WHO and other organisations promote the use of insecticide treated bednets (ITN) to prevent malaria. The use of nets is based on the hypothesis that malaria is spread by mosquito bites and nets prevent bites. Insecticide treated nets not only prevent a mosquito from biting someone sleeping underneath but also kill any insect that lands on them. WHO claim that if ITNs are in widespread use the reduction in insect numbers reduces overall malaria burden. I am unaware of any studies that prove this hypothesis.

However, an analysis in Malaria World this week on the 2019 Ghana Malaria Indicator Survey had a clue that sleeping under bednets has no benefit. ‘Malaria prevalence dynamics and risk covariates among children under 5 in Ghana: insights from a Bayesian multilevel approach’ by Asosega et al has several interesting findings. Children in wealthier homes are less likely to test positive for malaria than those with poor or middle incomes (P=0.24 vs 0.32). Children with severe anaemia (low iron) are more likely to test positive than those mild or not anaemic (P=0.54 vs 0.26). These data may suggest that children who are better fed are less likely to have malaria.

And there was no significant benefit associated with sleeping under an ITN (P=0.29 vs 0.30). In households that owned bednets there was slightly less malaria (P=0.29 vs 0.32) but this is not significant either. But most interesting of all was a reference in the discussion to ‘Factors associated with the risk of malaria among children: analysis of 2021 Nigeria Malaria Indicator Survey’ by Isiko et al published in April 2024 that found that having a bednet for sleeping under was positively associated with malaria incidence (P=0.1848 vs 0.1280). The authors explain the result by suggesting ‘… a potential over-reliance on ITNs as the sole preventive measure, neglecting other malaria prevention strategies’. Perhaps breathing air that has passed through an insecticide treated net is not healthful. Or perhaps it is just a random result?

There are a number of other interesting findings in this Nigeria study which concur with my earlier postings Occurrence of Malaria associated with Poverty – Tanzania Study and Study in Ghana Suggests Poverty is the Major Factor in Occurrence of Malaria. Higher malaria associated with other water source than improved source (P=0.2484 vs 0.1552), rudimentary wall than finished wall (P=0.2253 vs 0.1348), primary than secondary education of mother (P=0.1923 vs 0.1366) and lower wealth index poor (P=0.1870) vs rich (P=0.1315).

Also interesting is that children whose mothers had been exposed to malaria messaging within 6 months before the study showed a heightened risk of contracting malaria compared to those whose mothers hadn’t received such information (P=0.1875 vs 0.1487). How good is the messaging if it increases occurrence of the illness?

Picture from kesontechs.com

I am still unemployed in my search for engineering work. So, I am considering how I could find gainful employment exploiting my status as Planet Earth’s leading expert on the null hypothesis that mosquitos do not spread malaria. Direct research on the topic does not seem probable because all malaria funding is from businesses trying to sell cures or preventions. I expect the real cures and prevention are improved nutrition, clean water and improved sanitation. There are already strong health incentives to improve these in developing countries and adding malaria prevention and cure may not strengthen the case much. And the political strength of the medical lobby could harm these programs if they start to see them as a threat to their malaria cash cow.

Let’s consider the major costs of the ‘war on malaria’ – poisoning people and poisoning the environment. Potentially harmful and ineffective vaccines, prophylactics and other medications are the biggest harm, but I can see no gainful employment opportunities in tackling this head on.

Protecting the environment from poisoning is a better option. Killing mosquitos remains a major obsession of malaria researchers, e.g. in today’s Malaria World ‘Early evening outdoor biting by malaria-infected Anopheles arabiensis vectors threatens malaria elimination efforts in Zanzibar’.

Spreading insecticides to kill mosquitos has costs and negligible benefits. Rachel Carson’s ‘Silent Spring’ ignited the environmental movement in 1962 by highlighting the damage the insecticide DDT was doing to the environment. Unbelievably DDT is still used in malaria control programs in Africa with approval of the so-called World Health Organization.

But even if the insecticide does not create additional collateral damage up the food chain, it’s very purpose of killing insects can have a serious deleterious effect on the ecological balance. Insecticides kill other insects beside mosquitos that may be beneficial. And what most people fail to realise is that mosquitos themselves are pollinating insects. They feed on nectar from flowers, the same as honey bees. Only breeding females require blood meals to get additional protein for their eggs. Male mosquitos never bite.

