We examine MalariaWorld and other sources each week looking for interesting studies, especially those that look at the effect of poverty, nutrition, water quality and sanitation on the occurrence and severity of malaria. So  we were drawn to ‘Socioeconomic and household water management determinants of malaria and other vector-borne disease prevention in Urban Gujarat, India’ by Batheja et al in this week’s MalariaWorld.

However the abstract reveals that nothing useful was found in the study, a socioeconomic and health survey in the cities of Ahmedabad and Surat, India, between September and November 2023. Data were collected from 4,074 households, comprising 15,484 individuals, and associations were examined between socioeconomic indicators, water availability, storage practices, and mosquito-borne disease incidence and prevention behaviours. Logistic regressions were used to identify significant predictors.

They found that self-reported disease prevalence was low, with 77 cases of malaria, dengue, and chikungunya, equivalent to 18.90 cases per 1,000 households. Socioeconomic factors such as wealth, caste, and family size were significantly associated with disease reporting and prevention practices. Households in the richest wealth quintile were more likely to adopt prevention measures, but less likely to perceive mosquito-related risks. Water management practices, particularly storage in clean large containers, were associated with increased disease symptoms and prevention measures, highlighting the complexity of vector control. Households with impermeable storage containers reported reduced use of active prevention measures.

They concluded that socioeconomic disparities and water management practices significantly influence malaria incidence and prevention behaviours. Targeted interventions prioritizing disadvantaged households, improved water storage practices, and enhanced investments in preventive care are essential to reduce vector-borne disease vulnerability and accelerate India’s malaria elimination goals.

What a huge nothing burger! Malaria was reported for just 0.40% of study participants. This is very low compared to incidence of 61% in Bas-Uele province of DRC reported last week. Obviously, with such a low incidence it is impossible to draw any statistically significant conclusions from the data. The results reported relate more so to behaviours to prevent these supposedly mosquito transmitted ailments.

If this is the most relevant study the researchers could conduct, can we deduce that in common with much of the rest of Asia, malaria is ceasing to be a major health problem in India?

Two studies in MalariaWorld this week, in Congo and Ghana, clearly suggest that poverty is the key factor linked to the occurrence of malaria in children < 5 years. And Klu et al in the Ghana study interestingly found that children who did not sleep under ITNs had lower odds of malaria (aOR = 0.52) compared to those who did. And drinking untreated water (aOR = 0.47) was associated with lower malaria risk.

‘Prevalence and factors associated with malaria among children aged 6–59 months in the Democratic Republic of the Congo: a nationwide cross-sectional survey’ by Adam et al in Malaria Journal studied a weighted sample of 10,013 children aged 6–59 months who underwent a malaria rapid diagnostic test, drawn from the 2023/24 DRC Demographic and Health Survey. It found an overall prevalence of malaria among children aged 6–59 months in the DRC was 33%, varying significantly between provinces, from 5% in Kinshasa to 61% in Bas-Uele province. Factors associated with malaria in this age group included children of mothers with no education (APR = 1.15) and those with primary education (APR = 1.13), children from the poor wealth quintile (APR = 1.52) and the middle wealth quintile (APR = 1.42), children who never slept under an insecticide-treated net (ITN) (APR = 1.18), children from households without a television (APR = 1.73), and those living in houses with unimproved floor material (APR = 1.54) or unimproved roof material (APR = 1.27).

These factors clearly show the influence of poverty. Capital residents are wealthier, as are those with more education and those who can afford televisions and improved floor and roof materials. The authors make a big deal of the ITN results, but the 1.18 improvement is much less than 1.73 for televisions. I expect if malaria researchers could link televisions to mosquito elimination, they would be proposing TVs as a solution!

And this result is contradicted in ‘Household characteristics, water, sanitation and hygiene (WASH) and malaria prevalence among children aged 6–59 months in Ghana: an analysis of the 2022 Ghana Demographic and Health Survey’ by Klu et al also published in Malaria Journal. The study analyzed data from the 2022 Ghana Demographic and Health Survey (GDHS), using a weighted sample of 3,255 households with children aged 6–59 months. Malaria testing was performed with rapid diagnostic tests (RDTs).

