU-LOS was assessed using a multivariate Cox proportional hazard regression. The risk factors for the individual complications were determined using a multivariate Bayesian logistic regression. Among the 536 included cases, 68 (12.7%) required intensive care and 55 (10.3%) suffered from severe malaria (SM). The median ICU-LOS was 61 h (IQR 38–91 h). Respiratory distress, which occurred in 11 individuals , was the only complication independently associated with ICU-LOS . Shock , co-infections , and each mL/kg/h fluid intake in the first 24 treatment hours  were the independent risk factors for its development. Respiratory distress is not rare in severe imported falciparum malaria, and it is associated with a substantial burden. Cautious fluid management, including in shocked individuals, and the control of co-infections may help prevent its development and thereby reduce the ICU-LOS. Due to its unique pathophysiology, various life-threatening complications may develop suddenly in falciparum malaria, even after the initiation of an effective therapy. Most fatalities occur during the first 48 h of admission ,2. PatieHowever, the coronavirus pandemic demonstrated that even the capacities in HIC can rapidly be overburdened. Its consequences continue to have a substantial impact on available resources. Shortages of medication, materials, and, most importantly, nurses, currently affect medical care in many institutions. While the number of malaria cases imported to European countries has sharply decreased as a result of the international travel ban during the pandemic , case nuThe present study aimed to identify the complications associated with prolonged ICU-LOS among patients with falciparum malaria imported to Berlin, Germany, in the pre-pandemic era and to determine targets for improved management.All the adult patients (≥18 years) with imported falciparum malaria that were hospitalized between 1 January 2001 and 31 December 2015 in the Charité, University Hospital, Berlin, were included . Some in2/FiO2 ≤ 300 mmHg was recorded under the mechanical ventilation, applying a minimum positive end-expiratory pressure (PEEP) of 5 cmH2O respiratory distress was further discriminated into acute pulmonary oedema (APO) and the acute respiratory distress syndrome . Severe malaria was defined according to the World Health Organization (WHO) 2022 definition as the presence of ≥1 malaria-specific complication  [5]. Minme ARDS;  6]. Ant. Ant2/Fime ARDS; . After 4The study’s primary endpoint was the ICU-LOS, which was measured in hours. The secondary endpoints were the risk factors for the development of complications associated with a prolonged ICU-LOS.The best way to model the ICU-LOS has been debated in the literature. With an ICU-LOS of <4 days, the Cox proportional hazard (CPH) regression was considered an appropriate approach . The stup-value; a pd-value of 97.5% corresponds approximately to a two-sided p-value of 0.05). For the identification of the risk factors, a logistic regression was used. The covariates were selected on the basis of a review of the recent literature ,15,16,17For the statistical analysis, R version 4.1.0  was used  or severe congestive heart failure, were responsible for ICU admission. The median number of malaria-specific complications in ICU admission, according to the WHO 2022 definition, was one . With the exception of renal impairment and metabolic acidosis, a clear correlation between these complications was not evident  received artemisinin-based regimens. It was noted that all the patients were treated with a restrictive fluid management (P. vivax and hepatitis B). Respiratory distress complicated 11 cases and was diagnosed after a median of 17 h . With a median of 17 h , the six cases with APO were diagnosed earlier compared to the five ARDS cases that were diagnosed after a median of 51 h . Low-flow oxygen therapy was sufficient to treat hypoxia in three (4.4%) patients with respiratory distress, while mechanical ventilation was required in eight (11.8%) individuals . These eight individuals remained on mechanical ventilation for a median of 35 h . Weaning these patients from mechanical ventilation was uncomplicated in all cases. All the patients survived to discharge.A total of 558 imported falciparum malaria cases were treated during the study period in the institution, representing 7.1% of the total 7866 cases notified in Germany within that period. Twenty-two cases had to be excluded . Fifty-f evident . Nearly nagement . The mednagement . Vasoprenagement . Communip < 0.0001). Three complications were found to be associated with a prolonged ICU-LOS in the univariate Cox proportional hazard regression: severe malarial anemia, decompensated shock, and respiratory distress (The length of the ICU stay ranged between 9 and 644 h with a