We hear so often about the threat to pollinators from pesticides. Is this ever considered when anti-mosquito campaigns are launched? Perhaps there are opportunities protecting these essential insects. I will explore further.

I welcome your thoughts.

A study in Malaria World this week ‘Assessment of malaria treatment interventions: a critical analysis of government initiatives and causes of treatment failure at Port Loko Government Hospital, Sierra Leone’ by Sao Babawo et al has useful information on important factors for malaria occurrence and the ineffectiveness of the conventional treatments.

Healthcare workers and women of childbearing age were surveyed. The study assessed the effectiveness of government interventions such as the distribution of insecticide treated bed nets, indoor spraying with insecticides, and availability of anti-malarial drugs (ACTs). These interventions failed and authors blamed failure on the implementation or inconsistent supply.

(Or perhaps nets, insecticides and artemisinin based drugs are ineffective because the conventional understanding of malaria is incorrect?)

The most interesting observations came from the surveys of healthcare workers and of the women of childbearing age. The women considered the most important factors for malaria occurrence to be poor environmental sanitation (33.7%) and sub-standard housing (11.0%). Not sleeping under a bed net (6.7%) and lack of access and availability of health services (5.0%) were considered less important.

What is also interesting is the health worker survey in which 73.3% reported that malaria was the most prevailing medical condition affecting pregnant women who attend a clinic. Also reported are Iron deficiency at just 13.3%, Pre-eclampsia 4.3%, Typhoid 8.3%, Others 0.7%.

It seems to me that malaria is the name given the illness in these clinics when a patient is generally unwell with generic symptoms. In a country free of malaria perhaps influenza, COVID or ‘viral illness’ would be the diagnosis. This fits with my recent experience in Kenya when my friend with chest and stomach pains and no fever was diagnosed with malaria and treated with artesunate because of a positive test. It is not even clear if all the women attending clinics in this Sierre Leone study were tested because stock outs of RTDs were also reported.

At a social gathering in Nairobi this week the subject of Malaria prophylaxis was raised and I said nothing. And it bothers me. A European, who does not take anything to prevent malaria in Nairobi, asked some Kenyans about getting malaria tablets for a trip to Mozambique. They discussed that tablets could be obtained and even commented on how sick one gets from Malarone™ (GlaxoSmithKline atovaquone/proguanil HCl). The first line in medscape review is – In event of vomiting within 1 hour of dose, repeat dose!

And I said nothing. Why? I did not go to the gathering to discuss malaria. I am networking looking for engineering work in Nairobi. Was it cowardice – fear of discussing a controversial topic that may alienate potential clients? Or was I unprepared? I resolved to prepare a 30 second ‘elevator pitch’ on the topic. Afterall, it was the consideration of prophylaxis that started me on my journey studying malaria.

Or did I feel like an imposter? Wikipedia defines Impostor syndrome as a psychological experience in which a person suffers from feelings of intellectual and/or professional fraudulence. Being Irish what would I know about malaria?

But I have become the expert in this field in the world. I love the approach of Daniel Priestly, to become a KPI (Key Person of Influence) in your field.  While Daniel’s focus is on developing money making business, being the world’s leading expert on malnutrition as the major cause of malaria (and mosquitos and plasmodia not being a cause) is the opposite of a lucrative business opportunity. Selling drugs and insecticides to combat malaria, according to the conventional paradigm, is big business for Western, Indian and Chinese companies. Many researchers and medics are employed in malaria treatment and research.

As a mzungu (Swahili for white man) with a PhD and extensive medical industry experience I have credibility to question the narrative. The malaria transmission story was developed by other mzungu (Laveran, Ross, Grassi and others) against the instincts of many affected people. I am the first to translate Grassi’s work from Italian. I have written the most comprehensive book on the topic. I write a weekly blog on malaria research looking for clues for the malnutrition cause and obvious flaws in the conventional approach (this week GAVI are celebrating getting Ugandan minister to agree to vaccine roll-out).

I will not be dumbstruck on this topic again. I resolve to promote my understanding of malaria and the flaws of the conventional approach more strongly. At a later meeting this week I expounded my thoughts to a pharma industry person who asked me about my malaria research. I will make presentations for free to any gathering. I am a distinguished toastmaster and TED speaker and I guess I have found my vocation.

