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Introduction

In the world at large, over 2(K) million malaria cas• es occur yearly, out of which two million progresses to se. vere disease. According to WHO's latest world malaria report, there were an estimated 247 million malaria cases and 619 000 malaria deaths worldwide in 2021 [1], with the major causative agent being Plasmodium falciparum [1]. According to WHO latest World Malaria report released on the 6th of April 2022 there were 241 million cases of malaria in the year 2020 compared to 229 million cases in 2019. The estimated number of malaria deaths stood at in 2020 compared to 411,0 deaths in 2018. In 2019 accord. ing to WHO statistics, nearly half of the world's population was at risk with most cases and deaths occurring in sub — Sa- haran Africa [2].

Despite all management measures put in place, malaria still tops the list of Cameroon’s Public health concerns and other parts of Sub–Saharan Africa [3]. Also, children under 5 years of age were the most vulnerable group for malaria and accounted for 97% of all malaria deaths worldwide in the year 2019 [1]. The management Of malaria involves a coherent productive approach which includes preventive measures that aim at controlling the vectors such as use of insecticide-treated nets (ITNs), indcxyr residual sprays (IRS) and parasite elimination by use of conventional drugs including artemisinin monotherapies and artemisinin-based combination therapies (ACTs) 151. Due to increase resistance of parasite to ancient drugs such as Chloroquinine and mefloquine, ACT have been recommended as the first line treatment for patients infected with uncomplicated Plasmodium falciparum [2]. Artemether/Lumefantrine (AL) is one of the approved and most successful fixed dose ACT used in the treatment of uncomplicated malaria by P. falciparum. Unfortunately, recent partial artemisinin resistance has been reported, to be characterized by slow parasitological response defined as delayed parasite clearance to treatment during the 3 days' treatment with AL as recommended by the WHO as the stipulated time for complete parasite clearance from infected blood [6]. Early diagnosis and prompt treatment with an effective drug regiment remain important components of malaria control and elimination strategies [71. In Cameroon, one of the recommended drugs for the treatment of uncomplicated malaria caused by Plasmodium falciparum, is AL which is commonly known as Coartem. In a previous study designed to evaluate the efficacy Of Amodiaquine-Artesunate versus Artemether Lumefantrine against uncomplicated malaria in children less than 14 years in Ngaoundere, Cameroon [81, it was reported that, both drugs were effective in parasite clearance and PCR-corrected cure. The rates were and 96.4%. However, several laboratorial abnormalities occur in the course of the infection such as anemia, thrombocytopenia, and methemoglobinemia, 191. Different substances or extracts have been in use today such as quinine and artemisinin were either obtained directly from plants or are derivatives of plant components [10]. As such, plants have always been considered to be a possible alternative and rich source of new drugs. T. occidentalis for example (commonly known as pumpkin leaves); has been reported to exhibit antiplasmodial activity both in the 4-day early infection test and in established infection with a marked increase of the mean survival time [l II, The leaves of Telfairia occidentalis showed the presence of phenolic compounds, flavonoids, phytosterols, tan- nins, saponins, chlorophyll and glycosides which have reported to exhibit chemo suppressive activity [12]. Tel. fairia occidentalis prcÆuced a dose-dependent improve. ment in the seminal fluid analysis and the histology of the testes, showing a near complete morphological regeneration and increased spermatogenesis [13]. The leaf extract Of T. occidentalis increased sperm motility, sperm viability and sperm count in rat [141. Other components of the plant such as arginine, vitamin C and zinc may also play impor- tant roles since studies have shown that nutritional thera• pies with zinc, vitamin C, vitamin E and arginine proved to be of benefit in the treatment of male infertility [121, Both aqueous and ethanolic extracts of T. occidentalis leaf have hepatoprotective although the aqueous extract was more effective than the ethanolic extract, which could be attributed to the higher antioxidant activity of the aque- ous extract than the ethanolic extracts of T. occidentalis leaves [15].