The prevalence of malaria among children aged 6–59 months was much lower (3.7%). Insecticide-treated net (ITN) ownership was high (78.9%), but only 51.5% of children slept under ITNs. Approximately 41.5% of children were anaemic. In multivariate analysis, children in households headed by persons aged 40–59 years had lower odds of malaria compared to those in households headed by persons aged 70+. Children from wealthier households had significantly lower odds of malaria (aOR = 0.15). Unexpectedly, children who did not sleep under ITNs had lower odds of malaria (aOR = 0.52) compared to those who did. Anaemic children had more than twice the odds of malaria (aOR = 2.03) showing important of nutrition. Drinking untreated water (aOR = 0.47) and improved sanitation (aOR = 0.59) were associated with lower malaria risk, whereas having toilets located outside (aOR = 16.64) the dwelling was associated with higher odds of malaria.

Sanitation, nutrition and wealth are clearly important and the authors emphasise the need for targeted interventions in households with lower wealth and inadequate sanitation. They also, curiously, promote ITN distributions despite their finding.

(picture from ubongo.org)

This week our attention was drawn to a tweet by Kenyan lawyer and politician Paul Muite (@Paul_Muite) accusing the Gates Foundation of releasing genetically modified mosquitos in Nairobi. The claim was debunked by Gates foundation supposedly stating “We do not release mosquitoes, operate laboratories that do so, or run vector-control activities in Nairobi or anywhere else.” However, the referenced press release is not available on their website.

Despite this the controversy rumbles on. On February 12 an article in The Standard reports that advocates want to know the truth about GMO mosquitos in Nairobi. They want to see all documents related to Muite’s claim. This indicates that many Kenyans are uncomfortable with novel research malaria carried out by international organisations.

However, the Kenya government, along with many other African governments are supportive of new technology efforts. Another article today ‘Prof Faith Osier: The Kenyan scientist bringing vaccine manufacturing closer home’  promotes the malaria vaccines whose underwhelming nature we frequently discuss. They plan to start manufacturing in Kenya, although the article does not specify which vaccine. Dr Osier discusses mRNA vaccines whose use is very controversial as a result of the side-effects of the COVID ‘vaccines’.

Kenyan publication Daily Nation reported on August 20, 2025 about Gates’ plans to release genetically modified mosquitos in Tanzania in 2029, ‘Gene drive mosquitoes’ set for 2029 release to fight malaria in East Africa. This was addressed in this column in December 2025,  Innovative Bug Hunting in Tanzania. We have addressed gene drive mosquitos, especially in Burkina Faso here on August16, 2025, August 29, 2025 and August 18, 2024.

Daily Nation reported On February 11 about the suspected increase in mosquito numbers in Nairobi  ‘The buzzing crisis: Why mosquito numbers are rising’. Dr Eric Ochomo, an entomologist at KEMRI (Kenya Medical Research Institute) says they have noticed an increase in mosquito numbers but they are Aedes and Culex species, not Anopheles, the supposed malaria vector. He blamed the increase on increasing temperatures.

The gene drive mosquito controversy suggests that Africans are becoming more suspicious of technological solutions western organisations are introducing to the continent.

MalariaWorld this week reports a study ‘Determinants of malaria infection across different districts of Khyber Pakhtunkhwa, Pakistan: a cross-sectional study’ by Haq et al.  The study highlights the multifactorial nature of malaria transmission in KP, Pakistan, with strong associations found between malaria infection and various determinants. Key risk factors identified include younger age, male gender, low educational attainment, low household income, large family size, distance from health facilities, poor housing construction, and lack of modern sanitation.

The study did find that preventive measures such as bed net use showed significance in bivariate analysis, but their independent effect was not retained in the final model. This is because it is often confounded with other factors related to poverty. The authors recommend comprehensive interventions beyond individual behaviour change. Policymakers and public health authorities should use these findings to inform district-level malaria control strategies, focusing on education, improved housing, access to healthcare, and sanitation.

Missing is any reference to nutrition despite the fact that the main author is in Department of Clinical Nutrition at the College of Applied Medical Sciences, King Faisal University, Al Ahsa, Saudi Arabia. And throughout there are several references to how the factors might be related to more or fewer mosquito bite opportunities.

However, the clear message of this study is that factors related to poverty – income, housing quality, quality of sanitation, and level of education are linked to greater occurrence of malaria.

