malaria as a case study

Malaria: diagnosis, treatment and management of a critically ill patient

Affiliations.

• 1 Nurse Tutor, Defence School of Healthcare Education, Department of Healthcare Education, Birmingham City University, and Intensive Care Nursing Officer, Queen Alexandra's Royal Army Nursing Corps.
• 2 Principal Nursing Education Officer, Lusaka School of Nursing and Midwifery, Lusaka, Zambia.
• PMID: 28704089
• DOI: 10.12968/bjon.2017.26.13.762

Malaria is a significant cause of mortality in many countries and remains the most prevalent parasitic tropical infection. The World Health Organization estimates that 50% of the world's population is at risk of malaria, with most deaths occurring in sub-Saharan Africa. This case study explores the management of a malaria patient admitted to a critical care unit in Zambia, a lower-middle-income country in sub-Saharan Africa. While malaria is prevalent in Zambia and other countries, in the UK all malaria is imported and less frequently seen by health professionals. This case study will raise the profile of malaria, including its recognition, diagnosis and treatment. This information will assist nurses in both low- and high-income countries to translate theory into practice and improve nurses' understanding of a condition rarely seen in UK critical care practice.

Keywords: Critical care nursing; Developing countries; Disease prevention; International nursing; Malaria; Zambia.

Publication types

• Case Reports
• Antimalarials / therapeutic use
• Artemisinins / therapeutic use
• Critical Care Nursing
• Critical Illness
• Fatal Outcome
• Malaria, Cerebral / diagnosis
• Malaria, Cerebral / drug therapy
• Malaria, Cerebral / etiology
• Malaria, Falciparum / complications
• Malaria, Falciparum / diagnosis*
• Malaria, Falciparum / drug therapy*
• Antimalarials
• Artemisinins

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Two year old with spiking fevers and depressed level of consciousness

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Patient Presentation

Differential diagnosis, examination, investigations, final outcome.

• Evaluation - Questions & answers

A 2 year old boy presented to a district hospital with decreased oral intake, listlessness and fever. On arrival he was adequately resuscitated but continued to have spiking fevers and a depressed level of consciousness.

Acknowledgement This case study was kindly provided by Barclay Stewart, Medical University of South Carolina, Fogarty International Clinical Research Scholar, Nairobi, Keny a

Six months ago the patient presented to the hospital with a two day history of irritability, decreased appetite, discomfort on lying down, recurrent fever, profuse sweating and diarrhea, no vomiting. On admission he was lethargic and dehydrated which worsened over a few hours and culminated in a seizure. He had no prior history of seizures. He was then diagnosed with severe malaria. He was treated appropriately and discharged 2 weeks later with no residual effects.

Past medical and surgical history

• There is no additional significant medical or surgical history.
• Road to health card shows all growth parameters to be within normal limits, with all vaccinations up to date.

Family and social history

• He lives with his mother, father, and two older siblings who are all healthy.
• His mother was recently tested and is HIV negative; his father has not been tested.
• Their home, which has electricity and water, is located in a low-lying area near Musina, a town in South Africa’s Limpopo province. This is the country’s most northerly located town, with a seasonal high rate of malaria transmission from October through May.

Travel History No travel outside of Musina since birth.

• Encephalitis
• Gastroenteritis with severe dehydration
• Toxic Shock Syndrome
• Typhoid Fever
• Brucellosis
• Relapsing Fever
• Katayama Fever
• Urinary tract infection
• Bacteraemia

On appearance the child is miserable and toxic looking.

• Pulse – 166
• Respiratory Rate – 34
• Temperature – 39.8
• Pulse-Oxygen – 95%

Height and weight were in the 65 percentile

• Eyes were sunken and jaundiced.
• No lymphadenopathy
• Erythematous, non bulging tympanic membranes.
• Non-inflamed nasal passage, no discharge.
• Pale oral mucosa
• No papilloedema
• No retinal heamorrhages
• Midline trachea
• Chest shape normal in appearance, tachypnoea present
• Mild subcostal retractions.
• Clear on auscultation bilaterally.

Cardiovascular

• Tachycardia with a regular rhythm.
• Normal S1 and S2 with a 2/6 mid systolic murmur best auscultated over the upper left sternal border with minimal radiation.
• Bounding pulses felt radially, femorally and dorsalis pedis
• Capillary refill within 2 seconds.
• Normal on inspection.
• Bowel sounds diminished but present.
• No hepatomegaly.
• 4cm splenomegaly.

Neurological

• Child listless though attempts to follow commands.
• Not resisting or crying in response to aggravating stimuli.

Human malaria infection is caused by four protozoa species of the genus Plasmodium. These are P.falciparum, P. malariae, P. vivax, and P. ovalae , of which the preponderance of severe malaria and mortality is due to P.falciparum . Children living in endemic areas typically have a primary malaria episode during their first few years of life and most toddlers and juveniles develop some degree of acquired immunity against severe disease but still experience periodic clinical episodes. Those who survive to adulthood are often clinically immune, however, low grade parasitaemia is often present but causes few symptoms. Adults in endemic areas maintain low-grade infections throughout the transmission season. Endemicity is typically defined as parasitaemia rates or palpable spleens in children aged 2-9 years. The categories include holoendemic where the rate is >75% (transmission of infection is year round and the bulk of mortality is seen in infants), hyperendemic where the rate is 51-75% (mortality is also mostly seen in infants), mesoendemic where the rate is 11-50% (regular seasonal transmission affecting infants, toddlers and adults who develop chronic ill health) and hypoendemic which is <10% (occasional epidemics, whole population is susceptible to severe and fatal disease). Clinical immunity also fails if a person moves away from an endemic area and during pregnancy.

The female Anopheles mosquito inoculates the host with 10 to 100 malaria sporozoites from her salivary glands during a blood meal. These microscopic motile forms of the malaria parasite are carried via the bloodstream to the liver. Within 30 minutes, those sporozoites not bound by previously formed antibodies, invade and begin replicating in hepatocytes. Parasites not destroyed by cytotoxic T lymphocytes in the liver replicate for 2-10 days creating merozoites. Tens of thousands of merozoites are released into the bloodstream as the hepatocyte bursts. Each merozoite is then able to bind, invade, and infect erythrocytes. After red blood cell (RBC) infection, each merozoite matures to form a highly metabolically active trophozoite, which replicates asexually to become multinucleate schizonts. As the schizonts enlarge they rupture erythrocytes 48 hours after their formation which results in 20-30 new merozoites which continue the cycle. Some sexual forms of the parasite develop during this erythrocytic stage; these gametocytes are responsible for infecting the salivary glands of female Anopheles mosquitoes. The gametes mature into ookinetes then into an oocyst. The oocyst ruptures and releases sporozoites which can then infect another host during a blood meal.