median of 61 h (IQR 38–91 h) and a total of 6341 h (264 patient days). In the patients with SM, the ICU-LOS was significantly longer than in the UM cases  and non-infected erythrocytes (RBC) in the microcirculation, and the intense systemic inflammation with generalized endothelial dysfunction, which could ultimately lead to endothelial barrier breakdown, falciparum malaria has a unique pathophysiology. The plasma concentrations of the biomarkers for endothelial activation, such as the von Willebrand factor (vWF) and angiopoietin-2 (ANG-2), are markedly elevated in severe malaria and have been associated with both the severity and mortality of the illness ,23. MarkPlasmodium species also play a causative role [With this background, the risk factors for the development of respiratory distress in imported falciparum malaria identified in the present study are plausible. Pulmonary infections and bacterial sepsis are generally the most common causes of ARDS. In the respective endemic areas, various ive role . Numerouive role ,33 and oive role ,34,35. Hive role , the preShock is another well-established risk factor for the development of ARDS. This association was also evident in the multivariate analysis of the present study. Both falciparum malaria and concomitant infections can cause or worsen shock. Fluid therapy is an essential component of shock management. While the recommended fluid volumes for initial resuscitation in patients with septic shock are approx. 30 mL/kg/h, the fluid volumes recommended for falciparum malaria are approximately ten times lower . Due to These findings underscored that the risk factors leading to ARDS in other conditions were also associated with the development of respiratory distress in imported falciparum malaria. Importantly, the three risk factors identified in the present study were plausible individually as well as in their pathophysiologic interplay. Other factors, such as hypoalbuminemia or pre-existing chronic disorders, will likely also contribute to the development of respiratory distress in falciparum malaria. However, the present study was unable to define their roles, primarily due to the limited sample size.In a recently published study of patients with severe imported falciparum malaria treated in a Portuguese ICU, the median ICU-LOS of the patients with ARDS was 13 days compared to 3 days for those without this complication . These fSimilar to the other causes of ARDS, prevention may be the best medicine for respiratory distress in imported falciparum malaria ,41. HoweThe present study had several limitations, with the main limitation being its retrospective, single-center design and a long observation period that limited its generalizability. Few outcomes of interest were predisposed per se to sparse data bias. This inherent methodical problem was met by performing sensitivity analyses and by employing a Bayesian logistic regression, an approach known to yield robust results even in small data sets. The odds ratios determined for the individual risk factors may, nevertheless, still overestimate the true effects and should, therefore, be interpreted with caution.However, the study also had several strengths. The setting of well-equipped ICUs provided close monitoring of the respiratory rates, pulse oximetry, and blood gases, as well as high-quality chest imaging. This allowed for exact and timely diagnoses as well as the accurate differentiation of APO and ARDS. The usage of the same ePDMS in all ICUs allowed for accurate fluid balancing. In the absence of validated tools for guiding fluid management, clinicians need concrete recommendations. The study provided these figures and, thereby, emphasizes the importance of meticulous fluid management in falciparum malaria. Finally, to the best of our knowledge, the study was the first to identify the risk factors for the development of respiratory distress in imported falciparum malaria cases.The current study provided exact figures for the frequency of respiratory distress in a large cohort of imported falciparum malaria cases. The complication occurred in 2.1% of the total cases, 16.2% of the cases admitted to the ICU, and 20% among those with severe malaria. In a setting of nearly unlimited medical resources, respiratory distress proved to be the only malaria-specific complication independently associated with a prolonged ICU-LOS. The identified risk factors for the complication were the same associated with ARDS in other conditions. As such, they are likely, in large part, modifiable. A cautious fluid management, including in shocked individuals, and the best possible management of co-infections may help prevent the development of respiratory distress in imported falciparum malaria and thereby improve patient outcomes as well as relieve pressure on ICU capacities.


