The American Journal of Tropical Medicine and Hygiene

Durgama Anchalare Malaria Nirakaran (DAMaN) is a multi-component malaria intervention for hard-to-reach villages in Odisha, India. The main component, Malaria Camps (MCs), consists of mass screening, treatment, education, and intensified vector control. We evaluated MC effectiveness using a quasi-experimental cluster-assigned stepped-wedge study with a pretest-posttest control group in 15 villages: six immediate (Arm A), six delayed (Arm B), and three previous interventions (Arm C). The primary outcome was PCR+ Plasmodium infection prevalence. Across all arms, the odds of PCR+ malaria were 54% lower at the third follow-up compared to baseline. A time (i.e., visit) x study arm interaction revealed significantly lower odds of PCR+ malaria in Arm A versus B at the third follow-up. The cost per person ranged between US$3-8, the cost per tested US$4-7, and the cost per treated US$82-1,614, per camp round. These results suggest that the DAMaN intervention is a promising, financially feasible approach for malaria control.

Chikungunya, an arboviral disease transmitted by Aedes mosquitoes, shares clinical similarities with dengue, but is distinguished by prolonged joint pain. Following a major outbreak in Bangladesh in 2017, chikungunya nearly vanished from its territory. The study participants were recruited prospectively following specific inclusion criteria and obtained written informed consent. Out of 1280 febrile individuals screened, 569 met the criteria of fever onset within 2-5 days, accompanied by symptoms such as headache, myalgia, bone and joint pain, rash, nausea, vomiting, or diarrhea. Of these, 474 underwent real-time RT-PCR testing. Among the samples tested, 213 were PCR-positive for at least one arbovirus. Chikungunya cases totaled 55, including 7 coinfections (6 with DENV, and the first documented CHIKV-ZIKV coinfection in Bangladesh). No infections were reported from January to August, with a peak in October and November. Most CHIKV infections (72.7%) had moderate to high viral loads, with common symptoms of joint pain, myalgia, and headaches. The resurgence of Chikungunya in late 2024 underscores the potential for a major outbreak in 2025, necessitating proactive measures to mitigate public health impact and ensure a robust response to this re-emerging threat.

ObjectiveData from 19 years of national dengue surveillance in Cambodia (2002-2020) were analyzed to describe trends in dengue case characteristics and incidence. MethodsGeneralized additive models were fitted to dengue case incidence and characteristics (mean age, case phenotype, fatality) over time. Dengue incidence in a pediatric cohort study (2018-2020) was compared to national data during the same period to evaluate disease under-estimation by national surveillance. FindingsDuring 2002-2020, there were 353,270 cases of dengue (average age-adjusted incidence 1.75 cases/ 1,000 persons/ year) recorded in Cambodia, with an estimated 2.1-fold increase in case incidence between 2002 and 2020 (slope = 0.0058, SE = 0.0021, p = 0.006). Mean age of infected individuals increased from 5.8 years in 2002 to 9.1 years in 2020 (slope = 0.18, SE = 0.088, p <0.001); case fatality rates decreased from 1.77% in 2002 to 0.10% in 2020 (slope = - 0.16, SE = 0.0050, p <0.001). When compared to cohort data, national data under-estimated clinically apparent dengue case incidence by 5.0-fold (95% CI 0.2 - 26.5), and overall dengue case incidence (both apparent and inapparent cases) by 33.6-fold (range: 18.7-53.6). ConclusionDengue incidence in Cambodia is increasing and disease is shifting to older pediatric populations. National surveillance continues to under-estimate case numbers. Future interventions should account for disease under-estimation and shifting demographics for scaling and to target appropriate age groups.

