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Balerdi-Sarasola L, Muñoz J, Fleitas P, Rodriguez-Valero N, Almuedo-Riera A, Antequera A, Subirà C, Grafia-Perez I, Ortiz-Fernández M, de Alba T, Álvarez-Martínez MJ, Valls ME, Parolo C, Castro P, Camprubí-Ferrer D. Not all severe malaria cases are severe: Is it time to redefine severity criteria for malaria in non-endemic regions? Travel Med Infect Dis 2024; 60:102740. [PMID: 39002737 DOI: 10.1016/j.tmaid.2024.102740] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2024] [Revised: 06/14/2024] [Accepted: 06/16/2024] [Indexed: 07/15/2024]
Abstract
BACKGROUND The current definition of severe malaria in non-endemic areas follows WHO criteria, which mainly target children in malaria-endemic areas, potentially misclassifying cases in non-endemic regions. We assessed the performance of a modified severe malaria classification criteria within our patient cohort. METHODS A cohort study of patients managed for malaria in a non-endemic setting (2005-2023) was analyzed. We classified patients into severe malaria (SM) using WHO 2013 criteria except for hyperparasitemia, where 2 % threshold was applied. Patients with SM were distinguished as very severe malaria (VSM) when presenting at least one of the following conditions: parasitemia >10 %, pulmonary edema, impaired consciousness, seizures, renal failure, metabolic acidosis or hyperlactatemia, shock or hypoglycemia. In patients with SM and no criteria for VSM, less severe malaria (LSM) was defined by: 2-10 % parasitemia, hyperbilirubinemia, prostration, anemia or minor bleeding. The primary composite outcome was death or the need for a life-saving intervention, as analyzed in the three comparative groups. Secondary outcome was the prevalence of co-infections. RESULTS Among 506 patients with malaria, 176 (34.8 %) presented with SM. A total of 37 (7.3 %) patients developed a life-threatening condition, namely death (n = 4) and/or the need for life-saving interventions (n = 34). All fatalities and 33 out of the 34 life-saving interventions occurred in the VSM group. Patients in LSM group did not develop any life-threatening conditions. As to co-infections, 28 (5.5 %) patients had a community-acquired co-infection, with no differences between groups (p = 0.763). CONCLUSIONS Severity criteria definitions would benefit from a review when assessing patients with malaria in non-endemic areas. Within the spectrum of SM, patients reclassified as LSM have a low risk of developing a life-threatening condition and present low co-infection incidence and could benefit from management out of intensive care units and a restrictive use of empirical antibiotics.
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Affiliation(s)
- Leire Balerdi-Sarasola
- ISGlobal, Barcelona, Spain; International Health Department, Hospital Clínic de Barcelona, Barcelona, Spain; Facultat de Medicina i Ciències de la Salut, Universitat de Barcelona (UB), Barcelona, Spain.
| | - Jose Muñoz
- ISGlobal, Barcelona, Spain; International Health Department, Hospital Clínic de Barcelona, Barcelona, Spain; Facultat de Medicina i Ciències de la Salut, Universitat de Barcelona (UB), Barcelona, Spain
| | | | - Natalia Rodriguez-Valero
- ISGlobal, Barcelona, Spain; International Health Department, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Alex Almuedo-Riera
- ISGlobal, Barcelona, Spain; International Health Department, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Alba Antequera
- ISGlobal, Barcelona, Spain; International Health Department, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Carme Subirà
- ISGlobal, Barcelona, Spain; International Health Department, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Ignacio Grafia-Perez
- Medical Oncology Department, Hospital Clinic, Barcelona, Spain; Translational Genomics and Targeted Therapies in Solid Tumors, IDIBAPS, Barcelona, Spain
| | | | - Tessa de Alba
- International Health Department, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Miriam J Álvarez-Martínez
- ISGlobal, Barcelona, Spain; Microbiology Department, Hospital Clinic-Universitat de Barcelona, Spain; Facultat de Medicina i Ciències de la Salut, Universitat de Barcelona (UB), Barcelona, Spain
| | - M Eugenia Valls
- Microbiology Department, Hospital Clinic-Universitat de Barcelona, Spain
| | - Claudio Parolo
- ISGlobal, Barcelona, Spain; Facultat de Medicina i Ciències de la Salut, Universitat de Barcelona (UB), Barcelona, Spain
| | - Pedro Castro
- Medical Intensive Care Unit, Hospital Clínic-Universitat de Barcelona, Spain
| | - Daniel Camprubí-Ferrer
- ISGlobal, Barcelona, Spain; International Health Department, Hospital Clínic de Barcelona, Barcelona, Spain; Facultat de Medicina i Ciències de la Salut, Universitat de Barcelona (UB), Barcelona, Spain
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Abstract
Severe malaria is a medical emergency. It is a major cause of preventable childhood death in tropical countries. Severe malaria justifies considerable global investment in malaria control and elimination yet, increasingly, international agencies, funders and policy makers are unfamiliar with it, and so it is overlooked. In sub-Saharan Africa, severe malaria is overdiagnosed in clinical practice. Approximately one third of children diagnosed with severe malaria have another condition, usually sepsis, as the cause of their severe illness. But these children have a high mortality, contributing substantially to the number of deaths attributed to ‘severe malaria’. Simple well-established tests, such as examination of the thin blood smear and the full blood count, improve the specificity of diagnosis and provide prognostic information in severe malaria. They should be performed more widely. Early administration of artesunate and broad-spectrum antibiotics to all children with suspected severe malaria would reduce global malaria mortality.
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Affiliation(s)
- Nicholas J White
- Mahidol Oxford Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand. .,Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK.
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Audibert C, Tchouatieu AM. Perception of Malaria Chemoprevention Interventions in Infants and Children in Eight Sub-Saharan African Countries: An End User Perspective Study. Trop Med Infect Dis 2021; 6:tropicalmed6020075. [PMID: 34064620 PMCID: PMC8163176 DOI: 10.3390/tropicalmed6020075] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Revised: 05/03/2021] [Accepted: 05/06/2021] [Indexed: 11/16/2022] Open
Abstract
Preventive chemotherapy interventions have been identified as key tools for malaria prevention and control. Although a large number of publications have reported on the efficacy and safety profile of these interventions, little literature exists on end-user experience. The objective of this study was to provide insights on the perceptions and attitudes towards seasonal malaria chemoprevention (SMC) and intermittent preventive treatment of infants (IPTi) to identify drivers of and barriers to acceptance. A total of 179 in-depth qualitative interviews were conducted with community health workers (CHWs), health center managers, parents of children receiving chemoprevention, and national decision makers across eight countries in sub-Saharan Africa. The transcribed verbatim responses were coded and analyzed using a thematic approach. Findings indicate that, although SMC is largely accepted by end users, coverage remained below 100%. The main causes mentioned were children's absenteeism, children being sick, parents' reluctance, and lack of staff. Regarding IPTi, results from participants based in Sierra Leone showed that the intervention was generally accepted and perceived as efficacious. The main challenges were access to water, crushing the tablets, and high staff turnover. SMC and IPTi are perceived as valuable interventions. Our study identified the key elements that need to be considered to facilitate the expansion of these two interventions to different geographies or age groups.
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Kinyoki DK, Moloney GM, Uthman OA, Odundo EO, Kandala NB, Noor AM, Snow RW, Berkley JA. Co-morbidity of malnutrition with falciparum malaria parasitaemia among children under the aged 6-59 months in Somalia: a geostatistical analysis. Infect Dis Poverty 2018; 7:72. [PMID: 29986753 PMCID: PMC6036667 DOI: 10.1186/s40249-018-0449-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2017] [Accepted: 06/07/2018] [Indexed: 11/10/2022] Open
Abstract
Background Malnutrition and malaria are both significant causes of morbidity and mortality in African children. However, the extent of their spatial comorbidity remains unexplored and an understanding of their spatial correlation structure would inform improvement of integrated interventions. We aimed to determine the spatial correlation between both wasting and low mid upper arm circumference (MUAC) and falciparum malaria among Somalian children aged 6–59 months. Methods Data were from 49 227 children living in 888 villages between 2007 to 2010. We developed a Bayesian geostatistical shared component model in order to determine the common spatial distributions of wasting and falciparum malaria; and low-MUAC and falciparum malaria at 1 × 1 km spatial resolution. Results The empirical correlations with malaria were 0.16 and 0.23 for wasting and low-MUAC respectively. Shared spatial residual effects were statistically significant for both wasting and low-MUAC. The posterior spatial relative risk was highest for low-MUAC and malaria (range: 0.19 to 5.40) and relatively lower between wasting and malaria (range: 0.11 to 3.55). Hotspots for both wasting and low-MUAC with malaria occurred in the South Central region in Somalia. Conclusions The findings demonstrate a relationship between nutritional status and falciparum malaria parasitaemia, and support the use of the relatively simpler MUAC measurement in surveys. Shared spatial distribution and distinct hotspots present opportunities for targeted seasonal chemoprophylaxis and other forms of malaria prevention integrated within nutrition programmes. Electronic supplementary material The online version of this article (10.1186/s40249-018-0449-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Damaris K Kinyoki
- Spatial Health Metrics Group, INFORM Project, Kenya Medical Research Institute/Wellcome Trust Research Programme, Nairobi, Kenya.