The leaves are good sources of K, Cu, Fe and Mn, moderate sources of Mg and Zn which are essential in human and animal nutrition [161, "Ihe high content of Fe in the young tender fluted pumpkin leavesserves as the basis for which the leaf extract is administered traditionally as blood tonic in the treatment of anemia and to convalescing patients, With these numerous therapeutic potentials, pumpkin leaves can therefore used not only as a food sup- plement but also an adjunct therapy in the management of malaria alongside ACTs which is the first work carried out so far. This study aimed to investigate the effect of Telfairia cxcidentalis on the hemoglobin level of malaria patients, the clearance rate of parasite in the blood and its effects on liver activity of children less than 16 years of age,

Methods

Study Area

The study was carried out in the Bamenda Regional Hospital, Gilead Health Center and Solaman Multi-Care Foundation Laboratory which are all based in Bamenda situated in the Northwest Region of where it funds as the regional administrative headquarter. Bamenda is found in Mezam division and located between latitudes to 5058 North of Equator and between longitude 108 and 10010 East of Greenwich Meridian [18]; and oc. cupies a total surface area of 3,125 hectares 1191. It is bound. ed by Bafut subdivision to the North, flanked to the West by Mbengwi, to the South by Santa sub-division, to the South. west by Bali subdivision and bordered by Tubah sub-divi. Sion in the East

Study Design

This study was a randomized open label clinical trial carried outfrom March 2022 to May 2022 to assess the effect of Telfairia occidentalis on the Hemoglobin level, the liver enzyme activity and parasite clearance rate when in combination with artemether lumefantrine (AL) treat- ment regimen in children. After a proxy-informed consent was gotten from parents/guardians, children aged 3 to 16 years whopresented clinical signs and were diagnosedwith uncomplicated malaria and parasitaemia count above 20 blood, were recruited for this study through ran. dom sampling as case group. Subjects without malaria were recruited as control group. screened for the presence of co-infections were excluded from the study.The study was designed to have one control group and three treatment groups (Groups 1, 2, 3 and 4). Upon meeting all enrolment criteria, participants were randomized to receive either of the two treatment regimens; (i) AL (Coartem; Novartis Pharma AG, Basel Switzerland- 20 mg artemether and 120 mg lumefantrine) as a standard or (ii) therapeutic dose of AL and therapeutic dose of Telfairia occidentalis

Sample Population and Randomization

Overall, of 180 participants included in this study, 75 were females and 69 were males. Seventy participants were malaria positives giving a prevalence of 38.88% (70/180). Of the overall, 120 participants of all age groups were divided into 4 groups, 70 were study patients positive for malaria and 50 were the control group negative for malaria. Also, of the overall participants, a subset of 74 chil- dren between the ages of 3 to 15 belonging to the control and malaria infected group were selected for treatment. The children were enrolled and assigned to Four groups (control (RP, BP), AL, AL + RP and AL+BP groups) randomly in. cluding 70 malaria positives to the study groups 2, 3 and 4 (AL, AL + RP and AL+BP groups respectively) and 50 malaria negatives in the control group (Group l)- FOL low.up was done for seven days for the assessment of Hemoglobin Level and Liver Enzyme Activity.

Drug Administration, Treatment and Grouping

The 70 patients recruited as malaria cases were placed into three groups (groups 2, 3 and 4). Group 2 received artemether lumefantrine only while group 3 received artemether-lumefantrine together with capsulated Raw Telfairia cxcidentalis and group 4 received artemether lumefantrine together with Boiled Telfairia occidentalis Group one was made up of non-positive cases, that is children whose microscopic examination did not show the presence of P. falciparum or any other malaria species and were called normal individuals.

