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PubMedDate not supplied

Absence of malaria-specific mortality in children in an area of hyperendemic malaria.

We conducted a prospective community-based malaria surveillance study on a cohort of children < 10 years old living in an area of hyperendemic malaria (spleen rates > 50% in children aged 2-9 years) in Vanuatu, Melanesia, supported by a concurrent prospective descriptive study of malaria admissions to the local hospital. The incidence of clinical malaria in children < 10 years old was 1.9 episodes/year. The annual incidence of severe malaria (severe malarial anaemia and cerebral malaria) was only 2/1000 in children aged < 5 years. The only manifestation of severe malaria seen in indigenous children was anaemia. No death could be attributed to malaria. While the incidence of uncomplicated clinical malaria in this population was comparable to that in many parts of Africa, the incidence of severe forms of the disease was significantly lower. This could not be attributed to differing rates of malaria transmission, chloroquine resistance, or to host protective or behavioural factors. These findings suggest that studies which compare disease patterns in geographically disparate populations may be instrumental in developing a better understanding of the determinants of clinical outcome in Plasmodium falciparum malaria and that such regional differences must be considered when planning or interpreting the effects of malaria interventions.

Adolescent↗
PubMedDate not supplied

Clinical case definitions for malaria: clinical malaria associated with very low parasite densities in African infants.

In areas endemic for Plasmodium falciparum, clinical malaria is believed to be less common in infants than in older children, but specific case definitions have rarely been determined for this age group. As malaria case definitions are known to be both age- and site-specific, assessment of the risk of disease in infancy requires the development of appropriate diagnostic criteria. In southern Ghana, 154 children were recruited at birth and monitored for fever and malaria infection until 2 years of age. Logistic regression was used to model fever risk as a continuous function of parasite density to determine case definitions for the diagnosis of clinical malaria, and to determine age- and season-specific estimates of the fraction of fevers attributable to malaria (AF); 2360 observations were made on 154 children. For fevers defined by a measured temperature > or = 37.5 degrees C, the estimated population AF was 44% (95% confidence interval 34-53). Estimates of AF varied with age and season. For infants, AF was 51% during the wet season and 22% during the dry season; for children over one year of age, AF was 89% during the wet season and 36% during the dry season. The estimated parasite density threshold for initiation of a febrile episode was 100 parasites per microL of blood in infants, compared with 3500 parasites per microL for children over one year of age. Using these case definitions, the incidence of clinical malaria was estimated at 0.09 cases per child-year at risk for children less than 6 months of age, 0.40 for children aged 6-11 months, and 0.69 for children aged 12-23 months. Of 66 cases of clinical malaria, only 3 were observed in children under 5 months of age. We concluded that, although most fevers in infants are not due to malaria, infant clinical malaria may occur at extremely low parasite densities. This may be indicative of a lack of anti-disease immunity in this age group. In southern Ghana, an infant with axillary temperature > or = 37.5 degrees C and parasitaemia > or = 100/microL should be considered to have clinical malaria. Nevertheless, the incidence of clinical malaria is very low in children under 6 months of age, confirming that they are significantly protected from clinical malaria compared to older children.

Age Factors↗
PubMed2004

Falciparum malaria in malaria-naive travellers and African visitors.

BACKGROUND: Patients from malaria-endemic areas who present in non-endemic countries with Plasmodium falciparum malaria are often assumed to have some degree of immunity. If this were reliably true, it would simplify their management. AIM: To determine whether being born and resident in a malaria-endemic country is a predictor of clinical course in UK admissions for malaria. DESIGN: Prospective observational study. METHODS: We compared clinical and laboratory parameters between two groups of adult patients with acute P. falciparum malaria, admitted to the Hospital for Tropical Diseases in London: one born and resident in non-endemic countries (n=167); the other born and resident in malaria-endemic countries of Africa (n=93). Patients were excluded if they had taken prophylaxis or prior treatment. RESULTS: There were no differences between these two groups in terms of peak parasitaemia or time to parasite clearance. There was a significantly higher risk of malaria-naive patients having peak parasitaemia >5% (OR 4.5, 95%CI 1.5-13.2). Of those usually resident in Africa, 31% required parenteral treatment compared to 41% of the malaria-naive group. Of the visitors from Africa, 4.3% needed admission to the Intensive Therapy Unit (ITU), although there was a tendency for more malaria-naive patients to require ITU care (OR 2.69, 95%CI 0.9-8.1). DISCUSSION: While there are differences in presentation between those who are malaria-naive and those who live in malaria-endemic African countries, making assumptions about the immunity or clinical course of an individual patient with malaria presenting in the UK on the basis of presumed history of exposure is unwise.