A person’s first infection usually creates no symptoms for 7-10 days, which is followed first by nonspecific symptoms such as headache, fatigue, abdominal discomfort and muscle aches. This is then followed by fever. During this latent period, parasite maturation occurs in the liver and parasites undergo a cycle of blood stage replication. Symptoms begin when the parasites undergoing an asexual blood cycle, reach threshold density sufficient to initiate the host’s pathogenic immune response process. Fever, malaria’s hallmark, is due to parasite-derived molecules released from ruptured host cells. These molecules activate host inflammatory cells, such as macrophages, which secrete pro-inflammatory pyrogenic cytokines such as interleukin (IL)-1 and tumor necrosis factor (TNF)–α. As parasites synchronise their replication cycles the fever becomes periodic. Although childhood febrile convulsions can occur, generalised seizures are typically associated with P.falciparum infections and may herald cerebral malaria. Splenomegaly results from massive reticuloendothelial system activation to clear parasitised erythrocytes. Mild hepatomegally is common in young children, while mild jaundice is more common in adults. Anaemia is also common and is partly due to the phasic rupture of RBCs by mature schizonts, splenic sequestration of red blood cells and ineffective erythropoiesis.

Cerebral Malaria Onset may be gradual or sudden following a convulsion. Features include obtundation, delirium, abnormal behaviour and coma. Focal neurologic signs and meningism do not typically occur. Fifteen percent of children who survive cerebral malaria, especially when associated with hypoglycaemia, coma and anaemia will have some residual neurologic deficit.

Hypoglycaemia Common complication that is associated with a poor prognosis, particularly in children and pregnant women. Hypoglycaemia is due to a failure of hepatic gluconeogenesis and an increase in glucose consumption by host and parasite. This may manifest as an added complication during treatment as Quinine is also a potent stimulator of insulin secretion.

Haematologic Pathology Anaemia due to increased destruction and removal or red blood cells and dyserythropoesis. Mild thrombocytopaenia Mild coagulation abnormalities Bleeding and DIC in more severe cases

Renal pathology Interference in microcirculation resulting in tubular necrosis and acute renal failure, more common in adults.

Host Response-Immunology

• Antibody responses are induced during the sporozoite stage. Antibody bound sporozoites are prevented from invading hepatocytes.
• CD8 + T cells have been shown to be cytotoxic against maturing sporozoite infected liver cells.
• Both of these responses are potentially able to terminate the infection before the onset of clinical disease caused by the release of merozoites from hepatocytes and subsequent RBC invasion and rupture.
• CD4 + T cells are a requisite for the production of merozoite neutralising antibodies by B cells and the activation of macrophages which secrete interferon (INF) –γ to enhance parasitized RBC.
• The host is also able to develop transmission-blocking antibodies directed to gametocyte specific antigens. These antibodies hinder the development of the parasite within the mosquito vector, thereby preventing further infections. Though this immune response is not particularly valuable to the infected host, it does assist in reducing population level transmission.

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Plasmodium falciparum malaria.

It is recommended that patients receive prompt and effective treatment. Ideally, treatment should be initiated in a hospital setting. The choice of chemotherapy for malaria is dependent on the severity of disease, the known or suspected resistance pattern of the parasite in the area where the malaria infection was acquired, the species of parasite, patient characteristics (age, pregnancy, co-morbidity, allergies, other medications) and the presence or absence of vomiting. In South Africa, malaria treatment varies in the different provinces due to differences in the resistance patterns. These treatment guidelines may not be appropriate for infections contracted in other countries with high levels of multi-drug resistance.

The patient was treated with IV artesunate and anti-pyretics for 3 days. IV antibiotics were started on admission as there was no confirmatory diagnosis at the time and culture results were not yet available. On the third day the child was markedly improved. He was started on a full course of mefloquine on receiving laboratory results which confirmed infection with P.falciparum. Upon discharge there were no neurologic sequelae. He and his family were counseled on the use of insecticide-treated bed nets and indoor residual spraying.

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Link to Abstract Burns, J.M. et al. (1989). A protective monoclonal antibody recognizes a variant-specific epitope in the precursor of the major merozoite surface antigen of the rodent malarial parasite Plasmodium yoelii. J Immunol. 142(8): p. 2835-40.

Link to Abstract Smith, J.D. et al. (1995). Switches in expression of Plasmodium falciparum var genes correlate with changes in antigenic and cytoadherent phenotypes of infected erythrocytes. Cell. 82(1): p. 101-10.

Link to Abstract Flick, K. et al. (2004). var genes, PfEMP1 and the human host. Mol Biochem Parasitol. 134(1): p. 3-9.

Link to Abstract Williamson, W.A. et al. (1978). Impairment of the immune response to vaccination after acute malaria. Lancet. 1(8078): p. 1328-9.

Link to Abstract Takeda, K. et al. (2003). Toll-like receptors. Annu Rev Immunol. 21: p. 335-76.

Link to Abstract Urban, B.C. et al. (1999). Plasmodium falciparum-infected erythrocytes modulate the maturation of dendritic cells. Nature. 400(6739): p. 73-7.

Link to Abstract Ocana-Morgner, C. et al. (2003). Malaria blood stage suppression of liver stage immunity by dendritic cells. J Exp Med. 197(2): p. 143-51.

Link to Abstract Omer, F.M et al. (2003). Differential induction of TGF-beta regulates proinflammatory cytokine production and determines the outcome of lethal and nonlethal Plasmodium yoelii infections. J Immunol. 171(10): p. 5430-6.

Link to Abstract Shevach, E.M. (2002). CD4+ CD25+ suppressor T cells: more questions than answers. Nat Rev Immunol. 2(6): p. 389-400.

Hisaeda, H. et al. (2004). Escape of malaria parasites from host immunity requires CD4+ CD25+ regulatory T cells. Nat Med. 10(1): p. 29-30.

Evaluation – Questions & answers

What is the diagnosis?

With regards to parasitized erythrocytes which endothelial receptors do they bind to resulting in occlusion of microvessels?

What are the three ways that infected erythrocytes can bind to occlude microvessels?

What is the benefit of occlusion of microvessels?

Which organs are most affected by occlusion of microvessels?

Describe the immune response required to neutralize malaria parasites at each stage during their development.

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News releases.

News Release

Friday, April 26, 2024

Experimental NIH malaria monoclonal antibody protective in Malian children

Mid-stage trial shows treatment prevents infection, disease.

One injected dose of an experimental malaria monoclonal antibody was 77% effective against malaria disease in children in Mali during the country’s six-month malaria season, according to the results of a mid-stage clinical trial. The trial assessed an investigational monoclonal antibody developed by scientists at the National Institutes of Health (NIH), and results appear in The New England Journal of Medicine.

“A long-acting monoclonal antibody delivered at a single health care visit that rapidly provides high-level protection against malaria in these vulnerable populations would fulfill an unmet public health need,” said Dr. Jeanne Marrazzo, director of the National Institute of Allergy and Infectious Diseases, part of NIH.