A few articles caught the eye in Malaria World this week. Firstly, the US FDA has placed a clinical hold on COVID vaccine maker, BioNTech’s early-to-mid stage trial of an experimental RNA malaria vaccine. Curiously, no reason was given for the hold on the Phase I/IIa study testing BNT165e in nearly 180 healthy and malaria-naïve adults to primarily assess the safety and tolerability of the experimental shot, while also looking for signs of efficacy and immunogenicity. 

Secondly, ‘Subnational tailoring of malaria interventions to prioritize the malaria response in Guinea’ by Diallo et al examined attitudes only to chemical interventions – Indoor Residual Spraying, IG2 insecticide treated bed nets (see picture), seasonal malaria chemoprevention, perennial malaria chemoprevention (also known as intermittent preventive treatment for infants) and RTS,S vaccine. Clearly, better food or water are not considered as potential factors at reducing malaria.

And finally this is spelt out very clearly in ‘Survey on knowledge, attitudes and practices (KAP) of malaria prevention and control among Chinese expatriates in South Sudan’ by Su et al. In the survey of Chinese workers in South Sudan 99.0% ‘know’ that female Anopheles mosquito bites can transmit malaria. However, the authors report that ‘some respondents (21.64%) erroneously believe that contaminated food and water sources can also transmit malaria’.

Later, they state that ‘53.23% of respondents mistakenly believed that attention to food and drinking water hygiene could prevent malaria’. I consider it very promising that a majority of Chinese workers (the vast majority in South Sudan for < 1year) realise that attention to food and water could prevent malaria, despite the attitude of the malaria researchers. The authors, without any cited evidence, dismiss the link to food and water with the words ‘erroneously’ and ‘mistakenly’.

To again quote Upton Sinclair “It is difficult to get a man to understand something, when his salary depends on his not understanding it.” And so long as malaria research is flooded with funding from producers of chemical solutions to poison mosquitos and people, the nutrition and water hygiene connection will be suppressed in peer reviewed research.

I continue my visit to Kenya (back in Nairobi) and by coincidence the most interesting article in Malaria World this week relates to Kenya and was carried out by researchers from KEMRI, whose meeting I reported recently. ‘Impact of Titanium Mining and Other Anthropogenic Activities on Malaria Positivity Rates and Parasitemia in Five Selected Study Sites in Msambweni Subcounty, Kwale County, Kenya’ by Githinji et al studies Plasmodium positivity by RTD and microscopy in five villages. One village had titanium mining activities (Mwaloya), one sugar cane farming (Fahamuni), one had a dam (Marigiza), another had all three (Gonjora) and the fifth, the control (Mafisini), had none of these three human activities.

The results were quite clear especially comparing the village Mafisini (11.0% by RTD) with none and Gonjora with all three (33.7% by RTD). The villages with one activity had intermediate values. Mining, despite its prominence in the title, had the least effect (Mwaloya 17.6%) followed by Dam (Marigiza 23.3%) and Sugar cane farming (Fahamuni 26.8%).

No other differences between the villages were mentioned (e.g. poverty) and the authors admitted to limitations of the study. All of the explanations of the differences were linked to effect on mosquito habitats demonstrating the acceptance of the researchers of the conventional transmission model. The dam is a breeding ground for mosquitos. Sugar farming requires tilling of the land that results in additional pools in which mosquitos can breed. Mining requires the use of earth moving equipment that also results in pools for mosquito breeding. On the positive side, the wealth from mining pay packets, can benefit with improved houses and ability to buy malaria deterring items like bed nets. This explains why mining is the least bad of the three activities.

But what if mosquitos are not a factor in the transmission of malaria? We could explain the effects on increased positivity due to possible additional environmental toxins from these activities. The villages with a dam use potentially contaminated surface water instead of cleaner ground or piped water in areas without dams. Sugar cane farming uses a lot of pesticides. Mining operations use and unearth many toxic materials. And adding all three together could have a big additional effect.

I continue my stay in Kenya in Lodwar, Turkana, a desert area where many roads are like sand dunes and temperature usually reaches 40C each day. I was going to write about how annoying mosquitos are. One morning I awoke with five bites on my right little finger. I bought a bed net next day.

Perhaps only a resident of a mosquito free country like Ireland could have written in defense of such an annoying beast!