Background and AimsWolbachia are bacteria that inhibit dengue virus replication within the mosquito. A cluster-randomized trial found Wolbachia reduced virologically-confirmed dengue cases by 77% and previous models predicted Wolbachia to be highly cost-effective in Indonesia, Vietnam, and Brazil. in Colombia, Wolbachia was introduced in the Aburra Valley in 2015 and Cali in 2020. To inform decisions about future extensions, we performed economic evaluations of the potential expansion of Wolbachia deployments to 11 target Colombian cities. MethodsWe assembled quantities and the distribution by severity of reported dengue cases from Colombias national disease surveillance system and the health service provision registry (RIPS). An epidemiological panel of three experts estimated the shares of non-medical cases and adjustments for under-reporting and misclassifications. We determined costs (in 2020 US dollars) of treating dengue illness from the benchmark insurance tariff, RIPS data on treatment services per symptomatic dengue case, and the national government database for establishing insurance premiums. A cluster randomized trial quantified the effectiveness of Wolbachia against symptomatic dengue cases. ResultsProjecting impact over 10 years for Cali, we estimated a net health-sector savings of USD4.95 per person. We also estimated averting 369 disability-adjusted life years (DALYs) per 100,000 population. From a societal perspective, at 10 years Wolbachia deployment is expected to have highly favorable ConclusionsOver 10 years, Wolbachia is highly beneficial on economic grounds, and almost universally cost saving. That is, Wolbachias savings in health care costs alone would more than offset deployment costs nationally and in 9 target cities (those with adjusted annual dengue incidence at least 50/100,000 population). In these 9 target cities, Wolbachia would generate at least USD3.00 in benefits per dollar invested, giving substantial confidence that Wolbachia deployment would be cost-beneficial in Colombia.

Somaliland experienced a large dengue fever outbreak in 2023-2024, with 4,971 probable cases, 1,703 confirmed by rapid tests, and three deaths. Reported cases spanned five regions, with 74% in Marodijeh. We highlight the utility of the new laboratory surveillance and the need for mitigating dengue risks amid climatic fluctuations.

BackgroundDengue, a vector-borne disease caused by the dengue virus, has emerged as a global public health concern, given the tenfold rise in reported cases over the last two decades. In light of the upcoming dengue interventions, country-specific cost-of-illness estimates are required to evaluate the cost-effectiveness of new interventions against dengue. This study aims to conduct an updated systematic review of dengue cost-of-illness studies, extracting the relevant data, and conducting regression analysis to explore potential factors contributing to the cost variations among countries. We used the MEDLINE, EMBASE, PubMed, and Web of Science databases to systematically search for published dengue cost-of-illness studies reporting primary costs per dengue case. A descriptive analysis was conducted across all extracted studies. Linear regression analysis was performed to investigate the association between the GDP per capita and cost per case. The quality of the included studies was also assessed. Fifty-six studies were included, of which 22 used the societal perspective. The reported total cost per case ranged from $15.0 for outpatients in Burkina Faso to $9,386.1 for intensive care unit patients in Mexico. Linear regression analysis revealed that the cost of dengue illness varies significantly across countries and regions, and was positively related to the settings GDP per capita. The quality assessment demonstrated that improvements are needed in future studies, particularly in the reporting of the methodology. Future research should focus on understanding other drivers of cost variations beyond GDP per capita to improve the cost estimates for economic evaluation studies. The results presented in this study can serve as crucial input parameters for future economic evaluations, supporting decision makers in allocating resources for dengue intervention programs.

Aedes aegypti, presented with a source of L-lactic and 2-ketoglutaric acid in a wind-tunnel bioassay, takeoff, fly upwind, and land on the blend at rates comparable those exhibited by mosquitoes presented with a skin odor stimulus. Addition of carbon dioxide decreased takeoff latency but was not required to elicit upwind flight nor landings. Ketoglutaric acid, a recently identified component of human skin odor, combined with lactic acid elicits the full repertoire of mosquito host-seeking behaviors.

