There is a very interesting study in MalariaWorld this week examining the link between malaria and malnutrition. ‘Malaria-malnutrition interaction: prevalence, risk factors, and­ the ­impact of intermittent preventive therapy for ­malaria on­ nutritional status of­ school-age children in Muheza, Tanga, Tanzania — A ­cross-sectional survey and ­a­ randomized controlled open-label trial’ by Hhera et al compared three groups of children over eight months.

Two groups of school age children were treated periodically (so-called intermittent preventative treatment, IPT) with ACT drugs (arteminin-based combination therapy), either dihydroartemisinin-piperaquine (DP) or Artesunate amodiaquine (ASAQ). The third group was a control group who only received so-called standard care drug (Artemether Lumefantrine) if they tested positive for malaria plasmodia.

The main outcome of the study was that during the intervention, change in mean weight, height, and BMI over time as estimated from age-treatment interaction was not significantly different in the DP and ASAQ treatment groups compared with the control group.

Malaria, malnutrition and poverty are connected. At baseline, the prevalence of malaria was 27%, 23% of children were underweight, 21% were stunted and 28% were either thin or severely thin. The odds of stunting were 78% higher among children who had malaria compared with those who did not have malaria. Children from low socioeconomic status (SES) had higher odds of being underweight compared with their high SES counterparts.

Digging deeper into the study found interesting nuggets of information. During trial, the average weight gains for the DP, ASAQ, and Standard Care treatment groups were 5.0 kg, 5.1 kg, and 5.2 kg, respectively. For the children’s height, the net gains were 6.0 cm, 6.1 cm, and 6.5 cm in the DP, ASAQ, and Standard Care treatment groups, respectively. It would seem that children who were not dosed with the IPT drugs grew more than those who were, even if not statistically significant. At visit 4 13.2% were stunted compared to 24.8% for DP group and 21.8% for ASAQ group. Control children were also less likely to be underweight or thin. They were more likely to test positive for malaria plasmodia. It makes one wonder how important this fact is.

The authors conclude that public health efforts should combine malaria control with nutrition programs, including community driven strategies to enhance sustainable nutrition education and access to adequate food at home and school. It is great to see some malaria researchers becoming aware of the importance of nutrition.

One of the most bizarre proposals for solving the problem of the malaria is the release of genetically modified mosquitos. This method was questioned in the lead article in MalariaWorld last week ‘Releasing Genetically Modified Mosquitoes in Burkina Faso is Dangerous’ that links to a discussion by a French journal of a publication by Ms. Irina Vekcha, Professor of Genetics at ENSA (University of Agriculture of Senegal), which highlights the dangers of gene drive experimentation, which is currently at the end of its second phase in Burkina Faso, before moving on to the third phase that involves the use of gene drive technology.

And this week an article in Azo Life Sciences, ‘Gene-Edited Mosquitoes Block Malaria Transmission’  discusses a paper in Nature, ‘Driving a protective allele of the mosquito FREP1 gene to combat malaria’ by Li et al.

I am sceptical. The plan reads like one hatched up by a megalomaniacal ‘Bond Villain’. And the funding by many people’s real-life personification of such a character, Bill Gates, in the Burkina Faso release fuels this notion.

However, even if malaria were transmitted by mosquitos, it is difficult to understand how the genetic modifications of mosquitos would be evolutionarily stable to be effective or even dangerous as Ms Vekcha fears. Mosquitos have evolved over hundreds of millions of years and the human addition of a chunk of genetic material to its DNA is not likely to result in a creature as evolved and suited to its environment as those in the wild. While Li et al’s idea of creating Anopheles stephensi that is genetically less likely to be infected with Plasmodium falciparum, is not as ridiculous as the older idea of releasing sterile male mosquitos, the progeny of such creatures will not survive as well as those evolved by old fashioned Darwinism.

It is an effective method for genetic engineering researchers like Li to receive funding from people with more money than sense. But is it dangerous as Vekcha fears? There is much discussion in the article of how unsuccessful trials have been. Previous experiments with GM in Burkina Faso, such as Bt cotton, ended in failure.

The major fear highlighted about the introduction of modified Anopheles gambiae by a team from Imperial College London, led by Andrea Crisanti, is that the only male offspring will lead to the elimination of the species. However, reading a discussion of the natural balance of numbers of males and females in any good book about evolution such as ‘The Selfish Gene’ by Richard Dawkins will soon remove that fear.