| | - Grainne M Moloney
- Nutrition Section, United Nations Children's Fund (UNICEF), Kenya Country Office, UN Complex Gigiri, Nairobi, Kenya
| | - Olalekan A Uthman
- Warwick Medical School, Health Sciences Research Institute, Warwick Evidence, University of Warwick, Gibbet Hill, Coventry, CV4 7AL, UK
| | - Elijah O Odundo
- Food Security and Nutrition Analysis Unit (FSNAU) - Somalia, Food and Agriculture Organization of the United Nations, Ngecha Road Campus, Nairobi, Kenya
| | - Ngianga-Bakwin Kandala
- Department of Mathematics and Information sciences, Faculty of Engineering and Environment, Northumbria University, Newcastle upon Tyne, UK.,Faculty of Health and Sport Sciences, University of Agder, Kristiansand, Norway.,Division of Epidemiology and Biostatistics, School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | - Abdisalan M Noor
- Spatial Health Metrics Group, INFORM Project, Kenya Medical Research Institute/Wellcome Trust Research Programme, Nairobi, Kenya.,Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, CCVTM, Oxford, OX3 7LJ, UK
| | - Robert W Snow
- Spatial Health Metrics Group, INFORM Project, Kenya Medical Research Institute/Wellcome Trust Research Programme, Nairobi, Kenya.,Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, CCVTM, Oxford, OX3 7LJ, UK
| | - James A Berkley
- Kenya Medical Research Institute/ Wellcome Trust Research Programme, Centre for Geographic Medicine Research (coast), Kilifi, Kenya.,Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, CCVTM, Oxford, OX3 7LJ, UK
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Mornand P, Verret C, Minodier P, Faye A, Thellier M, Imbert P. Severe imported malaria in children in France. A national retrospective study from 1996 to 2005. PLoS One 2017; 12:e0180758. [PMID: 28749962 PMCID: PMC5531540 DOI: 10.1371/journal.pone.0180758] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2016] [Accepted: 06/21/2017] [Indexed: 11/19/2022] Open
Abstract
BACKGROUNDS Malaria is a leading cause of imported febrile illnesses in pediatric travelers, but few studies have addressed severe imported pediatric malaria. We aimed to determine the risk factors and the features of imported pediatric severe malaria. METHODS We conducted a retrospective, descriptive study using the French National Reference Center for Imported Malaria database, in children aged 0-15 years who were hospitalized with a falciparum malaria from January 1st 1996 to December 31th 2005. Uncomplicated and severe cases of falciparum malaria were compared to identify risk factors for severe cases. In the hospitals that reported more than five severe cases during the study period, we evaluated severe cases for prognostic factors and assessed the accuracy WHO criteria for predicting severity. Given the rarity of deaths, adverse outcomes were defined as requiring major therapeutic procedures (MTPs)-e.g., sedation, mechanical ventilation, nasal oxygen therapy, blood transfusions, hemodialysis, fluid resuscitation-or pediatric intensive care unit (PICU) admission. RESULTS Of 4150 pediatric malaria cases included in the study, 3299 were uncomplicated and 851 (20.5%) were severe. Only one death was recorded during this period. Predictors for severe falciparum malaria were: age <2 years (OR = 3.2, 95% CI = 2.5-4.0, p <0.0001) and a travel in the Sahelian region (OR = 1.7, 95% CI = 1.3-2.0, p = 0.0001). Of 422 severe malaria cases, a stay in a Sahelian region, lack of chemoprophylaxis, age <2 years or thrombocytopenia <100 x 10^3/mm^3 predicted adverse outcomes. Except for the hyperparasitemia threshold of 4%, the main WHO 2000 criteria for severe malaria reliably predicted adverse outcomes. In our study, the threshold of parasitemia most predictive of a poor outcome was 8%. CONCLUSION In imported pediatric malaria, children younger than 2 years deserve particular attention. The main WHO 2000 criteria for severity are accurate, except for the threshold of hyperparasitemia, which should be revised.
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Affiliation(s)
- Pierre Mornand
- Service de pédiatrie générale, Hôpital d’enfants A. Trousseau, 26 avenue du Dr Arnold Netter, 75571 Paris cedex 12, France
| | - Catherine Verret
- Institut de Recherche Biomédicale des Armées. BP 73, Brétigny Sur Orge Cedex, France
| | - Philippe Minodier
- Urgences pédiatriques, CHU Nord, Chemin des Bourrely, Marseille, France
| | - Albert Faye
- Assistance Publique des Hôpitaux de Paris, Service de Pédiatrie Générale, Hôpital Robert Debré, Paris, France
- INSERM 1123, Université Paris Diderot, Paris Sorbonne Cité, Paris, France
| | - Marc Thellier
- AP-HP, Service de Parasitologie-Mycologie, Centre National de Référence du paludisme, Hôpital Pitié-Salpêtrière, Paris, France
- INSERM, Centre d’Immunologie et des Maladies Infectieuses de Paris, CIMI-PARIS, U 1135 INSERM/UPMC, Paris, France
| | - Patrick Imbert
- Centre de vaccinations internationales, Hôpital d’instruction des armées Bégin, Saint-Mandé, France
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Das BS, Nanda NK, Rath PK, Satapathy RN, Das DB. Anaemia in acute,Plasmodium falciparummalaria in children from Orissa state, India. ANNALS OF TROPICAL MEDICINE AND PARASITOLOGY 2016. [DOI: 10.1080/00034983.1999.11813401] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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Ilunga-Ilunga F, Levêque A, Dramaix M. Influence de l’âge et du niveau de transmission sur l’expression clinique et biologique du paludisme grave de l’enfant. Arch Pediatr 2016; 23:455-60. [DOI: 10.1016/j.arcped.2016.01.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2014] [Revised: 11/27/2015] [Accepted: 01/29/2016] [Indexed: 10/22/2022]
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Ferreira ED, Alexandre MA, Salinas JL, de Siqueira AM, Benzecry SG, de Lacerda MVG, Monteiro WM. Association between anthropometry-based nutritional status and malaria: a systematic review of observational studies. Malar J 2015; 14:346. [PMID: 26377094 PMCID: PMC4574180 DOI: 10.1186/s12936-015-0870-5] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2015] [Accepted: 08/25/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Multiple studies in various parts of the world have analysed the association of nutritional status on malaria using anthropometric measures, but results differ due to the heterogeneity of the study population, species of the parasite, and other factors involved in the host and parasite relationship. The aim of this study was to perform a systematic review on the inter-relationship of nutritional status based on anthropometry and malarial infection. METHODS Two independent reviewers accessed the MEDLINE and LILACS databases using the same search terms related to malaria and anthropometry. Prospective studies associating anthropometry and malaria (incidence or severity) were selected. References from the included studies and reviews were used to increase the review sensitivity. Data were extracted using a standardized form and the quality of the prospective studies was assessed. Selected articles were grouped based on exposures and outcomes. RESULTS The search identified a total of 1688 studies: 1629 from MEDLINE and 59 from LILACS. A total of 23 met the inclusion criteria. Five additional studies were detected by reading the references of the 23 included studies and reviews, totaling 28 studies included. The mean sample size was 662.1 people, ranging from 57 to 5620. The mean follow-up was 365.8 days, ranging from 14 days to 1 year and 9 months, and nine studies did not report the follow-up period. Prospective studies assessing the relationship between malaria and malnutrition were mostly carried out in Africa. Of the 20 studies with malarial outcomes, fifteen had high and five had average quality, with an average score of 80.5 %. Most anthropometric parameters had no association with malaria incidence (47/52; 90.4 %) or parasite density (20/25; 80 %). However, the impact of malnutrition was noted in malaria mortality and severity (7/17; 41.2 %). Regarding the effects of malaria on malnutrition, malaria was associated with very few anthropometric parameters (8/39; 20.6 %). CONCLUSIONS This systematic review found that most of the evidence associating malaria and malnutrition comes from P. falciparum endemic areas, with a significant heterogeneity in studies' design. Apparently malnutrition has not a great impact on malaria morbidity, but could have a negative impact on malaria mortality and severity. Most studies show no association between malaria and subsequent malnutrition in P. falciparum areas. In Plasmodium vivax endemic areas, malaria was associated with malnutrition in children. A discussion among experts in the field is needed to standardize future studies to increase external validity and accuracy.
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Affiliation(s)
- Efrem d'Avila Ferreira
- Fundação de Medicina Tropical Dr. Heitor Vieira Dourado, Av. Pedro Teixeira, 25, Dom Pedro, Manaus, AM, 69040-000, Brazil.
- Universidade do Estado do Amazonas, Av. Pedro Teixeira, 25, Dom Pedro, Manaus, AM, 69040-000, Brazil.
| | - Márcia A Alexandre
- Fundação de Medicina Tropical Dr. Heitor Vieira Dourado, Av. Pedro Teixeira, 25, Dom Pedro, Manaus, AM, 69040-000, Brazil.
- Universidade do Estado do Amazonas, Av. Pedro Teixeira, 25, Dom Pedro, Manaus, AM, 69040-000, Brazil.
| | - Jorge L Salinas
- Division of Infectious Diseases, Department of Medicine, School of Medicine, Emory University, 49 Jesse Hill Jr Drive, Atlanta, GA, 30303, USA.
| | - André M de Siqueira
- Fundação de Medicina Tropical Dr. Heitor Vieira Dourado, Av. Pedro Teixeira, 25, Dom Pedro, Manaus, AM, 69040-000, Brazil.
- Universidade do Estado do Amazonas, Av. Pedro Teixeira, 25, Dom Pedro, Manaus, AM, 69040-000, Brazil.
- Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz, Av. Brasil, 4365, Manguinhos, Rio de Janeiro, RJ, 21040-360, Brazil.
| | - Silvana G Benzecry
- Universidade do Estado do Amazonas, Av. Pedro Teixeira, 25, Dom Pedro, Manaus, AM, 69040-000, Brazil.
| | - Marcus V G de Lacerda
- Fundação de Medicina Tropical Dr. Heitor Vieira Dourado, Av. Pedro Teixeira, 25, Dom Pedro, Manaus, AM, 69040-000, Brazil.
- Universidade do Estado do Amazonas, Av. Pedro Teixeira, 25, Dom Pedro, Manaus, AM, 69040-000, Brazil.
- Instituto de Pesquisas Leônidas and Maria Deane, Fundação Oswaldo Cruz, Rua Terezina, 476, Adrianópolis, Manaus, AM, 69057-070, Brazil.
| | - Wuelton M Monteiro
- Fundação de Medicina Tropical Dr. Heitor Vieira Dourado, Av. Pedro Teixeira, 25, Dom Pedro, Manaus, AM, 69040-000, Brazil.
- Universidade do Estado do Amazonas, Av. Pedro Teixeira, 25, Dom Pedro, Manaus, AM, 69040-000, Brazil.