The "Magude project" aimed but failed to interrupt local malaria transmission in Magude district, southern Mozambique, by using a comprehensive package of interventions, including indoor residual spraying (IRS), pyrethroid-only long-lasting insecticide treated nets (LLINs) and mass-drug administration (MDA). Here we present detailed information on the vector species that sustained malaria transmission, their association with malaria incidence and behaviors, and their amenability to the implemented control interventions. Mosquitoes were collected monthly between May 2015 and October 2017 in six sentinel sites in Magude district, using CDC light traps both indoors and outdoors. Anopheles arabiensis was the main vector during the project, while An. funestus s.s., An. merus, An. parensis and An. squamosus likely played a secondary role. The latter two species have never previously been found positive for Plasmodium falciparum in southern Mozambique. The intervention package successfully reduced vector sporozoite rates in all species throughout the project. IRS was effective in controlling An. funestus s.s. and An. parensis, which virtually disappeared after its first implementation, but less effective at controlling An. arabiensis. Despite suboptimal use, LLINs likely provided significant protection against An. arabiensis and An. merus that sought their host largely indoors when people where in bed. Adding IRS on top of LLINs and MDA likely added value to the control of malaria vectors during the Magude project. Future malaria elimination attempts in the area could benefit from i) increasing the use of LLINs, ii) using longer-lasting IRS products to counteract the increase in vector densities observed towards the end of the high transmission season, and iii) a higher coverage with MDA to reduce the likelihood of human infection. However, additional interventions targeting vectors that survive IRS and LLINs b,y e.g. biting outdoors or indoors before people go to bed, will be likely needed to achieve local malaria elimination.

Efforts to achieve malaria elimination need to consider both falciparum and non-falciparum infections. The prevalence and geographic distribution of four Plasmodium species were determined by real-time PCR using dried blood spots collected during the 2017 School Malaria Parasitological Survey of eight regions of Tanzania. Among 3,456 schoolchildren, 22% had P. falciparum, 24% P. ovale spp., 4% P. malariae, and 0.3% P. vivax. Ninety-one percent of P. ovale infections had very low parasite densities, based on amplification at later cycle thresholds. Sixty-four percent of P. ovale infections were single-species, and 35% of these were detected in low malaria endemicity regions. P. malariae infections were predominantly co-infections with P. falciparum (73%). P. vivax was largely detected in northern and eastern regions. Overall, 43% of children with P. falciparum were co-infected with at least one non-falciparum species. A large, previously under-appreciated burden of P. ovale spp. infection exists among Tanzanian schoolchildren. Article SummaryA previously unrecognized burden of non-falciparum malaria infections was detected among Tanzanian schoolchildren in a 2017 cross-sectional study, with P. ovale spp. prevalence comparable to P. falciparum, and low-level prevalences of P. malariae and P. vivax detected.

Insect repellents are important prophylactic tools for travelers to and populations living in endemic areas of malaria, dengue, encephalitis, and other vector-borne diseases, and the first line of defense against emerging arboviruses. However, the cost of daily applications of even the most affordable and the gold standard of insect repellents, DEET, is still high for low-income populations where repellents are needed the most. An Indian clove-based homemade recipe has been presented as a panacea. We analyzed this homemade repellent and confirmed by behavioral measurements and odorant receptor responses that eugenol is the active ingredient in this formulation. Prepared as advertised, this homemade repellent is ineffective, whereas 5X more concentrated extracts from the brand most enriched in eugenol showed moderate repellency activity against Culex quinquefasciatus and Aedes aegypti. DEET showed higher performance when compared to the 5X concentrated formulation and is available in the same market at a lower price than the cost of the ingredients to prepare the homemade formulation.

BackgroundThe Community Access to Rectal Artesunate for Malaria project investigated the feasibility of introducing pre-referral rectal artesunate into existing community-based health services. In that study, the case fatality rate of children visiting primary health centres (PHCs) was 19% compared to 6% in children first visiting community health workers, locally called Community Oriented Resource Persons (CORPs). As case management practices did not fully explain this finding, this publication investigates other reasons underlying the observed difference in case fatality. MethodsThe observational study enrolled 589 children under the age of five years with fever and danger signs indicative of severe malaria attending CORPs and PHCs in Adamawa State, Nigeria, between June 2018 and July 2020. After 28 days, follow-up visits were conducted with caregivers to understand background characteristics, severity of symptoms, home treatment administration, and treatment seeking practices during the childs illness. These factors were compared between children visiting CORPs versus those visiting PHCs as their first health provider. ResultsChildren visiting PHCs were more likely to display danger signs indicative of central nervous system involvement (90% vs. 74%, p < 0.01) and have four or more danger signs (50% vs. 39%, p = 0.02). The delay between illness onset and visiting the community-based provider did not differ between children attending a CORP and children attending a PHC. PHC attendances more often lived in urban areas (16% vs 4%, p=0.01) and travelled farther to their first health provider, which was usually a community-based provider. Although practicing home treatment was common, especially among children attending PHCs (42% vs 33%, p=0.04), almost none of the children were given an antimalarial. PHCs were visited for their professionalism and experience while CORPs were visited for their low cost and because caregivers personally knew and trusted the provider. ConclusionsOur comparison of children with suspected severe malaria seeking care from two kinds of community-based health care providers in Nigeria suggest that illness severity may be the primary driver behind the observed difference in case fatality rate.