The clinical trial assessed two dose levels, with 19% of the 300mg-dose group and 28% of the 150mg-dose group developing symptomatic malaria, providing protective efficacy of 77% and 67% against symptomatic malaria, respectively. Among children who received placebo, 81% became infected with Plasmodium falciparum , and 59% had symptomatic malaria during the six-month study period. The authors note that the trial demonstrated for the first time that a single dose of a monoclonal antibody given by subcutaneous injection can provide high-level protection against malaria in children in an area of intense malaria transmission.

In 2022, the P. falciparum parasite caused a majority of the nearly 250 million estimated cases of malaria globally and most of the more than 600,000 malaria deaths, according to the World Health Organization. Most malaria cases and deaths are among children in Africa. Malaria parasites such as P. falciparum are transmitted to people by mosquito bites.

In 2020, scientists at NIAID’s Vaccine Research Center reported that they had isolated the antibody from a volunteer who had been vaccinated with an experimental malaria vaccine. The antibody was modified with a mutation that prolonged its durability in the bloodstream following administration. In an earlier study, conducted in Mali by the same research group, a previously discovered antibody was highly protective against P. falciparum infection in adults when given intravenously. However, the new antibody was shown to be more potent in animal studies and was manufactured at a higher concentration than CIS43LS, allowing it to be given by subcutaneous injection.

The trial in Mali took place in two parts, first to assess safety in a small number of adults and children, and then in a larger clinical efficacy trial involving 225 children. The efficacy trial took place from July 2022 to January 2023 and included healthy children 6 to 10 years of age, 75 of whom received a 300 mg dose, 75 a 150 mg dose, and 75 of whom received a placebo.

The researchers are continuing clinical development of the experimental antibody, focusing on other high-risk populations, such as infants and young children, children hospitalized with severe anemia, and pregnant women. An ongoing clinical trial in Kenya is assessing the efficacy of the antibody in children 5 months to 5 years of age over a 12-month study period, and scientists are also conducting a clinical trial in Mali to assess the antibody in women of childbearing potential to prepare to test the antibody in pregnancy.

NIAID led the clinical trial in conjunction with the University of Sciences, Techniques and Technologies of Bamako, Mali, through NIAID’s Division of Intramural Research International Centers of Excellence in Research (ICER) program. For more details about the clinical trial, see clinicaltrials.gov using identifier NCT05304611 .

NIAID conducts and supports research—at NIH, throughout the United States, and worldwide—to study the causes of infectious and immune-mediated diseases, and to develop better means of preventing, diagnosing and treating these illnesses. News releases, fact sheets and other NIAID-related materials are available on the NIAID website .

About the National Institutes of Health (NIH): NIH, the nation's medical research agency, includes 27 Institutes and Centers and is a component of the U.S. Department of Health and Human Services. NIH is the primary federal agency conducting and supporting basic, clinical, and translational medical research, and is investigating the causes, treatments, and cures for both common and rare diseases. For more information about NIH and its programs, visit www.nih.gov .

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K Kayentao et al . Subcutaneous Administration of a Monoclonal Antibody to Prevent Malaria . The New England Journal of Medicine  DOI: 10.1056/NEJMoa2312775 (2024).

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Deeper understanding of malaria parasite development unlocks opportunities to block disease spread

For the first time, the developmental stages of the deadliest human malaria parasite have been mapped in high resolution, allowing researchers to understand this ever-adapting adversary in more detail than previously possible.

The study, published today (2 May) in Science , details the critical developmental stages of the malaria parasite, Plasmodium falciparum , using single-cell RNA sequencing. This gives detailed information on the life stages of this parasite as it matures, changing from an asexual state to a sexual state, which is necessary before the parasite can be transmitted to mosquitoes.

The research from the Wellcome Sanger Institute, the Malaria Research and Training Center (MRTC) in Mali, and other collaborators, adds to the freely available Malaria Cell Atlas 1 . The Atlas provides information for researchers worldwide to investigate and generate tools to track the disease.

The novel insights accessible through the Malaria Cell Atlas can also help identify new ways to block the parasite's development, including through new drugs or vaccines that can prevent transmission.

Malaria is a life-threatening disease with an estimated 249 million cases and 608,000 deaths globally in 2022 2 . It is caused by the Plasmodium parasite, with P. falciparum being the deadliest type of this parasite and the most prevalent on the African continent 2 .

P. falciparum is a single-celled parasite that evolves quickly, making it difficult to develop long-lasting and effective diagnostics, drugs and vaccines to protect against it. Malaria parasites have a huge amount of genetic diversity and people are frequently infected with multiple different parasite strains. In Mali, around 80 per cent of people infected with malaria carry multiple genetically distinct parasite strains 3 .

Malaria parasites are found in either an asexual or sexually developed form in the human host. Asexual replication in humans is what causes the symptoms of malaria, but to transmit, parasites have to develop and become either a male or female reproductive cell, known as a gametocyte.

Sexual commitment and development are controlled by transcription factors, which are proteins that regulate gene activity. The mature sexual forms of the parasite circulate in the bloodstream until they are taken up by mosquitoes.

In the latest research, from the Wellcome Sanger Institute and the MRTC in Mali researchers used both long-read and short-read single-cell RNA sequencing to map the sexual development stages of P. falciparum in the laboratory. This allowed them to track the gene expression levels and highlight which genes are involved in each stage of the process.

The team then applied this approach to parasites from blood samples collected from four people naturally infected with malaria in Mali. This is the first time that these technologies have been applied to real-time infection strains at such a high resolution.

By comparing the laboratory data with the natural infection data, the researchers found parasite cell types not previously seen in laboratory strains, highlighting the importance of real-world data.

The team compared different natural P. falciparum strains within each donor to identify genes of interest.

Some of the genes that were overexpressed in particular strains in the sexual development stages are involved in the survival of the parasite in the

ito, including one that plays a role in dampening mosquito immunity. The next step will be to assess the impact these genes have on transmission.

Jesse Rop, co-first author from the Wellcome Sanger Institute, said: "This is the first time that we have been able to map the sexual development stages of malaria parasites in both laboratory and natural strains, allowing us to gain deeper insight into the similarities and differences. Our research uncovered new biology present in the naturally occurring strains that are not seen in laboratory strains, improving our understanding of how malaria develops and spreads."

Dr Sunil Dogga, co-first author from the Wellcome Sanger Institute, said: "Our research adds to the growing Malaria Cell Atlas, giving a high-quality, open-access genomic resource for researchers worldwide. This high-resolution atlas can be used by scientists to gain a clear understanding of the genes they are investigating, combine research efforts, and help us more effectively prevent, control, and treat malaria. Working together as a scientific community is the only way we are going to successfully control and treat malaria."