P. falciparum recombinant proteins (n = 691) using samples collected from individuals residing in a low-malaria-transmission region of Thailand. We conducted the antibody assays using the AlphaScreen system, a high-throughput homogeneous proximity-based bead assay that detects protein interactions. We observed that out of the 691 variable surface and merozoite stage proteins included in the library, antibodies to 268 antigens significantly correlated with the absence of symptomatic malaria in an univariate analysis. Notably, the most prominent antigens identified were P. falciparum erythrocyte membrane protein 1 (PfEMP1) domains. These results align with our previous research conducted in Uganda, suggesting that similar antigens like PfEMP1s might play a pivotal role in determining infection outcomes in diverse populations. To further our understanding, it remains critical to conduct functional characterization of these identified proteins, exploring their potential as correlates of protection or as targets for vaccine development. Malaria poses a significant global health challenge, resulting in approximately 600,000 deaths each year. Individuals living in regions with endemic malaria have the potential to develop partial immunity, thanks in part to the presence of anti-plasmodium antibodies. As efforts are made to optimize and implement strategies to reduce malaria transmission and ultimately eliminate the disease, it is crucial to understand how these interventions impact naturally acquired protective immunity. To shed light on this, our study focused on assessing antibody responses to a carefully curated library of  Plasmodium falciparum, it is hypothesized that blood-stage antigens have the potential to stimulate strong immune responses that can be targeted for vaccine development [Malaria is a significant public health issue and a primary cause of illness in tropical and sub-tropical countries. There were approximately 247 million malaria cases in 2021, resulting in roughly 619,000 deaths . This imelopment . This haImmuno-epidemiological investigations have been instrumental in detecting, recognizing, and characterizing numerous dominant vaccine candidates currently under development. In particular, immunoscreening techniques that permit the simultaneous assessment of various proteins as prospective vaccine candidates or immune correlates have emerged as an imperative strategy. Several proteins, such as merozoite surface protein (MSP) 1, MSP2, MSP3; apical membrane antigen 1 (AMA1) ; serine Plasmodium proteins through heterologous expression systems has posed a significant challenge in identifying the proteins targeted by anti-malaria protective immunity. The wheat germ cell-free system (WGCFS) offers a eukaryotic alternative to expressing plasmodial proteins with broad applications in malaria studies [P. falciparum proteins and demonstrated that WGCFS-expressed proteins are greatly advantageous over conventional Escherichia coli system-expressed proteins in the pursuit of obtaining high yields of full-length proteins [E. coli cell-free systems [The production of  studies . In our proteins . Further systems . In addiP. falciparum genome, recent investigations have focused on identifying parasite proteins that are key targets of antibodies-mediated blood-stage immunity. This includes variable surface antigens (VSA) that are localized to the surface of infected red blood cells, such as P. falciparum erythrocyte membrane protein 1 (PfEMP1), repetitive interspersed family (RIFIN) proteins, sub-telomeric variable open reading frame (STEVOR) proteins, and surface-associated interspersed gene family (SURFIN) proteins, as well as other asexual-stage parasite proteins (here referred to as BSPs) [Leveraging the availability of a well-annotated 3D7 as BSPs) . In one as BSPs) . The anaas BSPs) . ImportaP. falciparum cases have significantly decreased in Southeast Asia and some African countries [P. falciparum-specific antibody responses in the affected populations. In line with this idea, we have previously profiled P. falciparum BSPs against clinical malaria by analyzing serum samples obtained from Thailand, a region of low malaria endemicity with an EIR of 1–3 infective bites/year [Because of the global concerted efforts to reduce the burden of malaria, ountries . Thus, ites/year ,16. In ttes/year ,17.P. falciparum antigens, including VSAs and BSPs. We observed that most of the antigens were immunoreactive, and subsequently identified P. falciparum antigens associated with reduced risk of symptomatic malaria from a wider range of proteins.In this study, we sought to comprehensively assess