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The disability adjusted life year (DALY) approach of defining cause-specific health burdens is becoming the benchmark for international disease control prioritization. For malaria, this categorical approach may not fully capture its burden that includes chronic anemia, low birth weight, and enhancement of the severity of other childhood diseases. We investigated the extent to which malaria acts as a risk factor for all-cause mortality in African children less than five years of age from 1) ecologic associations between Plasmodium falciparum infection prevalence (PR) and under-five mortality, and 2) reductions in all-cause under-five mortality achieved in malaria intervention trials. Across 48 demographic surveillance studies, when adjusted for secular trends, PR more than doubled all-cause mortality (P = 0.0001). Trials of insecticide-treated mosquito nets generally found smaller population-attributable fractions of pediatric mortality to malaria infection, which may relate to their imperfect coverage and efficacy. In conclusion, the disability and death burden due to malaria in African children could be higher than that detectable from cause-specific DALY estimations.
Received August 21, 2003. Accepted for publication November 18, 2003.
Acknowledgements: We are grateful to a variety of individuals who have supplied additional information to provide more reliable age-structured mortality and infection risk data as presented in this paper. These include Gilly Maude and the late Nicola Dollimore (Navrongo, Ghana Vitamin A Study Team [VAST] Program), Don de Savigny (Mapping Malaria Risk in Africa [MARA] data co-ordination in Tanzania), John Chilumba (National Malaria Control Program, Zambia), Tabitha Mwangi and Judy Omumbo (Kenya Medical Research Institute–Wellcome Trust Program, Kenya), Dennis Shanks (Walter Reed Research Program, Kericho, Kenya),) and Jean-Francois Trape (Institut de Recherche pour le Development, Dakar, Senegal). We are also grateful to Kevin Marsh and Brian Williams for comments on earlier presentations of these data and Claudia Stein, Rick Steketee, and Jo Schellenberg for comments on the manuscript. The paper is published with the permission of the Director of the Kenya Medical Research Institute.
Financial support: This work forms part of the Burden of Malaria in Africa (BOMA) project funded by the Wellcome Trust, United Kingdom, The Bill and Melinda Gates Foundation, and the Kenya Medical Research Institute. Robert W. Snow is supported by the Wellcome Trust Senior Research Fellows (#058992).
Authors’ addresses: Robert W. Snow, Kenya Medical Research Institute–Wellcome Trust Collaborative Program, 00100 GPO, PO Box 43640, Nairobi, Kenya and Centre for Tropical Medicine, University of Oxford, John Radcliffe Hospital, Oxford, OX3 9DU, United Kingdom, Telephone: 254-2-272-0163, E-mail: rsnow{at}wtnairobi.mimcom.net. Eline L. Korenromp Malaria Control Department, World Health Organization, Avenue Appia 20, CH 1211, Geneva 27, Switzerland. Eleanor Gouws, Department of Child and Adolescent Health and Development, World Health Organization, Avenue Appia 20, CH 1211, Geneva 27, Switzerland.
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