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Griffin JT, Hollingsworth TD, Reyburn H, Drakeley CJ, Riley EM, Ghani AC. Gradual acquisition of immunity to severe malaria with increasing exposure. Proc Biol Sci 2015; 282:20142657. [PMID: 25567652 PMCID: PMC4309004 DOI: 10.1098/rspb.2014.2657] [Citation(s) in RCA: 67] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2014] [Accepted: 12/04/2014] [Indexed: 11/12/2022] Open
Abstract
Previous analyses have suggested that immunity to non-cerebral severe malaria due to Plasmodium falciparum is acquired after only a few infections, whereas longitudinal studies show that some children experience multiple episodes of severe disease, suggesting that immunity may not be acquired so quickly. We fitted a mathematical model for the acquisition and loss of immunity to severe disease to the age distribution of severe malaria cases stratified by symptoms from a range of transmission settings in Tanzania, combined with data from several African countries on the age distribution and overall incidence of severe malaria. We found that immunity to severe disease was acquired more gradually with exposure than previously thought. The model also suggests that physiological changes, rather than exposure, may alter the symptoms of disease with increasing age, suggesting that a later age at infection would be associated with a higher proportion of cases presenting with cerebral malaria regardless of exposure. This has consequences for the expected pattern of severe disease as transmission changes. Careful monitoring of the decline in immunity associated with reduced transmission will therefore be needed to ensure rebound epidemics of severe and fatal malaria are avoided.
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Affiliation(s)
- Jamie T Griffin
- MRC Centre for Outbreak Analysis and Modelling, Department of Infectious Disease Epidemiology, Faculty of Medicine, Imperial College London, London W2 1PG, UK
| | - T Déirdre Hollingsworth
- Mathematics Institute, University of Warwick, Coventry CV4 7AL, UK School of Life Sciences, University of Warwick, Coventry CV4 7AL, UK Department of Clinical Sciences, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool L3 5QA, UK
| | - Hugh Reyburn
- Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK
| | - Chris J Drakeley
- Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK
| | - Eleanor M Riley
- Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK
| | - Azra C Ghani
- MRC Centre for Outbreak Analysis and Modelling, Department of Infectious Disease Epidemiology, Faculty of Medicine, Imperial College London, London W2 1PG, UK
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Jain V, Basak S, Bhandari S, Bharti PK, Thomas T, Singh MP, Singh N. Burden of complicated malaria in a densely forested Bastar region of Chhattisgarh State (Central India). PLoS One 2014; 9:e115266. [PMID: 25531373 PMCID: PMC4274025 DOI: 10.1371/journal.pone.0115266] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2014] [Accepted: 11/20/2014] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND A prospective study on severe and complicated malaria was undertaken in the tribal dominated area of Bastar division, Chhattisgarh (CG), Central India, with an objective to understand the clinical epidemiology of complicated malaria in patients attending at a referral hospital. METHODS Blood smears, collected from the general medicine and pediatric wards of a government tertiary health care facility located in Jagdalpur, CG, were microscopically examined for malaria parasite from July 2010 to December 2013. The Plasmodium falciparum positive malaria cases who met enrollment criteria and provided written informed consent were enrolled under different malaria categories following WHO guidelines. PCR was performed to reconfirm the presence of P.falciparum mono infection among enrolled cases. Univariate and multivariate logistic regression analysis was done to identify different risk factors using STATA 11.0. RESULTS A total of 40,924 cases were screened for malaria. The prevalence of malaria and P.falciparum associated complicated malaria (severe and cerebral both) in the hospital was 6% and 0.81%, respectively. P.falciparum malaria prevalence, severity and associated mortality in this region peaked at the age of > 4-5 years and declined with increasing age. P.falciparum malaria was significantly more prevalent in children than adults (P < 0.00001). Among adults, males had significantly more P.falciparum malaria than females (P < 0.00001). Case fatality rate due to cerebral malaria and severe malaria was, respectively, 32% and 9% among PCR confirmed mono P.falciparum cases. Coma was the only independent predictor of mortality in multivariate regression analysis. Mortality was significantly associated with multi-organ complication score (P = 0.0003). CONCLUSION This study has revealed that the pattern of morbidity and mortality in this part of India is very different from earlier reported studies from India. We find that the peak morbidity and mortality in younger children regardless of seasonality. This suggests that this age group needs special care for control and clinical management.
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Affiliation(s)
- Vidhan Jain
- Regional Medical Research Centre for Tribals (RMRCT), ICMR, Garha, Jabalpur, Madhya Pradesh, India
| | - Sanjay Basak
- District Malaria Office, Maharani Hospital and associated Medical College Jagdalpur, Chhattisgarh, India
| | - Sneha Bhandari
- Regional Medical Research Centre for Tribals (RMRCT), ICMR, Garha, Jabalpur, Madhya Pradesh, India
| | - Praveen K. Bharti
- Regional Medical Research Centre for Tribals (RMRCT), ICMR, Garha, Jabalpur, Madhya Pradesh, India
| | - Trilok Thomas
- Regional Medical Research Centre for Tribals (RMRCT), ICMR, Garha, Jabalpur, Madhya Pradesh, India
| | - Mrigendra P. Singh
- National Institute of Malaria Research, Field Unit, Jabalpur, Madhya Pradesh, India
| | - Neeru Singh
- Regional Medical Research Centre for Tribals (RMRCT), ICMR, Garha, Jabalpur, Madhya Pradesh, India
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Ursing J, Rombo L, Rodrigues A, Aaby P, Kofoed PE. Malaria transmission in Bissau, Guinea-Bissau between 1995 and 2012: malaria resurgence did not negatively affect mortality. PLoS One 2014; 9:e101167. [PMID: 24984039 PMCID: PMC4077730 DOI: 10.1371/journal.pone.0101167] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2014] [Accepted: 06/03/2014] [Indexed: 11/19/2022] Open
Abstract
Introduction As Plasmodium falciparum prevalence decreases in many parts of Sub-Saharan Africa, so does immunity resulting in larger at risk populations and increased risk of malaria resurgence. In Bissau, malaria prevalence decreased from ∼50% to 3% between 1995 and 2003. The epidemiological characteristics of P. falciparum malaria within Bandim health and demographic surveillance site (population ∼100000) between 1995 and 2012 are described. Methods and Findings The population was determined by census. 3603 children aged <15 years that were enrolled in clinical trials at the Bandim health centre (1995–2012) were considered incident cases. The mean annual malaria incidence per thousand children in 1995–1997, 1999–2003, 2007, 2011, 2012 were as follows; age <5 years 22→29→4→9→3, age 5–9 years 15→28→4→33→12, age 10–14 years 9→15→1→45→19. There were 4 campaigns (2003–2010) to increase use of insecticide treated bed nets (ITN) amongst children <5 years. An efficacious high-dose chloroquine treatment regime was routinely used until artemisinin based combination therapy (ACT) was introduced in 2008. Long lasting insecticide treated bed nets (LLIN) were distributed in 2011. By 2012 there was 1 net per 2 people and 97% usage. All-cause mortality decreased from post-war peaks in 1999 until 2012 in all age groups and was not negatively affected by malaria resurgence. Conclusion The cause of decreasing malaria incidence (1995–2007) was probably multifactorial and coincident with the use of an efficacious high-dose chloroquine treatment regime. Decreasing malaria prevalence created a susceptible group of older children in which malaria resurged, highlighting the need to include all age groups in malaria interventions. ACT did not hinder malaria resurgence. Mass distribution of LLINs probably curtailed malaria epidemics. All-cause mortality was not negatively affected by malaria resurgence.
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Affiliation(s)
- Johan Ursing
- Projecto de Saúde de Bandim, Indepth Network, Bissau, Guinea-Bissau
- Malaria Research Laboratory, Unit of Infectious Diseases, Department of Medicine, Karolinska University Hospital, Stockholm, Sweden
- Department of microbiology, Tumor and Cell Biology, Karolinska Institutet, Solna, Sweden
- * E-mail: (JU); (P-EK)
| | - Lars Rombo
- Malaria Research Laboratory, Unit of Infectious Diseases, Department of Medicine, Karolinska University Hospital, Stockholm, Sweden
- Department of Infectious Diseases Mälarsjukhuset, Eskilstuna, Sweden
- Centre for Clinical Research, Sörmland county council, Eskilstuna, Sweden
| | | | - Peter Aaby
- Projecto de Saúde de Bandim, Indepth Network, Bissau, Guinea-Bissau
| | - Poul-Erik Kofoed
- Projecto de Saúde de Bandim, Indepth Network, Bissau, Guinea-Bissau
- Department of Paediatrics, Kolding Hospital, Kolding, Denmark
- * E-mail: (JU); (P-EK)
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12
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Manning L, Laman M, Davis WA, Davis TME. Clinical features and outcome in children with severe Plasmodium falciparum malaria: a meta-analysis. PLoS One 2014; 9:e86737. [PMID: 24516538 PMCID: PMC3916300 DOI: 10.1371/journal.pone.0086737] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2013] [Accepted: 12/14/2013] [Indexed: 11/29/2022] Open
Abstract
Background Although global malaria mortality is declining, estimates may not reflect better inpatient management of severe malaria (SM) where reported case fatality rates (CFRs) vary from 1–25%. Methods A meta-analysis of prospective studies of SM was conducted to examine i) whether hypothesized differences between clinical features and outcome in Melanesian compared with African or Asian children really exist, and ii) to explore temporal changes in overall and complication-specific CFRs. The proportions of different SM complications and, overall and complication-specific CFRs were incorporated into the meta-analysis. Adjustments were made for study-level covariates including geographic region, SM definition, artemisinin treatment, median age of participants and time period. Findings Sixty-five studies were included. Substantial heterogeneity (I2>80%) was demonstrated for most outcomes. SM definition contributed to between-study heterogeneity in proportions of cerebral malaria (CM), metabolic acidosis (MA), severe anemia and overall CFR, whilst geographic region was a significant moderator in for CM and hypoglycemia (HG) rates. Compared with their African counterparts, Melanesian children had lower rates of HG (10% [CI95 7–13%] versus 1% [0–3%], P<0.05), lower overall CFR (2% [0–4%] versus 7% [6–9%], P<0.05) and lower CM-specific CFR (8% [0–17%] versus 19% [16–21%], P<0.05). There was no temporal trend for overall CFR and CM-specific CFR but declining HG- and MA- specific CFRs were observed. Interpretation These data highlight that recent estimates of declining global malaria mortality are not replicated by improved outcomes for children hospitalized with SM. Significant geographic differences in the complication rates and subsequent CFRs exist and provide the first robust confirmation of lower CFRs in Melanesian children, perhaps due to less frequent HG.
