MalariAI: A Label-Resilient Decoupled Framework for Annotation-Agnostic Cell Segmentation and Explainable Stage Classification in Dense Malaria Blood Smears

Abstract

Automated malaria diagnosis from blood smear microscopy is a critical global health AI challenge; expert scarcity remains the primary diagnostic bottleneck. Existing deep learning systems face three compounding failures: end-to-end detectors treat unannotated cells as background, skewing recall by annotation completeness rather than true cell recovery; Non-Maximum Suppression suppresses valid detections in dense smears; and pipelines lack per-cell spatial evidence for clinical audit. We present MalariAI, a two-stage decoupled framework addressing all three. Stage 1 applies an annotation-agnostic watershed algorithm to isolate every cell in a full 1600x1200 image, recovering 75.95% of ground-truth cells without any ground-truth input. End-to-end, the pipeline reaches a binary parasitized AP@0.5 of 29.10% - the clinically relevant metric for flagging any infected cell - while the stricter multi-class mAP@0.5 of 8.67% mainly reflects watershed's organic region boundaries being penalized against axis-aligned ground-truth boxes, not a localisation failure. Stage 2 fine-tunes EfficientNet-B0 with Focal Loss on ground-truth crops, achieving 98.36% classification accuracy - an oracle upper bound once a cell is correctly localised - with 87.5% and 75.0% accuracy on the rare schizont and gametocyte stages, versus 38.45% and 57.27% AP for a modern YOLOv8s detector evaluated end-to-end on the same classes. Grad-CAM++ heatmaps generated per detected cell provide instance-level spatial evidence for clinical audit; a quantitative energy-in-box analysis confirms this activation is concentrated on the annotated cell body significantly above a geometric chance baseline (+0.0485, paired p = 1.4 x 10^-33), letting microscopists verify predictions at the individual parasite level without sacrificing classification performance.