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All-Cause Mortality and Malaria in African Children: Trends and Controversies

This document summarizes a presentation on all-cause mortality and malaria in African children. It discusses trends showing declines in under-five mortality from 1990-2002 but controversies around data reliability and whether malaria is truly declining. It also examines malaria's disease burden through disability-adjusted life years. Research needs are outlined around determining all-cause and malaria mortality through improved population studies, surveillance, and intervention-linked research. Controversies exist around directly measuring malaria's impact and whether it is still a significant contributor to conditions like anemia and low birth weight.

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78 views32 pages

All-Cause Mortality and Malaria in African Children: Trends and Controversies

This document summarizes a presentation on all-cause mortality and malaria in African children. It discusses trends showing declines in under-five mortality from 1990-2002 but controversies around data reliability and whether malaria is truly declining. It also examines malaria's disease burden through disability-adjusted life years. Research needs are outlined around determining all-cause and malaria mortality through improved population studies, surveillance, and intervention-linked research. Controversies exist around directly measuring malaria's impact and whether it is still a significant contributor to conditions like anemia and low birth weight.

Uploaded by

Besong Michael
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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

Mortality and Malaria

All-cause
Malaria
Controversies
Research

All-cause Mortality
Regional, 1990 and 2000
Trends, 1970 to 2015
Africa, by area, 1960 to 2000

Trends in Under-Five Mortality


In 2002, about 10.5
million child deaths
Down from 12.4 in 1990
Child deaths (millions):

Under-Five Mortality by World Bank Region


200
180
160
140
120
100
80
60
40
20
0

AFR

SAR

MNA

1990 2000

EAP

LAC

ECA

Low and
middle
income

AFR
SAR
EAP
LAC
MNA
ECA

2000

1990

4.5
3.7
1.4
0.4
0.4
0.2

4.0
4.0
2.2
0.6
0.6
0.3

Reducing child deaths


Long-term (1970-2000) trends in under-five mortality and MDG
target for 2015 by World Bank region
250

Under-five mortality rate

200

150

100

50

0
1970

1975

AFR

1980

1985

SAR

1990

ECA

1995

LAC

2000

MNA

2005

2010

EAP

2015

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

Deaths and Malaria-related Deaths (1000s), 2000


Population
World

6,122,210

Africa
655,476
Americas
837,967
East Med.
493,091
Europe
874,178
SE Asia
1,559,810
West
1,701,689
Pacific

Malaria
Malaria/
All deaths (%) Deaths (%) total (%)
56,554

1,124

2.0

10,681 (18.9)
5,911 (10.5)
4,156 (7.3)
9,703 (17.2)
14,467 (25.6)
11,636 (20.6)

963 (85.7)
1 (-)
55 (4.9)
0
95 (8.5)
10 (0.9)

9.0
0.02
1.3
0.7
0

Disabilityadjusted Life Years (DALYs, 1000s),


All Cause and Malaria-related, 2002
Population

DALYs from
all deaths (%)

DALYs from
malaria
deaths (%)

World

6,122,210

1,467,257

42,280

Africa

655,476

357,884 (24.4)

Americas

837,967

145,217 (9.9)

108 (0.2)

East Med.

493,091

136,221 (9.3)

2,050 (4.8)

Europe

874,178

151,223 (10.3)

SE Asia

1,559,810

418,844 (28.5)

3,680 (8.7)

0.9

West Pacific

1,701,689

257,868 (17.6)

409 (1.0)

0.2

36,012 (85.2)

20 (0.04)

DALYs from
malaria
/total (%)
2.9
10.1
0.07
1.5
0.01

Estimated World and Regional Malaria


Deaths, 1952-1999
3,000,000

Worldwide
2,500,000

2,000,000

1,500,000

1,000,000

500,000

A frica

Asia

Malaria Burden
Clinical Manifestations
Hypoglycemia
Anemia
Acute
febrile
illness

Severe illness

Infected
Mosquito

Respiratory
distress
Cerebral malaria

Death

Anemia
Chronic
effects
Infected
Human

Neurologic/
cognitive
Developmental

Fetus

Impaired
growth and
development

Low birth weight

Pregnancy
Maternal

Acute illness
Anemia

Malnutrition

Infant
mortality
Impaired
productivit
y

MARA/ARMA Model of Malaria Transmission, 2003

Historic examples of severe epidemics


Place, year

Population
exposed

Episodes

Madagascar
highlands,
1987-1988 (1)

