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The Unmeasured Burden of Febrile, Respiratory, and Diarrheal Illnesses Identified Through Active Household Surveillance in a Low Malaria Transmission Setting in Southern Zambia

Alexandra K. Mueller1, Japhet Matoba2, Jessica L. Schue3, Harry Hamapumbu2, Tamaki Kobayashi4, Jennifer C. Stevenson2, Philip E. Thuma2, Amy Wesolowski4, William J. Moss3,4,5, and for the Southern and Central African International Center of Excellence for Malaria Research
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  • 1 Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, Maryland;
  • | 2 Macha Research Trust, Choma District, Zambia;
  • | 3 Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland;
  • | 4 Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland;
  • | 5 W. Harry Feinstone Department of Molecular Microbiology and Immunology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
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ABSTRACT.

Malaria incidence has declined in southern Zambia over recent decades, leading to efforts to achieve and sustain malaria elimination. Understanding the remaining disease burden is key to providing optimal health care. A longitudinal study conducted in a rural area of Choma District, Southern Province, Zambia, assessed the prevalence of and factors associated with symptoms of non-malarial illnesses and treatment-seeking behavior. We analyzed data collected monthly between October 2018 through September 2020 from 1,174 individuals from 189 households. No incident malaria cases were detected by rapid diagnostic tests among febrile participants. Mixed-effects logistic regression identified factors associated with cough, fever, diarrhea, and treatment-seeking. Incidence rates of cough (192 of 1,000 person-months), fever (87 of 1,000 person-months), and fever with cough (37 of 1,000 person-months) were highest among adults older than 65 years. Diarrhea incidence (37 of 1,000 person-months) was highest among children younger than 5 years. For every additional symptomatic household member, one’s odds of experiencing symptoms increased: cough by 47% (95% CI, 40–55), fever by 31% (95% CI, 23–40), diarrhea by 31% (95% CI, 17–46), and fever with cough by 112% (95% CI, 90–137), consistent with household clustering of illnesses. However, between 35% and 75% of participants did not seek treatment for their symptoms. Treatment-seeking was most common for children 5 to 9 years old experiencing diarrhea (adjusted odds ratio, 3.61; 95% CI, 1.42–9.18). As malaria prevalence reduces, respiratory and diarrheal infections persist, particularly among young children but, notably, also among adults older than 65 years. Increasing awareness of the disease burden and treatment-seeking behavior are important for guiding resource re-allocation as malaria prevalence declines in this region.

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Author Notes

Address correspondence to Alexandra K. Mueller, Johns Hopkins School of Medicine, 5200 Eastern Ave., Baltimore, MD 21224. E-mail: alexandra@jhmi.edu

Financial support: This work was supported by the Johns Hopkins Malaria Research Institute, the Bloomberg Philanthropies, the Division of Microbiology and Infectious Diseases, National Institutes of Allergies and Infectious Diseases, NIH as part of the International Centers of Excellence for Malaria Research (U19 AI089680), and a Global Health Established Field Placement award to A. K. M. from the Johns Hopkins University Centers for Global Health.

Authors’ addresses: Alexandra K. Mueller, Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, MD, E-mail: alexandra@jhmi.edu. Japhet Matoba, Harry Hamapumbu, Jennifer C. Stevenson, and Philip E. Thuma, Macha Research Trust, Choma District, Zambia, E-mails: japhet.matoba@macharesearch.org, harry.hamapumbu@macharesearch.org, jennycstevenson80@gmail.com, and phil.thuma@macharesearch.org. Jessica L. Schue, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, E-mail: jlschue@jhu.edu. Tamaki Kobayashi and Amy Wesolowski, Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, E-mails: tkobaya2@jhu.edu and awesolowski@jhu.edu. William J. Moss, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, and W. Harry Feinstone Department of Molecular Microbiology and Immunology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, E-mail: wmoss1@jhu.edu.

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