Professor Abdoulaye Djimdé, co-author from the Malaria Research and Training Centre, University of Bamako, Mali, and Honorary Faculty at the Wellcome Sanger Institute, said: "Malaria has a huge global impact, affecting millions of people each year, and attempts to control and treat the disease are quickly overcome by the parasite. Understanding more about the parasite's life cycle, the genes involved, and the factors that control these, can be vital to ongoing malaria research. Our research highlights key points in the sexual development of the parasite, which if targeted in future drug development could break the cycle of transmission and help minimise the spread."

Dr Mara Lawniczak, senior author from the Wellcome Sanger Institute, said: "This new focus of the Malaria Cell Atlas project on natural infections coincides with malaria vaccines being used for the first time and a continued rise of drug resistance. Single-cell RNA sequencing gives us a window into parasite gene usage that is not possible with any other approach, while also providing a much clearer understanding of just how genetically diverse parasites are, even within the same person. The Malaria Cell Atlas is a resource we hope will be increasingly useful on the path to malaria elimination."

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Materials provided by Wellcome Trust Sanger Institute . Note: Content may be edited for style and length.

Journal Reference :

• Sunil Kumar Dogga, Jesse C. Rop, Juliana Cudini, Elias Farr, Antoine Dara, Dinkorma Ouologuem, Abdoulaye A. Djimdé, Arthur M. Talman, Mara K. N. Lawniczak. A single cell atlas of sexual development in Plasmodium falciparum . Science , 2024; 384 (6695) DOI: 10.1126/science.adj4088

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Could malaria stage a comeback in the US, Europe and elsewhere because of climate change?

The mosquitoes that spread malaria are expanding their geographic distributions because of warming temperatures and altered rainfall patterns.

• 24 April 2024
• by Linda Geddes

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In August 2023, a person living in Maryland, US, close to Washington DC, contacted their doctor because they had been experiencing fever, body aches and feeling unwell for the past seven days. Hospital tests revealed that they were anaemic, with evidence of parasites living inside their red blood cells.

“Climate change is increasing the number of people around the world who are devastated by environmentally-linked crises – floods, droughts, food insecurity. This dramatically increases their vulnerability to debilitating diseases such as malaria. And these threats fall hardest on those populations that are already most vulnerable – in societies and around the world.” – W. Scott Gordon, Head of Gavi’s Malaria Vaccine Programme

Because the patient had recently been bitten by a tick, doctors initially suspected that they might have a parasitic disease called babesiosis. However, further tests revealed the presence of Plasmodium falciparum – the deadliest type of malaria parasite – even though the patient had not recently travelled abroad.

First US case in 20 years

Malaria was once common in the US and many European countries, but the draining of wetlands where mosquitoes breed, plus the use of insecticides, window screens, antimalarial drugs and improved diagnostics, led to its gradual elimination. Most countries in these regions were declared malaria-free by the 1970s.  

In the US, the Anopheles mosquitoes that carry malaria are still present and around 2,000 cases of malaria are detected in travellers returning from countries where the disease is endemic each year. However, because these cases are relatively rare and tend to be swiftly detected and treated, onwards transmission – through a mosquito biting an infected person, and then biting someone else – is rarer still.

Before last year, no such cases had been reported since 2003, and none had been reported in Maryland for more than 40 years. However, between May and October 2023, ten people were diagnosed with locally acquired malaria in Florida, Texas, Arkansas and Maryland – including the patient described above.

Is climate change to blame?

While it is too soon to know if such cases mark the start of a trend, scientists are increasingly predicting that malaria has the potential to rebound in countries or areas long declared malaria-free, including parts of the US, because of climate change.

"There is stuff happening that you wouldn’t necessarily say is consistent with the trend of malaria eradication, including in places where it has historically been eradicated, such as locally acquired malaria in, for example, Greece.” – Chris Murray, professor of climate change and health, London School of Tropical Medicine at the MRC unit in the Gambia

"Climate change is increasing the number of people around the world who are devastated by environmentally-linked crises – floods, droughts, food insecurity. This dramatically increases their vulnerability to debilitating diseases such as malaria," said W. Scott Gordon, Head of Gavi's Malaria Vaccine Programme. "And these threats fall hardest on those populations that are already most vulnerable – in societies and around the world."

Malaria isn't the only disease that researchers and health professionals are worried about. Other vector-borne diseases (those transmitted by blood-sucking arthropods) such as dengue, Zika, West Nile virus and chikungunya – are also expected to expand their geographic distributions to more temperate regions further north or south because of warming temperatures and altered rainfall patterns.  

"Vector-borne and zoonotic diseases [those transmitted from animals to humans] in particular, are climate-sensitive, because it [climate] impacts the life history, distribution and success of the hosts these things transmit from," said Chris Murray, a professor of climate change and health at the London School of Tropical Medicine at the MRC unit in the Gambia.

In its latest World Malaria Report , published in November 2023, the World Health Organization warned that climate change had the potential to undermine gains in the global fight against the disease, particularly in vulnerable regions where disrupted access to antimalarial drugs, vaccines and other preventive measures such as insecticide-treated bed-nets, e.g. as a result of conflict or natural disasters, further increases the risk of malaria outbreaks.

Longer summers and warmer winters could extend the breeding season for mosquitoes and enable more of them to survive and flourish, while stagnant pools of water left by receding floods or in plastic containers used to store water in temporary human settlements, make ideal breeding grounds. Warmer temperatures also speed up the growth cycle of malaria parasites, increasing their numbers.

Malaria transmission is changing

Already, there are indications that things are changing: "There is stuff happening that you wouldn't necessarily say is consistent with the trend of malaria eradication, including in places where it has historically been eradicated, such as locally acquired malaria in, for example, Greece," said Murray. "However, attributing individual events to climate change is difficult, because there are other factors that can contribute, such as changing [malaria] importation rates related to changing flows of people.

"The season of possible transmission in a lot of places is also increasing. Particularly in temperate areas, you've got a situation where local transmission is only possible within a given season – typically summer in Europe or the US. And what looks to be happening, at least from a theoretical perspective, is that the season is expanding."

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Some of the strongest evidence for a link between climate change and malaria transmission comes from long-term observations of cases in African highland areas on the fringes of endemic transmission, the WHO report said. These suggest that rising temperatures have led to the expansion of the disease in recent decades.

Extreme rainfall and flooding in Pakistan during 2022 also resulted in a fivefold increase in malaria cases compared with 2021, the report noted, and such extreme weather events are predicted to become more commonplace due to climate change.

Some regions could see a fall in cases

However, it is not all bad news. Some areas where malaria is currently endemic could experience a decrease in malaria because of changing temperatures.

