Volume 100, Issue 2
  • ISSN: 0002-9637
  • E-ISSN: 1476-1645



Prompt and effective treatment is key to malaria control and prevention, as it reduces disease morbidity and mortality and minimizes the number of transmission reservoirs. Transmission reduction may be particularly important among school-age children (SAC, 5–15 years old), who have the highest prevalence of infection in southern Malawi. We hypothesized that one factor contributing to this difference in prevalence is that SAC are less likely to seek appropriate treatment for fever than children younger than 5 years. In this study, we assessed treatment-seeking behaviors of people of all ages between 2012 and 2014 in Malawi. During each of the five cross-sectional surveys, all members of ∼900 households reported on fever and treatment-seeking in the previous 2 weeks. Multilevel logistic regression was used to analyze predictors of whether febrile people sought treatment and whether they did so at formal (government/private clinics) or informal sources (primarily shops). Twenty-two percent of participants (3,579/16,621) reported fever, and 2,715 of those (75.9%) sought treatment. Seeking treatment exclusively from local shops remains a common practice, although use of recommended diagnostic testing and antimalarial drugs was infrequently reported there. Although SAC were not significantly less likely than children aged < 5 years to seek treatment, SAC and adults (age ≥ 16 years) were significantly less likely to use formal sources. Our results indicate that encouraging treatment at government/private clinics and increasing retail access to appropriate antimalarial testing and treatment, especially among SAC, could help remedy inadequate treatment of symptomatic disease and potentially reduce transmission in Malawi.


Article metrics loading...

The graphs shown below represent data from March 2017
Loading full text...

Full text loading...