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Affiliation(s)
- Laurens Manning
- School of Medicine and Pharmacology, University of Western Australia, Fremantle Hospital, Fremantle, Western Australia, Australia
- * E-mail:
| | - Moses Laman
- School of Medicine and Pharmacology, University of Western Australia, Fremantle Hospital, Fremantle, Western Australia, Australia
| | - Wendy A. Davis
- School of Medicine and Pharmacology, University of Western Australia, Fremantle Hospital, Fremantle, Western Australia, Australia
| | - Timothy M. E. Davis
- School of Medicine and Pharmacology, University of Western Australia, Fremantle Hospital, Fremantle, Western Australia, Australia
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Billig EMW, O'Meara WP, Riley EM, McKenzie FE. Developmental allometry and paediatric malaria. Malar J 2012; 11:64. [PMID: 22394452 PMCID: PMC3331816 DOI: 10.1186/1475-2875-11-64] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2011] [Accepted: 03/06/2012] [Indexed: 12/02/2022] Open
Abstract
WHO estimates that 80% of mortality due to malaria occurs among infants and young children. Though it has long been established that malaria disproportionately affects children under age five, our understanding of the underlying biological mechanisms for this distribution remains incomplete. Many studies use age as an indicator of exposure, but age may affect malaria burden independently of previous exposure. Not only does the severity of malaria infection change with age, but the clinical manifestation of disease does as well: younger children are more likely to suffer severe anaemia, while older children are more likely to develop cerebral malaria. Intensity of transmission and acquired immunity are important determinants of this age variation, but age differences remain consistent over varying transmission levels. Thus, age differences in clinical presentation may involve inherent age-related factors as well as still-undiscovered facets of acquired immunity, perhaps including the rates at which relevant aspects of immunity are acquired. The concept of "allometry" - the relative growth of a part in relation to that of an entire organism or to a standard - has not previously been applied in the context of malaria infection. However, because malaria affects a number of organs and cells, including the liver, red blood cells, white blood cells, and spleen, which may intrinsically develop at rates partly independent of each other and of a child's overall size, developmental allometry may influence the course and consequences of malaria infection. Here, scattered items of evidence have been collected from a variety of disciplines, aiming to suggest possible research paths for investigating exposure-independent age differences affecting clinical outcomes of malaria infection.
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Affiliation(s)
- Erica M W Billig
- Fogarty International Center, National Institutes of Health, Building 16, Bethesda, MD 20892, USA.
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John CC, Kutamba E, Mugarura K, Opoka RO. Adjunctive therapy for cerebral malaria and other severe forms of Plasmodium falciparum malaria. Expert Rev Anti Infect Ther 2011; 8:997-1008. [PMID: 20818944 DOI: 10.1586/eri.10.90] [Citation(s) in RCA: 93] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Severe malaria due to Plasmodium falciparum causes more than 800,000 deaths every year. Primary therapy with quinine or artesunate is generally effective in controlling P. falciparum parasitemia, but mortality from cerebral malaria and other forms of severe malaria remains unacceptably high. Long-term cognitive impairment is also common in children with cerebral malaria. Of the numerous adjunctive therapies for cerebral malaria and severe malaria studied over the past five decades, only one (albumin) was associated with a reduction in mortality. In this article, we review past and ongoing studies of adjunctive therapy, and examine the evidence of efficacy for newer therapies, including inhibitors of cytoadherence (e.g., levamisole), immune modulators (e.g., rosiglitazone), agents that increase nitric oxide levels (e.g., arginine) and neuroprotective agents (e.g., erythropoietin).
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Affiliation(s)
- Chandy C John
- Center for Global Pediatrics, 717 Delaware Street SE, Room 363, Minneapolis, MN 55455, USA.
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15
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Roca-Feltrer A, Carneiro I, Smith L, Schellenberg JRA, Greenwood B, Schellenberg D. The age patterns of severe malaria syndromes in sub-Saharan Africa across a range of transmission intensities and seasonality settings. Malar J 2010; 9:282. [PMID: 20939931 PMCID: PMC2992028 DOI: 10.1186/1475-2875-9-282] [Citation(s) in RCA: 62] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2010] [Accepted: 10/13/2010] [Indexed: 11/25/2022] Open
Abstract
Background A greater understanding of the relationship between transmission intensity, seasonality and the age-pattern of malaria is needed to guide appropriate targeting of malaria interventions in different epidemiological settings. Methods A systematic literature review identified studies which reported the age of paediatric hospital admissions with cerebral malaria (CM), severe malarial anaemia (SMA), or respiratory distress (RD). Study sites were categorized into a 3 × 2 matrix of Plasmodium falciparum transmission intensity and seasonality. Probability distributions were fitted by maximum likelihood methods, and best fitting models were used to estimate median ages and to represent graphically the age-pattern of each outcome for each transmission category in the matrix. Results A shift in the burden of CM towards younger age groups was seen with increasing intensity of transmission, but this was not the case for SMA or RD. Sites with 'no marked seasonality' showed more evidence of skewed age-patterns compared to areas of 'marked seasonality' for all three severe malaria syndromes. Conclusions Although the peak age of CM will increase as transmission intensity decreases in Africa, more than 75% of all paediatric hospital admissions of severe malaria are likely to remain in under five year olds in most epidemiological settings.
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Affiliation(s)
- Arantxa Roca-Feltrer
- Department of Disease Control, Faculty of Infectious & Tropical Disease, London School of Hygiene & Tropical Medicine, Keppel Street, London, UK.
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16
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Carneiro I, Roca-Feltrer A, Griffin JT, Smith L, Tanner M, Schellenberg JA, Greenwood B, Schellenberg D. Age-patterns of malaria vary with severity, transmission intensity and seasonality in sub-Saharan Africa: a systematic review and pooled analysis. PLoS One 2010; 5:e8988. [PMID: 20126547 PMCID: PMC2813874 DOI: 10.1371/journal.pone.0008988] [Citation(s) in RCA: 203] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2009] [Accepted: 01/06/2010] [Indexed: 11/19/2022] Open
Abstract
Background There is evidence that the age-pattern of Plasmodium falciparum malaria varies with transmission intensity. A better understanding of how this varies with the severity of outcome and across a range of transmission settings could enable locally appropriate targeting of interventions to those most at risk. We have, therefore, undertaken a pooled analysis of existing data from multiple sites to enable a comprehensive overview of the age-patterns of malaria outcomes under different epidemiological conditions in sub-Saharan Africa. Methodology/Principal Findings A systematic review using PubMed and CAB Abstracts (1980–2005), contacts with experts and searching bibliographies identified epidemiological studies with data on the age distribution of children with P. falciparum clinical malaria, hospital admissions with malaria and malaria-diagnosed mortality. Studies were allocated to a 3×2 matrix of intensity and seasonality of malaria transmission. Maximum likelihood methods were used to fit five continuous probability distributions to the percentage of each outcome by age for each of the six transmission scenarios. The best-fitting distributions are presented graphically, together with the estimated median age for each outcome. Clinical malaria incidence was relatively evenly distributed across the first 10 years of life for all transmission scenarios. Hospital admissions with malaria were more concentrated in younger children, with this effect being even more pronounced for malaria-diagnosed deaths. For all outcomes, the burden of malaria shifted towards younger ages with increasing transmission intensity, although marked seasonality moderated this effect. Conclusions The most severe consequences of P. falciparum malaria were concentrated in the youngest age groups across all settings. Despite recently observed declines in malaria transmission in several countries, which will shift the burden of malaria cases towards older children, it is still appropriate to target strategies for preventing malaria mortality and severe morbidity at very young children who will continue to bear the brunt of malaria deaths in Sub-Saharan Africa.
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Affiliation(s)
- Ilona Carneiro
- Disease Control and Vector Biology Unit, Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom.
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Machault V, Gadiaga L, Vignolles C, Jarjaval F, Bouzid S, Sokhna C, Lacaux JP, Trape JF, Rogier C, Pagès F. Highly focused anopheline breeding sites and malaria transmission in Dakar. Malar J 2009; 8:138. [PMID: 19552809 PMCID: PMC2713260 DOI: 10.1186/1475-2875-8-138] [Citation(s) in RCA: 61] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2009] [Accepted: 06/24/2009] [Indexed: 11/19/2022] Open
Abstract
Background Urbanization has a great impact on the composition of the vector system and malaria transmission dynamics. In Dakar, some malaria cases are autochthonous but parasite rates and incidences of clinical malaria attacks have been recorded at low levels. Ecological heterogeneity of malaria transmission was investigated in Dakar, in order to characterize the Anopheles breeding sites in the city and to study the dynamics of larval density and adult aggressiveness in ten characteristically different urban areas. Methods Ten study areas were sampled in Dakar and Pikine. Mosquitoes were collected by human landing collection during four nights in each area (120 person-nights). The Plasmodium falciparum circumsporozoite (CSP) index was measured by ELISA and the entomological inoculation rates (EIR) were calculated. Open water collections in the study areas were monitored weekly for physico-chemical characterization and the presence of anopheline larvae. Adult mosquitoes and hatched larvae were identified morphologically and by molecular methods. Results In September-October 2007, 19,451 adult mosquitoes were caught among which, 1,101 were Anopheles gambiae s.l. The Human Biting Rate ranged from 0.1 bites per person per night in Yoff Village to 43.7 in Almadies. Seven out of 1,101 An. gambiae s.l. were found to be positive for P. falciparum (CSP index = 0.64%). EIR ranged from 0 infected bites per person per year in Yoff Village to 16.8 in Almadies. The An. gambiae complex population was composed of Anopheles arabiensis (94.8%) and Anopheles melas (5.2%). None of the An. melas were infected with P. falciparum. Of the 54 water collection sites monitored, 33 (61.1%) served as anopheline breeding sites on at least one observation. No An. melas was identified among the larval samples. Some physico-chemical characteristics of water bodies were associated with the presence/absence of anopheline larvae and with larval density. A very close parallel between larval and adult densities was found in six of the ten study areas. Conclusion The results provide evidence of malaria transmission in downtown Dakar and its surrounding suburbs. Spatial heterogeneity of human biting rates was very marked and malaria transmission was highly focal. In Dakar, mean figures for transmission would not provide a comprehensive picture of the entomological situation; risk evaluation should therefore be undertaken on a small scale.
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Affiliation(s)
- Vanessa Machault
- Unité d'Entomologie Médicale, Equipe 7 Maladies Emergentes et Moustiques, Institut de Médecine Tropicale du Service de Santé des Armées, Allée du Médecin colonel Jamot, Parc du Pharo, 13262 Marseille cedex 07, France.