Prof Jane Carlton, Director of the Malaria Research Institute at the Johns Hopkins Bloomberg School of Public Health, said: "An interesting fact about malaria is that the parasite itself can only develop in a mosquito over quite a tight temperature range: if it is too cold, the parasite won't grow, and if it is too hot, the parasite won't grow. This means that if it gets too hot in a particular area, the parasite will die, and you may get fewer malaria cases.

“An interesting fact about malaria is that the parasite itself can only develop in a mosquito over quite a tight temperature range: if it is too cold, the parasite won’t grow, and if it is too hot, the parasite won’t grow. This means that if it gets too hot in a particular area, the parasite will die, and you may get fewer malaria cases." – Prof Jane Carlton, Director of the Malaria Research Institute at the Johns Hopkins Bloomberg School of Public Health

"However, it also means that in more temperate regions, including highland areas of countries where malaria is already endemic, there could be increases in cases because the range that the mosquitoes can live in, and that the parasite can develop in, will change. So, we might see a geographical change in the distribution of malaria, which is concerning."

Whether such factors contributed to the flurry of locally acquired malaria cases in the US last year is impossible to say for sure. Seven of these cases occurred in Sarasota County, Florida, south of Tampa; one occurred in Texas, just north of the border with Mexico; and another occurred near Little Rock, Arkansas . Unlike the Maryland case, these ones involved Plasmodium vivax , the dominant malaria parasite outside sub-Saharan Africa. All of the patients recovered, and there is no evidence to suggest that any of the cases were related, the US Centers for Disease Control and Prevention has said .

"If there are more [locally acquired] cases this year, then that will certainly be something to be more aware of," said Carlton. "But I think what these cases have really triggered is a realisation that we need to do more studies to better understand the local mosquito populations."

Italian studies

Such studies are already taking place elsewhere. For instance, in Italy, where malaria was endemic until the 1970s, a cluster of seven non-imported, and seemingly unrelated, cases of malaria occurred in 2017, including one case of P. falciparum malaria in which a four-year-old girl died. A later investigation suggested she might have caught it during a hospital stay, as the malaria strain was the same as one infecting another family at the hospital who had caught it during a recent trip to Burkina Faso. Possibly, the reuse of a needle or some other human error resulted in the girl becoming infected, investigators said.

“Humans are a critical element in the transmission cycle of malaria and many other vector-borne diseases. If we can ensure better care for our most vulnerable populations – such as making sure that they are vaccinated, properly nourished and have access to prevention such as bed-nets – we may be able to limit some of the most dramatic impacts from the changing climate.” – W. Scott Gordon, Head of Gavi’s Malaria Vaccine Programme

Increased surveillance in the wake of these cases has detected mosquito species capable of carrying malaria parasites in several regions of Italy, including rice fields in northern regions, while a study published in Parasites and Vectors earlier this month found Anopheles sacharovi mosquitoes – historically, one of the two key malaria vectors in Italy, and which were thought to have disappeared from the country more than 50 years ago – in the southern Apulia region.

Although the density of these mosquitoes is unlikely to pose a health threat at the current time, "to prevent the risk of reintroduction of the disease, the need to strengthen the surveillance of [ Anopheles mosquitoes] throughout the South should be considered," the study authors said.  

Even though the risk of catching malaria in temperate regions remains very low at the current time, "it is important that we have systems in place that we can detect unusual changes in the distribution or the abundance of [disease-carrying] species," said Murray.

Also needed is greater public awareness of the signs and symptoms of malaria and other vector-borne diseases in countries where they are not currently widespread. "It is important to start to inform populations in the US about how to protect themselves during the summer months, such as by wearing long-sleeved shirts, and just being more aware of if they are being bitten," Carlton said.

Focus on the most vulnerable countries

Yet it is important not to lose sight of the huge gains that have been made against malaria in recent decades, and to recognise that the bulk of transmission still occurs in low-income countries. Continuing to focus prevention and surveillance efforts on these countries is crucial, as health disparities only magnify global and regional socio-economic disparities, leaving populations even more vulnerable to the impact of climate-related disasters and other crises.

T he biggest threat to the progress that has been made against malaria is the disruption of public health systems, whether because of civil strife, poverty or climate-related disaster. "That's when you start to get an increase in malaria cases," Carlton said.

Our global climate is changing. The best way to protect ourselves against malaria is to shore up those health care systems to ensure that everyone stays safe. "Humans are a critical element in the transmission cycle of malaria and many other vector-borne diseases. If we can ensure better care for our most vulnerable populations – such as making sure that they are vaccinated, properly nourished and have access to prevention such as bed-nets – we may be able to limit some of the most dramatic impacts from the changing climate," said Gordon.

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• Published: 02 May 2024

Active self-treatment of a facial wound with a biologically active plant by a male Sumatran orangutan

• Isabelle B. Laumer 1 ,
• Arif Rahman 2 ,
• Tri Rahmaeti 2 ,
• Ulil Azhari 3 ,
• Hermansyah 4 ,
• Sri Suci Utami Atmoko 5 &
• Caroline Schuppli 1  

Scientific Reports volume  14 , Article number:  8932 ( 2024 ) Cite this article

Metrics details

Although self-medication in non-human animals is often difficult to document systematically due to the difficulty of predicting its occurrence, there is widespread evidence of such behaviors as whole leaf swallowing, bitter pith chewing, and fur rubbing in African great apes, orangutans, white handed gibbons, and several other species of monkeys in Africa, Central and South America and Madagascar. To the best of our knowledge, there is only one report of active wound treatment in non-human animals, namely in chimpanzees. We observed a male Sumatran orangutan ( Pongo abelii ) who sustained a facial wound. Three days after the injury he selectively ripped off leaves of a liana with the common name Akar Kuning ( Fibraurea tinctoria ), chewed on them, and then repeatedly applied the resulting juice onto the facial wound. As a last step, he fully covered the wound with the chewed leaves. Found in tropical forests of Southeast Asia, this and related liana species are known for their analgesic, antipyretic, and diuretic effects and are used in traditional medicine to treat various diseases, such as dysentery, diabetes, and malaria. Previous analyses of plant chemical compounds show the presence of furanoditerpenoids and protoberberine alkaloids, which are known to have antibacterial, anti-inflammatory, anti-fungal, antioxidant, and other biological activities of relevance to wound healing. This possibly innovative behavior presents the first systematically documented case of active wound treatment with a plant species know to contain biologically active substances by a wild animal and provides new insights into the origins of human wound care.

Introduction

In the early 1960s Jane Goodall first described the presence of whole leaves in the feces of chimpanzees ( Pan troglodytes ) at Gombe Stream, Tanzania 1 . By the late 1990s, this behavior, now called whole leaf swallowing, was documented at several African great ape study sites, along with bitter pith chewing, and demonstrated to have therapeutic, anti-parasitic functions 2 . Since then, various forms of self-medication have been observed in wild great apes (e.g., 2 , 3 , 4 , 5 , 6 ). Some of the most detailed evidence for animal self-medication comes from research in primates (e.g., 1 , 2 , 3 , 4 , 5 , 6 , 7 , 8 , 9 , 10 , 11 , 12 ).