My most profound enlightenment during COVID came from reading the book Virus Mania by Englebrecht et al. It drew my attention to the work of Drs Sam and Mark Bailey, Mike Stone, Stefan Lanka and others. This broad topic is well covered by others more expert than me and outside the scope of my column.

But in common with malaria, some viral illnesses are associated with mosquitos and other biting insects. Dengue, Zika and West Nile virus are probably best known. Disease transmission by mosquito is questionable for two reasons – the small aliquot of infected material that could be spread by mosquito bites and the questionable infective nature of viruses themselves.

Two other diseases have been in the news over the last two weeks. Last week News-medical dot net published an ebook on infectious diseases that included an article on Oropouche virus, that is supposedly transmitted through bites from infected Culicoides paraensis biting midges and Culex quinquefasciatus mosquitos. Some of the common symptoms include fever, chills, headache, and myalgia that persist for two to seven days.

And this week BBC reported 7,000 cases of chikungunya virus in China. I previously described chikungunya, whose symptoms are fever and joint pain. This outbreak is being tackled by the Chinese authorities with similar enthusiasm they showed for the three years they tackled COVID. During COVID China implemented severe restrictions, including forcing people into quarantine camps and sealing residential buildings and whole neighbourhoods on short notice for days or even weeks.

In Foshan city, which has been hit the hardest, chikungunya patients must stay in hospital, in beds protected with mosquito nets. They can only be discharged after they test negative or at the end of a week-long stay.

12 other cities in the southern Guangdong province have reported infections. Nearly 3,000 cases were reported in the last week alone. Authorities have instructed residents to remove stagnant water in their homes, such as in flowerpots (see picture), coffee machines or spare bottles – and warned of fines up to 10,000 yuan ($1,400) if they don’t do this. They are also releasing giant “elephant mosquitos” that can devour smaller, chikungunya-spreading bugs; and an army of mosquito-eating fish. Last week, officials in Foshan released 5,000 of these larvae-eating fish into the city’s lakes. In parts of the city, they are even flying drones to detect sources of stagnant water.

Some people have compared these measures to those imposed during the pandemic, and questioned their necessity. This is especially so considering how dubious the link of chikungunya to mosquitos is.

Just two weeks after reporting that Ivermectin was not effective at preventing malaria, I am surprised to see the lead story in MalariaWorld this week is ‘New research supports ivermectin as an effective strategy to control malaria transmission’.

Ivermectin to Control Malaria —  A Cluster-Randomized Trial by Chaccour et al reports from a study in Kwale, Kenya that children 5 to 15 years of age living in an area with high coverage and use of bed nets, ivermectin, administered once a month for three consecutive months, resulted in a 26% lower incidence of malaria infection than albendazole.

So what is the major difference between the two studies, one of children up to 10 years in Burkina Faso and the other of children 5-15 in Kenya? … The control.

The study in Burkina Faso that did not show a significant effect used a placebo control (no effect) while this study carried out by ISGlobal of Barcelona used an ‘active’ control, another anti-parasitic drug called albendazole, which has side-effects. To quote the study ‘Albendazole, which does not have mosquitocidal properties, was used as an active control to provide these participants with the deworming benefit of ivermectin and to facilitate comparability.’

Dewormers are toxic drugs that poison parasites more that the host. They should not be taken unless one needs to. It continues to surprise me that ‘ethics committees’ approve studies without true placebo controls.

This study was approved by the Scientific and Ethics Review Unit of the Kenya Medical Research Institute, the Oxford Tropical Research Ethics Committee, the institutional review board of the Hospital Clinic of Barcelona, and the Research Ethics Review Committee of the World Health Organization.

And while the study noted that the cumulative rate of malaria infection measured using rapid diagnostic tests was 26% lower with ivermectin than albendazole, there were 65% more adverse events (6.19 vs 3.75 per 100). The authors state that there were no serious adverse effects from 56,000 treatments to justify a recommendation of mass treatment. If tested against a true placebo, would they have found a benefit?

Malaria is much less of an issue in Southern Africa than in my current abode in East Africa. But it was a trip to Botswana a few years ago that first drew my attention to this tropical malady. While my destination near Gaborone in the south was not on the malaria map, Kasane in the north and Zimbabwe, to which I intended to travel were. So my travel companion tasked me with getting malaria prophylactics.

My investigation raised my doubts about malaria transmission story and effectiveness of treatments, so I did not get anything. And we did not contract malaria! The East – South difference in the perception of malaria was confirmed after returning to Ireland when the blood transfusion service declined my donation for 12 months because I changed planes at Addis Ababa in Ethiopia!