This weekly column will also be promulgated on Facebook from now on in addition to usmalaria website, X and LinkedIn. Understanding Malaria has been established as a non-profit organization to raise money to fund research on malaria with emphasis on how the occurrence and severity of malaria can be reduced by improvements in nutrition and drinking water quality. Its main goal is to expand knowledge to reduce the burden of the disease particularly in Africa. I invite you all to assist.

In my LinkedIn feed this week there was a posting by Nigerian pharmacy assistant Precious Ugwa about undiagnosed customers requesting malaria treatments. This reminded me of the impression I got in Kenya that when people are ill, the first illness they suspect is malaria. One time when I was unwell my friend was encouraging me to go to a hospital. I refused to go immediately, but did agree to go in a day or two if my health did not improve. I fasted and drank plenty of water and quickly recovered.

If I had gone to the hospital, no matter what the symptoms were, I know the first thing I would be tested for is malaria. Possibly by a microscopic examination of my blood, but more likely using a RDT (rapid diagnostic test). And the result would a lottery, not unlike the COVID19 testing that was so common in 2020. I did not think that a course of artesunate injections and a follow up course of tablets, probably another artemisinin combination therapy was going to do anything good for me.

It struck me that in countries with malaria, many people think of malaria in the same way as ‘the flu’, ‘a bug’, ‘a virus’, (or COVID19 in 2020-2022), are thought of in western countries. And many people suffering from such a self-diagnosed malady will go to a pharmacy to buy various treatments. In many cases they will try their best to get anti-biotics, convinced that these potent pills are needed for their condition even though doctors will always say they don’t work on viruses.

Of course, it is doubtful that any of these treatments will cure their illness, but the power of the placebo effect and suppression of symptoms may convince them that it has.

Illness is nearly always caused by lifestyle factors. Malnutrition, both lack of food and too much of the wrong foods and drinks, lack of sleep, lack of sunshine and fresh air, stress from workplace and personal problems. People get generic symptoms – fever, headaches, other pains and aches, vomiting, diarrhoea, tiredness, etc, and are convinced that they caught a bug or malaria. Perhaps a test will confirm this diagnosis.

But the best cure is to get rid of whatever lifestyle factor caused the issue in the first place. Fasting and water are good for too much of the wrong food. Rest and relaxation will help in most cases. Unfortunately, most serious malaria cases are malnourished and may not have access to safe water. Their serious illness is a result of their poverty so a quick cure is less likely.

In MalariaWorld this week there is a link to CBC Youtube Video entitled ‘Malaria vaccine rollout undercut by losses to global health funding’. The highlight of the video is a recent study that found that children who received three doses of Mosquirix™ (RTS,S/AS01) manufactured by GSK (Glaxo Smith Kline) were less likely to suffer from severe malaria.

The study ‘Effectiveness of the RTS,S/AS01(E) malaria vaccine in a real-world setting over 1 year of follow-up after the three-dose primary schedule: an interim analysis of a phase 4 study in Ghana, Kenya, and Malawi’ by Ndeketa et al was featured on MalariaWorld. It was published in Lancet in November 2025 and is also available to download there.

The headline results of this GSK sponsored study are that comparing vaccinated children from exposed clusters with unvaccinated children from unexposed clusters, country-adjusted incidence rate ratios were 0·70 (95% CI 0·67–0·73; p<0·001) for any malaria, 0·42 (0·30–0·60; p<0·001) for severe malaria, 0·64 (0·56–0·72; p<0·001) for malaria-related hospitalisations, 0·79 (0·74–0·84; p<0·001) for all-cause hospitalisations, and 0·83 (0·64–1·09; p=0·18) for all-cause mortality. The adjusted odds ratio for the prevalence of anaemia among children who were hospitalised (vaccinated children from exposed clusters vs unvaccinated children from unexposed clusters) was 0·81 (95% CI 0·73–0·90; p<0·001).

I always understood that a vaccine was supposed to make if very unlikely one would get the target disease. This reported result states that a vaccine recipient is still 70% as likely to get the disease as one who doesn’t. Is this reduction worthwhile? Note that the all-cause mortality improvement is not statistically significant. This means that the study did not statistically prove that vaccine recipients were less likely to die.

But this is a study paid for by the manufacturer. And of course, their paid scribes ignore the statistical uncertainty and interpret thus ‘These findings reinforce the continued use of RTS,S/AS01E vaccination in children as an effective public health measure to reduce malaria-related illness and mortality in endemic regions’.