Animal self-medication is now divided into five categories 2 , 4 : (1) sick behaviors, such as anorexia; (2) avoidance behaviors, such as avoiding e.g. feces, contaminated food or water; (3) prophylactic behaviors, such as routine consumption of foods with preventive or health maintenance effects; (4) therapeutic behaviors, defined by the ingestion of a small amount of a biologically active or toxic substance with no or little nutritional value for the curative treatment of a disease or its symptoms, and; (5) therapeutic topical application of pharmacologically active plants onto the body for the treatment of external health conditions or placement of such species in the nest as a fumigant or insect repellent 13 . Several of these behaviors can be found in wild apes 2 .

While sick and avoidance behavior (category 1 and 2) can be regularly observed in non-human animals (e.g. 14 ), self-medication in the form of ingestion of specific plant parts (prophylactic and therapeutic behavior, category 3 and 4) is widespread, albeit exhibited at low frequencies (e.g., 15 , but see 16 ). So far, leaf swallowing has been reported in chimpanzees ( Pan sp. ; e.g., 7 , 9 , 16 , 17 ), bonobos ( Pan paniscus 3 ), gorillas (e.g. Gorilla beringei graueri 18 ), and in only one Asian ape species, the white-handed gibbon ( Hylobates lar ) 19 . Another study reported the consumption of plant species directly related to the occurrence of parasite infections in individual orangutans ( Pongo sp. ), but not correlated with the plant’s distribution in the environment 20 . Another therapeutic self-medicative behavior seen in chimpanzees is bitter pith chewing of Vernonia amygdalina to treat worm infection 8 , 10 , 13 . Despite the plant’s year-round availability, the behavior is highly seasonal, peaking during the rainy season when worm infections also peak 8 , 13 . Interestingly, as Vernonia amygdalina is not evenly distributed in their home range, the apes often need to actively adapt their usual travel routes to gain access to the plant 13 .

Among Bornean orangutans ( Pongo pygmaeus ) there are several reports proposing the intentional ingestion of specific plant species also used in ethnomedicine for their medicinally active properties. In Sabah, Malaysia, a 4- to 5-year-old severely wounded female Bornean orangutan was observed eating ginger leaves and stem (Zingiberaceae) 21 . Ginger is known as a traditional medical plant against inflammation with antibacterial, antiviral, antifungal properties 22 , 23 , 24 , 25 . In 7 years of observation, no other individual, except two flanged males was ever observed feeding on the same ginger species at that study site. The researchers concluded that the juvenile may have attempted to treat itself with these plants. Another study, which interviewed 13 traditional healers from Central Kalimantan, showed that Bornean orangutans feed on the same plant parts from two plant species ( Uncaria gambir Roxb and Pternandra galeata Ridl ), used by traditional healers for treating internal illness, tumors, and haemorrhage 26 . Additionally, they observed a female Bornean orangutan selectively choosing young leaves of Mezzetia sp. , the pulp of Dyera lowii and Ilex cymosa , and leaves of Belang Handipek ( Scolopia macrophylla) 27 . This plant combination is used in ethnomedicine as a prevention against fatigue 27 . Despite these reports, overall, evidence of plant consumption for self-medication in orangutans is still limited.

Reports of the topical application of plants or insects to one’s own body (category 5) are found in a limited number of taxa, but the evidence for medicinal benefits remain mostly anecdotal (e.g. 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 ). However, there is growing evidence for the application of biologically active plant compounds to the skin in orangutans. At Sabangau peat swamp forest in Central Kalimantan, two adult female and one adolescent female Bornean orangutans were observed chewing leaves of Dracaena cantleyi for three to five minutes and then rubbing the resulting green-white lather onto their arms and legs for up to 35 min 11 . Ten years later, a follow-up study confirmed the same behavior in six additional adult females and one flanged male of the same population (the lather was similarly applied and massaged into the skin for up to 45 min 6 ). The behavior appeared to be intentional as only specific body parts were treated, the behavior was repeated several times until the hair was fully wet and the entire process took a considerable amount of time 6 , 11 . Orangutans were never observed ingesting the leaves 6 . Dracaena cantleyi is a medicinal plant used by indigenous people for several medical treatments including sore muscles, joint or bone pain 6 , pain after a stroke 6 and swelling 11 . Indeed, pharmacological analyses revealed that Dracaena cantleyi inhibits TNFα-induced inflammatory cytokine production thereby acting as an anti-inflammatory agent 6 .

There are some brief anecdotal mentions of chimpanzees using leaves (plant species unknown) to wipe blood from their wounds 39 , 40 . Active wound treatment with a substance has only recently been documented for the first time in a great ape species. Chimpanzees of the Rekambo community ( Pan troglodytes troglodytes ) in the Loango National Park, Gabon, were observed applying insects to their own wounds (n = 19) and to the wounds of conspecifics (n = 3) 5 . The five adult males, one adult female, and one juvenile female applied the insects in the same sequence: they caught a dark-colored, winged insect approximately 5 mm in size (unidentified at the time of publication), immobilized it by squeezing it between the lips, then applied the insect to the wound moving it with their mouth or finger, then removed it. The last two steps were usually repeated several times. Further research is needed to investigate the efficiency of this behavior. Active wound treatment has also been described in a captive capuchin monkey, that was observed grooming her vaginal area and four of her own wounds with a sugar-coated tool 41 . However, as the authors noted that the capuchin was used to having her wounds treated with an antibacterial salve topically applied by caregivers.

We here report for the first time active wound treatment with a known biologically active plant substance by a male Sumatran orangutan in the wild, and discuss the hypothesis that this may be a form of self-medication to treat a wound and possibly prevent infection and accelerate wound healing.

The observations took place in the Suaq Balimbing research area (N 3° 02.873′, E97° 25.013′), a part of the Gunung Leuser National Park in South Aceh, Indonesia. The research area is approximately 350 ha and consists mainly of peat swamp forest. Since 1994, the wild Sumatran orangutans ( Pongo abelii ) at Suaq have been the subjects of non-invasive, almost exclusively observational research.

Subject information

A male Sumatran orangutan named Rakus was first observed in March 2009. At that time, Rakus was an unflanged male (i.e., adult but without secondary sexual characteristics 42 ) and was estimated to be born in the late 1980s. He is either a resident to the area or a frequent visitor 43 , 44 , 45 . Rakus went through a secondary growth spurt in 2021 and has been a fully flanged male since August 2021.

