Infection prevalence, as judged by RDT positivity rates, among 21,988 people sampled across 300 communities of the 15 northern states Sudan was very low, 1.8%. These results have not been corrected using polymerase chain reaction detection, to account for the documented false positive rates [13, 32] and it is possible that the true prevalence between October and November 2009 is lower. The prevalence documented across eight northern states in 2005 using microscopy was 3.7% and it is possible that prevalence might be declining in the northern states of Sudan. However, such comparisons should be made with caution because of the acutely seasonal nature of transmission in semi-arid areas and the limitations of point-estimates of transmission in such areas. Nevertheless against a background of low malaria infection risk, nearly one in five people reported a febrile event during the two-week period prior to the survey. It is not clear what the majority of these events represent in clinical and public health terms as almost 60% of febrile people do not seek any treatment and are apparently well during the survey interview. However 40% did seek treatment and almost half of these treatment actions included the use of anti-malarials. The prevalence of "malaria" treatment is higher than a point prevalence of infection and may suggest a degree of over-treatment. However, it is also important to note that the prevalence of infection is over six-times higher (OR = 6.2; Table 2) among patients with a fever on the day of the survey and in an area where transmission intensity is low and the acquisition of functional clinical immunity to new infections is low , infection may be more directly related to symptoms, as such the prevalence of fever and infection is closer to the reported anti-malarial use recorded during this survey. Clearly this presumes that those fevers that don't seek treatment are not associated with malaria and those who seek treatment are appropriately defined as malaria. Neither of these caveats can be tested directly through cross-sectional surveys.
When treatment for fevers was sought, over 70% of patients were managed at the Government's health facilities that are managed by State health authorities. The use of the private retail sector in the northern states of Sudan is not as prolific as described in many other African settings . Partly as a consequence of the high government sector use, the most striking observation was the wide-spread reported access to parasitological diagnosis among febrile respondents who sought treatment (53%; Table 3). Strengthened laboratory support for malaria diagnosis has been an important part of the recent malaria case-management strategy . It was not possible to stratify analysis on the reported test results as these data were incomplete and were not verified against patient or care-giver notes to distinguish true test positive results from the results told to the patients. However, what is clear is that parasitological testing per se did influence the prescriptions made and a higher proportion of tested patients received the nationally recommended first-line treatment compared for uncomplicated malaria to those not tested for malaria (data not shown). Separate studies are underway to examine the quality of care and prescription practices among health workers in the government health sector to investigate prescribers' adherence to parasitological test results and the associated prescriptions. The international milestones for successful implementation of case-management are currently anchored around 60%, 80% or universal treatment of all fevers with anti-malarial drugs within 24/48 hours [35–37]. The Sudan National Malaria Strategy for the northern states outlines the ambition that by 2012 "80% of malaria patients will receive prompt and effective treatment" . In addition the current national malaria strategy aims at reaching 100% laboratory confirmation of reported malaria incidence by 2010 . A more adequate target for Sudan and many countries in Africa is that all fevers are tested for malaria and all those reported as positive for malaria infection are treated with national first-line recommended therapy. That only 19% of fevers (and 45% of those who were treated with anti-malarials) were treated with nationally recommended AS+SP and that only 14% were managed with AS+SP within 48 hours is not a failure to reach established milestones as most fevers are not malaria and thus should not be held to account as a failure. Indeed it could be argued that the fewer fever/anti-malarial drug exposures the greater the success of programmes promoting effective diagnostic strategies.
Of greatest concern was the reported use of artemether, available in injectable forms at Government clinics, despite an international ban on its use to manage uncomplicated malaria by the World Health Organization in 2006 . The use of artemether in Sudan has been attributed to a belief by some prescribers and patients that injections have a stronger effect and work faster than oral medications and that there may be patient pressure to use these medicines [39, 40]. Furthermore parasitological diagnosis of malaria was a predictor of artemether use, where patients were almost 3 times more likely to receive this drug if tested compared to if no parasitological test was done (data not shown). Chloroquine and SP continue to be available at government clinics and are prescribed, more frequently if no parasitological diagnosis is attempted than when malaria testing is performed, despite the reported wide-spread resistance across Sudan to both these mono-therapies [22, 41, 42]. Non-adherence to national standard treatment guidelines at the point of care is common across many settings in Africa [43–47], previously reported in Sudan  and their reasons and determinants complex [45, 49]. Exploring the prescription practices and patient treatment actions demands a more rigorous combination of facility and community-based qualitative and quantitative investigations than was possible through the large-scale single cross-sectional sample survey described here.
About 67% of fevers that sought treatment in the current study were treated after 48 hours of onset of symptoms. Similar findings have been reported in Sudan where 40% of the fever cases sought treatment after 72 hours of onset of symptoms and a mean delay of 67.8 hours before attending a health facility [22, 50]. Lack of money, waiting for improvement, low coverage with health facilities, dissatisfaction with services, difficulty to reach the facilities especially during rainy season, and waiting for the effect of traditional remedies have been highlighted as some of the reasons for delayed treatment [26, 51].