Histidine-rich protein 2- (HRP2-) based rapid diagnostic tests (RDTs) are widely used to detect Plasmodium falciparum in sub-Saharan Africa. Reports of parasites with pfhrp2 and/or pfhrp3 (pfhrp2/3) gene deletions in Africa raise concerns about the long-term viability of HRP2-based RDTs. We evaluated changes in pfhrp2/3 deletion prevalence over time using a 2018-2021 longitudinal study of 1,635 enrolled individuals in Kinshasa Province, Democratic Republic of the Congo (DRC). Samples collected during biannual household visits with [&ge;] 100 parasites/L by quantitative real-time PCR were genotyped using a multiplex real-time PCR assay. Among 2,726 P. falciparum PCR-positive samples collected from 993 participants during the study period, 1,267 (46.5%) were genotyped. No pfhrp2/3 deletions or mixed pfhrp2/3-intact and -deleted infections were identified in our study. Pfhrp2/3-deleted parasites were not detected in Kinshasa Province; ongoing use of HRP2-based RDTs is appropriate.

IntroductionFalciparum is the major contributor to malaria and causes the most lethal disease in humans globally. Although several government-funded interventions exist to help eliminate malaria, the disease persists and continues to afflict Ghanaians of all ages, including children, pregnant mothers, and adults. MethodsThis single-facility retrospective study was carried out at Sunyani Municipal Hospital. Patients malaria records spanning December 2020 and November 2021 were collected, analyzed, and visualized using IBM SPSS and GraphPad Prism. Proportions, associations, odds ratios, confidence intervals, and effect sizes were determined. ResultsPrevalence of malaria was 11.9%, with increased burden in males (14.5%), children 5-17 years (19.7%), pregnant women (17.2%), and in the rainy season (13.0%). Male sex (OR: 1.440, p<0.001), ages 5-17 years (OR: 2.538, p<0.001), <5 years (OR: 1.471, p<0.001), pregnancy (OR: 1.559, p=0.003), and rainy (OR: 1.251, p<0.001) were significant risk factors for falciparum malaria. Also, 78.2% (p<0.001) of cases were from the OPD irrespective of season (rainy [79.2%, p<0.045]; dry [76.8%, p<0.001]). Malaria was high in males in rainy (15.3%, p<0.001) and dry seasons (13.6%, p<0.001). Rainy (r=0.111) and dry seasons (r=0.115) showed a weak positive association with malaria. ConclusionPfHRP2 antigen positivity was associated with sex, age, patient type, and season, with increased prevalence in males, children 5-17 years, pregnancy, and the rainy season. Age showed a weak positive association with PfHRP2 antigen positivity, whereas sex, patient type, and season showed negligible effects. Male sex, children 5-17 years, <5 years, pregnancy, and rainy season were risk factors for falciparum malaria. Malaria was associated with the source of laboratory request, with the bulk of the malaria cases reported among OPD patients, regardless of season. Rainy and dry seasons showed a weak positive association with malaria when stratified by age.