However, now after all the COVID vaccine controversies many of us are aware that vaccine studies are often manipulated to benefit the sponsor, and I suspect this study is no different. The usual approach is to selectively exclude inconvenient subjects from the study. In this 20% of the 22,564 subjects in the six vaccinated clusters were excluded from the follow up and 5% of the unvaccinated. Many of of the exclusions were because the subject had not received three doses. Perhaps many of these suffered adverse reactions after the first or second dose. These would have been many of the weaker children of this cohort and their exclusion could significantly skew the results.

A recent story in Techpoint Africa is a good example of how the scourge of malaria is used to justify new technologies. ‘Sora raises $2.5 million additional seed to eradicate malaria in Africa with AI-powered drones’ by Bolu Abiodun discusses the fundraising by Japanese start-up Sora Technology, that uses drones (see picture) and artificial intelligence to fight infectious diseases, mainly malaria.

Through its flagship initiative, SORA Malaria Control, the company combines satellite data, drones, and AI models to predict outbreaks, analyse environments, and deploy targeted vector control interventions. The company uses AI to find and map mosquito breeding sites while also ranking which ones pose the highest risk. It is active in many African nations including Ghana, Sierra Leone, Benin, the Democratic Republic of Congo, Senegal, Kenya, and Mozambique. The fresh capital will be used to advance Sora’s AI-powered disease prediction tools, team expansion, and strengthen partnerships with governments and international health institutions. Sora has partnered with the World Health Organisation to support sustainable malaria control efforts in Mozambique.

And this week in MalariaWorld there are descriptions of many other projects linking funding to malaria and novel research and technologies. There is research linking malaria vaccines to Parkinson’s disease progression, $7M Gates support of more vaccine development, in-silico studies of Plasmodia invading erythrocytes, Automated microscopy for malaria diagnosis in a reference laboratory in nonendemic settings, Housing modifications for heat adaptation, thermal comfort and malaria vector control in rural African settlements, as well as he usual drug testing and other research studies.

There is one study looking at nutrition. ‘Essential Trace Elements and Their Impact on Immune Response and Disease Severity in Malaria Infection: A Systematic Review’ by Hanifian et al found that across human and experimental studies, malaria infection was consistently associated with reduced serum concentrations of iron, zinc, and magnesium. The full study is behind a paywall but in the abstract it is stated that zinc supplementation improved micronutrient status but showed limited impact on malaria incidence. They also found that plasma levels of sodium, magnesium, calcium, and zinc were significantly reduced in malaria patients.

Malaria is a disease of poverty and it is clear that malnutrition plays an important role in its occurrence and severity. This, rather than novel technologies, is the area where research will have the greatest impact at actually reducing the burden of the illness.

In MalariaWorld this week there is reference to the major public health challenge of Malaria in sub-Saharan Africa, and how its burden may be influenced by access to clean water, sanitation, and childhood vitamin A supplementation. ‘Investigating the relationship between malaria incidence and public health infrastructure in sub-Saharan Africa’ by Shin is in publication by Malaria Journal. Country-level data from global health databases were analysed using nonparametric statistical tests and machine learning models to assess differences in malaria incidence across categories of water and sanitation access.

Significant differences in malaria incidence were found across water and sanitation access groups, with the lowest access groups consistently exhibiting the highest incidence. Vitamin A supplementation showed statistically significant group differences, though effect sizes were generally small.

The WHO/UNICEF Joint Monitoring Programme (JMP) for Water Supply, Sanitation and Hygiene. Two variables were used to represent water supply access: (1) safely managed water supply and (2) least basic water supply. Two variables were used to represent access to sanitation services: (1) safely managed sanitation services and (2) least basic sanitation services.

Safely managed water supply refers to drinking water from an improved source that is accessible on premises, available when needed, and free from faecal and priority chemical contamination. Examples include piped water, boreholes or tubewells, protected dug wells, protected springs, and packaged or delivered water. The least basic category also includes sources with collection times of no more than 30 minutes round-trip, focusing on accessibility.

Safely managed sanitation services include improved facilities not shared with other households and where excreta are safely disposed of or treated off-site. The least basic category also includes basic services (improved facilities not shared with other households but without requiring safe disposal of excreta).

The initial dataset included a comprehensive table of malaria incidence and predictor variables for sub-Saharan African countries over the 2014 2022 period. Malaria incidence was categorised as Rare, Moderate Low, Moderate High and High. The full detailed statistical analysis is in the paper.