But in the wee hours of Tuesday morning my friend suffered from serious chest pains and we attended local A&E. Routine blood tests for infection and a microscope slide for Malaria plasmodia were negative. They prescribed a mild opiate painkiller and amoxicillin antibiotic anyway. Later that day my friend vomited and pain went away.

However, it returned suddenly three days later. This time we attended a small private hospital. Immediately the patient had a nice gurney and was put on painkilling drip from start. The same routine blood tests, but this time positive for malaria (malaria test was RDT and level detected very low). Hydration drips were administered and pain eased and moved to stomach. We suspected aggravation of gastric nerve was cause from diet or other reasons.

But lastly administration of artesunate injection, Argesun, and appointments to return for two more at 12 and 24 hours. And a follow up course of artemether-lumefantrine tablets.

And side effects of artesunate include stomach pain and nausea/vomiting, which were the main symptoms of the illness.

So what changed in the three days? The symptoms were not classical malaria symptoms. But a positive test for plasmodium generates this response.

How real is malaria? It seems to be a disease of any symptom, just so long as there is positive plasmodium test.

The gulf between me and the allopathic medical establishment (and its belief in germ theory) was very clear at the poster session of Kenya Medical Research Institutes Annual Scientific and Health Conference. Maurine Mwalo presented the paper by Obilo et al, ‘Updating Malaria Risk-Map of Kenya Through Diagnosis of Asymptomatic Malaria-Infected Individuals’. Just 3.6% of 13,719 tested were positive for plasmodia. And of these 490, 99.5% had no symptoms. They were treated with the ACT Artemether-Lumefantrine anyway.

I asked how it could be said that these 99.5% asymptomatic positive individuals had malaria if they were not ill. The presenter and the rest of the audience all said in unison ‘They have the parasite!’. It reminded me of the recent COVID war and the obsession with positive test results whether patients had symptoms of illness or not.

And this week Malaria World features a review paper ‘The Burden of Asymptomatic Malaria Infection in Children in Sub-Saharan Africa: A Systematic Review and Meta-Analysis Exploring Barriers to Elimination and Prevention’ by Asmelash et al. The results of 24 studies were combined and found 25% prevalence of asymptomatic malaria in children 6 months to 15 years. The two notable findings were that children who tested positive were 3.53 times more likely to be anaemic, and families who never or sometimes used ITN (insecticide treated nets) were 3.89 times more likely to have asymptomatic malaria compared to families who usually utilized ITN. The study also revealed that the prevalence of asymptomatic malaria was not significantly associated with stunted children.

The authors state that anaemia is a symptom of malaria and the ITN result is proof of the effectiveness of nets for excluding mosquitos and preventing malaria transmission.

This paper is a good example of the confirmation bias present in every study of malaria since the time of Ross and Grassi. There are other possible explanations for the results if one does not try to fit them to the mosquito-plasmodium transmission theory.

I suspect that malaria is an illness caused by malnutrition. If a person becomes quite ill, plasmodia present in the blood will multiply to consume the dead tissue, especially blood cells of the ill individual. If well (asymptomatic) these plasmodia will remain dormant and undetectable in the healthiest people. But people who may be a little run down might have more, a detectable number. The coincidence with anaemia is not surprising. If red blood cells are breaking down (anaemia) plasmodia will start to multiply.

And the ITN result may be a marker of other factors, in particular, the economic status of the family. I expect better off families are more likely to have and use ITNs. They are also more likely to be able to afford nutritious food and clean water.

And the bottom line is that people without symptoms and not actually ill. How can an asymptomatic person be said to have malaria?

On 12 February I attended Kenya Medical Research Institutes Annual Scientific and Health Conference (11-14 Feb) which had sessions on malaria. The conference was held in the magnificent Safari Park Hotel in Nairobi and included plenty of food and a lovely lunch. And I got a nice bag (picture).

However, this was very much a medical establishment event and as a medical heretic I was either a fox in a henhouse or a chicken in a fox den!

The keynote address was by Feiko ter Kuile of Liverpool School of Tropical Medicine who discussed their long-established research base in Kisimo that has grown from 50 to 450 researchers.  He expressed concern about the Trump USAID actions. A research topic he discussed was SP (sulfadoxine-pyrimethamine) resistance and said DP (dihydroartemisinin‐piperaquine) had most potential, but SP is still better at preventing severe malaria. DP is a newer ACT not addressed in my book ‘Malaria is Spread by Mosquitos?’ and I will examine it in more detail later.