the antimalarial immune profiles in residents of a low malaria transmission region in Thailand . The anaPlasmodium falciparum malaria (Asy) case was defined as having a detectable parasitic infection, following a microscopic examination of Giemsa-stained blood films, but with no fever (<37.5 °C) at the time of sample collection [P. falciparum malaria (Sym) between May and June 2005. These individuals resided in Tak Province, adjacent to Kanchanaburi Province in western Thailand. All 21 Sym cases had at least one microscopically confirmed and recorded P. falciparum malaria episode before the one corresponding to the sample collection. Sym malaria was defined as the presence of fever (≥37.5 °C) during sample collection and any parasitemia detectable by microscopy. The Sym group study received ethical approval from the Faculty of Medicine’s ethical review committees at Ramathibodi Hospital, Mahidol University (ID: 09-46-10 dated 24 September 2003). All individuals who participated in this study provided written informed consent. The Institutional Review Boards of Ehime University Hospital, Japan, also approved the protocol for using the archived serum samples in Japan (Aidaiibyourin 1507005 dated 1 August 2015) [From June 2001 to May 2005, we collected serum samples from residents of Kong Mong Tha, located in Kanchanaburi Province in western Thailand. These individuals were enrolled in an active follow-up study. An asymptomatic llection . Althougllection . In addist 2015) .P. falciparum, such as blood stage proteins , selected from our previous study based on their significant immunoreactivities [P. falciparum erythrocyte membrane protein 1 (PfEMP1) , Duffy binding-like domains of PfEMP1 , repetitive interspersed family (RIFIN) proteins (n = 178), sub-telomeric variable open reading frame (STEVOR) proteins (n = 53), and surface-associated interspersed gene family (SURFIN) proteins (n = 32). The target genes were cloned into the pEU plasmid vector  as previously described [P. falciparum 3D7 reference strain [The protein library used in this study included a total of 691 proteins, which represented various protein families of tivities , cysteineins n = 8, sub-teescribed . Mono-bie strain .P. falciparum proteins (5 µL) were mixed with 4000-fold-diluted serum in reaction buffer (10 µL) and incubated for 30 min at 26 °C to form a protein–antibody complex. Suspension of streptavidin-coated donor-beads and acceptor-beads conjugated with Protein G in the reaction buffer was added to the mixture (10 µL), and the whole mixture was incubated in the dark for 1 h for optimal binding of the donor- and acceptor-beads to biotin and human antibody, respectively. The luminescence signal emitted by the protein–antibody complex at 620 nm was detected by the EnVision plate reader (PerkinElmer) and captured as raw AlphaScreen Counts (ASCraw). Biotin-SP-conjugated ChromPure human IgG  was added to each plate to ensure day-to-day and plate-to-plate normalization. A 5-parameter logistic standardization curve was then used to generate normalized ASCnor, which is described as ASC in this paper. The biotinylated IgG was also used as the positive control, while translation mixtures with wheat germ extract (WGE) but lacking the parasite mRNA transcript were used as the negative control. To avoid any experimental bias, all assays were randomized [The AlphaScreen platform was used to quantify serum antibodies in malaria-exposed individuals using a previously validated protocol . Brieflyndomized .p < 0.05. Mann–Whitney test was performed to evaluate the statistical difference between median parasitemia of Asy vs. Sym groups. Spearman’s rank correlation test was used to evaluate the correlation between seroprevalences of Thai vs. Ugandan serum samples.Data analyses were performed using R software  and Prism 9 . Data obtained from the AlphaScreen were log-transformed before analysis. Statistical significance was defined as The protein seropositivity cut-off value to human sera was defined at the lowest non-negative ASC value from the assayed samples. A protein was considered immunoreactive if more than 10% of the volunteers had ASC levels above the seropositivity cut-off value . To furtWe used principal component analysis (PCA) to evaluate antibody responses to different proteins among individuals with or without clinical malaria. PCA essentially reduces the dimensionality of antibody responses by generating fewer composite variables to capture as much variance in that dataset. The model then assesses and compares the relationship between the scores obtained for each of these components per subject. We included all immunoreactive