Data collection procedure

Data on orangutans at Suaq Balimbing are collected using all-day focal follows. Data collection starts when an individual is found or when they leave their night nest in the morning until they build a new night nest in the evening. Data is collected at two-minute intervals following standardized protocols for orangutan behavioural observations. Furthermore, all rare behaviors are described in detail on an all-occurrence basis in the notes section of the data sheets.

Rakus was a focal individual from June 22 (on the day this fresh wound was first noted) to June 26, from June 28 to 30, on July 5, July 19, and August 5, 2022. The wound treatment data was collected on June 25, 2022, and described in detail in the notes section of the data sheets. Unfortunately, no photos or videos were taken of the wound treatment.

We took detailed pictures of the plant specimen that was used by the orangutan to ensure reliable identification (see Fig.  2 ). However, due to a lack of the necessary permits, we were unable to collect and store a physical sample of the specimen. The pictures of the specimen were compared to the site’s detailed picture-based herbarium which was established at the beginning of the research activities at Suaq Balimbing via samples collected at the site in partnership with the National Herbarium of Indonesia and the National University of Indonesia (UNAS).

Ethical guidelines

The data collection in wild orangutans was strictly observational and collected without any interaction with the study animals. The research protocols were approved by the Ministry of research and technology (RISTEK; research permit no. 152/SIP/FRP/SM/V/2012 and following) and complied with the legal requirements of Indonesia.

On June 22, 2022, our research team (including UA) first noticed that Rakus had a fresh wound on his right flange (see Fig.  1 , see movie S1 ) and inside his mouth, first visible when he emitted a long call; see movie S2 ). How he got the wound is unknown, however typically flanged males acquire these kinds of wounds during fights with other flanged males. Vocal evidence of a fight between orangutan males was reported earlier on the same day of this observation.

Process of wound healing. Rakus fed on and later applied the masticated leaves of Fibraurea tinctoria to his facial wound on June 25. On June 26 he was again observed feeding on Fibraurea tinctoria leaves (see photo). By June 30 the wound was closed and by August 25 was barely visible anymore.

On June 25 at 11:16, Rakus started feeding on the stem and the leaves of the liana of Fibraurea tinctoria (see Fig.  2 ), also known as ‘Akar Kuning’ (for other synonyms and classification of the plant, please see SI, Table S1 ), which is part of the orangutans’ diet in this area. The liana is rarely eaten (0.3% of all feeding scans, n = 390′000), but 47 out of a total of the 132 orangutans on which we have collected feeding data were observed consuming its leaves, fruits, or parts of the stem. Thirteen minutes after Rakus had started feeding on the liana, he began chewing the leaves without swallowing them and using his fingers to apply the plant juice from his mouth directly onto his facial wound. This behavior was repeated several times and lasted seven minutes. After this period, at 11:36, flies of an unknown species appeared on the wound. Rakus then smeared the entire wound with the plant pulp until the red flesh was fully covered with the green leaf material. He then continued feeding on this plant for a total of 34 min. The next day (June 26), but not on any other of the following observation days (June 28, 29, 30; July 5, 19, 20), he ate leaves of Fibraurea tinctoria again for two minutes (pictures (Figs.  1 and 2 ) and one video (see movie S1 ) were taken on June 26th while he was feeding on Fibraurea tinctoria ).

Left: Pictures of Fibraurea tinctoria leaves. The length of the leaves is between 15 to 17 cm. Right: Rakus feeding on Fibraurea tinctoria leaves (photo taken on June 26, the day after applying the plant mesh to the wound).

Observations over the following days did not show any signs of the wound becoming infected (see photos taken on June 26 and 28; Fig.  1 ) and by June 30 the facial wound was already closed (see Fig.  1 and movie S1 ). By July 19, 2022, the wound appeared to have fully healed and only a faint scar remained (see Fig.  1 ).

Furthermore, UA (who collected the focal data) noted that Rakus rested more than usual after being wounded, which may positively affect wound healing as growth hormone release, protein synthesis and cell division are increased during sleep 46 , 47 . When considering the percentage of time spent resting (based on 2-min interval activity scans) between January 30, 2021 (since then he has been considered a flanged male; this is important to consider, as flanged males in general rest more than unflanged males 12 , 48 ) to February 22, 2023, we noticed that resting time increased after being wounded (June 22, 2022, to July 20, 2022; mean = 33 ± 17.2%) compared to the time before (January 30, 2021, to November 8, 2021; mean = 14.8 ± 7.4%) and that resting time decreased again after the wound had closed (August 5, 2022, to February 22, 2023; mean = 23.6 ± 12.9%; see SI, Figure S1 ). He spent more than 50% the day resting after he was found with the fresh wound (June 23, 2022; 52.2% of resting), the day after wound treatment (June 26, 2023; 51%), and four days after treatment (June 29, 2023; 54.3%; see SI, Fig. S1 ).

To the best of our knowledge, this study is the first systematic documentation of the putative active wound treatment with a biologically active plant substance in great apes and other non-human species. In this study, the flanged male orangutan Rakus was observed to selectively detach, chew, and repeatedly apply the chewed leave juice directly on his three-day-old facial wound for several minutes and covered the entire wound with a chewed-up leaf mash. Additionally, Rakus rested more when the wound was fresh compared to before and after wounding.

The treatment of human wounds was most likely first mentioned in a medical manuscript that dates back to 2200 BC, which included cleaning, making plasters and bandaging of wounds 49 . One of the earliest known wound care products used by the Sumerians, Greek, Mayans and Egyptians were oil, herbs, maggots, beer, vinegar, wine, green paint containing copper and honey 49 , 50 .

Fibraurea tinctoria , has other generic names such as Akar Kuning (Central Kalimantan), Akar Palo (Aceh), and Yellow Root (East Kalimantan 51 ). It is an evergreen, climbing plant in the family Menispermaceae, with a broad distribution across Mainland China, Indonesia, Malaysia, Thailand, Vietnam and other areas of Southeast Asia 52 , 53 , and is known for its analgesic, antipyretic, antidote, and diuretic effects, and is used in traditional medicine to treat condition such as dysentery, diabetes, and malaria 51 , 54 , 55 . All plant parts have been reported to be used for these medical applications, including leaves, stems, roots and bark 54 .

Pharmacological analysis of the plant’s chemical compounds shows the presence of furanoditerpenoids 56 , a special group of diterpenoids composed of one or more aromatic furan rings (with four carbon atoms and one oxygen), which are reported to have antibacterial, anti-inflammatory, anti-fungal, antioxidant, and anticarcinogenic biological activities 55 , 56 . Fibraurea tinctoria also has a high concentration of protoberberine alkaloids, which have anti-inflammatory, analgesic, anticonvulsant, antiamnesic, narcotic, antiarrhythmic, antihemorrhagic, hypotensive, antioxidant, antitumoral, antidiuretic, antiulcer, and muscle relaxant properties 57 . It also contains jatrorrhizine (antidiabetic, antimicrobial, antiprotozoal, anticancer, and hypolipidemic properties; reviewed in 58 ) and palmatine (anticancer, antioxidation, anti-inflammatory, antibacterial, antiviral properties; reviewed in 59 , 60 ). Among 38 plants used in ethnomedicine and grown in South Vietnam, Fibraurea tinctoria showed the highest activity tested for antimalarial effects 61 . It has also been shown that the leaves and stems of Fibraurea tinctoria inhibit the growth of several bacteria species, including Bacillus cereus , Staphylococcus aureus, and Escherichia coli 53 , 62 . Fibraurea tinctoria also showed a significant anti-inflammatory effect in reducing mouse paw edema 55 .