But a news story in MalariaWorld this week reports increased malaria in Southern Africa. Africa CDC (Centres for disease control) reports that up to week 23, of 2025, Zimbabwe has reported 111,998 cases and 310 deaths (case fatality rate [CFR]: 0.27%) as compared to 29,031 cases with 49 deaths (CFR: 0.17%) in the same period in 2024. Botswana in same period has recorded 2,223 cases and 11 deaths, compared to 218 cases and no deaths in same period in 2024. Namibia also had a significant rise in malaria cases, with over 89,959 cases and 146 deaths reported since November 2024.

So why the increase which is a reverse of recent trends? Dr Memory Mapfumo, an epidemiologist at the Africa CDC blamed prolonged rains that fuelled mosquito breeding, and activities like gold panning, fishing and artisanal mining are exposing more individuals to risk, especially during peak mosquito activity hours. The belief in infectious disease including mosquito transmission of malaria is core belief of Africa CDC, like its well-known US namesake.

But what if malaria is caused by toxins? I wrote about connection to mining before, and last week visited an artisanal goldmine in Kenya that clearly exposes workers to additional health risks such as finely ground mineral material and various toxic chemicals.

Africa CDC reports low usage of mosquito nets, but this does not explain an increase in cases. Movement of people is also used as an explanation of increase, but it is not clear how. Flooding in Okavango (picture from my visit) increasing mosquito habitat was blamed for increase in Botswana. The possible effect of flooding on drinking water quality was not considered.

In Eswatini 20% of cases were among farmers, many involved in illegal farming activities. These farmers often work at night leaving them exposed to mosquito bites. Or is increase in illness influenced by the effects on health of a disrupted body clock?

It is important to be concerned about the increase of cases of malaria in Southern Africa. However, much as Africa CDC tries, it is difficult to explain the increase in case number by concentrating on the supposed link to mosquitos and ignoring other factors that affect health.

Ivermectin is an anti-parasite medication used to treat parasitic diseases, including parasitic worms, hookworm, whipworm, and external parasites and many others off label. Ivermectin works by paralyzing muscles in parasites, causing them to die. Since malaria is supposedly caused by a plasmodium parasite transmitted by mosquito bites, one might expect this powerful anti-parasitic medication to prevent malaria.

And indeed an article in this week’s MalariaWorld tests this hypothesis. ‘Safety and efficacy of repeat ivermectin mass drug administrations for malaria control (RIMDAMAL II): a phase 3, double-blind, placebo-controlled, cluster-randomised, parallel-group trial’ by Somé et al was published by The Lancet Infectious Diseases. Unfortunately, the full article is behind a paywall, but the summary does provide sufficient information for a preliminary examination and study details are available on clinicaltrials.

The study aimed to test the safety of repeated, high-dose ivermectin mass drug administration (MDA) and its efficacy for reducing malaria incidence among children when integrated with seasonal malaria chemoprevention (SMC) delivery. They provided background that previous studies had shown that ivermectin in the blood could kill mosquitos that fed on it.

They conducted a double-blind, placebo-controlled, trial in southwest Burkina Faso over two consecutive rainy seasons (2019–20). 14 villages were randomly assigned (1:1) to ivermectin or placebo MDA by random draw. Each rainy season, eligible participants from the intervention group clusters received monthly high-dose oral ivermectin MDA (three daily doses, approximately 300 μg/kg dosed by height bands) and those from the control group received monthly oral placebo MDA for up to eight treatment rounds. All participants and study personnel, apart from the pharmacist, were masked to group assignment. The primary outcome was weekly malaria incidence in children aged 10 years and younger, as assessed by weekly active case detection until week 16 of year 2, by intention to treat. Adverse events were monitored in all MDA participants through active and passive surveillance. Blood was sampled for secondary parasitological outcomes, including analysis of parasite species distribution among malaria cases. Mosquitos were sampled from pre-selected households in three clusters per group for secondary entomological outcomes, including analysis of blood-fed mosquito survivorship, mosquito biting rates, and entomological inoculation rates.

The average estimated weekly malaria incidence rate per 100 person-weeks among children in the test group was 1·78 (95% CI 1·24–2·53) and 1·84 (1·29–2·64) in the control group (statistically indistinguishable). The risk of adverse events was lower in test group (arthralgia and skin conditions higher in control group), but risk of death (0.27% vs 0.16%) and serious adverse events greater in test group (0.36% vs 0.31%). There was evidence of mosquito deaths in test group week after test but not three weeks later.

