Collectively our data suggests that in the context of an ongoing infection by malaria parasites, the relative frequency of monocytes to lymphocytes in peripheral circulation reflects an individual's capacity to mount an effective immune response. This is not surprising given that monocytes are an essential component of the innate immune response that acts as a link to the adaptive immune system through antigen presentation to lymphocytes. Thus any factors that perturb the function or relative frequency of either cell type could potentially affect an individual's response to infection. So why is the association between ML ratio and risk of clinical malaria only evident among parasite positive children?
Derangement in monocyte or lymphocyte function or frequency is likely to be most evident during an infection, and this may be supported by the observation that ML ratios were consistently higher among parasite positive children in all five cross-sectional surveys (see ). Thus, one possible explanation is that ML ratio is a marker of an individual's capacity to mount an effective immune response against clinical malaria but that it is most informative during an on-going parasite challenge. However, the possibility that presence of asymptomatic parasitaemia at survey merely reflects more frequent exposure to P. falciparum that allows greater power to detect associations between ML ratio and clinical malaria needs to be ruled out.
The innate immune response, through pro-inflammatory cytokines such as IFNγ, is thought to contribute to the initial control of parasitaemia following infection by P. falciparum
, but to also correlate with development of clinical symptoms 
. This has led to the notion that such a predominantly anti-parasitic immune response requires tempering by the adaptive immune response if effective immunity to clinical malaria is to be achieved. In fact, mounting evidence suggests that the balance of pro- and anti-inflammatory immune responses following exposure to malaria parasites may be an important factor in determining clinical protection 
. It is plausible that the ML ratio reflects where in the spectrum of these immune responses an individual is. Hence in the presence of an ongoing asymptomatic infection, a high ML ratio might indicate a predominantly pro-inflammatory immune response that renders individuals susceptible to clinical malaria, but with repeated exposure to P. falciparum
the adaptive immune response “learns” to produce anti-inflammatory cytokines that effectively temper the pro-inflammatory immune response, leading to a lower ML ratio and prevention of immunopathology. Assessment of the relationship between ML ratio and cellular immune responses is clearly needed if the mechanism underlying the association between elevated ML ratio and susceptibility to clinical episodes of malaria is to be determined.
Our study had several limitations. First, though we used data from children sampled at five annual cross-sectional surveys, both the ML ratios and parasite positive/negative status were measured at a single time-point within any year. Second, monitoring was not done for asymptomatic P. falciparum
infections hence there is no way of telling whether some children harbored asymptomatic infections in the previous week(s) during monitoring for clinical episodes or shortly before sampling of ML ratios at cross-sectional survey. This is further compounded by the possibility that our microscopy based parasite detection method, which is less sensitive than PCR 
, might have missed some low parasitaemia infections in children classified as parasite negative. The interaction between parasite positive/negative status and ML ratio in predicting risk of clinical malaria is likely to be dynamic and a better understanding of these relationships will be gained from future studies with more frequent sampling of ML ratio and PCR-based monitoring for both asymptomatic P. falciparum
infections and clinical malaria episodes. Finally, we did not assess the presence of co-infections, either at cross-sectional survey or during monitoring for clinical malaria episodes. Thus, the effect of potential helminth, bacterial or viral co-infections on the relationship between ML ratio and clinical malaria will need to be examined in future studies.
Despite these limitations our results support an association between high ML ratio at recruitment to cross-sectional surveys and increased risk of clinical malaria during follow-up. This observation now needs to be confirmed in other geographic settings.