antigens to assess the overall variance among the antigens, regardless of their groupings. To identify PCA-derived clusters of antibody responses that were involved in protection against clinical malaria, we selected principal components where at least three variables were loaded and the eigenvalue was greater than 2 or the proportion of variance explained was > 5%. Individual contributions to the PCA were assessed in association with clinical malaria outcomes .p < 0.0001).Serum samples were obtained from adult participants in Thailand, as shown in p = 0.92) nor the geometric means of ASC of all antigens recognized by an individual  . The geometric means of the AlphaScreen count (ASC) of all proteins were compared between Asy and Sym groups A. Of 691 = 0.27) .To gain further insight into the relationship between the antibody levels and malaria outcomes, we performed univariate logistic regression analysis to determine the odds ratios (ORs) using antibody responses as the independent variable and clinical outcomes as the dependent variable. Of the 674 immunoreactive antigens, 268 were significantly associated with reduced risk of clinical malaria, with Ors less than 1, indicating a negative correlation between antibody responses and symptomatic malaria outcomes . The topSince the antibody responses and their corresponding protective immunity involve numerous antibodies acting simultaneously but targeting different proteins, we performed principal component analysis (PCA) with different proteins to capture the effect of all antibodies in a single analysis and extract important associations . The anaP. falciparum antigens associated with reduced risk of symptomatic malaria. To do this, we compared the antibody levels in blood samples from Thailand—this study—and from our recent study in Uganda [P. falciparum erythrocyte membrane protein 1 (PfEMP1) domains as well (p < 0.0001).We sought to further investigate how to leverage samples from multiple regions to identify n Uganda . In bothn Uganda . Of all  as well C,D. In pEscherichia coli cell-free system have been widely utilized. This approach could identify seroreactivity to some Plasmodium falciparum erythrocyte membrane protein 1 (PfEMP1) domains [P. falciparum antigens expressed mostly by mammalian Expi293 cells has been reported [P. falciparum infection are useful for the identification of recent infections [E. coli cell-free system is that the synthesized proteins exhibit low immunoreactivities with sera derived from malaria-exposed individuals, suggesting incorrect folding of the proteins [E. coli cell-free system [Residents of malaria-endemic regions develop immunity to life-threatening malaria complications after repeated exposure . To iden domains , blood-s domains , or prot domains . In addireported . These afections . The majproteins ,27. On tproteins . It was e system .AlphaScreen has been widely used for the detection of protein–protein, protein–DNA, and protein–RNA interactions and for the screening of proteins interacting with the target proteins, inhibitors of the target complex of proteins, and so on . BecauseP. falciparum infections has considerably decreased in several African countries and Southeast Asia [P. falciparum-specific antibody responses in the affected populations. Thus, this study aimed to comprehensively identify P. falciparum antigens that are the targets of naturally acquired immunity with serum samples taken from Thailand, a region of low malaria endemicity. Antibody responses to 268 out of 691 antigens were positively associated with the reduced risk of symptomatic malaria. Most antigens selected were PfEMP1 domains  samples was also observed [We found a significant positive correlation of seroprevalence for  samples A. Moreov samples C, even t PfEMP1s . Althoug PfEMP1s , it coulobserved , indicatThe identification of a domain of PfEMP1, DBLβ3_D4 of PF3D7_1150400, as one of the top-ranked proteins in this study was very encouraging for several reasons. First, the results were consistent with a study showing that peptides and recombinant proteins from the domain reacted higher in asymptomatic malaria than severe malaria samples obtained from Benin . Second,PCA is a valuable tool for analyzing complex datasets involving multi-dimensional data, mixed infections, and complex host-parasite interactions. Using PCA, we can explore the joint effects of multiple variables and identify underlying patterns that may not be obvious . Here, tP. falciparum infections. The antigens identified by this study could serve as valuable serological markers for identifying asymptomatic infections and as potential candidates for blood-stage vaccines. Thus, to gain detailed knowledge of protective immunity against symptomatic malaria, functional characterization of the selected proteins, and the antibodies against them, needs to be elucidated.In summary, in regions of differing malaria transmission, and differing human and parasite genetic backgrounds, host immune responses targeting specific parasite antigens could play a crucial role in determining the outcomes of


