Skip to main content

Thank you for visiting You are using a browser version with limited support for CSS. To obtain the best experience, we recommend you use a more up to date browser (or turn off compatibility mode in Internet Explorer). In the meantime, to ensure continued support, we are displaying the site without styles and JavaScript.

Reducing the burden of childhood malaria in Africa: the role of improved

Malaria kills > 1 million children aged < 5 years in sub-Saharan Africa annually. Current control efforts are hampered by increasing drug resistance, unreliable diagnostics, widespread overtreatment and rising drug costs. In this environment, new and widely available malaria diagnostics have the potential to save lives and drastically reduce overtreatment.

This is a preview of subscription content, access via your institution

Relevant articles

Open Access articles citing this article.

Access options

Rent or buy this article

Prices vary by article type



Prices may be subject to local taxes which are calculated during checkout

Figure 1
Figure 2
Figure 3: Elasticities associated with each model input parameter.
Figure 4: Elasticities associated with each model input parameter.
Figure 5: Trade-off between sensitivity and specificity for a new diagnostic requiring minimal infrastructure.
Figure 6: Trade-off between improvements in diagnostic specificity and broader access to a diagnostic.


  1. World Health Organization. New Perspectives: Malaria Diagnosis, Report of a Joint WHO/USAID Informal Consultation 25–27 October 1999. WHO/CSD/RBM/200.14; WHO/MAL/2000.1019 (WHO, Geneva, 2000).

  2. Breman, J. G., Egan, A. & Keusch, G. T. The intolerable burden of malaria: a new look at numbers. Am. J. Trop. Med. Hyg. 64, IV (2001).

    Google Scholar 

  3. Rowe, A. K. et al. Estimates of the Burden of Mortality Directly Attributable to Malaria for Children under 5 Years of Age in Africa for the Year 2000: Final Report for the Child Health Epidemiology Reference Group (CHERG) (WHO, Geneva, 2004).

    Google Scholar 

  4. Snow, R. W., Craig, M. H., Newton, C. & Steketee, R.W. The Public Health Burden of Plasmodium falciparum Malaria in Africa: Deriving the Numbers. Disease Control Priorities Project Working Paper No 11 (Fogarty International Center, National Institutes of Health, Bethesda, Maryland, 2003).

    Google Scholar 

  5. Greenberg, A. E. et al. Hospital-based surveillance of malaria-related paediatric morbidity and mortality in Kinshasa, Zaire. Bull. World Health Organ. 67, 189–196 (1989).

    CAS  PubMed  PubMed Central  Google Scholar 

  6. World Health Organization. Guidelines for the Treatment of Malaria. WHO/HTM/MAL/2006.1108 (WHO, Geneva, 2006).

  7. Bojang, K. A., Obaro, S., Morison, L.A. & Greenwood, B.M. A prospective evaluation of a clinical algorithm for the diagnosis of malaria in Gambian children. Trop. Med. Int. Health 5, 231–236 (2000).

    Article  CAS  PubMed  Google Scholar 

  8. Chandramohan, D., Jaffar, S. & Greenwood, B. Use of clinical algorithms for diagnosing malaria. Trop. Med. Int. Health 7, 45–52 (2002).

    Article  PubMed  Google Scholar 

  9. Muhe, L., Oljira, B., Degefu, H., Enquesellassie, F. & Weber, M.W. Clinical algorithm for malaria during low and high transmission seasons. Arch. Dis. Child. 81, 216–220 (1999).

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  10. Reyburn, H. et al. Overdiagnosis of malaria in patients with severe febrile illness in Tanzania: a prospective study. BMJ 329, 1212 (2004).

    Article  PubMed  PubMed Central  Google Scholar 

  11. UN Millennium Project 2005. Coming to Grips with Malaria in the New Millennium. Task Force on HIV/AIDS, Malaria, TB and Access to Essential Medicines, Working Group on Malaria (Earthscan, Sterling, Virginia, 2005).

  12. Nosten, F. & Ashley, E. The detection and treatment of Plasmodium falciparum malaria: time for a change. J. Postgrad. Med. 50, 35–39 (2004).

    CAS  PubMed  Google Scholar 

  13. Bell, D., Wongsrichanalai, C. & Barnwell, J.W. Ensuring quality access for malaria diagnosis: how can it be achieved? Nat. Rev. Microbiol. 4 (suppl.), S7–S20 (2006).