Adolescent↗
PubMed2006

Rapid Urban Malaria Appraisal (RUMA) IV: epidemiology of urban malaria in Cotonou (Benin).

BACKGROUND: An estimated 40 % of the population in Benin lives in urban areas. The purpose of the study was to estimate malaria endemicity and the fraction of malaria-attributable fevers in health facilities in Cotonou. METHODS: A health care system evaluation and a series of school parasitaemia surveys and health facility-based surveys were carried out during the dry season in of 2003, applying standard Rapid Urban Malaria Appraisal (RUMA) methodology. This study was part of a multi-site assessment supported by the Roll Back Malaria Partnership. RESULTS: The field work was carried out in February-March 2003. In 2002 and out of 289,342 consultations in the public health facilities of Cotonou there were 100,257 reported simple malaria cases (34.6%) and 12,195 complicated malaria cases (4.2%). In the school parasitaemia surveys, a malaria infection was found in 5.2 % of all samples. The prevalence rates of parasitaemia in the centre, intermediate and periphery zones were 2.6%, 9.0% and 2.5%, respectively. In the health facility surveys the malaria infection rates in presenting fever cases were 0% (under one year old), 6.8% (one to five years old), 0% (> five to 15 years old) and 0.9% (over 15 years old), while these rates in the control group were 1.4%, 2.8%, 1.3% and 2.0%. The malaria-attributable fractions among presenting fever cases were 0.04 in the one to five years old and zero in the three other age groups. Hence, malaria played only a small role in fever episodes at the end of the dry season. In total, 69.2% of patients used a mosquito net the night before the survey and 35.1% used an insecticide-treated net, which was shown to be protective for an infection (OR = 0.23, 95% CI 0.07-0.78). Travelling to a rural area (5.8% of all respondents) did not increase the infection risk. CONCLUSION: The homogenously low malaria prevalence might be associated with urban transformation and/or a high bednet usage. Over-diagnosis of malaria and over-treatment with antimalarials was found to be a serious problem.

Adolescent↗
PubMed2000

[WHO's malaria program Roll Back Malaria].

Malaria is one of the main health problems in the world with 300-500 millions cases yearly and about one million deaths, mainly children in Sub-Saharan Africa. In the 1990s the malaria problem in Africa has increased, although we have methods to control the disease. In 1998 the new secretary general of WHO, Gro Harlem Brundtland, established the Roll Back Malaria programme, with the aim to markedly reduce malaria morbidity and mortality. Governments in malaria-affected countries have to take the lead in Roll Back Malaria. Their health systems must be improved and malaria control integrated into the general health system, and the methods available for prevention and treatment have to be intensified and improved. At the same time, Roll Back Malaria will encourage and promote malaria research which hopefully will result in new medicines, vaccines and other tools which will improve the chances of reducing malaria-related deaths and suffering. Roll Back Malaria is a cabinet project within the WHO, and the organisation has a key role as manager, co-ordinator and monitor of the project. However, it depends for resources on international support and commitment from other UN bodies, the World Bank, governments in the western world, pharmaceutical industry, philanthropists and other sources. At present an optimistic view prevails, and the preliminary aim, to halve the malaria mortality by the year 2010, seems realistic even with the control methods of today. However, if research efforts result in new and better tools to combat the disease, the task will definitely be easier.

Adult↗
PubMed1994

Malaria treatment in Queensland, 1992. The use of malaria treatment guidelines.