Repeated high-dose ivermectin MDA integrated with SMC distributions at the study site did not reduce malaria incidence among children relative to placebo.

The malaria community was abuzz this week with news of the approval of a drug to treat babies 2-5 kg for malaria. Swissmedic approved Riamet Baby (also known as Coartem baby), the first drug designed specifically to treat malaria in very young children. It is available as a dispersible, cherry-flavoured formulation to help improve administration. A friend alerted me to a BBC news article on July 8 that erroneously referred to it as a vaccine (since corrected). MalariaWorld has link to Novartis Press Release also.

It is a new reformulation of the well-established ACT (artemisinin combination therapy) artemether-lumefantrine. The current paediatric version (pictured) for children ≥5kg on the market, Coartem dispersible, has 20 mg of artemether and 120 mg of lumefantrine. Novartis is the only major producer of artemether-lumefantrine and will benefit for many years from intellectual property protection of this new formulation. I only found one generic version of this ACT, the Indian produced Falcynate LF 80/480mg tablets only suitable for people >35 kg.

Novartis have produced a very readable patient summary of the trial to approve the new formulation and a more detailed summary. The trial included just 28 babies (10 boys, 18 girls) in Burkina Faso (7) and DRC (21), 22 older than 1 month and 6 younger than 1 month who tested positive to malaria parasites whether symptomatic or not. The reason for the reformulation was that in a trial of young babies with 20/120 formulation artemether reached higher levels than expected while lumefantrine stayed at expected levels. Dosing was twice a day for three days by syringe of dispersed tablet in mouth after feeding. Blood was tested at intervals for artemether and lumefantrine. They were also retested for malaria parasites that cleared in 35 hours. Malaria recurred (or was reinfected) in 8/22 of the older babies. The formulation met its design goal and both actives were within expected limits during the trial.

75% (21/28) had adverse events (10 fever, 9 recurring malaria, 7 anaemia, 6 vomiting, 2 bacterial rhinitis). The researchers stated none died and there were no ‘serious adverse events’. However, there was no control. Only five of the babies had fever at the start of the trial and no other symptoms are mentioned. This suggests that the vast majority (82%, 23/28) were asymptomatic. But 75% became sick in some manner in the trial.

The study concludes that the safety profile was consistent with the safety profile of artemether and lumefantrine. Serious side effects include worsening malaria symptoms; severe vomiting, loss of appetite, or being unable to eat; fast or pounding heartbeats; a light-headed feeling, like you might pass out.

Hardly a game changer. Without a control the trial is nearly worthless.

In MalariaWorld this week the study ‘Knowledge, attitudes, and practices regarding malaria in rural Uganda: a cross-sectional study’ by Cathorall et al is featured. In four villages in rural Uganda 106 adults, heads of household, were questions about a variety of issues related to malaria and, in particular, bed net use.

The major findings from this study indicate high rates of net ownership and self-reported use within the rural areas. Perceived susceptibility and barriers were greater among those with a recent diagnosis of malaria within the household. The positive association remained significant after controlling for household size.

Net usage is reported as high. It is difficult to know if the respondents told the truth or what the researcher wanted to hear. However, for comfort why not sleep under a bed net if one is available? I know from experience living in Lodwar, Kenya, and often sleeping outside or with windows open because of the heat that accumulates in houses during the day, that mosquitos will bite exposed skin at night if not excluded by a net. And the bites are uncomfortable.

However, an observation in the study caught my attention. They stated ‘However, only 63 (60%) correctly identified that a mosquito bite was the only way to contract malaria’. I am tempted to ask the corresponding author how they ‘know that’, but I suspect this question is a question of faith analogous to asking a priest or Imam how he knows God exists.

What is curious is the other answers given to these questions by people who live with the disease, showing that some are not convinced by the mosquito tale of the educated westerners. In March 2025 I reported that Chinese expatriates are not convinced either. In the study 42% indicated factors like eating mangos, other foods or bad water as a cause of malaria. Even if they indicated mosquito bites as a risk, they were unsure of the actual route of transmission. The mango theory could be because malaria transmission is seasonal in this region, increasing at the end of the rainy season and coinciding with mango ripening.

The authors suggest that this knowledge gap must be addressed. In surveys in Guinea-Bissau (85%) and Eswatini (99.7%) higher levels of belief in the mosquito transmission hypothesis were measured. I would love to know how they try to convince people of the mosquito hypothesis. I have investigated this topic for years and have found no convincing evidence. Yes, mosquito bites are annoying and uncomfortable, but what is the actual evidence of disease transmission?

