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The rapid increase in the world’s urban population has major implications for the epidemiology of malaria. A review of malaria transmission in sub-Saharan African cities shows the strong likelihood of transmission occurring within these sprawling cities, whatever the size or characteristics of their bioecologic environment. A meta-analysis of results from studies of malaria transmission in sub-Saharan Africa shows a loose linear negative relationship between mean annual entomologic inoculation rates (EIR) and the level of urbanicity. Few studies have failed to find entomologic evidence of some transmission. Our results show mean annual EIRs of 7.1 in the city centers, 45.8 in periurban areas, and 167.7 in rural areas. The impact of urbanization in reducing transmission is more marked in areas where the mean rainfall is low and seasonal. Considerable variation in the level of transmission exists among cities and within different districts in the same city. This article presents evidence from past literature to build a conceptual framework to begin to explain this heterogeneity. The potential for malaria epidemics owing to decreasing levels of natural immunity may be offset by negative impacts of urbanization on the larval ecology of anopheline mosquitoes. Malaria control in urban environments may be simpler as a result of urbanization; however, much of what we know about malaria transmission in rural environments might not hold in the urban context.
Received June 10, 2002. Accepted for publication October 10, 2002.
Financial support: This study was funded in part by Institut de Recherche pour le Développement and by NIH grants U19 AI45511, D43 TW01142, D43 TW00920, and NSF DEB-0083602.
Authors’ addresses: Vincent Robert, UR paludologie afro-tropicale de l’Institut de Recherche pour le Développement, and Institut Pasteur de Madagascar, B.P. 1274, Antananarivo 101, Madagascar, E-mail: robert{at}pasteur.mg. Kate Macintyre and Joseph Keating, Department of International Health and Development, Tulane University, 1440 Canal Street, Suite 2200, New Orleans, LA 70112. Jean-François Trape, UR paludologie afro-tropicale de l’Institut de Recherche pour le Développement, B.P. 1386, Dakar, Senegal. Jean-Bernard Duchemin, Institut Pasteur de Madagascar, B.P. 1274, Antananarivo 101, Madagascar. McWilson Warren, Retired Public Health Service Officer, Grafton, NH. John C. Beier, Department of Tropical Medicine, Tulane University, 1501 Canal Street, Room 505, New Orleans, LA 70112.
Reprint requests: Vincent Robert, Institut Pasteur de Madagascar, B.P. 1274 Antananarivo 101, Madagascar, E-mail: robert{at}pasteur.mg
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