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18
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Mfonkeu JBP, Gouado I, Kuate HF, Zambou O, Grau G, Combes V, Zollo PHA. Clinical presentation, haematological indices and management of children with severe and uncomplicated malaria in Douala, Cameroon. Pak J Biol Sci 2009; 11:2401-6. [PMID: 19137849 DOI: 10.3923/pjbs.2008.2401.2406] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
This study carried out from January to June 2007, was undertaken to describe the clinical presentation of childhood malaria in Douala, a meso-endemic area as far as malaria transmission is concerned. One hundred and seventy eight children were enrolled after informed consent of their parents. The sample characteristics were recorded and clinical as well as preliminary laboratory investigations were performed. Thirty eight children coming for vaccination and counselling was targeted to serve as control. According to the results obtained, cerebral malaria (CM) seems to be associated with young age, whilst Malaria anaemia (MA) was predominant among older children. Hyperpyrexia and hyperparasitaemia were high among CM patients and 11.1% of them died, however, no neurological squeal was noticed immediately after discharge on those who survived. Haemoglobin and glycaemia were low on MA and CM patients; these groups had low percentage in bed nets utilization as well. These results suggest that the clinical presentation of the disease differ with the geographic location and malaria disease features varies according to the severity. Such studies could contribute to the management of the disease.
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Affiliation(s)
- J B Pankoui Mfonkeu
- Department of Biochemistry, Faculty of Science, University of Douala, Cameroon
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19
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Age patterns of severe paediatric malaria and their relationship to Plasmodium falciparum transmission intensity. Malar J 2009; 8:4. [PMID: 19128453 PMCID: PMC2630996 DOI: 10.1186/1475-2875-8-4] [Citation(s) in RCA: 103] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2008] [Accepted: 01/07/2009] [Indexed: 11/18/2022] Open
Abstract
Background The understanding of the epidemiology of severe malaria in African children remains incomplete across the spectrum of Plasmodium falciparum transmission intensities through which communities might expect to transition, as intervention coverage expands. Methods Paediatric admission data were assembled from 13 hospitals serving 17 communities between 1990 and 2007. Estimates of Plasmodium falciparum transmission intensity in these communities were assembled to be spatially and temporally congruent to the clinical admission data. The analysis focused on the relationships between community derived parasite prevalence and the age and clinical presentation of paediatric malaria in children aged 0–9 years admitted to hospital. Results As transmission intensity declined a greater proportion of malaria admissions were in older children. There was a strong linear relationship between increasing transmission intensity and the proportion of paediatric malaria admissions that were infants (R2 = 0.73, p < 0.001). Cerebral malaria was reported among 4% and severe malaria anaemia among 17% of all malaria admissions. At higher transmission intensity cerebral malaria was a less common presentation compared to lower transmission sites. There was no obvious relationship between the proportions of children with severe malaria anaemia and transmission intensity. Conclusion As the intensity of malaria transmission declines in Africa through the scaling up of insecticide-treated nets and other vector control measures a focus of disease prevention among very young children becomes less appropriate. The understanding of the relationship between parasite exposure and patterns of disease risk should be used to adapt malaria control strategies in different epidemiological settings.
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O'Meara WP, Bejon P, Mwangi TW, Okiro EA, Peshu N, Snow RW, Newton CRJC, Marsh K. Effect of a fall in malaria transmission on morbidity and mortality in Kilifi, Kenya. Lancet 2008; 372:1555-62. [PMID: 18984188 PMCID: PMC2607008 DOI: 10.1016/s0140-6736(08)61655-4] [Citation(s) in RCA: 339] [Impact Index Per Article: 21.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND As efforts to control malaria are expanded across the world, understanding the role of transmission intensity in determining the burden of clinical malaria is crucial to the prediction and measurement of the effectiveness of interventions to reduce transmission. Furthermore, studies comparing several endemic sites led to speculation that as transmission decreases morbidity and mortality caused by severe malaria might increase. We aimed to assess the epidemiological characteristics of malaria in Kilifi, Kenya, during a period of decreasing transmission intensity. METHODS We analyse 18 years (1990-2007) of surveillance data from a paediatric ward in a malaria-endemic region of Kenya. The hospital has a catchment area of 250 000 people. Clinical data and blood-film results for more than 61 000 admissions are reported. FINDINGS Hospital admissions for malaria decreased from 18.43 per 1000 children in 2003 to 3.42 in 2007. Over 18 years of surveillance, the incidence of cerebral malaria initially increased; however, malaria mortality decreased overall because of a decrease in incidence of severe malarial anaemia since 1997 (4.75 to 0.37 per 1000 children) and improved survival among children admitted with non-severe malaria. Parasite prevalence, the mean age of children admitted with malaria, and the proportion of children with cerebral malaria began to change 10 years before hospitalisation for malaria started to fall. INTERPRETATION Sustained reduction in exposure to infection leads to changes in mean age and presentation of disease similar to those described in multisite studies. Changes in transmission might not lead to immediate reductions in incidence of clinical disease. However, longitudinal data do not indicate that reductions in transmission intensity lead to transient increases in morbidity and mortality.
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Affiliation(s)
- Wendy P O'Meara
- Kenya Medical Research Institute, Centre for Geographic Medicine Research–Wellcome Trust Collaborative Program, Kilifi, Kenya
- Fogarty International Center, National Institutes of Health, Bethesda, MD, USA
- Correspondence to: Dr Wendy Prudhomme O'Meara, Fogarty International Center, National Institutes of Health, 16 Center Drive, Bethesda, MD 20892, USA
| | - Phillip Bejon
- Kenya Medical Research Institute, Centre for Geographic Medicine Research–Wellcome Trust Collaborative Program, Kilifi, Kenya
- Centre of Tropical Medicine, Nuffield Department of Clinical Medicine, University of Oxford, John Radcliffe Hospital, Oxford, UK
| | - Tabitha W Mwangi
- Kenya Medical Research Institute, Centre for Geographic Medicine Research–Wellcome Trust Collaborative Program, Kilifi, Kenya
| | - Emelda A Okiro
- Kenya Medical Research Institute–Wellcome Trust Collaborative Program, Nairobi, Kenya
| | - Norbert Peshu
- Kenya Medical Research Institute, Centre for Geographic Medicine Research–Wellcome Trust Collaborative Program, Kilifi, Kenya
| | - Robert W Snow
- Kenya Medical Research Institute–Wellcome Trust Collaborative Program, Nairobi, Kenya
- Centre of Tropical Medicine, Nuffield Department of Clinical Medicine, University of Oxford, John Radcliffe Hospital, Oxford, UK
| | - Charles RJC Newton
- Kenya Medical Research Institute, Centre for Geographic Medicine Research–Wellcome Trust Collaborative Program, Kilifi, Kenya
- Institute of Child Health, University College London, UK
| | - Kevin Marsh
- Kenya Medical Research Institute, Centre for Geographic Medicine Research–Wellcome Trust Collaborative Program, Kilifi, Kenya
- Centre of Tropical Medicine, Nuffield Department of Clinical Medicine, University of Oxford, John Radcliffe Hospital, Oxford, UK
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Odhiambo CO, Otieno W, Adhiambo C, Odera MM, Stoute JA. Increased deposition of C3b on red cells with low CR1 and CD55 in a malaria-endemic region of western Kenya: implications for the development of severe anemia. BMC Med 2008; 6:23. [PMID: 18717995 PMCID: PMC2562382 DOI: 10.1186/1741-7015-6-23] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2007] [Accepted: 08/21/2008] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Severe anemia due to Plasmodium falciparum malaria is a major cause of mortality among young children in western Kenya. The factors that lead to the age-specific incidence of this anemia are unknown. Previous studies have shown an age-related expression of red cell complement regulatory proteins, which protect erythrocytes from autologous complement attack and destruction. Our primary objective was to determine whether in a malaria-endemic area red cells with low levels of complement regulatory proteins are at increased risk for complement (C3b) deposition in vivo. Secondarily, we studied the relationship between red cell complement regulatory protein levels and hemoglobin levels. METHODS Three hundred and forty-two life-long residents of a malaria-holoendemic region of western Kenya were enrolled in a cross-sectional study and stratified by age. We measured red cell C3b, CR1, CD55, and immune complex binding capacity by flow cytometry. Individuals who were positive for malaria were treated and blood was collected when they were free of parasitemia. Analysis of variance was used to identify independent variables associated with the %C3b-positive red cells and the hemoglobin level. RESULTS Individuals between the ages of 6 and 36 months had the lowest red cell CR1, highest %C3b-positive red cells, and highest parasite density. Malaria prevalence also reached its peak within this age group. Among children </= 24 months of age the %C3b-positive red cells was usually higher in individuals who were treated for malaria than in uninfected individuals with similarly low red cell CR1 and CD55. The variables that most strongly influenced the %C3b-positive red cells were age, malaria status, and red cell CD55 level. Although it did not reach statistical significance, red cell CR1 was more important than red cell CD55 among individuals treated for malaria. The variables that most strongly influenced the hemoglobin level were age, the %C3b-positive red cells, red cell CR1, and red cell CD55. CONCLUSION Increasing malaria prevalence among children >6 to <or= 36 months of age in western Kenya, together with low red cell CR1 and CD55 levels, results in increased C3b deposition on red cells and low hemoglobin. The strong contribution of age to C3b deposition suggests that there are still additional unidentified age-related factors that increase the susceptibility of red cells to C3b deposition and destruction.
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Affiliation(s)
- Collins O Odhiambo
- The US Army Medical Research Unit and the Kenya Medical Research Institute, Nairobi, Kenya.