    Article  PubMed  Google Scholar 

  14. Moody, A. Rapid diagnostic tests for malaria parasites. Clin. Microbiol. Rev. 15, 66–78 (2002).

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  15. Amexo, M., Tolhurst, R., Barnish, G. & Bates, I. Malaria misdiagnosis: effects on the poor and vulnerable. Lancet 364, 1896–1898 (2004).

    Article  PubMed  Google Scholar 

  16. Warhurst, D. C. & Williams, J. E. ACP Broadsheet no 148. July 1996. Laboratory diagnosis of malaria. J. Clin. Pathol. 49, 533–538 (1996).

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  17. Barat, L., Chipipa, J., Kolczak, M. & Sukwa, T. Does the availability of blood slide microscopy for malaria at health centers improve the management of persons with fever in Zambia? Am. J. Trop. Med. Hyg. 60, 1024–1030 (1999).

    Article  CAS  Google Scholar 

  18. Coleman, R. E. et al. Comparison of field and expert laboratory microscopy for active surveillance for asymptomatic Plasmodium falciparum and Plasmodium vivax in western Thailand. Am. J. Trop. Med. Hyg. 67, 141–144 (2002).

    Article  PubMed  Google Scholar 

  19. Reyburn, H., Ruanda, J., Mwerinde, O. & Drakeley, C. The contribution of microscopy to targeting antimalarial treatment in a low transmission area of Tanzania. Malar. J. 5, 4 (2006); published online 20 January 2006 (doi:10.1186/1475-2875-5-4)

    Article  PubMed  PubMed Central  Google Scholar 

  20. World Health Organization. The Role of Laboratory Diagnosis to Support Malaria Disease Management: Focus on the use of Rapid Diagnostic Tests in Areas of High Transmission. Report of WHO Technical Consultation. WHO/HTM/MAL/2006.1111 (WHO, Geneva, 2006).

  21. Ochola, L. B., Vounatsou, P., Smith, T., Mabaso, M. & Newton, C. The reliability of diagnostic techniques in the diagnosis and management of malaria in the absence of a gold standard. Lancet Infect. Dis. 6, 582–588 (2006).

    Article  CAS  PubMed  Google Scholar 

  22. Schellenberg, J. R., Smith, T., Alonso, P. L. & Hayes, R. J. What is clinical malaria? Finding case definitions for field research in highly endemic areas. Parasitol. Today 10, 438–442 (1994).

    Article  Google Scholar 

  23. Rafael, M. et al. Reducing the Burden of Malaria in Africa: The Role of Improved Diagnostics. WR-419-HLTH (RAND Corporation, Santa Monica, 2006).

    Google Scholar 

  24. Barnish, G., Bates, I. & Iboro, J. Newer drug combinations for malaria. BMJ 328, 1511–1512 (2004).

    Article  PubMed  PubMed Central  Google Scholar 

  25. Abuya, T. O., Molyneux, C. S., Orago, A. S., Were, A. & Marsh, V. Quality of care provided to febrile children presenting in rural private clinics of the Kenyan coast. Afr. Health Sci. 4, 160–170 (2004).

    CAS  PubMed  PubMed Central  Google Scholar 

  26. Goodman, C. et al. Retail supply of malaria-related drugs in rural Tanzania: risks and opportunities. Trop. Med. Int. Health 9, 655–663 (2004).

    Article  PubMed  Google Scholar 

  27. Taylor, R. B. et al. Pharmacopoeial quality of drugs supplied by Nigerian pharmacies. Lancet 357, 1933–1936 (2001).

  28. Amin, A. A., Marsh, V., Noor, A.M., Ochola, L. B. & Snow, R. W. The use of formal curative services in the management of pediatric fevers in four districts in Kenya. Trop. Med. Int. Health 8, 1143–1152 (2003).

    Article  PubMed  Google Scholar 

  29. de Savigny, D. et al. Care-seeking patterns for fatal malaria in Tanzania. Malar. J. 3, 27 (2004).

    Article  PubMed  PubMed Central  Google Scholar 

  30. Slutsker, L., Chitsulo, L., Macheso, A. & Steketee, R. W. Treatment of malaria fever episodes among children in Malawi: results of a KAP survey. Trop. Med. Parasitol. 45, 61–64 (1994).

    CAS  PubMed  Google Scholar 

  31. Girosi, F. et al. Developing and interpreting models to improve diagnostics in developing countries. Nature S1, 3–8 (2006).

