Allcause Mortality and Malaria in African children: Trends and Controversies

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All-cause Mortality and Malaria in African
children Trends and Controversies

• Joel G. Breman, MD, DTPH
• Fogarty International Center
• National Institutes of Health
• The Epidemiology of Malaria
• Gordon Research Conference
• Oxford, England
• 6 11 July 2003

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Mortality and Malaria

• All-cause
• Malaria
• Controversies
• Research

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All-cause Mortality

• Regional, 1990 and 2000
• Trends, 1970 to 2015
• Africa, by area, 1960 to 2000

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Trends in Under-Five Mortality

• In 2002, about 10.5 million child deaths
• Down from 12.4 in 1990
• Child deaths (millions)
• 2000 1990
• AFR 4.5 4.0
• SAR 3.7 4.0
• EAP 1.4 2.2
• LAC 0.4 0.6
• MNA 0.4 0.6
• ECA 0.2 0.3

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Reducing child deaths
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Malaria Burden

• Percent of deaths, 2002
• Percent of DALYS, 2002
• Estimation of deaths, Africa, 1952 to 1999
• Manifestations
• Hospital visits and admissions, 1985 to 2000
• Chloroquine resistance
• Epidemics

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Deaths and Malaria-related Deaths (1000s), 2000
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Disabilityadjusted Life Years (DALYs,
1000s),All Cause and Malaria-related, 2002
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Estimated World and Regional Malaria Deaths,
1952-1999
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Malaria BurdenClinical Manifestations
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MARA/ARMA Model of Malaria Transmission, 2003
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Historic examples of severe epidemics
Episodes
Population exposed
Place, year
Causes
Deaths
Abandonment of IRS and shortage of antimalarials
15,000-30,000 each year
Over 200,000 each yr at peak, 27 of outpatient
attendances
2.5 million
Madagascar highlands, 1987-1988 (1)
High rainfall and temperature
Over 150,000 (case fatality rate gt5)
3 million
8-10 million
Ethiopia highlands/ Dumbia plain, 1958(1)
High rainfall and temperature
3271 officially reported
gt1 million
45 million
Ethiopia, Dec. 1997 Feb. 1998 (1)
Abandonment of control (in relation to complex
emergency), chloroquine resistance and expanded
rice cultivation
1287 reported, true number estimated to be 10-15x
higher
2 million during 6 months a 4-fold increase in
confirmed cases (10)
NE Burundi, Oct-2000 May 2001 (9)
Table 5.1
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RBM baseline survey
Table 5.3
Note SAMC reference 7
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Controversies
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Controversies

• Reliability of WHO and World Bank data
• - Demographic Surveillance Systems
• - Demographic and Health Surveys
• Do we accept
• - Overall mortality trends?
• - Disease-specific trends?

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Controversies (2)Whither Malaria

• Is malaria withering?
• Directly causes acute neurologic disease
• Indirectly contributes to conditions and
  co-morbidity
• - Anemia
• - Malnutrition
• - Low birth weight
• - Decreased cognition
• - Susceptibility to other infections
• - Hypoglycemia
• - Respiratory distress

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Malaria Morbidity and Mortality Estimates for
African Children lt5 years Possible Gaps
Mortality total cases
Morbidity total cases
Case fatality rate ()
Manifestations
110,000
575,000
19.2
Cerebral malaria
sequelae lt 6 mos. gt 6 mos.
No data No data
47,000 - 75,000 9,000 - 19,000
- -
190,000 974,000
1.42 5.66 million
13.4 - 17.2
Severe anemia
110,000
792,000
13.9
Respiratory distress
153,000 267,000
764,000
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Hypoglycemia
62,000 363,000
167,000 967,000
37.5
Low-birth weight
3.718 8.758 million
625,000 1.824 million
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maximum estimate all children lt5 years of age
except cerebral malaria (lt10 years)
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Controversies (3)

• Measurements
• - Hospital-based admissions total and with
  malaria and anemia
• - Hospital-base deaths total and with malaria
  and anemia
• - Patient management clinical and laboratory
  diagnosis, treatment, education, referral
• - Maternal and fetal care low birth weight
  babies in hospitals, with and without maternal
  infection

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Research
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Research

• Relationship between research training and
  support
• Themes tied to burden
• Definition of burden of epidemic and urban malaria

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Research, Training, and Support Needs According
to Understanding of Diseases and Efficacy of
Control Methods
High
High
Training
Efficacy of Control Methods
Research Needs
Low
Low
Some
High
Moderate
Research Support Needs
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Research, Training, and Support Needs According
to Understanding of Diseases and Efficacy of
Control Methods
High
High
Training
Efficacy of Control Methods
Malaria Dengue HIV/AIDSTuberculosisEbola/Marbur
g InfluenzaCancersAlzheimers
SmallpoxGuinea wormPoliomyelitisH. influenzae
type BMeaslesTetanus
Research Needs
Low
Low
Some
High
Moderate
Research Support Needs
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Research Needs for Determining All-cause and
Malaria Mortality

• Pathology and pathogenesis (case control)
• Population based studies (prospective)
• Passive/routine surveillance vs. surveys
• Intervention-linked research
• Patient management
• Chemoprophylaxis
• Personal protection
• Vector control
• Environmental improvement
• Vaccination

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Fevers of the South        Humanity has
but three great enemies,   Fever, famine
and war of these by far the   greatest,
by far the most terrible is fever.  
William Osler,1896