OBJECTIVE: To investigate treatment patterns for malaria and the use of Australian guidelines which were then current for the treatment of malaria in Queensland in 1992. DESIGN AND PARTICIPANTS: A review of patient treatment and demographic details, obtained from the treating doctor by questionnaire, for all cases of malaria in Queensland in 1992 which were reported to Queensland Health (316 people treated for 341 episodes of malaria). RESULTS: Plasmodium falciparum infections were treated according to the recommendations in the guidelines in 20% of cases. Thirty-five per cent of infections were treated with chloroquine, even though most of these were acquired in countries where chloroquine or chloroquine/antifolate-resistant P. falciparum malaria existed. Plasmodium vivax infections were treated with the recommended course of chloroquine in 58% of cases. Fifty per cent of patients with P. vivax infection were treated with primaquine, but only 57% of these received the dose recommended in the guidelines for the eradication of hypnozoites. Patterns of malaria treatment were basically similar in the malaria-receptive zone and elsewhere in Queensland, although P. falciparum infections in the receptive zone were treated according to the guidelines at a higher rate (32%) than in the rest of Queensland (13%). CONCLUSION: In 1992, many cases of malaria in Queensland were not treated according to the recommendations in the Australian malaria treatment guidelines. We suggest that improved distribution of simple but comprehensive guidelines for malaria treatment may assist medical practitioners in the provision of prompt, effective treatment, and help prevent the reestablishment of endemic malaria in Australia.

Adolescent↗
PubMed2002

Predictive factors of malaria in travelers to areas where malaria is endemic.

BACKGROUND: The differentiation of malaria from other causes of fever is difficult. The development of tools for rapid and specific clinical diagnosis is of paramount importance for the identification of individuals infected with malaria. METHOD: A 4-year prospective study to identify the clinical and biological variables associated with malaria included all patients suspected of having malaria who presented in the emergency department (ED) of a French hospital. RESULTS: Of 783 patients admitted to the ED with suspected malaria, 145 had positive findings of a thick smear for Plasmodium species, mainly Plasmodium falciparum (90.3%). In univariate analysis, the following 12 variables were significantly associated with diagnosis of malaria: older than 30 years, male sex, immigration to France from an area where malaria is endemic, a visit to sub-Saharan Africa, insufficient antimalaria prophylaxis, fever, chills, absence of diarrhea, a leukocyte count within the reference range, thrombocytopenia, and increased lactate dehydrogenase and bilirubin levels. In multivariate analysis, the factors predictive of malaria included a visit to sub-Saharan Africa (odds ratio [OR], 7.7; 95% confidence interval [CI], 2.8-21.3), a temperature of at least 38.5 degrees C (OR, 6.2; 95% CI, 2.8-13.3), chills (OR, 3.0; 95% CI, 1.4-6.6), thrombocytopenia (OR, 16.5; 95% CI, 7.1-38.3), and abnormally high total bilirubin levels (OR, 21.5; 95% CI, 6.4-72.5). However, alone or combined, these features had insufficient sensitivity (95.0%) and low specificity (55.0%) for the diagnosis of malaria. CONCLUSIONS: Malaria should be suspected in all patients presenting with complaints after travel to an area where malaria is endemic, and these patients should undergo blood microscopy.

Adult↗
PubMed2000

Prevention versus treatment for malaria in pregnant women.

OBJECTIVES: Malaria contributes to antenatal anaemia and slowing of fetal growth, especially in first-time mothers. It is thought that these effects harm the mother and baby, and interventions to prevent or mitigate the effects of malaria are often recommended. The objective of this review was to assess the effects of anti-malarial interventions in pregnant women living in malarial areas on the mother and the infant. SEARCH STRATEGY: We searched the Cochrane Infectious Diseases Group trials register, the Cochrane Controlled Trials Register, Medline, Embase. We contacted researchers in the field. SELECTION CRITERIA: Randomised and quasi-randomised trials in pregnant women of interventions that aim to mitigate the effects of malaria in pregnancy, including drugs given routinely and mosquito control measures. DATA COLLECTION AND ANALYSIS: Trial quality was assessed. Data extraction was done by two reviewers using standard criteria. MAIN RESULTS: Fifteen trials were included. Drugs given regularly and routinely were associated with fewer episodes of fever in the mother, fewer women with severe anaemia antenatally, and higher average birthweight in infants. These effects appear to be greater in primigravidae. No difference in perinatal, neonatal and infant mortality were detected in studies of prophylaxis in all parity groups, or studies confined to women of low parity. REVIEWER'S CONCLUSIONS: Drugs locally effective for malaria when given routinely for malaria during pregnancy may reduce the incidence of low birth weight and anaemia. This effect appears to be limited to low parity women. Given the costs and inputs required to effectively deliver widescale prophylaxis programmes, we believe a large simple placebo- controlled trial testing the impact of drugs given routinely on pregnancy outcome and neonatal/infant survival is warranted.