However, knowledge gaps exist in Ethiopia on the diagnostic performance of hsRDT for the detection of Plasmodium falciparum in school children with asymptomatic malaria.One of the major roadblocks to the falciparum malaria elimination programme is the presence of a portion of the population, such as school children, with asymptomatic malaria infection. Targeting such reservoirs of infections is critical to interrupting transmission and enhancing elimination efforts. The NxTek™ 3 Real—Time PCR system (qPCR). The hsRDT was compared to cRDT and microscopy. qPCR and microscopy were used as reference methods.A school-based cross-sectional study was conducted from September 2021 to January 2022 on 994 healthy school children (aged 6–15 years). Finger-pricked whole blood samples were collected for microscopy, hsRDT, conventional RDT , and QuantStudioPlasmodium falciparum was 1.51%, 2.2%. 2.2% and 4.52%, by microscopy, hsRDT, cRDT and qPCR, respectively. Using qPCR as reference, the sensitivity of hsRDT was higher (48.89%) than the microscopy (33.3%), and showed 100% specificity and a positive predictive value (PPV). Microscopy showed similar specificity and PPV as hsRDT. Using microscopy as a reference, the diagnostic perforrmances of both hsRDT and cRDT were similar. Both RDTs demonstrated identical diagnostic performances in both comparison methods.The prevalence of P. falciparum in school children with asymptomatic malaria. It can be a useful tool for the national malaria elimination plan of Ethiopia.hsRDT has the same diagnostic performance as cRDT but improved diagnostic characteristics than microscopy for detection of  Plasmodium falciparum . Recent scientific recommendations also underlined the need to use such RDTs to identify asymptomatic infection reservoirs to achieve the goal of malaria elimination , is an hsRDT developed to detect P. falciparum HRP2 [22]. Few studies conducted field evaluation of the kit in Uganda and Myanmar in detecting HRP2 among malaria infected individuals including asymptomatic population in varying geographical settings showed superior sensitivity of the hsRDT over conventional malaria diagnostic tools .Therefore, there is an urgent need for a malaria RDT that is highly sensitive to detect low-density parasitaemias, quality-assured, and easy to use in remote settings with limited resources  in this study is lower than a study conducted in Uganda /994, hig and in i, differences in the intensity of the HRP2 positive band lines were observed. For example, some cRDT tests showed very faint positive Pf band lines that was difficult to declare, but all were clearly visible with the new RDT. These differences could be attributed either to the assumption of a low concentration of circulating HRP2 antigen in asymptomatic school children or the fluoresce material used. Briefly, both tests are lateral flow immunochromatographic kits that allow for a qualitative diagnosis based on the detection of HRP2 expressed by P. falciparum in the blood of infected individuals [Although the performance of both RDTs were identical in this studyividuals . Availabividuals  and the ividuals , indicatAnother plausible piece of evidence in support of this observations is a study on the analytical performance of hsRDT , which d™ Elimination Malaria Pf Ag test in detecting P. falciparum in school children with asymptomatic malaria in Ethiopia. The hsRDT detected 7- fold more low-density P. falciparum malaria infections and provides a better measure of discriminating children with and without asymptomatic malaria  than the malaria gold standard tool, microscopy. On the contrary, the new kit did not outperform the conventional RDT  in the current study. The study provides significant numbers of asymptomatic submicroscopic P. falciparum infections. This active and silent transmission of malaria in school-age children is an alarm for the malaria control programme in the Gomma District of the Jima Zone for appropriate interventions. The results of the current study also underscore the importance of molecular tools for screening asymptomatic populations to achieve malaria elimination goals.The current study reports the diagnostic performance of the NxTek