    Article  Google Scholar 

  32. Korenromp, E.L. et al. Malaria attributable to the HIV-1 epidemic, sub-Saharan Africa. Emerging Infect. Dis. 11, 1410–1419 (2005).

    Article  Google Scholar 

  33. Najera, J. A. & Hempal, J. The Burden of Malaria. CTD/MAL/96.10 (WHO, Geneva, 1996).

    Google Scholar 

  34. Manning, W., Fryback, D. & Weinstein, M. in Cost Effectiveness in Health and Medicine (eds Gold, M., Siegel, J., Russell, L. & Weinstein, M.) 247–275 (Oxford Univ. Press, New York, 1996).

    Google Scholar 

  35. Rowe, A. et al. The burden of malaria mortality among African children in the year 2000. Int. J. Epidemiol. 35, 691–704 (2006).

    Article  PubMed  Google Scholar 

  36. Castro-Leal, F., Dayton, J., Demery, L. & Mehra, K. Public spending on health care in Africa: do the poor benefit? Bull. World Health Organ. 78, 66–74 (2000).

    CAS  PubMed  PubMed Central  Google Scholar 

  37. Whitty, C. J. M. et al. Averting a malaria disaster in Africa — where does the buck stop? Bull. World Health Organ. 82, 381–384 (2004).

    PubMed  PubMed Central  Google Scholar 

  38. Guthmann, J. P. et al. Validity, reliability and ease of use in the field of five rapid tests for the diagnosis of Plasmodium falciparum malaria in Uganda. Trans. R. Soc. Trop. Med. Hyg. 96, 254–257 (2002).

    Article  CAS  PubMed  Google Scholar 

  39. Mboera, L. E. et al. Comparison of the Paracheck-Pf test with microscopy, for the confirmation of Plasmodium falciparum malaria in Tanzania. Ann. Trop. Med. Parasitol. 100, 115–122 (2006).

    Article  CAS  PubMed  Google Scholar 

  40. Perkins, M. & Crawley, J. New diagnostic tests for malaria. Africa Health Supp. 31 (2001); published online September 2001 &lt;;.

  41. Chinbuah, A. M., Gyapong, J. O., Pagnoni, F., Wellington, E.K. & Gyapong, M. Feasibility and acceptability of the use of artemether-lumafantrin in the home management of uncomplicated malaria in children 6–59 months old in Ghana. Trop. Med. Int. Health 11, 1003–1016 (2006).

    Article  CAS  PubMed  Google Scholar 

  42. Mutabingwa, T. K. et al. Amodiaquine alone, amodiaquine+sulfadoxine-pyrimethamine, amodiaquine+artesunate, and artemether-lumefantrine for outpatient treatment of malaria in Tanzanian children: a four-arm randomised effectiveness trial. Lancet 365, 1474–1480 (2005).

    Article  CAS  PubMed  Google Scholar 

  43. Amin, A. A. et al. The difference between effectiveness and efficacy of antimalarial drugs in Kenya. Trop. Med. Int. Health 9, 967–974 (2004).

    Article  CAS  PubMed  Google Scholar 

Download references


The views of Dr. Maghill are his personal viewpoints and do not represent official policy of the US Department of Defense or the US Army.

The authors thank T. Brewer and R. Rabinovich (Bill & Melinda Gates Foundation, Washington, USA), P. Duffy (Seattle Biomedical Research Institute, Washington, USA), N. White (Mahidol University, Bangkok, Thailand) and A. Shepherd (Omega Diagnostics Group PLC, Alva, Scotland, UK) for comments on earlier presentations of this work.

Author information

Authors and Affiliations


Corresponding author

Correspondence to Maria E. Rafael.

Additional information

This article has not been written or reviewed by the Nature editorial team and Nature takes no responsibility for the accuracy or otherwise of the information provided.

Rights and permissions

Reprints and Permissions

About this article

Cite this article

Rafael, M., Taylor, T., Magill, A. et al. Reducing the burden of childhood malaria in Africa: the role of improved. Nature 444 (Suppl 1), 39–48 (2006).

Download citation

  • Published:

  • Issue Date:

  • DOI:

This article is cited by


By submitting a comment you agree to abide by our Terms and Community Guidelines. If you find something abusive or that does not comply with our terms or guidelines please flag it as inappropriate.


Quick links

Nature Briefing

Sign up for the Nature Briefing newsletter — what matters in science, free to your inbox daily.

Get the most important science stories of the day, free in your inbox. Sign up for Nature Briefing