  1. World Health Organization, 2017. World Malaria Report 2017. Geneva, Switzerland: WHO. [Google Scholar]
  2. World Health Organization Global Malaria Programme, 2015. Global Technical Strategy for Malaria 2016–2030. Geneva, Switzerland: WHO. [Google Scholar]
  3. World Health Organization, 2009. WHO Country Cooperation Strategy 2008–2013: Malawi. Brazzaville, Republic of Congo: WHO Regional Office for Africa. [Google Scholar]
  4. Government of Malawi Ministry of Health, 2013. Guidelines for the Treatment of Malaria in Malawi, 4th edition. Lilongwe, Malawi: National Malaria Control Programme, Community Health Sciences Unit. [Google Scholar]
  5. Malawi Ministry of Health, 2009. Malawi Standard Treatment Guidelines, 4th edition. Lilongwe, Malawi: Malawi Ministry of Health. [Google Scholar]
  6. Ewing VL, Lalloo DG, Phiri KS, Roca-Feltrer A, Mangham LJ, SanJoaquin MA, , 2011. Seasonal and geographic differences in treatment-seeking and household cost of febrile illness among children in Malawi. Malar J 10: 32. [Google Scholar]
  7. Galactionova K, Tediosi F, De Savigny D, Smith T, Tanner M, , 2015. Effective coverage and systems effectiveness for malaria case management in sub-Saharan African countries. PLoS One 10: e0127818. [Google Scholar]
  8. Johansson EW, Gething PW, Hildenwall H, Mappin B, Petzold M, Peterson SS, Selling KE, , 2014. Diagnostic testing of pediatric fevers: meta-analysis of 13 national surveys assessing influences of malaria endemicity and source of care on test uptake for febrile children under five years. PLoS One 9: e95483. [Google Scholar]
  9. Walldorf JA, 2015. School-age children are a reservoir of malaria infection in Malawi. PLoS One 10: e0134061. [Google Scholar]
  10. Buchwald A, 2016. Bed net use among school-aged children after a universal bed net campaign in Malawi. Malar J 15: 127. [Google Scholar]
  11. Coalson JE, Cohee LM, Buchwald AG, Nyambalo A, Kubale J, Seydel KB, Mathanga D, Taylor TE, Laufer MK, Wilson ML, , 2018. Simulation models predict that school-age children are responsible for most human-to-mosquito P. falciparum transmission in southern Malawi. Malar J 17: 147. [Google Scholar]
  12. Molyneux CS, Mung’ala-Odera V, Harpham T, Snow RW, , 1999. Maternal responses to childhood fevers: a comparison of rural and urban residents in coastal Kenya. Trop Med Int Health 4: 836845. [Google Scholar]
  13. Mujica Mota RE, Lara AM, Kunkwenzu ED, Lalloo DG, , 2009. Health seeking behavior after fever onset in a malaria-endemic area of Malawi. Am J Trop Med Hyg 81: 935943. [Google Scholar]
  14. Chuma J, Okungu V, Molyneux C, , 2010. Barriers to prompt and effective malaria treatment among the poorest population in Kenya. Malar J 9: 144. [Google Scholar]
  15. Vialle-Valentin CE, LeCates RF, Zhang F, Ross-Degnan D, , 2015. Treatment of febrile illness with artemisinin combination therapy: prevalence and predictors in five African household surveys. J Pharm Policy Pract 8: 1. [Google Scholar]
  16. Guyatt HL, Snow RW, , 2004. The management of fevers in Kenyan children and adults in an area of seasonal malaria transmission. Trans R Soc Trop Med Hyg 98: 111115. [Google Scholar]
  17. Roll Back Malaria Monitoring and Evaluation Reference Group, World Health Organization, United Nations Children’s Fund, MEASURE DHS, MEASURE Evaluation, US Centers for Disease Control and Prevention, 2005. Malaria Indicator Survey: Basic Documentation for Survey Design and Implementation. Calverton, MD: World Health Organization. [Google Scholar]
  18. Harris PA, Taylor R, Thielke R, Payne J, Gonzalez N, Conde JG, , 2009. Research electronic data capture (REDCap)—a metadata driven methodology and workflow process for providing translational research informatict support. J Biomed Inform 42: 377381. [Google Scholar]
  19. Filmer D, Pritchett L, , 2001. Estimating wealth effects without expenditure data—or tears: an application to educational enrollments in states of India. Demography 38: 115132. [Google Scholar]
  20. Geldsetzer P, Williams TC, Kirolos A, Mitchell S, Ratcliffe LA, Kohli-Lynch MK, Bischoff EJ, Cameron S, Campbell H, , 2014. The recognition of and care seeking behaviour for childhood illness in developing countries: a systematic review. PLoS One 9: e93427. [Google Scholar]
  21. Holtz TH, Kachur SP, Marum LH, Mkandala C, Chizani N, Roberts JM, Macheso A, Parise ME, , 2003. Care seeking behaviour and treatment of febrile illness in children aged less than five years: a household survey in Blantyre District, Malawi. Trans R Soc Trop Med Hyg 97: 491497. [Google Scholar]