There were no topics of great interest at the morning scientific sessions. The main malaria session had a variety of the usual scientific topics highlighted in Malaria World each week. There was one talk about the evaluation of nutrition improvement for children 0-36 months in Rising Star session. However, I missed the talk and malaria is not mentioned in title.

I did ask both sessions if any of the presenters were aware of research on the effect of improved nutrition and clean water on the severity and occurrence of malaria and got no answer. One delegate did talk to me at the lunchbreak intrigued by my question.

The gulf between me and the allopathic medical establishment (and its belief in germ theory) was very clear at the poster session. Maurine Mwalo presented the paper by Obilo et al, ‘Updating Malaria Risk-Map of Kenya Through Diagnosis of Asymptomatic Malaria-Infected Individuals’. Just 3.6% of 13,719 tested were positive for plasmodia. And of these 490, 99.5% had no symptoms. They were treated with the ACT Artemether-Lumefantrine anyway.

I asked how it could be said that these 99.5% asymptomatic positive individuals had malaria if they were not ill. The presenter and the rest of the audience all said in unison ‘They have the parasite!’. It reminded me of the BS with COVID positives.

I attended a Symposium on tackling climate-driven zoonotic disease threats in East Africa. Topics included Ebola, Rift Valley Fever and Brucellosis. I don’t believe in viral illness but had no interest in getting involved. Brucellosis is a disease of cattle in Ireland but I have not heard of it being spread to humans. Curiously, its symptoms seem similar to malaria – 1) fever, 2) Another generic symptom, 3) positive test (for Brucella bacteria). Older people with symptoms are less likely to test positive than the young. I suspect that the bacteria, much like plasmodium in malaria is not the cause of the malady.  

I continue my visit to Kenya, now in Nairobi, and have now seen and been bitten by mosquitos. Unpleasant, but not a disease threat. With a planned visit the Turkana the article in Malaria World reporting ‘Prevention Trial Cuts Malaria Cases in Children by 70 Percent’ by a team from Duke University led by Duke Global Health Institute professor Wendy Prudhomme O’Meara caught my attention. However, it was only a preliminary report. I asked Dr O’Meara for a research paper to review the details of the methods and analysis. She promptly and politely responded that publication was delayed by current funding crisis related to the future of USAID.

So instead my attention was drawn to the subject of vaccines, which I have addressed before, (here, here, here, here and here), but not to any particular article. But rather to the number of articles (six). The first is a press release from WHO, ‘Child health improves in Cameroon one year after malaria vaccine introduction’. A 20% reduction in cases from 2023 to 2024 is reported but there is no clear linkage to the vaccine. And of course correlation does not imply causation.

The second (and first research paper) ‘Acceptability of the R21/Matrix-M malaria vaccine alongside existing malaria interventions in the trial context’ by Diawara et al examine the acceptability of the R21/Matrix-M vaccine in Mali. They found it generally acceptable but article adds nothing on safety of effectiveness.

The third  ‘Malaria vaccine introduction in Africa: progress and challenges’ by Impouma et al. This Lancet article discusses the roll-out of malaria vaccines RTS,S/AS01 and R21/Matrix-M in the first year of malaria vaccine implementation, examining achievements, challenges, and strategic opportunities. A discussion article adding little new.

The fourth ‘Genetically attenuated parasites show promise as a next-generation malaria vaccine’ by Hafalla et al discussed genetically modified parasite use in vaccine. I covered this topic recently here. It is early stage of experimentation.

The fifth ‘Malaria: Factors affecting disease severity, immune evasion mechanisms, and reversal of immune inhibition to enhance vaccine efficacy’ by Su et al is a review of the challenges developing malaria vaccines.

The sixth ‘The R21/Matrix-M malaria vaccine: questions remain’ by Aaby et al has the most interesting finding. In a letter to the Lancet they report that supplementary material of Dattoo study previously discussed reports 18 deaths—15 in the experimental group and three in the control group and state it is not significant. The statistics reported suggest otherwise (relative risk 2·50, 95% CI 0·72–8·62; Fisher exact test, p=0·21). They also state that it is important to know the correct number of deaths in both the vaccine and the control group and by sex.

And note – the control group was not even a true control, but recipients of a rabies vaccine.