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Malaria not only remains a leading cause of morbidity and mortality, but it also impedes socioeconomic development, particularly in sub-Saharan Africa. Rapid and unprecedented urbanization, going hand-in-hand with often declining economies, might have profound implications for the epidemiology and control of malaria, as the relative disease burden increases among urban dwellers. Reviewing the literature and using a modeling approach, we find that entomologic inoculation rates in cities range from 0 to 54 per year, depending on the degree of urbanization, the spatial location within a city, and overall living conditions. Using the latest United Nations figures on urbanization prospects, nighttime light remotely sensed images, and the "Mapping Malaria Risk in Africa" results on climate suitability for stable malaria transmission, we estimate that 200 million people (24.6% of the total African population) currently live in urban settings where they are at risk of contracting the disease. Importantly, the estimated total surface area covered by these urban settings is only approximately 1.1–1.6% of the total African surface. Considering different plausible scenarios, we estimate an annual incidence of 24.8–103.2 million cases of clinical malaria attacks among urban dwellers in Africa. These figures translate to 6–28% of the estimated global annual disease incidence. Against this background, basic health care delivery systems providing early diagnosis and early treatment and preventive actions through mother and child health programs and the promotion of insecticide-treated bed nets for the rapidly growing numbers of the urban poor must be improved alongside well-tailored and integrated malaria control strategies. We propose environmental management and larviciding within well-specified productive sites as a main feature for such an integrated control approach. Mitigation of the current burden of malaria in urban African settings, in turn, is a necessity for stimulating environmentally and socially sustainable development.
Received August 21, 2003. Accepted for publication November 15, 2003.
Acknowledgments: We thank Dr. G. F. Killeen for his helpful comments on the manuscript and Nafomon Sogoba for access to data summaries from the MARA database.
Financial support: This work was supported by the Center for Health and Wellbeing at Princeton University (Jürg Utzinger and Marcia Caldas de Castro), the Office of Population Research (Marcia Caldas de Castro), and the Swiss Tropical Institute (Jürg Utzinger).
Authors’ addresses: Jennifer Keiser, Jürg Utzinger, Marcia Caldas de Castro, and Burton H. Singer: Office of Population Research, Wallace Hall, Princeton University, Princeton, NJ 08544, Telephone: 609-258-6965, Fax: 609-258-1039. Thomas A. Smith and Marcel Tanner, Swiss Tropical Institute, PO Box, 4002 Basel, Switzerland, Telephone: 41-61-284-8273, Fax: 41-61-271-7951.
Reprint requests: Jennifer Keiser, Swiss Tropical Institute, PO Box, CH-4002, Basel, Switzerland, Telephone: 41-61-225-2666, E-mail: Jennifer.Keiser{at}unibas.ch.
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