Low recovery rates stabilize malaria endemicity in areas of low transmission in coastal Kenya.

The prevalence of Plasmodium falciparum malaria in African communities can be high and stable even in areas of relatively low transmission where people expose to only a few infectious bites per year. We show in this field study conducted in 30 sites along the coastal Kenya that prevalence in school children was consistently high, although there were many sites where transmission intensity measured by exposure to infectious bites was less than 10 per year. Statistical analyses revealed that prevalence was significantly correlated with the infectious exposure occurring 10-11 months previously, suggesting that long-lived infections were commonplace and one of the major contributors for the stability of malaria in these sites. Using mechanistic models of malaria transmission, we found that the association of high prevalence and low transmission could be due to low recovery rates. Therefore, significant reductions of malaria prevalence and burden require substantial reductions of the duration of acquired infections, even in areas that have quite low transmission intensities by the standards of sub-Saharan Africa. Infection control featured by active detection and drug treatment as well as vector control is critical to combat malaria in areas of relatively low transmission intensity.