Written By: Pallavi Garje BPharm
Medically Reviewed By: Dr. Seema Satbhai, BAMS, MPH, PhD-Public Health
Malaria remains one of the most devastating infectious diseases in Sub-Saharan Africa claim thousands of lives each year, where infants are among the most vulnerable. In many communities, including Uganda, mothers traditionally carry their babies on their backs wrapped in cloth. This practice is seems to be emotional but filled with responsibility to do daily household task along with caring of baby. However this practice sometimes keeps children close but leaves them exposed to mosquito bites during the day as bed nets are unavailable. A recent study published in the New England Journal of Medicine explored whether treating these wraps with permethrin, a commonly used insecticide, could reduce malaria transmission. The findings were remarkable; infants carried in permethrin-treated wraps experienced significantly fewer malaria cases compared with those in untreated wraps, suggesting that this culturally rooted practice could be adapted into an effective public health intervention.
Malaria
Children under the age of five, particularly infants, carry the highest risk of severe illness and death due to Malaria because their immune systems are not yet fully developed. According to the World Health Organization (WHO), Sub-Saharan Africa accounts for more than 90% of global malaria cases and deaths, with nearly half a million child deaths annually attributed to the disease.
Over the past two decades, significant progress has been made through distribution of insecticide-treated bed nets, indoor residual spraying, and intermittent preventive treatment during pregnancy and infancy. These interventions have reduced malaria incidence and mortality, but challenges remain. Bed nets primarily protect at night, leaving children vulnerable during the day when they are outdoors or carried by their mothers.
The recent introduction of malaria vaccines, such as RTS,S/AS01 and R21/Matrix-M, offers new hope, but these vaccines are not scaled-up to the point that it could available to everyone. These highlight an urgent need for balancing and culturally integrated strategies that can protect infants during periods of high exposure, especially outside of nighttime sleeping hours when traditional nets are of no use.
Cultural Context
In most of Sub-Saharan Africa, child- nurturing practices are closely tied to cultural traditions and community life. One common practice particularly in Uganda is that for mothers to carry their infants on their backs, secured with a length of cloth that wraps around both mother and child. This method keeps babies safe, promotes constant skin-to-skin contact, and allows mothers to continue household and agricultural work while giving attention to their children. It is more than just a practical solution; it is an integral part of daily life and maternal identity.
However, this practice also has accidental health implications. When infants are carried outdoors during the day, their arms, legs, and sometimes parts of their face are exposed; also due to thin nature of cloths, mosquito can bite on back also through cloths. This leaves them vulnerable to mosquito bites at a time when traditional insecticide-treated bed nets are not available during daytime. The constant close contact between mother and child also means that if mothers are bitten, mosquitoes remain in proximity to the infant that can augment the risk.
Researchers saw in this cultural habit an opportunity for innovation. By treating the baby wraps with permethrin, the same insecticide used in long-lasting bed nets, the fabric could serve as both a traditional garment and a protective barrier against malaria-carrying mosquitoes. In this way, a long-standing cultural practice could be transformed into a novel vector control tool, merging tradition with modern public health strategy.
Study Details
A double-blind, randomized, placebo-controlled trial was conducted in Uganda to test this idea. Researchers enrolled 400 mother–child pairs between June 2022 and April 2024. Eligible children were 6 to 18 months old.
Pairs were randomly assigned in a 1:1 ratio to receive either permethrin-treated wraps (intervention group, n=200) or sham-treated wraps (control group, n=200).
Wraps were retreated every 4 weeks to maintain insecticidal activity.
All participants also received pyrethroid-only insecticide-treated bed nets for nighttime use, ensuring an equal baseline of protection and maintaining ethical standards of care in this malaria-endemic setting.
Mothers and children attended clinic visits every 2 weeks for 24 weeks with unscheduled visits if a child developed fever.
The primary outcome of the study was the incidence of clinical malaria, defined by fever and a positive rapid malaria diagnostic test.
Results
The Clinic follow-up of participants was excellent, with 99.9% of planned visits completed and no participants lost to follow-up. The incidence of clinical malaria was 0.73 cases per 100 person-weeks in the intervention group (Permethrin treated wraps) compared with 2.14 cases per 100 person-weeks in the control group. This corresponded to an incidence rate ratio of 0.34, indicating a 66% reduction in malaria cases among infants carried in permethrin-treated wraps. However, rash was reported slightly more often in the intervention group than in the control group (8.5% vs. 6.0%), but no severe adverse effects were observed.
Implications
The trial demonstrates that permethrin-treated baby wraps can significantly reduce malaria incidence among infants in a high-burden setting. By aligning with an established cultural practice, this intervention provides daytime protection that matches the nighttime coverage of bed nets. If validated in larger studies, this approach could represent an affordable and practical addition to current malaria prevention strategies.
Limitations
Safety is a primary concern, as continuous contact between an infant’s skin and permethrin-treated wraps could potentially cause irritation or sensitization. However the study reported only mild rashes (8.5% in the intervention group vs. 6.0% in controls) and no severe adverse events, the long-term effects of chronic exposure on infants’ delicate skin are not yet fully understood.
Conclusion
The NEJM trial demonstrates that permethrin-treated baby wraps can significantly reduce malaria incidence in infants in high-burden settings like Uganda. By leveraging a long-standing cultural practice like mothers carrying babies on their backs the intervention provides daytime protection that has equal protection ability to traditional insecticide-treated bed nets. While the results are promising, safety considerations regarding prolonged skin contact must be carefully addressed before widespread implementation.
Overall, permethrin-treated baby wraps represent a novel, culturally integrated strategy that could become an important addition to the malaria prevention toolkit in Sub-Saharan Africa. If further studies confirm safety, acceptability, and feasibility at large scale, this simple yet innovative approach could protect one of the most vulnerable populations from malaria.
References
Ross M. Boyce et al., Permethrin-Treated Baby Wraps for the Prevention of Malaria, New England Journal of Medicine, September 24, 2025, DOI: 10.1056/NEJMoa2501628
Snow RW, Lindsay SW, Hayes RJ, Greenwood BM. Permethrin-treated bed nets (mosquito nets) prevent malaria in Gambian children. Trans R Soc Trop Med Hyg. 1988;82(6):838-42. doi: 10.1016/0035-9203(88)90011-9. PMID: 2908286.
Thiévent, K., Hauser, G., Elaian, O. et al. The interaction between permethrin exposure and malaria infection affects the host-seeking behavior of mosquitoes. Malar J 18, 79 (2019). https://doi.org/10.1186/s12936-019-2718-x