For group 2, artemether—lumefantrine was admin. istered according to the manufacturer's prescription which is based on the weight ofthe child. The treatment lasted for a period of 3 days (72 hours) with a treatment inter. val of 8 hours as recommended by WHO. That is, drugs taken twice a day; morning and evening [21]. For 5 kg to less than 15 kg body weight, patients took one tablet as an initial dose, I tablet again after 8 hours and then I tablet twice daily (morning and evening) for the following 2 days (total course of 6 tablets). For 15 kg to less than 25 kg bodyweight, two tablets as an initial dose, 2 tablets again after 8 hours and then 2 tablets twice-daily (morning and evening) for the following 2 days (total course of 12 tablets). For 25 kg to less than 35 kg bodyweight, three tablets as an initial dose, 3 tablets again after 8 hours and then 3 tablets twice-daily (morning and evening) for the following 2 days (total course of 18 tablets). For 35 kg bodyweight and above, four tablets as a single initial dose, 4 tablets again after 8 hours and then 4 tablets twice-daily (morning and evening) for the following 2 days (total course of 24 tablets). Each tablet of AL contains 20 mg of artemether and 120 mg of lumefantrine. For group 3 and 4, artemether lumefantrine was ad. ministered the same way as in group 2 Telfairia occidentalis was administered on age ranges.

For follow—up, the treatment was initiated on IN) (enrollment Day) and participants were asked to return to study clinic on days 1, 2 and 7. On each follow-up day, study participants were assessed for any symptoms, Bassible adverse effects, concomitant medication, measuring axillary temperature and collecting samples. In case a partici- pant did not show up at the clinic, a field worker was sent to the house to find out the reason and possibly to bring the participant at the clinic for clinical examination and sam- pling. At all visits, blood was collected by finger-prick for blood smears and 2mls of blood collected in red tubes for lipid V%trameter quantifications. A patients' case report form was filled each day of follow up. 111is was to check for de- crease of clinical signs of malaria (fever, temperature, vomit. ing, loss of appetite, abdominal pain, headache, dizziness and weakness) and if there was any adverse effect of the drug administered.

Hemoglobin Measurement

Hb measurements were done using the mission plus Hb Hemoglobin Testing System VR (AconBiotech San Diego USA) intended for the quantitative determination of hemoglobin (Hb) and calculated hematocrit (Hct) in capillary and venous human whole blood. Before collecting the sample, the individual's finger was cleaned with a cotton containing a prepared 75 % alcohol, after which a lancet was then used to prick the finger, The first blood was wiped off using a cotton and a light pressure applied to obtain a second drop of blood. About 10gL of capillary blood was then collected using a capillary transfer tube. The tube was held slightly downwards and its tip touched the drop. Capillary action automatically draws the sample to the fill line and stop. The Hb meter turned on after it was correctly set with the correct time and the appropriate test strip was inserted and its c€kle shown on the screen of meter after insertion for confirmation. After some few seconds after inserting the test strip a signal is made for specimen to be applied in the specimen application area. The tip of the capillary transfer tube was then aligned with the specimen application area of the strip and the second drop of blood approximately applied, After which the Hb and Hct were read after a few seconds and the respective readings were noted at every occasion. This procedure was repeated for Dl, D2 and D7 follow up of patients.

Malaria Parasite Count Estimation

The method used for quantification or estimation of density in enrolled patients was microscopy which was performed by counting within a given number of microscopic fields against counted white blood cells (WBCs) within the same fields [21] with an assumed WBC count of 8.0 x 109cells/L Blood samples were collected from patients on DO upon recruitment by finger pricking using lancets and the slides labelled with patient ID number and day of collection. The blood was then made to drop on a clean sterilized microscopic slide (approximately 10111) and a thick smear made in a circular motion, The slides were allowed to air dry before staining with giemsa Air dried slides were fixed with methanol by dipping into the container of methanol for 2—3 minutes, 'Ihe slides were then placed back-to-back in a staining trough containing giemsa solution making sure all fixed sample faced to one direction and allowed for 20 minutes, After which the slides were rinsed with clean water, allowed to air dry for 5minutes then viewed under the microscope. The slides were examined under the xl(H) oil immersion objective lens of a light microscope, 'Ihe asexual parasites density was counted against WBCs counted in microscopic field examination, A patient was considered positive if P. falciparum was seen during the microscopic examination. This procedure was repeated for Dl, D2 and D7 follow up of patients.