Antimalarials↗
PubMed2005

Clinical pattern of severe Plasmodium falciparum malaria in Sudan in an area characterized by seasonal and unstable malaria transmission.

A hospital-based study was carried out in Gedarif town, eastern Sudan, an area of markedly unstable malaria transmission. Among the 2488 diagnosed malaria patients, 4.4% fulfilled the WHO criteria for severe malaria, and seven died of cerebral malaria. The predominant complication was severe malarial anemia (45.4%), followed by convulsions (21%), cerebral malaria (16. 4%) and hypotension (11.8%). Severe malaria was recognized in all age groups, but 44.5% of patients were aged 2 to 4 years. The mean ages of patients with severe anemia (5.6 years) and convulsions (5.9 years) were significantly lower than the mean ages of patients with cerebral malaria (14.1 years) or hypotension (35.2 years). Patients with convulsions and cerebral malaria had significantly higher mean parasite count (69972 and 56110 parasites/microL, respectively) than patients with severe anemia (24637 parasites/microL) or hypotension (13667 parasites/microL). The mean blood glucose level was higher in patients with cerebral malaria than in patients with anemia, and higher in patients who died than in patients who survived. In this setting, the clinico-epidemiological pattern of severe malaria varies considerably from that of hyperendemic regions in sub-Saharan Africa, and there is considerable variation between the individual complications of severe malaria.

Acute Disease↗
PubMed2002

Spatial simulation of malaria transmission and its control by malaria transmission blocking vaccination.

A simple, visual representation of spatial aspects of malaria transmission in successive snap-shots in time, is presented. The spatial components of the simulation involve (i) the identification of mosquito vector breeding sites of defined shape and area, (ii) the identification of a zone of malaria transmission determined by the shapes and areas of the vector breeding sites and the distance from these sites that the mosquitoes disperse, (iii) a human population dispersed in relation to the malaria transmission zone, (iv) perimeters around each individual human within which his or her infection can be transmitted by the local vector mosquitoes. The intensity of transmission within a malaria transmission zone is given by a number which is the number of new cases of malaria that each existing case will distribute through the human population within the duration of an infection. The simulation has been used here to examine the effects of vaccination against malaria transmission. Different levels of vaccine coverage are represented under endemic and epidemic malaria. The consequences of full or partial coverage of a zone of malaria transmission are also examined. The results are numerically compatible with the predictions of previous simple mathematical simulations of malaria transmission and interventions. The present simulation allows the nature of malaria transmission and the effects of interventions to be communicated easily and directly to an audience. It could have practical value in discussions of malaria control strategies with health planners.

Animals↗
PubMed1999

Lack of difference in iron status assessed by soluble transferrin receptor between children with cerebral malaria and those with non-cerebral malaria.

We conducted this study to determine whether children with cerebral malaria are less likely to have tissue iron deficiency than those with non-cerebral malaria. Iron status was assessed by soluble transferrin receptor (sTfR), serum ferritin, and haemoglobin in 44 Zaïrian children: 15 with cerebral malaria, 14 with non-cerebral malaria, and 15 without malaria (age range 0.5-16 years). Although there was no significant difference in the mean concentrations of sTfR, serum ferritin, or haemoglobin between either group of patients, a higher percentage of children with cerebral malaria (27 per cent) than those with non-cerebral malaria (14 per cent) or controls (7%) had sTfR levels above 7.3 mg/l (suggestive of tissue iron deficiency). A higher percentage of children with cerebral malaria (40 per cent) than with non-cerebral malaria (29 per cent) or controls (20 per cent) also had either serum ferritin < 100 micrograms/l and inflammation or sTfR > 7.3 mg/l or both. The data suggest that children with cerebral malaria are as likely to have tissue iron deficiency as those with non-cerebral malaria.