The author concluded that access to clean water and adequate sanitation is strongly associated with lower malaria incidence, underscoring their importance in malaria control efforts. While vitamin A supplementation shows weaker associations, it may still interact with broader health conditions.

(image from dreamstime)

In MalariaWorld this week there is reference to a publication preprint in BMC Pediatrics ‘The double burden: co-occurrence of malaria and anaemia in children under five in Ghana – a multilevel mixed-effects logistic regression analysis’ by Karikari et al. The study utilised data from the 2022 Ghana Demographic and Health Survey to assess the co-occurrence of malaria and anaemia in young children and found a significant number (6.4%)  with the double burden of both conditions.

What is most notable is how serious a public health burden anaemia is – 49% of children under five in Ghana in the survey were found to be anaemic. Malaria was detected by microscopy in 8.1%. It is quite clear that the majority of these are also anaemic, those to whom the authors refer as double burdened.

It is quite clear from other results of the survey that this double burden is linked to poverty with the poorest households most likely to experience the double burden. However, this study and other studies report that prevalence of anaemia in Ghana and other African nations often exceeds 50% for this age cohort, e.g. 70.8% in Liberia and 72.9% in Mozambique. This clearly includes many more than the poorest children.

While the authors report that malaria occurrence has been falling it still seems to be linked to malnutrition. They recommend that anaemia be treated as a significant public health priority. They recommend interventions such as iron-folic acid supplementation, routine deworming, nutrition counselling, and screening for haemoglobinopathies.

It seems very clear from this and other studies that prioritizing improvements in nutrition for under fives other age groups is key to improving overall health. This will inevitably reduce and eventually eliminate the burden of malaria. I agree with the authors’ recommendation of education on basic nutrition.

Support to help people, especially the poorest, to obtain and eat better food is required most of all. Perhaps more people could be encouraged to raise chickens for eggs and meat. Such programs would have far more beneficial effects than the current medical intervention approach to malaria and other ailments of poverty and malnutrition.

In MalariaWorld this week there is a news story about an evolutionary model that examines the tradeoffs that limit harm caused by the malaria parasite. An article in phys org discusses the paper ‘Immunity can impose a reproduction–survival tradeoff on human malaria parasites’ by Patterson et al published in the journal, Evolution.

The long modelling article reaches the conclusion that pathogenic organisms themselves can be subject to a reproduction–survival tradeoff due to pressure from the immune system. This conclusion invites further examination of the germ theory/terrain theory debate from late 19^th century France between Louis Pasteur (died 1895 aged 72) and Antoine Béchamp (died 1908 aged 91).

Pasteur is regarded as one of the fathers of the germ theory of diseases and conducted experiments that demonstrated that diseases could be prevented by killing or stopping germs.

Béchamp contended that bacteria could not invade a healthy animal and cause disease. He claimed instead that unfavorable host and environmental conditions destabilize the host’s native microzymas (tiny enzymes) and decompose host tissue by producing pathogenic bacteria.

The medical establishment embraced germ theory and discredits alternative approaches. However, the concept of immunity had to be developed to explain why exposure to germs is not always a cause of illness.

Which brings us back to malaria. I have seen some lists that discuss parasitic illnesses and ignore malaria. Others include it and explain that the tiny protozoa, whose presence indicates malaria, is not a bacterium or virus.  

But are these protozoa the cause of illness or a reaction to illness? This in a nutshell is the essential germ theory/terrain theory debate applied to malaria. Proponents of terrain theory contend that the protozoa are present in most people. If they are healthy Protozoa are present in very low numbers and are not detectable by microscopy. But if they are in poor health due to poor nutrition or poisoning many cells die. These dead cells are then consumed by the protozoa, which multiply and become easily visible. They act as a cleanup crew to remove the dying cells. Malaria is an illness of poverty and its most seriously affects malnourished children in Africa.

If you are healthy you resist illness so exposure to microbes does not affect you. Even Pasteur on his death bed is supposed to have said “le terrain est tout, le microbe n’est rien” (The terrain is everything, the microbe is nothing).

Merry Christmas and a Happy and Prosperous New Year to all readers.

(Image of Protozoa from ‘Studi di uno zoologo sulla malaria’ by J Battista Grassi. Translation available on usmalaria website).