Liver Enzyme Activity Measurements

The method used for the measurement of ALT, AST and GGT was spectrophotometry using the Humalyzer 3500 machine which is automated with a built-in inventory management system. On DO, D3, D7 of follow-up, 2ml of blcx.yd was collected from patients via venipuncture and placed in to a 4ml EDTA test tube. samples were cen- trifuged using a centrifuge at rpm for 15 minutes as per standard clinical laboratory procedures. The plasma was then separated and transferred into dry tubes and stored in a refrigerator set at 0 to 40C.The samples were then ana- ly-zed using Humalyzer 3500 for AST, ALT and GGT which uses enzymatic colorimetric and spectrophotometric test. Blood analyzed were collected on DO before treatment and D2 and D7 after treatment.

Data Analysis

Data were entered and analyzed using Microsoft excel 2013 and Graph Bld prism version 8.0.1. Descriptive statistics were done, All values were expressed as Mean ± S.E (Mean standard error of Difference). The analysis of variance (ANOVA) was employed to know mean differences of liver enzymes and parasite density. P-values < 0.05 were considered as statistically significant and Confidence limit was at 95%.

Results

Socio-Demographic Data

The baseline characteristics of participants (180) who met the inclusion criteria are displayed in Table 1. Of the overall, children enrolled had a mean weight of 36.4 kg. There was a significant difference in hemoglobin (Hb gldL) study cases and control group (p = 0.02) and a significant difference in temperature.

The combined effect of Telfairia occidentalis and AL on the parasite clearance rate in children infected with Plasmodium falciparum

We observed a positive response in individuals suf. fering from P. falciparum who received AL + Placebo as their only treatment. Their parasitemia dropped from high- er to lower values of trophozoites/ul of bloodwith a signifi- cant change even though during the third day (D2) of treat- ment some trophozoites were still found in the blood sam- ples of some patients as shown in the figure below (l a), It was observed that there was a significant difference in mean between Do and D1 at 4000ul of blood and 1500ul of blood (3778±378.3), 95% Cl(1044 to 3467) with p.value 0.0015, as well as between DO and at 4(mul of blood and The ef- fect of AL+BP on the parasite clearance rate of P. falci- parum infected children among the different treatment days showed a significant decrease in parasitemia between DO and D7 from 35(X) trophozoites/ul of (3450±861.3) with a p.value ofO.02 and O trophozoites/ul of blood. Mean. while the analysis also showed a in parasitemia tweenD1 vs D2, Dl vs D7and D2 vs D7 though not statisti- cally significant (Figure lb). The combined effect of AL + RP on the parasite clearance rate between the different days of treatment showed a significant decrease (p-value s 0.05) in the number of parasites (Figure lc). No trophozoites were observed on D2 and D7 showing a significant decrease with p.value 0.0037.

Comparison between BP+ AL and Placeb0+ AL, RP + AL and Placebo + AL effects on parasite clearance

As shown in fig 2, parasite clearance differs, though not statistically significant, except for D2 in figure 2a which showed a significant decrease in mean from 3000 trophozoites/ul of blood (30.0±0.0), 95% Cl 95.22 to (504.8) With p-value S 0.05. 'Ihe parasite clearance rate washigher in the BP+AL group from 35(K) trophozoites/ul of blockl (3756±1170, to p>0.05) trophozoites/ul of blood (112.5±106.7, P>0.05) compared to the placebo + AL group from trophozoites/ul of blood (3475±1170, p>0.05) to 8(K) trophozoites/ul of blood (300±106.7, p>O.05). In the RP + AL group a small decrease in para sitemia was observed though not statistically significant as no parasites were seen after the third day of treatment (02) and D7 of follow up from 4000 trophozoites/ul of blood (3412.5±1044, p>0.05) in D0 to 0 trophozoites/ul of blood.