BackgroundIdentifying effective malaria elimination strategies for remote forested regions in Southeast Asia is challenging given limited resources. In this study, two malaria elimination strategies were evaluated in partnership with the Royal Cambodian Armed Forces - monthly malaria prophylaxis (MMP) and focused screening and treatment (FSAT). MethodsEight primarily military clusters (1,050 volunteers total) along the Cambodian-Thai border were randomized to 3 months of MMP or FSAT with monthly malaria testing by RDT, PCR, and microscopy for six months. Clusters were sub-randomized to permethrin treated (ITU) or sham water-treated clothing (sITU). Volunteers in MMP clusters were given three full monthly dihydroartemisinin-piperaquine (DP) treatment courses with 12 weekly 22.5mg primaquine. Volunteers in FSAT clusters were treated with appropriate first-line antimalarials if malaria-positive by microscopy or PCR. ResultsPf positivity in MMP clusters was reduced by 90% (10% at enrollment to 1% at 6 months; absolute risk reduction (ARR) 9%) at 6 months. However, 32% of Pf cases treated with DP as MMP at baseline recrudesced, requiring rescue treatment at 1 month with artesunate-mefloquine. Pf positivity in FSAT clusters declined 66% over 6 months (7.6% to 2.7%; ARR 4.9%). MMP reduced Pv positivity from 9% to 0% at 3 months, but Pv rebounded to 6.7% at 6 months. FSAT failed to significantly reduce Pv positivity during the study. The 22.5mg weekly primaquine MMP regimen was safe, even for the 15% of volunteers with G6PD-deficiency. Those wearing ITU had additional Pv parasitemia reductions compared to sITU in the FSAT but not MMP groups. PCR was more sensitive than microscopy and RDT for detecting both species. ConclusionsMMP was safe, and superior to FSAT to reduce Pf and Pv, suggesting greater utility to achieve malaria elimination in Cambodia. Low dose (22.5mg) weekly primaquine was a safe adjunct in this setting, even for those with G6PD-deficiency. Permethrin-treated clothing further reduced Pv parasitemia for FSAT but not MMP. MMP may be more easily scaled to eliminate malaria. The military may provide substantial support for regional elimination efforts.

Mobile poultry vending and slaughtering of sick poultry have been linked to the spread of highly pathogenic avian influenza (HPAI) H5N1 in Bangladesh. However, limited data exist on associated practices and potential interventions to improve biosecurity among mobile poultry vendors. This mixed-method study was conducted in three phases across four sub-districts in Bangladesh. In phase 1, researchers conducted 416 hours of structured observation, 40 in-depth interviews with poultry vendors, and 40 informal interviews with the customers. Phase 2 involved the development and pilot testing of an intervention package, which included poultry slaughtering cones, hand sanitizers, disinfectants, and a hygiene pamphlet, with 10 vendors. Phase 3 implemented the full intervention with 20 vendors, followed by 94 hours of observation and 17 customer interviews. At baseline, vendors sourced poultry from multiple locations, kept them in small cages on rickshaw vans, and slaughtered them in open spaces, drains, or near water sources. Waste was often discarded in the environment or fed to animals. Vendors demonstrated limited hygiene knowledge and were not observed using personal protective equipment, soap, or disinfectants. Post-intervention, vendors adopted improved practices such as using killing cones, containing waste, disinfecting the slaughtering area, and cleaning hands before eating. Customers also viewed the intervention positively. The study highlights significant risks of AIV transmission through mobile poultry vending but demonstrates that low-cost, targeted interventions can enhance hygiene and biosecurity. Further research is needed to assess long-term sustainability and scalability.

Laboratory confirmation of infection is an essential component of measles surveillance. Detection of measles specific IgM in serum by enzyme linked immunosorbent assay (ELISA) is the most used method for confirming measles infection. ELISA formats vary as does the sensitivity and specificity of each assay. Specimens collected within 3 days of rash onset can yield a false negative result, which can delay confirmation of measles cases. Interfering substances can yield a false positive result, leading to unnecessary public health interventions. The IgM capture assay developed at the Centers for Disease Control (CDC) was compared against 5 commercially available ELISA kits for the ability to detect measles virus-specific IgM in a panel of 90 well-characterized specimens. Serum samples were tested in triplicate using each commercial kit as recommended by the manufacturer. Using the CDC measles IgM capture assay as the reference test; sensitivity and specificity for the commercial kits ranged from 50 to 83% and 86.9 to 98%, respectively. Discrepant results were observed for samples tested with all five commercial kits and ranged from 13.8 to 28.8% of the specimens tested. False positive results occurred in 2.0 to 13.1% of sera while negative results were observed in 16.7 to 50% of sera that were positive by the CDC measles IgM capture assay. Evaluation and interpretation of measles IgM serologic results can be complex, particularly in measles elimination settings. The performance characteristics of a measles IgM assay should be carefully considered when selecting an assay to achieve high quality measles surveillance.

