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Borgstein A, Zhang B, Lam C, Gushu MB, Liomba AW, Malenga A, Pensulo P, Tebulo A, Small DS, Taylor T, Seydel K. Delayed presentation to hospital care is associated with sequelae but not mortality in children with cerebral malaria in Malawi. Malar J 2022; 21:60. [PMID: 35193585 PMCID: PMC8864854 DOI: 10.1186/s12936-022-04080-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2021] [Accepted: 02/06/2022] [Indexed: 11/10/2022] Open
Abstract
Background Cerebral malaria is still a major cause of death in children in sub-Saharan Africa. Among survivors, debilitating neurological sequelae can leave children with permanent cognitive impairments and societal stigma, resulting in taxing repercussions for their families. This study investigated the effect of delay in presentation to medical care on outcome in children with cerebral malaria in Malawi. Methods This retrospective study included participants enrolled in a longstanding study of cerebral malaria between 2001 and 2021 and considered coma duration prior to arrival at hospital (with or without anti-malarial treatment), HIV status, blood lactate levels at admission and age as factors that could affect clinical outcome. Outcomes were categorized as full recovery, sequelae at the time of discharge, or death. A multinomial regression was fit and run controlling for coma duration, HIV status, lactate levels and age, to determine the association between each explanatory variable and outcome. Results A total of 1663 children with cerebral malaria, aged 6 months to 14 years were included. Longer coma duration (in hours) was associated with greater odds of developing sequelae (OR = 1.023, 95% CI 1.007–1.039, p = 0.006) but not death (OR = 1.00, 95% CI 0.986–1.015, p = 0.961). Younger age (in months) was also correlated with higher rates of sequelae, (OR = 0.990, 95% CI 0.983–0.997, p = 0.004) but not with increased mortality (OR = 0.998, 95% CI 0.993–1.003, p = 0.335). Blood lactate levels on admission were correlated with mortality (OR = 1.125, 95% CI 1.090–1.161, p < 0.001) but not associated with increased rates of sequelae (OR = 1.016, 95% CI 0.973–1.060, p = 0.475). Positive HIV status and treatment with an anti-malarial (artemisinin or non-artemisinin-based) prior to arrival at the hospital were not significantly associated with either adverse outcome. Conclusions In Malawian children with cerebral malaria, higher rates of sequelae were significantly associated with extended coma duration prior to admission and younger age. Mortality rates were correlated with increased lactate levels on admission. The differential effects of variables on clinical outcomes suggest that there may be different pathogenic pathways leading to sequelae and death. Actions taken by parents and health care professionals are critical in defining when patients arrive at hospital and determining their ultimate outcome. Supplementary Information The online version contains supplementary material available at 10.1186/s12936-022-04080-2.
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Affiliation(s)
- Arabella Borgstein
- Blantyre Malaria Project, Kamuzu University of Health Sciences, Private Bag 360, Blantyre, Malawi.,St. George's University of London/University of Nicosia Medical School, Nicosia, Cyprus
| | - Bo Zhang
- Department of Statistics and Data Science, The Wharton School, University of Pennsylvania, Philadelphia, USA
| | - Colin Lam
- Bronx High School of Science, Bronx, NY, USA
| | - Montfort Bernard Gushu
- Blantyre Malaria Project, Kamuzu University of Health Sciences, Private Bag 360, Blantyre, Malawi
| | - Alice Wangui Liomba
- Blantyre Malaria Project, Kamuzu University of Health Sciences, Private Bag 360, Blantyre, Malawi
| | - Albert Malenga
- Blantyre Malaria Project, Kamuzu University of Health Sciences, Private Bag 360, Blantyre, Malawi
| | - Paul Pensulo
- Blantyre Malaria Project, Kamuzu University of Health Sciences, Private Bag 360, Blantyre, Malawi
| | - Andrew Tebulo
- Blantyre Malaria Project, Kamuzu University of Health Sciences, Private Bag 360, Blantyre, Malawi
| | - Dylan S Small
- Department of Statistics and Data Science, The Wharton School, University of Pennsylvania, Philadelphia, USA
| | - Terrie Taylor
- Blantyre Malaria Project, Kamuzu University of Health Sciences, Private Bag 360, Blantyre, Malawi.,Department of Osteopathic Medical Specialties, College of Osteopathic Medicine, Michigan State University, East Lansing, MI, USA
| | - Karl Seydel
- Blantyre Malaria Project, Kamuzu University of Health Sciences, Private Bag 360, Blantyre, Malawi. .,Department of Osteopathic Medical Specialties, College of Osteopathic Medicine, Michigan State University, East Lansing, MI, USA. .,Malawi-Liverpool-Wellcome Trust Research Programme, Kamuzu University of Health Sciences, Blantyre, Malawi.