Hemoglobin levels in normal individuals and malaria patients

An increase in the means of Hb in children not af- fected by the parasite from that Of individuals affected by the parasite was observed as follows, According to the differ- ent treatment days it was observed that, on DO an incre- ment was recordedfrom 1030g/dL to 12.19 gldL with a P-- value of 0.02, Dl from 10.M)g/dL to 12.19g/dL with a p-val- ue of 0.02, from a mean of 10.79g/dL to a mean of12.31g/dL and a p. value of 0.11 and D7 from a mean ofll.08g/dL to 12.43 and with a p.value of 0.13, even though days 2 and 7 were not statistically significant. In the Sadik's multiple comparison of the means of Hb in normal, there was a general increase in the Hb level in the blood sam- ple of normal childreneven though not statistically signifi- cant from days 2 and 7. There was a decrease in the means of Hb in children not affected by the parasite (RP vs BP) from that of individuals affected by the parasite. DO from 12.26g/dL to 12.19 gldL with a p-value of 0.98, Dl from 12.26g/dL to 12.19g/dL with a p.value of 0.98, D2 from a mean of 12.49g/dL to a mean and a p. value of and D7 from a mean to 12.42g/dL and with a p.value of 0.43, even though days O, I and 7 were not statistically significant, while a decrease in mean was as well observed between RP vs PA(Placebo + AL) though statisti- cally significant-DO from 12,26g/dLto 10.63g/dLp-value Dl was from 12.26g/dL to 10,63g/dL with a p.val. ue of D2 from 12.49g/dL to 10.03g/dL with a p-val• ue of and D7 was from 1300g/dL to 10.21g/dL with p.value and Bp vs PA showed a decrease in mean as well though statistically significantD012.19g/dL to 10.03g/dL with p.value 003, Dl was from 12.19g/dL to 10.03g/dL with a p.value of D2 from 12.31g/Dl to 10.03g/dL with p-value and D7 from 12.43gJdL to 10.21g/dL with a p.value of 002

Effects of Artefan +Placebo, RP and BP on the Hb level of Test and groups

In the bar chart Tukeys multiple comparison, it was observed that there was an increase in Hb between RP vs BP (figure 3 bl) though not statistically significant, while a significant increase in Hb was observed between RP vs PAL (b2) with a very tiny p-value of as well as be- tween BP vs PAL With a small p-value Of 0.003.This Ob- served increments in the hemoglobin levels as displayed by the graphs below can be attributed to the fact that the active ingredients iron specifically are still very much intactthere by boosting the hem+bin levels most especially in the RP group.

Therapeutic effect of Telfairia occidentalis on liver activity of Plasmodium falciparum infected children

Therapeutic effect Of RP, BP and AL+ Placetbo on liver activity

It was observed that, the AST, ALT and GGT levels in the RP group showed a great significant decrease between the different days, compared to the BP group which as well showed a significant decrease in these liver enzymes The level of these enzymes decreased significantly as well in the treatment group (AL + Placebo) (p 0.01). An observed decrease in the three Liver enzymes in the RP + ALcan be explained by the fact that the phytochemical contentsof this functional focxi was still intact, unlike in the BP + RP group wherein we observed a small significant decreasecan be dueto thermal denaturation of most of these phytochemicals thereby decreasing its effects

Effect of BP +AL and RP + AL on liver activity of Plasmodium falciparum infected children

The figure 5 shows comparison of the effect of BP+ AL and RP + AL on the liver activity of the patients (treatment groups) which showed no significant difference between the different liver enzymes (ALT, AST and GGT) during the different treatment days though it was observed that there was a decrease in mean during the different treatment days. Figure a showed a significant decrease in ALT for both treatment groups (BP and RP *AL) on p and (40.53±2.715, p 0.003).