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Dongus S, Nyika D, Kannady K, Mtasiwa D, Mshinda H, Fillinger U, Drescher AW, Tanner M, Castro MC, Killeen GF. Participatory mapping of target areas to enable operational larval source management to suppress malaria vector mosquitoes in Dar es Salaam, Tanzania. Int J Health Geogr 2007; 6:37. [PMID: 17784963 PMCID: PMC2025588 DOI: 10.1186/1476-072x-6-37] [Citation(s) in RCA: 60] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2007] [Accepted: 09/04/2007] [Indexed: 11/18/2022] Open
Abstract
Background Half of the population of Africa will soon live in towns and cities where it can be protected from malaria by controlling aquatic stages of mosquitoes. Rigorous but affordable and scaleable methods for mapping and managing mosquito habitats are required to enable effective larval control in urban Africa. Methods A simple community-based mapping procedure that requires no electronic devices in the field was developed to facilitate routine larval surveillance in Dar es Salaam, Tanzania. The mapping procedure included (1) community-based development of sketch maps and (2) verification of sketch maps through technical teams using laminated aerial photographs in the field which were later digitized and analysed using Geographical Information Systems (GIS). Results Three urban wards of Dar es Salaam were comprehensively mapped, covering an area of 16.8 km2. Over thirty percent of this area were not included in preliminary community-based sketch mapping, mostly because they were areas that do not appear on local government residential lists. The use of aerial photographs and basic GIS allowed rapid identification and inclusion of these key areas, as well as more equal distribution of the workload of malaria control field staff. Conclusion The procedure developed enables complete coverage of targeted areas with larval control through comprehensive spatial coverage with community-derived sketch maps. The procedure is practical, affordable, and requires minimal technical skills. This approach can be readily integrated into malaria vector control programmes, scaled up to towns and cities all over Tanzania and adapted to urban settings elsewhere in Africa.
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Affiliation(s)
- Stefan Dongus
- Department of Public Health and Epidemiology, Swiss Tropical Institute, Basel, Switzerland
- Department of Physical Geography, University of Freiburg, Freiburg, Germany
- Ifakara Health Research and Development Centre, Coordination Office, Dar es Salaam, United Republic of Tanzania
| | - Dickson Nyika
- Ifakara Health Research and Development Centre, Coordination Office, Dar es Salaam, United Republic of Tanzania
- City Medical Office of Health, Dar es Salaam City Council, Dar es Salaam, United Republic of Tanzania
- Ministry of Agriculture and Food Security, Dar es Salaam, United Republic of Tanzania
| | - Khadija Kannady
- City Medical Office of Health, Dar es Salaam City Council, Dar es Salaam, United Republic of Tanzania
| | - Deo Mtasiwa
- City Medical Office of Health, Dar es Salaam City Council, Dar es Salaam, United Republic of Tanzania
| | - Hassan Mshinda
- Ifakara Health Research and Development Centre, Coordination Office, Dar es Salaam, United Republic of Tanzania
| | - Ulrike Fillinger
- Institute of Ecosystems Science, School of Biological and Biomedical Sciences, Durham University, Durham, UK
| | - Axel W Drescher
- Department of Physical Geography, University of Freiburg, Freiburg, Germany
| | - Marcel Tanner
- Department of Public Health and Epidemiology, Swiss Tropical Institute, Basel, Switzerland
| | - Marcia C Castro
- Department of Population and International Health, Harvard School of Public Health, Boston, USA
| | - Gerry F Killeen
- Department of Public Health and Epidemiology, Swiss Tropical Institute, Basel, Switzerland
- Ifakara Health Research and Development Centre, Coordination Office, Dar es Salaam, United Republic of Tanzania
- Institute of Ecosystems Science, School of Biological and Biomedical Sciences, Durham University, Durham, UK
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Tripathy R, Parida S, Das L, Mishra DP, Tripathy D, Das MC, Chen H, Maguire JH, Panigrahi P. Clinical manifestations and predictors of severe malaria in Indian children. Pediatrics 2007; 120:e454-60. [PMID: 17766489 DOI: 10.1542/peds.2006-3171] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE Although the greatest morbidity and mortality attributable to malaria occurs among children in Africa, up to one third of the world's malaria burden is borne by non-African countries, where levels of endemicity are lower. Because there are few published criteria for managing life-threatening malaria in children in these countries, we conducted a study of major syndromes and predictors of death among critically ill Indian children to identify factors that could be used to improve the approach to their treatment. METHODS A prospective study was conducted at the pediatric ward of SCB Medical College in eastern India (Orissa). Baseline demographic data were collected on all of the patients with confirmed slide-positive falciparum malaria. Patients satisfying any 1 of the 2000 World Health Organization criteria for severe malaria were included in the analysis. Prevalence of and mortality as a result of major symptoms were calculated followed by multiple regression modeling to identify major predictors of death. RESULTS Of 1682 confirmed cases of malaria during a 32-month period, 374 subjects met the World Health Organization criteria for severe malaria. The case fatality rate was 12% in this series. Multiple regression analysis identified respiratory distress, coma, multiple organ dysfunctions, and hyperparasitemia as major predictors of death. Anemia and jaundice did not emerge as important markers of mortality. Many patients presented with multiple major complications, and the mortality rate was consistently high when >1 major predictor was present in a patient. CONCLUSIONS Clinical features in Indian children differed from those reported in most studies that involved an African population. Multiple organ dysfunctions emerged as an important presenting feature and a new predictor of death in childhood malaria.
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Affiliation(s)
- Radha Tripathy
- Center for Research on Maternal and Childhood Malaria, SCB Medical College, Cuttack, Orissa, India
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Mishra SK, Mohanty S, Satpathy SK, Mohapatra DN. Cerebral malaria in adults -- a description of 526 cases admitted to Ispat General Hospital in Rourkela, India. ANNALS OF TROPICAL MEDICINE AND PARASITOLOGY 2007; 101:187-93. [PMID: 17362593 DOI: 10.1179/136485907x157004] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
Although the clinical picture of cerebral malaria in children has been reported extensively, scant information is available about cerebral malaria in adults. This report relates to one of the largest series of adult cases of cerebral malaria patients ever described. At Rourkela, in eastern India, 526 adults (aged >12 years) who each satisfied the World Health Organization's criteria for cerebral malaria were admitted to Ispat General Hospital between 1995 and 2001. These cases represented 18% of the 2994 adult patients who were admitted with Plasmodium falciparum malaria over the same period. Most (76%) of the adult cases of cerebral malaria were male, 48% were aged 21-40 years, and only 4% were older than 60 years. The most common presenting symptoms were fever (97.7%), vomiting (54.6%), headache (30.8%) and seizures (17.1%). Most (62.4%) of the cases had associated severe complications: jaundice (47.5%), acute renal failure (28.9%), and/or severe anaemia (9.7%). Overall, 175 (23%) of the cases were fatal, mortality being particularly high (59%) among those with multi-organ failure. Of the fatal cases, 107 (61%) died within the first 24 h of hospitalization, presumably indicative of late presentation. As the management of multiple complications may be inadequate at primary centres, early referral to higher centres is recommended.
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Affiliation(s)
- S K Mishra
- Department of Internal Medicine and Critical Care Unit, Ispat General Hospital, Rourkela 769 005, Orissa, India.
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Outcome of life-threatening malaria in African children requiring endotracheal intubation. Malar J 2007; 6:51. [PMID: 17470294 PMCID: PMC1867821 DOI: 10.1186/1475-2875-6-51] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2006] [Accepted: 04/30/2007] [Indexed: 12/02/2022] Open
Abstract
Background Little is known about children undergoing critical care for malaria. The purpose of this survey was to evaluate the outcome in African children requiring endotracheal intubation for life-threatening malaria. Methods All children with a primary diagnosis of severe malaria (2000 WHO definition) requiring endotracheal intubation, hospitalised over a five-year period, within a tertiary-care hospital in Dakar, Senegal, were enrolled in a retrospective cohort study. Results 83 consecutive patients were included (median PRISM h24 score: 14; IQR: 10–19, multiple organ dysfunctions: 91.5%). The median duration of ventilation was 36 hrs (IQR: 4–72). Indications for intubation were deep coma (Glasgow score ≤7, n = 16), overt cortical or diencephalic injury, i.e, status epilepticus/decorticate posturing (n = 20), severe brainstem involvement, i.e., decerebrate posturing/opisthotonus (n = 15), shock (n = 15), cardiac arrest (n = 13) or acute lung injury (ALI) (PaO2/FiO2 <300 Torr, n = 4). Death occurred in 50 cases (case fatality rate (CFR), 60%) and was associated with multiple organ dysfunctions (median PELODh24 scores: 12.5 among non-survivors versus 11 among survivors, p = 0.02). Median PRISMh24 score was significantly lower when testing deep coma against other indications (10 vs 15, p < 0.001), ditto for PELODh24 score (2.5 vs 13, p = 0.02). Multivariate analysis identified deep coma as having a better outcome than other indications (CFR, 12.5% vs 40.0 to 93.3%, p < 0.0001). Decerebrate posturing/opisthotonus (CFR 73.3%, adjusted relative risk (aRR) 10.7, 95% CI 2.3–49.5) were associated with a far worse prognosis than status epilepticus/decorticate posturing (CFR 40.0%, aRR 5.7, 95% CI 1.2–27.1). Thrombocytopaenia (platelet counts <100,000/mm3) was associated with death (aRR 2.6, 95% CI 1.2–5.8) and second-line anticonvulsant use (clonazepam or thiopental) with survival (aRR 0.4, 95% CI 0.2–0.9). Complications, mostly nosocomial infections (n = 20), ALI/ARDS (n = 9) or sub-glottic stenosis (n = 3), had no significant prognostic value. Conclusion In this study, the outcome of children requiring intubation for malaria depends more on clinical presentation and progression towards organ failures than on critical care complications per se. In sub-Saharan Africa, mechanical ventilation for life-threatening childhood malaria is feasible, but seems unlikely to dramatically improve the prognosis.
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Lalloo DG, Olukoya P, Olliaro P. Malaria in adolescence: burden of disease, consequences, and opportunities for intervention. THE LANCET. INFECTIOUS DISEASES 2007; 6:780-93. [PMID: 17123898 DOI: 10.1016/s1473-3099(06)70655-7] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The problem of malaria in adolescence has largely been overshadowed by the huge burden of disease in young children. A substantial number of adolescents are at risk from malaria infection, but the burden of disease and consequences of infection in this age-group have rarely been studied. Our understanding of specific risk factors and beneficial interventions for adolescents is also limited. Data show that, from an adolescent viewpoint, malaria is a common cause of clinical illness and a preventable cause of death, even in areas of stable malaria transmission. Younger adolescents might be at a higher risk than older adolescents, because of immunological and hormonal factors. There are limited data about the adverse consequences of malaria in non-pregnant adolescents. However, in pregnant adolescents, the consequences of malaria are of great concern and simple interventions might lead to a substantial benefit. Malaria infection in adolescents is an under-recognised problem, and the prevention, diagnosis, and treatment of malaria should have a high priority within adolescent health programmes.