Like all self-medication behavior in non-human animals, the case reported in this study raises questions about how intentional these behaviors are and how they emerge. Similar to plant ointment behavior in Bornean orangutans 6 , 11 , the behavior of the Sumatran flanged male orangutan reported here appeared to be intentional as (I) he selectively treated his facial wound on his right flange with the plant juice (and no other body parts), (II) the behavior was repeated several times, not only plant juice but later also more solid plant material was applied until the wound was fully covered and (III) the entire process took a considerable amount of time. It is possible, that wound treatment with Fibraurea tinctoria emerges through accidental individual innovation 63 . Individuals may accidentally touch their wounds while feeding on Fibraurea tinctoria and thus unintentionally apply the plant’s juice to their wounds. As Fibraurea tinctoria has potent analgesic effects, individuals may feel an immediate pain release, causing them to repeat the behavior several times and subsequently apply solid plant matter possibly to also cover the wound as a protection against flies (as the case reported here suggests). Immature orangutans rely on observational social learning for the acquisition of their skill repertoires 64 and recent evidence suggests that social learning continues into adulthood 65 . Therefore, given that it occurs frequent enough and in social contexts, wound treatment with Fibraurea tinctoria may also spread socially from individual to individual.

However, up to date, in 21 years and 28′000 observation hours, we never observed any other orangutans at Suaq using Fibraurea tinctoria to treat their wounds. On the one hand, this may be due to the fact that we rarely encounter injured orangutans at Suaq. Due to high food availability, high social tolerance between orangutans and relatively stable social hierarchies (each area is usually inhabited by a dominant male and several females 66 ), there are few physical fights. However, during the time of this study, there was no clearly dominant male present in the research area. Rakus had just gone through his secondary sexual development in the year before the incident and, as a newly flanged male, he seemed to try to establish himself as the new dominant local male which is reflected in our behavioral data collected during this time. As a result of that, Rakus was involved in several long-call battles 66 and physical altercations with other flanged males that were resident in and around the area at that time. On the other hand, it may be that wound treatment with Fibraurea tinctoria has so far been absent in the behavioral repertoire of the Suaq orangutan population. Like all adult males in the area, Rakus was not born in Suaq (his origin is unknown). Orangutan males disperse from their natal area during/after puberty over long distances to either establish a new home range in another area (mostly as dominant flanged male) or are moving between other’s home ranges (as unflanged males or flanged males) 67 . Therefore, any adult male in an area does not originate from the area 67 . Thus, as of now, it is impossible to find out where the males come from. Therefore, it is possible that the behavior is shown by more individuals in his natal population.

Of the few injured orangutans that we observed at Suaq so far, we observed one other instance of possible wound soothing/treatment behavior. Flanged male named Pluto repeatedly put his injured finger into the water of a pitcher plant. The water may have had a cooling effect that could eventually relieve pain or help clean the wound.

Taken together, chemical analyzes of the properties of the Fibraurea tinctoria and the orangutan's particular goal-oriented behavior are consistent with the hypothesis that the process of preparing and applying herbal ointments may be a form of self-medication that reduces pain, prevents inflammation, and accelerates wound healing. The present study may thus present the first report of active wound management with a biological active substance in a great ape species and provides new insights into the existence of self-medication in our closest relatives and in the evolutionary origins of wound medication more broadly. As forms of active wound treatment are not just a human universal but can also be found in both African and Asian great apes, it is possible that there exists a common underlying mechanism for the recognition and application of substances with medical or functional properties to wounds and that our last common ancestor already showed similar forms of ointment behavior.

Data availability

The data of this study consist of detailed pictures of the wounded orangutan and the specimen used by the orangutan to treat the wound. All data are provided in the manuscript.

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Acknowledgements

The research at Suaq is funded by the Max Planck Institute of Animal Behavior, the University of Zurich, the SUAQ Foundation, Stiftung Mensch und Tier Freiburg im Breisgau, and by a Freigeist Grant of the Volkswagen Stiftung to CS. We acknowledge all students, volunteers and local field assistants involved in the collection of standard behavioural data at Suaq. We gratefully acknowledge the Indonesian State Ministry for Research and Technology Badan Riset dan Inovasi Nasional (BRIN), Departement Dalam Negri, the Sumatran Orangutan Conservation Program (SOCP), Yayasan Ekosistem Lestari (YEL), the local government in South Aceh, the Balai Besar Taman Nasional Gunung Leuser (TNGL) in Medan and Tapak Tuan, and the Director General Departemen Kehutanan (PHKA) for their permission and support to conduct this research. We also thank the Fakultas Biologi Universitas Nasional (UNAS) in Jakarta for their collaboration and support, in particular, Tatang Mitra Setia.

Open Access funding enabled and organized by Projekt DEAL.

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Development and Evolution of Cognition Research Group, Max Planck Institute of Animal Behavior, Konstanz, Germany

Isabelle B. Laumer & Caroline Schuppli

Department of Biology, Graduate Program, Faculty of Biology and Agriculture, Universitas Nasional, Jakarta, 12520, Indonesia

Arif Rahman & Tri Rahmaeti

SUAQ Project, Medan, Indonesia

Ulil Azhari

Yayasan Ekosistem Lestari (YEL), Medan, Indonesia

Fakultas Biologi, Universitas Nasional, Jakarta, Indonesia

Sri Suci Utami Atmoko

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Contributions

IBL wrote the manuscript. UA collected the data and took photos and videos. AR helped obtaining detailed accounts of the observed behavior and commented on the manuscript. TR helped to obtain detailed accounts of the observed behavior, translated the focal follow protocol from Indonesian to English and commented on the manuscript. H and SSUA commented on the manuscript. CS reviewed and edited the manuscript text.

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Correspondence to Isabelle B. Laumer .

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Laumer, I.B., Rahman, A., Rahmaeti, T. et al. Active self-treatment of a facial wound with a biologically active plant by a male Sumatran orangutan. Sci Rep 14 , 8932 (2024). https://doi.org/10.1038/s41598-024-58988-7

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Received : 19 December 2023

Accepted : 05 April 2024

Published : 02 May 2024

DOI : https://doi.org/10.1038/s41598-024-58988-7

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