Effect Of BP +AL and Placeb0+ AL on liver activity of Plasmodium falciparum infected children

The below figure 6 shows comparison of the effect of BP + AL and Placebo + AL on liver activity of the treatment group.lt was in Figure 6(a) that there was a significant decrease in mean of AST between the two treatment groups with mean difference (21.87±2.244, p< 0.0001), as well as in means Of ALT figure 6(b) With mean difference (6.390±2.053,p0.0302) though no significant difference was observed on 07 of follow up, but inthere was no significant decrease in mean of GGT was observed between the two treatment groups.

Comparison between RP +AL and Placebo+ AL on the liver enzyme activity of Plasmodium falciparum infected children

A comparison of the effect between RP + AL and AL + Placebo on the liver activity enzymes of P, falciparum infected children is shown in figure 7, It was observed that there was a significant increase in means of AST and ALT between the two treatment groups, AST po.0153) on DO, (-15.39± 3.085, po.0012) on m, (-17.87±2.693, and (-21.24±-21.24, p< o.01) on m, ALT (16.75±5.385, po.0332) on DO, (1666±4.884, pO.0223) on DI and no significant difference was observed on D2 and D7 of treatment. There was no observed significant difference in GGT between the two treatment groups.

Comparison Of the different treatment groups Parasitemia levels between AL + placebo vs. AL + RP, AL + placebo Vs. AL + BP and AL + RPVs. AL + BP

Figure 8 below brings out comparison of parasite clearance rate among the different treatment groups, and it observed that there was a significant parasite clearance rate in the AL + RP group as compared to the other two treatment groups that is AL +placebo and AL + BP groups.

HB level between AL + placebo vs. AL + RP, AL + placebo Vs. AL + BP and AL + RPVs. AL + BP

Figure 9below brings out comparison of HB levels among the three different treatment groups, and the results obtained shows that there was a significant difference in means of HB level of the AL + RP treatment group from (10.93± 0.1225), (12.43±0.1225) with p-value when compared with the AL + placebo group and from (9.37± 0.1500), with p.value 0.0007 when compared with AL + BP group.

Liver enzyme activity between AL + placebo vs. AL + RP, AL + placebo Vs. AL + BP and AL + RPVs. AL + BP

It was observed in figure 10 below when a compari- son of the three liver enzymes activity (ALT, AST, GGT) we compared among the three treatment groups that, there was a significant decrease in ASTin the AL + RP groupfrom (49.94± 1.532),(22.61± 1.532) with p-value when compared with the AL + placebo group, main while no significant difference in the decreased liver en- zyme (ALT)was observed when the AL + RP group was compared with the AL + BP group from (22.61± 3.466). For ALT and GGT no significant decrease was observed in these two liver enzymes among the different treatment groups when compared.

Discussion

Anemia is a common blood disorder that affects people of all age groups [211. It is marked by a reduced red blood cell (RBC) countand hemoglobin (Hb) levels [22]. Iron deficiency induced anemia negatively affects motor and development, resulting in fatigue and low pro- ductivity. During parturition, it may be linked with reduced birth weight and an increased risk of maternal and perinatal death [231 [241. In 2013, iron deficiency anemia accounted for approximately deaths in both sexes across all age groups in developing nations 171. Anemia is one of the sever- al diseases asserted to have been successfully treated with plant principles by herb doctors [211. In the recent past, an assortment of natural compounds from plant extracts has been studied by different researchers [251. This study was aimed at evaluating the effect of Telfairia occidentalis on the hemoglobin level, parasite clearance rate, and liver enzyme activity in children in the age of range 2 to 15 years.