In Cameroon, recent studies have documented several cases of dengue infection in some urban areas, but dengue-malaria coinfection malaria was little investigated, especially in the East region. From the 6th July to the 4th September 2020, a case-control study including 50 cases (malaria-positive subjects) and 90 controls (non-malaria subjects) was carried out at the Bertoua Regional Hospital. Participants were prospectively enrolled and administered with a questionnaire to record information such as age, sex, dwelling place, dengue knowledge, and the environments quality. Blood specimens were then collected and screened for dengue infection using the NS1/IgG/IgM rapid diagnostic tests and hematological parameters were measured using a MINDRAY-type hemacytometer. Of the malaria patients, 14% (7/50) were tested positive for dengue fever against 66.66% for the controls (60/90). Most malaria patients had a secondary dengue infection (57.14%, 4/7) while most of the non-malaria patients faced a primary infection (61.66%, 37/60). In both groups, women were more exposed than men to dengue and there was a significant association between the dwelling place and dengue seropositivity. Moreover, young subjects <16 years old were significantly more associated with dengue than 16-30 years old (OR=16.24, P=0.042 for cases vs, OR=21, P=0.0001 for controls). The analysis of hematological parameters showed a significant decrease (P<0.001) in platelets in cases compared to control. These results suggest that dengue fewer targets malaria- than non- malaria patients with different serological characteristics in Bertoua city. However, co-infected patients demonstrated a greater clinical vulnerability than monoinfected patients, urging the need for epidemiological surveillance.

Diarrhea is the third leading cause of malnutrition and mortality in children under five globally. However, a few studies have examined predictors of child diarrheal disease in arid or semi-arid regions of sub-Saharan Africa. This study aimed to assess the prevalence and risk factors of diarrhea among children under five in the drylands of Northern Kenya. Data are from a longitudinal, population-based study of children younger than 36 months at recruitment (N = 1,211) and their caregivers in Turkana County, Kenya. Households were followed from May 2021 to September 2023, with survey data collected every four months across six waves. Caregivers reported on household conditions and observed episodes of diarrhea among index children in the two weeks before the survey. Trends in the prevalence of diarrhea were stratified by administrative zone, livelihood zone, and child sex. Risk factors of child diarrhea across survey waves were identified using multivariable generalized estimating equations. Diarrhea prevalence decreased from 32.1% [95% confidence interval (CI): 28.3%-36.1%] at Wave 1 to 8.7% (95% CI: 6.3%-11.7%) at Wave 6. Risk factors for diarrhea included caregivers alcohol consumption [adjusted odds ratio (AOR) = 1.30; 95% CI: 1.04-1.62], households experiencing three (AOR = 1.78; 95% CI: 1.29-2.45) or four (AOR = 2.58; 95% CI: 1.86-3.58) climatic, biological, economic or conflict shocks in the prior 4 months compared to those experiencing less than 2 shocks, households with moderate (AOR = 1.25; 95% CI: 1.04-1.50) or high (AOR = 1.50; 95% CI: 1.22-1.85) water insecurity in the prior 4 weeks compared to those with no-to-marginal water insecurity, and child wasting (AOR = 1.22; 95% CI: 1.05-1.41). These findings suggest that multisectoral interventions that reduce alcohol consumption among women, improve access to safe water services, manage malnutrition, and mitigate household shocks could reduce the burden of diarrhea among child under five in this region.