An architectural blog article referenced in MalariaWorld provides further support for the linkage of occurrence of malaria to the quality of housing to which I have frequently made reference.  ‘Can better housing help prevent malaria? The Star Homes Project in Sub-Saharan Africa’ by Lonati in designwanted.com describes a custom-built housing project in Mtwara region of Tanzania.

The project started in 2015 when the team noted that traditional rural houses in hot, humid Africa are often built in ways that inadvertently worsen health outcomes: thick walls trap heat, making it uncomfortable to sleep, and ground-level bedrooms and poor ventilation create ideal conditions for disease transmission. They observed that the typology of rural housing in hot-humid Asia differs significantly, despite being in the same climate zone. Houses are often light, air-permeable structures frequently made of bamboo, often on stilts. African houses have earth floor, wattle and daub walls, and thatched, or corrugated iron roofs.

They designed six house types clad in shadenet, timber and bamboo and chose a two-storey shadenet design (picture) which proved the most effective at reducing indoor heat and mosquito entry. However, not insignificantly it had additional features such as rainwater collection tanks, ventilated pit latrines, and washable surfaces to improve hygiene and reduce exposure to disease.

They constructed 110 units of the new Star homes in Mtwara and compared with 440 traditional houses in a study with households of three children to track malaria, respiratory diseases and diarrhoea for three years from 2021. The final report has not yet been published, and preliminary results suggest a 30–40% reduction in malaria among children living in the Star Homes, children under five have shown improved growth, and indoor mosquito abundance has decreased by 50%.

Naturally, much emphasis is placed on excluding mosquitos. The reduction was 50%. There is no doubt that it is more comfortable to sleep if not at risk of mosquito bites. But is the benefit the result of better sleep or less vector borne disease?

And perhaps the health benefit was the result of the other improvements – rainwater collection tanks, ventilated pit latrines, and washable surfaces. Many studies have shown that children who live in better houses are less affected by malaria.

Picture – Ingvartsen Architects © Julien Lanoo

Despite underwhelming performance (see my June 6, 2025 post) the malaria vaccines, that were tested against a rabies vaccine and not a true placebo (see February 8, 2025, December 22, 2024, August 11, 2024, & June 5, 2024) are being promoted heavily in malaria stricken areas, selling people hope that can not be backed by reliable, unbiased studies.

The lead blog in Malaria World this week is ‘How the malaria vaccine came to the world’s most mosquito-bitten district’, a discussion of how Gavi (vaccineswork) is rolling out R21/Matrix-M vaccine in the world’s most mosquito-bitten district, Apac in Uganda. Complete with a YouTube video the promotion is laden with false hope. Children are administered four does at 6, 7, 8, and 18 months), and Dr Odongo, the health officer for the region, stated “We wanted to get on top of any misinformation that could cause hesitancy, and encourage mothers to bring their eligible children for the vaccination”. And the campaign is succeeding with most of the mothers and community leaders in the district as enthusiastic about the vaccine as the health professionals and looking forward to the roll-out.

It reminds me of the enthusiasm in most countries in 2021 for the COVID19 vaccines, and we know how that panned out. They’re even describing it as a ‘magic bullet’. Minister of Health, Dr Jane Ruth Aceng, made the same argument during the April 2 launch. She said that the vaccine was expected to prevent at least 800 cases of severe malaria in children every day.

A research article in Malaria World, ‘Malaria vaccine acceptance and associated factors in Cameroon: A nationwide cross-sectional survey’ by Njoh et al discusses vaccine acceptance. Sadly, the full article is behind a paywall.  In summary, they found 91% malaria vaccine acceptance. This rate varied from 78% in the Littoral to 94% in the Far North and Southwest regions. Factors that favour vaccine acceptance include a history of severe malaria, awareness of the availability of the malaria vaccine for infants and working in the vaccination service. Elements reported for vaccine hesitancy include fear of unsafe and negative rumours about the vaccine.

The authors concluded that people in Cameroon are willing to get their children vaccinated against malaria. However, following regional acceptance disparities and identified hesitancy points, it is crucial to reinforce communication to address population groups, doubts, and rumours about vaccines to ensure optimal uptake in the country’s regions during the malaria vaccine rollout.

Tackling misinformation and disinformation. About what have we heard that lately? Will any of these promoters tell the truth about how the vaccines were tested and how much they, personally, are benefitting financially from the rollout?