Adolescent↗
PubMed2003

Association of intraleukocytic Plasmodium falciparum malaria pigment with disease severity, clinical manifestations, and prognosis in severe malaria.

Peripheral parasite density of Plasmodium falciparum is used as an indicator of malaria disease severity, but does not quantify central sequestration, which is important in the pathogenesis of severe disease. Malaria pigment, recognizable within the cytoplasm of phagocytic cells by light microscopy may represent a peripheral marker for parasite biomass. One hundred seventy-two index cases of severe malaria and 172 healthy age-, residence-, and ethnicity-matched controls with uncomplicated malaria in Bandiagara, Mali were analyzed prospectively for presence of malaria pigment. The presence of polymorphonuclear cell (PMN) and monocyte pigment was strongly associated with severe disease compared with uncomplicated malaria. Total PMN pigment burden in children with severe malaria was higher in those with cerebral manifestations and with combined cerebral manifestations and severe anemia (hemoglobin < or = 5 g/dL) but was not associated with hyperparasitemia (> 500,000 asexual forms/mm3). Additionally, pigmented PMNs/mm3 was associated with a fatal outcome in patients with severe malaria. This study validates the presence of malaria pigment in monocytes and neutrophils as a marker for disease severity, and demonstrates that pigmented neutrophils are associated with cerebral malaria and with death in children with severe malaria.

Adolescent↗
PubMed1995

Species-specific PCR detection of malaria parasites by microtiter plate hybridization: clinical study with malaria patients.

A simple and convenient PCR method that amplifies the 18S rRNA genes has been developed for the purpose of detecting and differentiating four species causing malaria in humans. The advantage of the assay is that the biotinylated PCR product is visualized following hybridization with specific probes which are immobilized on plate wells (microtiter plate hybridization). This method has been previously evaluated in a field study and was found to be sensitive and specific for the detection of Plasmodium falciparum and Plasmodium vivax. In the current study, the microtiter plate hybridization PCR method was evaluated by using blood specimens from malaria patients. All of 36 cases of falciparum malaria, 26 of 27 cases of vivax malaria, all of 11 cases of ovale malaria, and 2 cases of malariae malaria were diagnosed species specifically by the PCR method. There were four smear-negative, PCR-positive cases that seemed to correspond to the convalescent stage of malaria. In contrast, 30 cases for which the diagnosis of malaria has been excluded on the basis of microscopy and clinical courses showed negative PCR results. By comparing parasite densities and PCR results following antimalarial treatment of some patients, it was revealed that the PCR results largely paralleled the parasite densities and that PCR could detect as few as 10 parasites per microliter of blood. We conclude that this PCR method is highly sensitive and specific for the detection of all four parasite species and can serve as a useful supplement to microscopy for the clinical management of malaria.

Animals↗
PubMedDate not supplied

In-hospital morbidity and mortality due to malaria-associated severe anaemia in two areas of Malawi with different patterns of malaria infection.

We examined the relative contribution of malaria-associated severe anaemia (parasitaemia and haematocrit < or = 15%) to malaria-related morbidity and mortality among children admitted at 2 hospitals in areas with different seasonal patterns of malaria infection in Malawi. The prevalence of malaria-associated severe anaemia was 8.5% among admissions at the hospital in an area with sustained, year-round infection (Mangochi District Hospital [MDH]), compared to 5.2% at the hospital in an area with a fluctuating pattern of infection (Queen Elizabeth Central Hospital [QECH]). Infants at MDH were nearly twice as likely to have malaria-associated severe anaemia as were those at QECH. Parasite density on admission was not related to the risk of severe anaemia at MDH, but it was at QECH. A similar proportion of all deaths was attributed to malaria at MDH (17.5%) and QECH (20.4%). However, malaria-associated severe anaemia accounted for 54% of malaria-related deaths at MDH compared to only 32% at QECH. Malaria-associated severe anaemia contributed significantly to morbidity and mortality at both sites, but its impact was more marked in the area with a sustained pattern of infection. These findings suggest that seasonal fluctuations in malaria infection may contribute to differences in patterns of malaria disease.