Measurement of glucose-6-phosphate dehydrogenase (G6PD) activity guides hypnozoitocidal treatment of P. vivax malaria. The G6PD Standard (SDBiosensor, Republic of Korea) here referred to as "Biosensor" is a quantitative point-of-care diagnostic that measures G6PD activity in U/gHb . The manufacturer recommends cutoffs to define G6PD deficient ([&le;]4.0U/gHb), intermediate (4.1-[&le;]6.0U/gHb) and normal (>6.0U/gHb) individuals. The aim of this individual patient data (IPD) meta- analysis was to evaluate these cutoffs (CRD42023406595). A systematic review identified studies reporting population-level G6PD activity measured by Biosensor, published between January 2017 and May 2023. IPD were collated and standardised. The adjusted male median (AMM) was defined as 100% activity and calculated across all studies (universal AMM) and separately for each setting. The proportion of participants classified as deficient or intermediate were compared using the manufacturer-recommended cutoffs and 30% and 70% of the universal AMM and setting-specific AMM. Associations between G6PD activity and blood sampling method, malaria status, and age were assessed. Eleven studies with 9,724 participants from eight countries were included in this analysis. The universal AMM was 7.7U/gHb and the setting-specific AMMs ranged from 6.2U/gHb to 9.9U/gHb. When using the universal AMM, 4.2% of participants were classified as deficient and 11.9% as intermediate or deficient. The corresponding values were 3.9% and 10.8% for setting-specific cutoffs, and 7.2% and 18.3% for manufacturer-recommended definitions for deficients and intermediates respectively. The manufacturer-recommended cutoff for deficient individuals fitted the distribution of G6PD activities better than definitions based on the percentage of AMM. There was no significant association between malaria status or blood sampling method and G6PD activity. Measured G6PD activity decreased in children 1 to 5 years and plateaued thereafter. The manufacturers recommended cutoff is conservative but more reliable at categorising G6PD deficient individuals than those based on calculations of 30% activity using the AMM. The observed decrease in G6PD activity in children between 1 to 5 years of age warrants further investigation.

BackgroundIncomplete antimalarial medication and insufficient patient follow-up, particularly among migrant labourers and destitute inpatients, pose significant challenges to malaria treatment and hinder elimination efforts in India. Patients who escape from hospitals during intermittent treatment or fail to receive medication despite tested positive for malaria parasites (MP) contribute to transmission, antimalarial resistance, genetic mutations, recurrent malaria, early treatment failure (ETF) and late treatment failure (LTF). MethodsA clinical case study was conducted at Wenlock District Government Hospital, Mangalore, India, from 2002 to 2022. Suspected malaria cases were confirmed using symptomatic clinical features and microscopic examination of peripheral blood smears. Clinical parameters were monitored and a second smear was taken on day 7 to assess drug response and treatment efficacy. AI-driven tools analysed 21 years of malaria cases including heatmaps of Plasmodium species correlations, peak malaria incidences by month and year and visualization of year-wise infections, medication status and follow-up rates using Python, Plotly and R Studio. FindingsAmong 317,210 suspected malaria patients 77,995 (24.58%) were microscopy-confirmed cases: Plasmodium vivax (P.v) (72.52%), Plasmodium falciparum (P.f) (24.78%) and mixed infections (2.67%). Out of these, 99.22% received treatment, while 0.77% did not take medication despite tested positive. Follow-up rates on day 7 were low (12.48%), highlighting a significant gap in post-treatment monitor. Hypertension was observed in 39.60% of malaria patients with mixed infections exhibits the highest prevalence 98.32%, followed by P. falciparum 75.54% and P. vivax 25.16%. Notably, mixed infections are associated with severe clinical outcomes. Parasitaemia levels were highest in P. falciparum (1,668,824/{micro}l), followed by mixed infections (78,986/{micro}l) and P. vivax (56,694/{micro}l). Over the study period, P. vivax incidence rose from 53.39% in 2005 to 86.95% in 2022, while P. falciparum infections declined from 45.15% in 2005 to 10.81% in 2016, reflecting advancements in malaria control measures. InterpretationDeficient treatment completion and insufficient follow-up significantly hinder malaria control in India. Strengthen patient tracking mechanisms and ensuring medication adherence, especially among vulnerable populations are crucial to reduce malaria recurrence and prevent resistance. The decline trend in P. falciparum infections underscores progress in control efforts, but the rising incidence of P. vivax and mixed infections warrants further investigation and targeted interventions.