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Al-Taiar A, Jaffar S, Assabri A, Al-Habori M, Azazy A, Al-Mahdi N, Ameen K, Greenwood BM, Whitty CJM. Severe malaria in children in Yemen: two site observational study. BMJ 2006; 333:827. [PMID: 17053235 PMCID: PMC1618439 DOI: 10.1136/bmj.38959.368819.be] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
OBJECTIVES To assess the burden of malaria on health services, describe the clinical presentation of severe malaria in children, and identify factors associated with mortality by means of a prospective observational study. SETTING Two public hospitals in Taiz (mountain hinterland) and Hodeidah (coastal plain), Yemen. PARTICIPANTS Children aged 6 months to 10 years. RESULTS Of 12,301 paediatric admissions, 2071 (17%) were for suspected severe malaria. The proportion of such admissions varied according to the season (from 1% to 40%). Falciparum malaria was confirmed in 1332 children; 808 had severe disease as defined by the World Health Organization. Main presentations were respiratory distress (322/808, 40%), severe anaemia (291/800, 37%), and cerebral malaria (60/808, 8%). Twenty two of 26 children who died had a neurological presentation. No deaths occurred in children with severe anaemia but no other signs of severity. In multivariate analysis, a Blantyre coma score < or = 2, history of fits, female sex, and hyperlactataemia predicted mortality; severe anaemia, respiratory distress, and hyperparasitaemia were not significant predictors of mortality. CONCLUSIONS Severe malaria puts a high burden on health services in Yemen. Although presentation is similar to African series, some important differences exist. Case fatality is higher in girls.
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Affiliation(s)
- Abdullah Al-Taiar
- Faculty of Medicine and Health Sciences, Sana'a University, PO Box 13078, Sana'a, Yemen.
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Tobón C. A, Giraldo S. C, Pineros J. JG, Arboleda N. M, Blair T. S, Carmona-Fonseca J. Epidemiologia de la malaria falciparum complicada: estudio de casos y controles en Tumaco y Turbo, Colombia, 2003. REVISTA BRASILEIRA DE EPIDEMIOLOGIA 2006. [DOI: 10.1590/s1415-790x2006000300003] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
OBJETIVOS: Identificar aspectos del hospedero, del parásito y del ambiente asociados con ocurrencia de malaria por Plasmodium falciparum complicada. MÉTODOS: Estudio de casos y controles en pacientes de Tumaco y Turbo (Colombia) aplicando los criterios de complicación de la Organización Mundial de la Salud. RESULTADOS: Entre noviembre 2002 y julio 2003 se captaron 64 casos (malaria complicada) y 135 controles (malaria no complicada). Las complicaciones fueron: hiperparasitemia (40%), falla hepática (36%), síndrome dificultad respiratoria aguda (7%), falla renal (4%), trombocitopenia grave (3%), anemia grave (2%), malaria cerebral (2%) e hipoglicemia grave (1%). Se encontraron como factores de riesgo para malaria falciparum complicada: a) Los antecedentes de malaria falciparum durante el último año fueron menores en los casos (OR= 7.0 (1.2-43.6) P=0.019); b) Mayor uso previo de antimaláricos en los casos (OR=2.2 (1.1-4.4) P=0.031) y c) mayor uso de cloroquina en los casos (OR=7.4 (1.1-7.8) P=0.017). Se hallaron los alelos MAD-20 y K1 del gen msp1 y FC-27 e IC-1 del gen msp2, cuya distribución de frecuencias fue similar entre casos y controles, aunque el alelo K1 mostró una variación importante entre grupos (casos: 9.4%, controles: 3.5%). La frecuencia de "signos de peligro" fue significativamente mayor en los casos (OR= 3.3, (1.5-7.4) P=0.001). Los criterios de complicación malárica de la Organización Mundial de la Salud se comparan con otros y se discuten algunas implicaciones. CONCLUSIÓN: Se identificaron como factores de riesgo para malaria falciparum complicada, la ausencia de antecedentes de malaria falciparum en el último año y el uso de antimaláricos antes de llegar al hospital.
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Idro R, Aloyo J, Mayende L, Bitarakwate E, John CC, Kivumbi GW. Severe malaria in children in areas with low, moderate and high transmission intensity in Uganda. Trop Med Int Health 2006; 11:115-24. [PMID: 16398762 DOI: 10.1111/j.1365-3156.2005.01518.x] [Citation(s) in RCA: 65] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVES Age and transmission intensity are known to influence the manifestations of severe falciparum malaria in African children. However, it is unclear how specific clinical features such as seizures, impairment of consciousness, or respiratory distress vary with the parasite load and transmission intensity. We examined how the peripheral parasite load varies with transmission intensity and how this influences the symptoms and manifestations of severe malaria in children under 5 years in three areas with different malaria transmission intensity across Uganda. METHODS We consecutively recruited 617 children with severe malaria presenting to three hospitals in areas with very low (51), moderate (367) and very high (199) transmission intensities and compared the age, admission parasite density and proportions of patients with different manifestations of severe disease. RESULTS The median age (months) was inversely proportional to transmission intensity and declined with rising transmission (26.4 in very low, 18.0 in moderate and 9.0 under very high transmission). The highest proportion of patients reporting previous malaria admissions came from the area with moderate transmission. The geometric mean parasite density (18,357, 32,508 and 95,433/microl) and the proportion of patients with seizures (13.7%, 36.8% and 45.7%, P < 0.001) from very low, moderate and very high transmission respectively, increased with rising transmission. A linear increase with transmission was also observed in the proportion of those with repeated seizures (9.8%, 13.4% and 30.2%, P < 0.001) or impaired consciousness (7.8%, 12.8% and 18.1%, P = 0.029) but not respiratory distress. The proportion of patients with severe anaemia (19.6%, 24.8% and 37.7%, P = 0.002) mirrored that of patients with seizures. CONCLUSIONS These findings suggest that heavy Plasmodium falciparum parasitaemia may be important in development of seizures, severe malarial anaemia and impaired consciousness in children under 5 years of age but may not be important in the development of respiratory distress.
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Affiliation(s)
- R Idro
- Department of Paediatrics and Child Health, Mulago Hospital/Makerere University Medical School, Kampala, Uganda.
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Gérardin P, Rogier C, Leteurtre S, Jouvencel P, Ka AS, Imbert P. Evaluation of Pediatric Risk of Mortality (PRISM) scoring in African children with falciparum malaria. Pediatr Crit Care Med 2006; 7:45-7. [PMID: 16395074 DOI: 10.1097/01.pcc.0000192321.66637.e6] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Little is known about the use of generic severity scores in severe childhood infectious diseases. The purpose of this prospective study was to evaluate the performance of the Pediatric Risk of Mortality (PRISM) scoring system in predicting the outcome of falciparum malaria in African children. DESIGN, SETTING, PATIENTS All children admitted to a 120-bed pediatric ward in a tertiary care hospital in Dakar, Senegal, with a primary diagnosis of acute malaria were assigned a PRISM score after 24 hrs or at time of death. INTERVENTIONS None. RESULTS PRISM discrimination, evaluated by areas under receiver operating characteristic curves (AUC), was good both for all acute malaria cases (n = 311; lethality, 9%; AUC, 0.89; 95% confidence interval [CI], 0.85-0.92) and for severe malaria cases (n = 233; lethality, 12%; AUC, 0.86; 95% CI, 0.81-0.90). However, the number of children who died was greater than the number of deaths predicted by PRISM (standardized mortality ratio, 2.16; 95% CI, 1.46-2.87). CONCLUSION This discrepancy observed in five classes of expected mortality (Hosmer-Lemeshow chi-square test, p < .001) may have been due to chance (sample size too small for a valid test), to a lower standard of care in Dakar than in the American hospitals where PRISM was designed, or to a failure of PRISM to classify risk in severe malaria.
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Affiliation(s)
- Patrick Gérardin
- Department of Pediatrics, Hôpital Principal, Dakar, Senegal, Neonatal and Pediatric Intensive Care Unit, Hôpital de Terre-Sainte, Saint-Pierre, Reunion Island, France
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Gay-Andrieu F, Adehossi E, Lacroix V, Gagara M, Ibrahim ML, Kourna H, Boureima H. Epidemiological, clinical and biological features of malaria among children in Niamey, Niger. Malar J 2005; 4:10. [PMID: 15703076 PMCID: PMC549526 DOI: 10.1186/1475-2875-4-10] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2004] [Accepted: 02/09/2005] [Indexed: 12/02/2022] Open
Abstract
Background Malaria takes a heavy toll in Niger, one of the world's poorest countries. Previous evaluations conducted in the context of the strategy for the Integrated Management of Childhood Illness, showed that 84% of severe malaria cases and 64 % of ordinary cases are not correctly managed. The aim of this survey was to describe epidemiological, clinical and biological features of malaria among <5 year-old children in the paediatric department of the National Hospital of Niamey, Niger's main referral hospital. Methods The study was performed in 2003 during the rainy season from July 25th to October 25th. Microscopic diagnosis of malaria, complete blood cell counts and measurement of glycaemia were performed in compliance with the routine procedure of the laboratory. Epidemiological data was collected through interviews with mothers. Results 256 children aged 3–60 months were included in the study. Anthropometrics and epidemiological data were typical of a very underprivileged population: 58% of the children were suffering from malnutrition and all were from poor families. Diagnosis of malaria was confirmed by microscopy in 52% of the cases. Clinical symptoms upon admission were non-specific, but there was a significant combination between a positive thick blood smear and neurological symptoms, and between a positive thick blood smear and splenomegaly. Thrombopaenia was also statistically more frequent among confirmed cases of malaria. The prevalence of severe malaria was 86%, including cases of severe anaemia among < 2 year-old children and neurological forms after 2 years of age. Overall mortality was 20% among confirmed cases and 21% among severe cases. Conclusions The study confirmed that malaria was a major burden for the National Hospital of Niamey. Children hospitalized for malaria had an underprivileged background. Two distinctive features were the prevalence of severe malaria and a high mortality rate. Medical and non-medical underlying factors which may explain such a situation are discussed.