Age Factors↗
PubMed2000

Economic burden of malaria illness on households versus that of all other illness episodes: a study in five malaria holo-endemic Nigerian communities.

We compared the financial and economic costs of malaria attack to that of a combination of other illness episodes on households in five malaria holo-endemic rural communities. The data was collected from household heads or their representatives using pre-tested interviewer-administered questionnaire. Information was collected on the amount of money household spent to treat both malaria and other illnesses respectively, together with the time lost due to both the groups of illnesses within 1 month prior to the interview. The findings showed that the cost of treating malaria illness accounted for 49.87% of curative health care costs incurred by the households. Average malaria expenditure was $1.84 per household per month, while it was $2.60 per month for the combination of other illness episodes. The average person-days lost due to malaria and the combination of other illnesses were almost equal. If the financial costs of treating malaria and other illnesses are combined, this cost will deplete 7.03% of the monthly average household income, with treatment of malaria illness alone depleting 2.91%. Thus, malaria is a big contributor to the economic burden of disease, in malaria holo-endemic communities. Community-effective malaria control programs are needed to reduce this burden on the households.

Cost of Illness↗
PubMed2004

HIV infection as a cofactor for severe falciparum malaria in adults living in a region of unstable malaria transmission in South Africa.

BACKGROUND: Malaria and HIV are two of the most important diseases facing Africa. It remains uncertain whether HIV-related immunosuppression adversely affects the clinical outcome of malaria. OBJECTIVE: To measure the association between HIV status and outcome from malarial infection in adults living in a region of unstable malaria transmission. DESIGN: Observational cohort study. SETTING: Four community clinics and the Government hospital in Hlabisa district, KwaZulu-Natal, South Africa; a region of high HIV prevalence. METHODS: Consecutive febrile adults were screened for malaria with a rapid antigen test. Those with malaria provided blood spots for HIV testing, a thick blood film for confirmation of malaria and clinical data. Outcome was established following management according to South African government guidelines. RESULTS: Malaria was microscopically confirmed in 613. HIV prevalence was 29.9% (180/613); 110 (18%) had severe/complicated malaria and 28 (4.6%) died. HIV-infected patients were more likely to vomit or be confused and were more likely to be admitted to hospital (P = 0.05). In patients admitted to hospital, HIV infection was associated with severe/complicated malaria [adjusted odds ratio (OR) 2.3; 95% confidence interval (CI), 1.4-3.9] and with death (OR 7.5; 95% CI, 2.2-25.1). Acidosis and coma were also strong independent risk factors for death. CONCLUSION: HIV infection had an unexpectedly large association with the outcome of falciparum malaria in a region of unstable transmission. Both diseases are widespread in Africa and these results add to the body of knowledge suggesting an interaction of significant public health importance between HIV and malaria in Africa.

Adolescent↗
PubMed2006

Review: Intermittent preventive treatment--a new approach to the prevention of malaria in children in areas with seasonal malaria transmission.

Intermittent preventive treatment, the administration of a full course of an anti-malarial treatment to a population at risk at specified time points regardless of whether or not they are known to be infected, is now a recommended approach to the prevention of malaria in pregnancy and is being explored as a potential way of preventing malaria in infants. However, in many malaria endemic areas, the main burden of malaria is in older children and increasing use of insecticide treated bednets is likely to increase further the proportion of episodes of malaria that occur in older children. Recently, it has been shown in Senegal and in Mali that intermittent preventive treatment given to older children during the malaria transmission season can be remarkably effective in preventing malaria. This approach to malaria control is likely to be most effective in areas with a high level of malaria transmission concentrated in a short period of the year. However, several issues need to be addressed before intermittent preventive treatment in children can be advocated for use in malaria control programmes. These include: (1) determination of whether intermittent preventive treatment adds to the protection afforded by other control measures such as insecticide-treated bednets; (2) whether an effective and sustainable delivery system can be found; (3) choice of drug to be used; (4) optimum timing of drug administration; (5) the requisite interval between treatments. The potential benefits of intermittent preventive treatment in children are substantial; more research is needed to determine if this is a practical approach to malaria control.

Africa South of the Sahara↗