This study investigated the parasite clearance rate in three treatment groups. T. xcidentalis in combination with AL recorded a high rate of parasite clearance, in the case group 3 ( RP + AL) when compared with the case groups 2 ( AL + Placebo) and 4 ( BP + AL ) where there was no recorded significant difference in parasite clearance rate between the two groups.ln case group 3 it was recorded that there was a significant total parasite clearance on D2 as compared to case groups 2 and 4 where there was no significant difference in parasite clearance, but there was a complete parasite clearance on D7 in all three case groups-No significant difference was recorded for DO and Dl for all the three case groups. Furthermore, signs such as high temperature, fever and vomiting were not the case for those who took AL+ RP, AL + BP during the treatment days but these was found to be the case for in AL + Placebo group, whereas patients in the AL+ RP and AL + BP groups were not indifferent in the case Of appetite from those in the AL+ Placebo group. It was also observed that the AL + RP group exhibited the highest parasite clearance rate when compared with the other treatment groups (AL + placebo, AL +BP). The possible explanation for this could be that T. occi- dentalis played a role in the eradication of parasitemia in the host's blood, which had a combined effect with that already done by AL and subsequently increased the parasite clearance rate. This could be because of the rich content of flavonoids, tannins, alkaloids, saponins, and alkaloids. Previous research has shown that, T. occidentalis has a potent antioxidant capacity through its ability to prevent lipid peroxidation and DNA damage and to increase the of antioxidant enzymes [26]. The antioxidant and anti-inflammatory effects of this plant result from the carotenoids, vitamins C, flavonoids, and other substances it contains. As the body cannot manufacture these nutrients, they must sup. plied in the diet. Therefore, the synergistic antimalarial effect of T. occidentalis when used in combination with ACT likely resulted from the antioxidant activities that are associated with the beta carotene (carotenoids) and chlorophyll it contains [27]. The results obtained from this study are there. fore in line with those of Okokon et al, [28], whoreported significant antiplasmodial activity With the seed and leaf extracts of T. occidentalis durin ear and established infections. The seed extract exhibited schimntocidal activity. An- tiplasmodic activity Of fluted pumpkin was also validated by Adegbolagun et al, [29], who documented a reduction in parasitemia within 48 hours, when bergheiinfected albino mice were administered an aqueous extract of T. cxcidentalis alone or in combination with artesunate.

Being one of the largest organs in the human 1301, the liver plays a key role in the regulation of variegated processes, which include metabolism, storage, secretion, and detoxification of endogenous and exogenous com- pounds 13 II. Hepatocytes are the functional cells of the liver [32]. Globally, liver disorders are a major problem. Ortho- dox drugs employed in the treatment of liver diseases are sometimes ineffective and can have grave untoward effects [33]. In addition, the treatment interventions are usually expensive for resourcepoor countries. Herbal medicines constitute a group of therapeutic agents with a lowside effect profile.