2.5 million

Over 200,000
15,000-30,000 Abandonment
each yr; at peak, each year
of IRS and
27% of outpatient
shortage of
attendances

Deaths

Causes

antimalarials

Ethiopia
highlands/
Dumbia plain,
1958(1)

8-10 million

Ethiopia, Dec. 45 million


1997
Feb. 1998 (1)
NE Burundi,
Oct-2000
May 2001 (9)

3 million

Over 150,000
(case fatality
rate >5%)

High rainfall
and
temperature

>1 million

3271
officially
reported

High rainfall
and
temperature

2 million
during 6
months a 4fold increase
in confirmed
cases (10)

Abandonment of

1287
control (in relation
reported, true to complex
number
emergency),
estimated to chloroquine
be 10-15x
resistance and
expanded rice
higher
cultivation

Epidemics
identified
1998-2000

Percentage
detected
within 2
weeks

Percentage
responded to
within 2 weeks
of detection

Source

Angola

SAMC

Botswana

100

100

SAMC

Malawi

SAMC

Mozambique

67

67

SAMC

Namibia

33

SAMC

South Africa

100

100

SAMC

Swaziland

100

100

SAMC

Tanzania

SAMC

Zambia

SAMC

Zimbabwe

33

67

SAMC

Eritrea

4 (districts) 75

100

RBM baseline survey

Ethiopia

102

55

100

RBM baseline survey

Uganda

100

RBM baseline survey

Controversies

Controversies
Reliability of WHO and World Bank data
- Demographic Surveillance Systems
- Demographic and Health Surveys

Do we accept
- Overall mortality trends?
- Disease-specific trends?

Controversies (2)
Whither Malaria
Is malaria withering?
Directly causes acute neurologic disease
Indirectly contributes to conditions and comorbidity
- Anemia
- Malnutrition
- Low birth weight
- Decreased cognition
- Susceptibility to other infections
- Hypoglycemia
- Respiratory distress

Malaria Morbidity and Mortality Estimates for


African Children <5 years: Possible Gaps
Manifestations

Case fatality
rate (%)

Morbidity
total cases

Mortality
total cases

19.2

575,000

110,000

47,000 - 75,000
9,000 - 19,000

No data
No data

13.4 - 17.2

1.42 5.66 million

13.9

792,000

20 35

764,000

153,000 267,000

37.5

167,000 967,000

62,000 363,000

Cerebral malaria
sequelae* < 6 mos.
> 6 mos.
Severe anemia
Respiratory distress
Hypoglycemia
Low-birth weight

3.718 8.758 million

190,000 974,000
110,000

625,000 1.824
million

Contribution (%) of Specific Gaps to African Childhood


Malaria Morbidity (up to 8.76 million children affected) *
Cerebral malaria
7%
Hypoglycemia
9%
Respiratory
disease
9%

Severe anemia
64%

Low birth weight


11%

*maximum estimate; all children <5 years of age


except cerebral malaria (<10 years)

Contribution (%) of Specific Gaps to African Childhood


Malaria Mortality (up to 1.82 million children die)

Cerebral malaria
6%
Respiratory
disease
6%
Hypoglycemia
15%
Severe Anemia
53%

Low birth weight


20%

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

Research

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

Research, Training, and Support Needs


According to Understanding of Diseases and
Efficacy of Control Methods
High

High

Training

Efficacy
of
Control
Methods

Low

Research
Needs

Some

Moderate

Research Support Needs

High

Low

Research, Training, and Support Needs


According to Understanding of Diseases and
Efficacy of Control Methods
High

Efficacy
of
Control
Methods

Low

High

Training

Malaria Research
Dengue

Smallpox
Guinea worm
Poliomyelitis
H. influenzae type B
Measles
Tetanus

Some

HIV/AIDS
Tuberculosis
Ebola/Marburg
Influenza
Cancers
Alzheimers

Moderate

Research Support Needs

High

Needs

Low

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

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

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