title: School-Age Children Are a Reservoir of Malaria Infection in Malawi.
abstract: Malaria surveillance and interventions in endemic countries often target young children at highest risk of malaria morbidity and mortality. We aimed to determine whether school-age children and adults not captured in surveillance serve as a reservoir for malaria infection and may contribute to malaria transmission. Cross-sectional surveys were conducted in one rainy and one dry season in southern Malawi. Demographic and health information was collected for all household members. Blood samples were obtained for microscopic and PCR identification of Plasmodium falciparum. Among 5796 individuals aged greater than six months, PCR prevalence of malaria infection was 5%, 10%, and 20% in dry, and 9%, 15%, and 32% in rainy seasons in Blantyre, Thyolo, and Chikhwawa, respectively. Over 88% of those infected were asymptomatic. Participants aged 6-15 years were at higher risk of infection (OR=4.8; 95%CI, 4.0-5.8) and asymptomatic infection (OR=4.2; 95%CI, 2.7-6.6) than younger children in all settings. School-age children used bednets less frequently than other age groups. Compared to young children, school-age children were brought less often for treatment and more often to unreliable treatment sources.
  
  
  CONCLUSIONS
  School-age children represent an underappreciated reservoir of malaria infection and have less exposure to antimalarial interventions. Malaria control and elimination strategies may need to expand to include this age group.
authors.affiliation: Center for Malaria Research, Institute for Global Health, University of Maryland School of Medicine, Baltimore, Maryland, United States of America.
authors.forename: Jenny A
authors.initials: JA
authors.lastname: Walldorf
authors.affiliation: Center for Malaria Research, Institute for Global Health, University of Maryland School of Medicine, Baltimore, Maryland, United States of America.
authors.forename: Lauren M
authors.initials: LM
authors.lastname: Cohee
authors.affiliation: Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor, Michigan, United States of America.
authors.forename: Jenna E
authors.initials: JE
authors.lastname: Coalson
authors.affiliation: Blantyre Malaria Project, University of Malawi College of Medicine, Blantyre, Malawi.
authors.forename: Andy
authors.initials: A
authors.lastname: Bauleni
authors.affiliation: Blantyre Malaria Project, University of Malawi College of Medicine, Blantyre, Malawi.
authors.forename: Kondwani
authors.initials: K
authors.lastname: Nkanaunena
authors.affiliation: Blantyre Malaria Project, University of Malawi College of Medicine, Blantyre, Malawi.
authors.forename: Atupele
authors.initials: A
authors.lastname: Kapito-Tembo
authors.affiliation: Michigan State University, East Lansing, Michigan, United States of America.
authors.forename: Karl B
authors.initials: KB
authors.lastname: Seydel
authors.affiliation: National Malaria Control Program, Ministry of Health, Lilongwe, Malawi.
authors.forename: Doreen
authors.initials: D
authors.lastname: Ali
authors.affiliation: Blantyre Malaria Project, University of Malawi College of Medicine, Blantyre, Malawi.
authors.forename: Don
authors.initials: D
authors.lastname: Mathanga
authors.affiliation: Michigan State University, East Lansing, Michigan, United States of America.
authors.forename: Terrie E
authors.initials: TE
authors.lastname: Taylor
authors.affiliation: Department of Immunology and Infectious Diseases, Harvard School of Public Health, Boston, Massachusetts, United States of America.
authors.forename: Clarissa
authors.initials: C
authors.lastname: Valim
authors.affiliation: Center for Malaria Research, Institute for Global Health, University of Maryland School of Medicine, Baltimore, Maryland, United States of America.
authors.forename: Miriam K
authors.initials: MK
authors.lastname: Laufer
mesh_terms: D000293:Adolescent; D000328:Adult; D002648:Child; D002675:Child, Preschool; D005260:Female; D006801:Humans; D007223:Infant; D008288:Malaria / Q000453:epidemiology* / Q000469:parasitology / Q000635:transmission; D008295:Malawi; D008297:Male; D010963:Plasmodium falciparum / Q000302:isolation & purification