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Affiliation(s)
| | - Eric Adehossi
- Department of Internal Medicine, B3, National Hospital of Niamey, Niamey, Niger
| | - Véronique Lacroix
- Clinique Gamkalley, Niamey, Niger
- Université Victor Segalen, Bordeaux 2, Bordeaux, France
| | - Moussa Gagara
- Department of Internal Medicine, B3, National Hospital of Niamey, Niamey, Niger
| | | | - Hama Kourna
- Department of Paediatrics B, National Hospital of Niamey, Niamey, Niger
| | - Hamadou Boureima
- Department of Paediatrics A, National Hospital of Niamey, Niamey, Niger
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Abstract
Severe falciparum malaria is responsible for 2 million annual deaths, mostly among children under five years living in sub-Saharian Africa. In France, about 1500 paediatric malaria cases are diagnosed each year, among which 1% are severe and 1-2 deaths occur. Children are at high risk for severe forms, since malarial immunity is not yet acquired and symptoms are rapidly progressive. The definition of severe malaria relies upon WHO criteria revised in 2000. In children living in endemic areas, the most frequent criteria are impaired consciousness, severe anaemia, respiratory distress or acidosis, multiple convulsions and hypoglycaemia. Some of them have a high prognostic value, e.g., coma, hypoglycaemia or respiratory distress. The pertinence of WHO criteria was not assessed in travelling children, since severe cases are rare. Other severity criteria found in recent surveys from endemic zones, such as thrombocytopenia or, in infants, dehydration or bacteraemia, should also be investigated in childhood imported malaria. However, any fever associated with a convulsion, prostration, or impaired consciousness, in a child returning from the tropics, should be consider severe malaria and indicate an emergency admission to hospital. In France, intravenous quinine is recommended for the treatment of severe forms, without loading dose in children.
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Affiliation(s)
- P Imbert
- Service des maladies infectieuses et tropicales, hôpital d'instruction des armées Bégin, 69, avenue de Paris, 94163 Saint-Mandé, France.
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Abstract
Anemia due to infection is a major health problem in endemic areas for young children and pregnant women. The anemia is caused by excess removal of nonparasitized erythrocytes in addition to immune destruction of parasitized red cells, and impaired compensation for this loss by bone marrow dysfunction. The pathogenesis is complex, and a predominant mechanism has not been identified. Certain parasite and host characteristics may modify the anemia. Concomitant infections and nutritional deficiencies also contribute to anemia and may interact with the malarial infection. Few preventive strategies exist, and the management of severe malarial anemia with blood transfusion carries a risk of HIV transmission. The current increase in malaria-specific childhood mortality in sub-Saharan Africa attributed to drug-resistant infection is likely partly related to an increase in severe anemia. This review summarizes recent findings on the pathogenesis and epidemiology of malarial anemia.
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Affiliation(s)
- Håkan Ekvall
- Division of Medicine, Unit of Infectious Diseases, Karolinska Institute, Karoliniska Hospital, Stockholm, Sweden.
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Abstract
Malaria is a leading cause of morbidity and mortality worldwide, and anemia is a common and sometimes serious complication of Plasmodium falciparum infection. Although micronutrient malnutrition is usually highly prevalent in malaria endemic areas, the contribution of micronutrient deficiencies to malarial anemia is often overlooked. Recent investigation suggests that micronutrients such as vitamin A, vitamin E, and zinc, may improve the morbidity of malaria through immune modulation and alteration of oxidative stress. Micronutrients are also involved in the pathogenesis of anemia and likely play a role in malarial anemia, but many clinical trials have not specifically addressed the impact of micronutrient supplementation on malarial anemia. Further work is needed to assess the effect of both clinic and community-based micronutrient interventions on malarial anemia in infants, children, and pregnant women.
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Affiliation(s)
- Veronique Nussenblatt
- Department of Ophthalmology, Center for Human Nutrition, Johns Hopkins University School of Medicine, 550 No. Bdwy., Suite 700, Baltimore, MD 21205, USA
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Imbert P, Gérardin P, Rogier C, Ka AS, Jouvencel P, Brousse V, Guyon P. Severe falciparum malaria in children: a comparative study of 1990 and 2000 WHO criteria for clinical presentation, prognosis and intensive care in Dakar, Senegal. Trans R Soc Trop Med Hyg 2002; 96:278-81. [PMID: 12174779 DOI: 10.1016/s0035-9203(02)90099-4] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
The relevance of WHO criteria for severe and complicated malaria has been debated for a while, especially as regards children. Recent data led WHO experts to modify the definition of severe malaria. The objective of this study was to evaluate retrospectively the significance of the new definition on severity, lethality and intensive care distribution in children admitted with falciparum malaria (in 1997-99) to Hôpital Principal de Dakar, Senegal. We used the paediatric risk of mortality score (PRISM) to compare the 2 definitions, WHO 2000 and WHO 1990. Finally, we evaluated the impact of the new definition in terms of major therapeutic interventions (MTIs): mechanical ventilation, haemodynamic support, transfusion, haemodialysis, and the use of sedatives. Among 311 patients, the frequencies of severe malaria cases and case-fatality rates thereof were 52% (n = 161) and 17% (n = 28) respectively using the 1990 WHO criteria, and 75% (n = 233) and 12% (n = 28) using the 2000 WHO criteria. Mean PRISM score among severe cases decreased with the new definition (6.5 versus 8.6). Both definitions predicted neurological sequelae and deaths with 100% sensitivity. One or more MTIs were required in severe malaria cases in 86% (n = 139) under the 1990 criteria and 73% (n = 170) under the 2000 criteria. In this area of low and seasonal transmission, the 2000 WHO definition of severe malaria proved broader and less specific, but was easier to apply and retained the high sensitivity of the earlier definition in identifying life-threatening infections.
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Affiliation(s)
- P Imbert
- Service des Maladies Infectieuses et Tropicales, Hôpital d'Instruction des Armées Bégin, 69 Avenue de Paris, 94163 Saint-Mandé, France.
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Prusty SKR, Das BS. Low incidence of the severe complications of malaria and absence of malaria-specific mortality, in Tensa, Sundergarh district, Orissa state, India, an area hyper-endemic for malaria. ANNALS OF TROPICAL MEDICINE AND PARASITOLOGY 2001. [DOI: 10.1080/00034983.2001.11813623] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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Abstract
Human infections with Plasmodium falciparum may result in severe forms of malaria. The widespread and rapid development of drug resistance in P. falciparum and the resistance of the disease-transmitting mosquitoes to insecticides make it urgent to understand the molecular background of the pathogenesis of malaria to enable the development of novel approaches to combat the disease. This review focuses on the molecular mechanisms of severe malaria caused by the P. falciparum parasite. The nature of severe malaria and the deleterious effects of parasite-derived toxins and host-induced cytokines are introduced. Sequestration, brought about by cytoadherence and rosetting, is linked to severe malaria and is mediated by multiple receptors on the endothelium and red blood cells. P. falciparum erythrocyte membrane protein 1 (PfEMP1) is the ligand responsible for a majority of binding interactions, and the multiply adhesive features of this sticky molecule are presented. Antigenic variation is also a major feature of PfEMP1 and of the surface of the P. falciparum-infected erythrocyte. Possible mechanisms of P. falciparum antigenic variation in asexual stages are further discussed. We conclude this review with a perspective and suggestions of important aspects for future investigations.
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Abstract
Human infections with Plasmodium falciparum may result in severe forms of malaria. The widespread and rapid development of drug resistance in P. falciparum and the resistance of the disease-transmitting mosquitoes to insecticides make it urgent to understand the molecular background of the pathogenesis of malaria to enable the development of novel approaches to combat the disease. This review focuses on the molecular mechanisms of severe malaria caused by the P. falciparum parasite. The nature of severe malaria and the deleterious effects of parasite-derived toxins and host-induced cytokines are introduced. Sequestration, brought about by cytoadherence and rosetting, is linked to severe malaria and is mediated by multiple receptors on the endothelium and red blood cells. P. falciparum erythrocyte membrane protein 1 (PfEMP1) is the ligand responsible for a majority of binding interactions, and the multiply adhesive features of this sticky molecule are presented. Antigenic variation is also a major feature of PfEMP1 and of the surface of the P. falciparum-infected erythrocyte. Possible mechanisms of P. falciparum antigenic variation in asexual stages are further discussed. We conclude this review with a perspective and suggestions of important aspects for future investigations.
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Affiliation(s)
- Q Chen
- Microbiology and Tumour Biology Centre, Karolinska Institutet, and Swedish Institute for Infectious Disease Control, S-171 77 Stockholm, Sweden
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Mockenhaupt FP, May J, Bergqvist Y, Ademowo OG, Olumese PE, Falusi AG, Grossterlinden L, Meyer CG, Bienzle U. Concentrations of chloroquine and malaria parasites in blood in Nigerian children. Antimicrob Agents Chemother 2000; 44:835-9. [PMID: 10722478 PMCID: PMC89779 DOI: 10.1128/aac.44.4.835-839.2000] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/1999] [Accepted: 12/27/1999] [Indexed: 11/20/2022] Open
Abstract
Consumption of chloroquine (CQ) and subtherapeutic drug levels in blood are considered to be widespread in areas where malaria is endemic. A cross-sectional study was performed with 405 Nigerian children to assess factors associated with the presence of CQ in blood and to examine correlations of drug levels with malaria parasite species and densities. Infections with Plasmodium species and parasite densities were determined by microscopy and PCR assays. Whole-blood CQ concentrations were measured by high-performance liquid chromatography. Plasmodium falciparum, P. malariae, and P. ovale were observed in 80, 16, and 9% of the children, respectively, and CQ was detected in 52% of the children. CQ concentrations were >17 and <100 nmol/liter in 25% of the children, 100 to 499 nmol/liter in 14% of the children, and > or =500 nmol/liter in 13% of the children. Young age, attendance at health posts, and absence of parasitemia were factors independently associated with CQ in blood. With increasing concentrations of CQ, the prevalence of P. falciparum infection and parasite densities decreased. However, at concentrations corresponding to those usually attained during regular prophylaxis (> or =500 nmol/liter), 62% of children were still harboring P. falciparum parasites. In contrast, no infection with P. malariae and only one infection with P. ovale were observed in children with CQ concentrations of > or =100 nmol/liter. These data show the high prevalence of subcurative CQ concentrations in Nigerian children and confirm the considerable degree of CQ resistance in that country. Subtherapeutic drug levels are likely to further promote CQ resistance and may impair the development and maintenance of premunition in areas where malaria is endemic.
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Affiliation(s)
- F P Mockenhaupt
- Institute of Tropical Medicine and Medical Faculty Charité, Humboldt-University, Berlin, Germany.
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