  22. Kazembe LN, Appleton CC, Kleinschmidt I, , 2007. Choice of treatment for fever at household level in Malawi: examining spatial patterns. Malar J 6: 40. [Google Scholar]
  23. Oyekale AS, , 2015. Assessment of Malawian mothers’ malaria knowledge, healthcare preferences and timeliness of seeking fever treatments for children under five. Int J Environ Res Public Health 12: 521540. [Google Scholar]
  24. Weil A, , 2003. Home management of fever in children in Zomba, Malawi. Malawi Med J 15: 9598. [Google Scholar]
  25. Coalson JE, 2016. High prevalence of Plasmodium falciparum gametocyte infections in school-age children using sensitive molecular detection: patterns and predictors of risk from a cross-sectional study in southern Malawi. Malar J 15: 527. [Google Scholar]
  26. Chen I, Clarke SE, Gosling R, Hamainza B, Killeen G, Magill A, O’Meara W, Price RN, Riley EM, , 2016. “Asymptomatic” malaria: a chronic and debilitating infection that should be treated. PLoS Med 13: e1001942. [Google Scholar]
  27. Lindblade KA, Steinhardt L, Samuels A, Kachur SP, Slutsker L, , 2013. The silent threat: asymptomatic parasitemia and malaria transmission. Expert Rev Anti Infect Ther 11: 623639. [Google Scholar]
  28. Nankabirwa J, Brooker SJ, Clarke SE, Fernando D, Gitonga CW, Schellenberg D, Greenwood B, , 2014. Malaria in school-age children in Africa: an increasingly important challenge. Trop Med Int Health 19: 12941309. [Google Scholar]
  29. Gonçalves BP, 2017. Examining the human infectious reservoir for Plasmodium falciparum malaria in areas of differing transmission intensity. Nat Commun 8: 1133. [Google Scholar]
  30. Jeffery GM, Eyles DE, , 1954. The duration in the human host of infections with a Panama strain of Plasmodium falciparum. Am J Trop Med Hyg 3: 219224. [Google Scholar]
  31. Abdel-Wahab A, Ali E, Suleiman S, Ahmed S, Walliker D, Babiker HA, , 2002. Dynamics of gametocytes among Plasmodium falciparum clones in natural infections in an area of highly seasonal transmission. J Infect Dis 185: 18381842. [Google Scholar]
  32. Nassir E, Abdel-Muhsin AM, Suliaman S, Kenyon F, Kheir A, Geha H, Ferguson HM, Walliker D, Babiker HA, , 2005. Impact of genetic complexity on longevity and gametocytogenesis of Plasmodium falciparum during the dry and transmission-free season of eastern Sudan. Int J Parasitol 35: 4955. [Google Scholar]
  33. Chuma J, Abuya T, Memusi D, Juma E, Akhwale W, Ntwiga J, Nyandigisi A, Tetteh G, Shretta R, Amin A, , 2009. Reviewing the literature on access to prompt and effective malaria treatment in Kenya: implications for meeting the Abuja targets. Malar J 8: 243. [Google Scholar]
  34. Namuyinga RJ, 2017. Health worker adherence to malaria treatment guidelines at outpatient health facilities in southern Malawi following implementation of universal access to diagnostic testing. Malar J 16: 114. [Google Scholar]
  35. Opiyo N, Yamey G, Garner P, , 2016. Subsidising artemisinin-based combination therapy in the private retail sector. Cochrane Database Syst Rev 3: CD009926. [Google Scholar]
  36. Sabot OJ, Mwita A, Cohen JM, Ipuge Y, Gordon M, Bishop D, Odhiambo M, Ward L, Goodman C, , 2009. Piloting the global subsidy: the impact of subsidized artemisinin-based combination therapies distributed through private drug shops in rural Tanzania. PLoS One 4: e6857. [Google Scholar]
  37. Rutta E, 2011. Increasing access to subsidized artemisinin-based combination therapy through accredited drug dispensing outlets in Tanzania. Health Res Policy Syst 9: 22. [Google Scholar]
  38. Morris A, Ward A, Moonen B, Sabot O, Cohen JM, , 2015. Price subsidies increase the use of private sector ACTs: evidence from a systematic review. Health Policy Plan 30: 397405. [Google Scholar]
  39. Mbonye AK, Magnussen P, Lal S, Hansen KS, Cundill B, Chandler C, Clarke SE, , 2015. A cluster randomised trial introducing rapid diagnostic tests into registered drug shops in Uganda: impact on appropriate treatment of malaria. PLoS One 10: e0129545. [Google Scholar]
  40. Cohen JL, Yadav P, Moucheraud C, Alphs S, Larson PS, Arkedis J, Massaga J, Sabot O, , 2013. Do price subsidies on artemisinin combination therapy for malaria increase household use? Evidence from a repeated cross-sectional study in remote regions of Tanzania. PLoS One 8: 110. [Google Scholar]

Data & Media loading...

Supplemental Figure and Table

  • Received : 21 Aug 2018
  • Accepted : 23 Oct 2018
  • Published online : 10 Dec 2018

Most Cited This Month

This is a required field
Please enter a valid email address
Approval was a Success
Invalid data
An Error Occurred
Approval was partially successful, following selected items could not be processed due to error