In this study, all participants in groups 1A and B registered a normal Hb level compared to the other groups. However, such levels were lowered, though not statistically significant in children with malaria compared to the healthy control. lhere was no significant difference in Hb levels between the two control groups (RP and BP), but a significant difference in Hb levels was observed between RP vs. placebo + AL and between BP vs. placebo + AL. There was a significant difference in Hb (increased in AL + RP) when the three treatment groups were well compared. "Ibis increase in hematological parameters (Hb and Hct) investigated could 1k as a result of some constituents such as iron and some B complexes vitamins that it B)ssesses as the* serve as hematopoietic factors that influence directly on blood production in the bone marrow [34]. This study agreed with the findings of [35], who reported that, consequently upon administration, the methanolic leaf extract of T. dentalis stimulated si 'ficant erythropoietin and leukopoi-in mice. Atabo et al, 1361, demonstrated that leaf, seed, and stem extracts of fluted pumpkin have the capacity to reduce endogenous methemoglobin (metHb) concentrations converting metHb to Hb at a high rate. Ogbe., et al in 010, [211 found that an oral daily dose of T. cxcidentalis showed significant antianemic activity in phenylhydrazineinduced anemia in rabbits. A significant increase in Hb was al") reported bylweala E., 137], whodocumented the ematinic activity of the aqueous crude extract. According to the findings of [38], preparations of fluted pumpkin significantly increased PCV, Hb concentrations, RBCs, and white cell (WBC) counts, This study also corroboates with the work of Salman et al. 1391, who reported that there was a significant increase in the hematological parame- rs of rats that were treated for two weeks with the aqueous leaf extract of fluted pumpkin. Some scientists have proposed the use Of fluted pumpkin in the treatment Of anemia, following studies that reported that extracts of fluted pumphelped to maintain blood levels in subjects given their extracts 1401. This study further explored the combined efect of T. occidentalis and AL on the liver activity enzymes.The group control group IAadministered with RP showed a significant decrease in all three liver enzymes analyzed (AST, ALT and GGT) when the different treatment days re compared,as compared to the BP control group which showed a significant decrease in AST and C,CGT but no significant difference was observed for ALT when D2 was compared with D7. While for case group 2 (AL + Placebo) a sig- nificant decrease in AST and ALT was recorded When the different treatment days were compared except for GGT where there was no significant difference when Dl was compared with D2. When a comparison between case groups 2 and 4 was made, it was observed that there was a significant decrease in AST, while a significant decrease in ALT was recorded just for DO and Dl but no significant decrease on and D7, between case groups 3 and 4 was made, it was also observed that there was a significant decrease in AST and ALT except for D7 where no significant decrease was recorded, meanwhile no significant decrease was observed with GGT. When group 3 was compared with group 4, it was noticed that there was a significant decrease in AST on DO and there was no observed significant decrease on days l, 2 and 7, while no significant decrease was recorded for ALT and GGT from which we can draw a con.clusion that RP group IA and case group 3 recorded the greatest effect on decreasing the three analyzed liver en. zymes. This can be attributed to the rich phenolic content of T. cxcidentalis as well as its antioxidant potentials. A significant difference in AST was also observed in AL + RP group when compared with the other treatment groups (AL + placebo and AL + BP), While there was no significant difference in ALT and GGT when the treatment groups where as well compared. The results of this study were in agreement with those of Oboh G., et al, [41 | who reported that an aqueous extract of fluted pumpkin was more effective than the ethanolic extract in protecting hepatcxytes against garlicinduced oxidative stress. NwannaEE., et al 1421 in their work found that both solublefree and bound phenolic ex. tracts of the leaves protected hepatocytes from oxidative stress. However, solublefree phenolic extract showed signifi- candy higher hepatoprotective activity as compared to bound phenolic extract. Ihe hepatoprotective property of fluted pumpkin may be attributed to its rich phenolic content as rted b Obohetal [21].

Conclusion

This study investigated the effectiveness of artemether/lumefantrine and its combination with raw or boiled leaves of T. occidentalis in the treatment of uncomplicated malaria. The degree of anemia was lowered as evidenced a restored hemo in level and there was a rapid parasite clearance upon administration of the combination of T. occidentalis and artemether/lumefantrine. The young leaves of T. occidentalis significantly normalized the level of hepatic enzyme activity in the course of the treatment of P. falciparum infected children, Globally, it can concluded that, the combination artemether/ lumefantrine with the leaves of T. Occidentalis can be effective in the treatment of malaria and that the effects are more pronounced in combination with the raw leaves of T. occidentalis. Thus, this study displayed T. occidentalis as an enriched functional food with outmost benefits to human health when consumed naturally.

Ethical Consideration

Ethical approval was sought and obtained from the Regional of public health Bamenda, Northwest Region Cameroon through N/Ref: 028/ATT/NWR/RDPH/BRIGAD of 8 th FEBRUARY 2022: and the Ethical and Research committee of the University of Bamenda, Northwest Region Cameroon. A Proxy-informed consent was gotten from all individuals enrolled in the study or from parents and guardians of the children for their willingness to participate in the study after explaining the rational of the study and en-Suring their confidentiality. Participation was voluntary.

Disclosure statement

The authors, declare there is no conflict Of interest

Acknowledgements

The authors appreciate the technical staff of the Bamenda Regional Hospital, Gilead Health Center and Soleman Laboratory for their support.