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Abstract
BACKGROUND The impact of HIV infection on malaria is unclear in nonendemic areas. In endemic territories, HIV has been reported to be a risk factor for higher morbidity. Nowadays, as HIV-infected patients travel more, it is important to assess the impact of HIV at the individual level on imported malaria. MATERIAL AND METHODS This retrospective case-control study collected data on HIV-infected patients diagnosed with malaria (2000-2017) and matched them with two controls based on age, sex and ethnicity. Clinical and biological parameters were collected and compared. RESULTS We identified 47 cases and matched them with 94 controls. Comparing each of the WHO 2014 severity criteria, hyperparasitemia above 10% (P = 0.006; 12.8 versus 1.1%), icterus (P = 0.042; 14.9 versus 4.3%), acute renal failure (P = 0.022; 25.5 versus 9.6%) and bacteraemia (P = 0.014; 6.4 versus 0%) were significantly more present in HIV-infected patients with a trend to more cerebral malaria (12.8 versus 6.4%). HIV- infected patients were hospitalized more frequently and for longer periods. We observed a higher number of severity criteria when CD4 T-cell count was lower, especially below 200 cells/μl. The difference in occurrence of severe malaria disappeared when patients with CD4 T-cell count more than 500 cells/μl and undetectable viral load (n = 9) were compared with controls. De-novo HIV diagnosis was made during the malaria episode in 17% of cases. CONCLUSION HIV infection has an impact on the imported malaria profile, although it is unclear whether well controlled HIV-infected patients have a higher risk of severe malaria. HIV-infected patients should be particularly targeted for pretravel advice.
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Martin-Blondel G, Soumah M, Camara B, Chabrol A, Porte L, Delobel P, Cuzin L, Berry A, Massip P, Marchou B. [Impact of malaria on HIV infection]. Med Mal Infect 2009; 40:256-67. [PMID: 19951829 DOI: 10.1016/j.medmal.2009.10.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2009] [Revised: 09/15/2009] [Accepted: 10/28/2009] [Indexed: 10/20/2022]
Abstract
Malaria and HIV are two major public health issues, especially in sub-Saharan Africa. HIV infection increases the incidence of clinical malaria, inversely correlated with the degree of immunodepression. The effect of malaria on HIV infection is not as well established. Malaria, when fever and parasitemia are high, may be associated with transient increases in HIV viral load. The effect of subclinical malaria on HIV viral load is uncertain. During pregnancy, placental malaria is associated with higher plasma and placental HIV viral loads, independently of the severity of immunodeficiency. However, the clinical impact of these transient increases of HIV viral load remains unknown. Although some data suggests that malaria might enhance sexual and mother-to-child transmissions, no clinical study has confirmed this. Nevertheless pregnant women and children with malaria-induced anemia are also exposed to HIV through blood transfusions. Integrated HIV and malaria control programs in the regions where both infections overlap are necessary.
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Affiliation(s)
- G Martin-Blondel
- Service des maladies infectieuses et tropicales, hôpital Purpan, place du Docteur-Baylac, TSA 40031, 31059 Toulouse cedex 9, France
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