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    Malaria cases and death in South East Asia region of WHO, 2004.

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    Regional malaria morbidity trend in the Americas: 2000, 2005, 2010, 2015.

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    Number of autochthonous cases of malaria in the European region of WHO, 2005.

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    Conjunctival pallor in patient with severe anemia.

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Malaria Surveillance Counts

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  • 1 Fogarty International Center, National Institutes of Health, Bethesda, Maryland

Clinical and epidemiologic surveillance of malaria cases and deaths is required to follow the progress of the reinvigorated malaria control programs nationally and internationally. Current recording, transmittal, analysis, feedback, and use of malaria surveillance information is delayed and imprecise: substantially < 10% of the malaria cases and deaths are being reported. Improvements are occurring, but more emphasis should be placed on prompt, accurate diagnosis, patient management, and recording of clinical manifestations at hospitals. Neurologic signs, severe anemia, metabolic changes, hyperparasitemia, and concurrent sepsis are medical emergencies and require proper clinical and laboratory detection; equipment, reagents, supervision, and certification of laboratorians and clinicians are necessary. Birth weight should also be a major measure of progress in malarial control and overall prenatal care. Although malaria is the most frequent diagnosis at outpatient clinics and hospitals in Africa, co-existing conditions also mandate improved diagnosis, treatment, and registration. Monthly transmittal of information from health units and collation, analysis and feedback through electronic reporting systems using modern information technologies are necessary for resource planning and staff motivation. Denominators to compute rates of illness and death require accurate censuses of communities from which patients come to health units: specialized disease and demographic household surveys designed and performed by nationals are needed to complement hospital-based numerator data. Plasmodium falciparum and P. vivax should be distinguished in the laboratory; the former causes the greatest mortality but the latter is increasingly recognized as a major peril. Because vector control is now a major component of all malaria control programs, there is an urgent need to monitor anopheline sensitivity to insecticides and entomologic inoculation rates. Where interrupting transmission is a goal, parasite rates in groups at greatest risk should be performed. Continual monitoring of plasmodial sensitivity to drugs is necessary using WHO protocols. Human, entomological, and parasitological surveillance must be performed at the same time in the same places and the information shared widely and used for improving control strategies and tactics. These surveillance priorities require training, provision of equipment, supervision, and commitment to sustainability by national authorities and international collaborators and donors.

INTRODUCTION

“When you cannot measure it, when you cannot express it in numbers, you have scarcely . advanced to the stage of Science, whatever the matter may be.”

William Thomson, Lord Kelvin, 1824–1907.

The goal of all malaria research and control efforts is to increase understanding of and decrease illness, death, disability, and economic loss from this scourge. It really does matter if the “case count” is 1, 2, or 3 million deaths, and 500 million malaria illnesses or 5 billion clinical episodes resembling malaria in endemic areas.15 Without an accurate count, one has difficulty setting and reaching objectives, ordering diagnostics and interventions, and attracting supporters who are result focused.6 Would higher or lower numbers change the Millennium Development Goals or the World Health Organization (WHO) policies, strategies, and tactics based on the Abuja Declaration?79 Probably not: those are political pronouncements and not based on epidemiologic reality. Data from the current indices designated for assessing the malaria burdens are overly delayed, incomplete, and imprecise; these measures do not help clinicians manage acutely ill patients. Such information does not optimally guide epidemiologists, public health workers, and decision makers to know how well they are doing in controlling and conquering malaria locally, nationally, and internationally.

There is greater need to focus on human illness first through clinical and epidemiologic surveillance: this is the main subject of this paper. As vector control is now one of the major malaria control strategies aimed toward reducing transmission, entomologic and parasitologic indicators need to be followed concurrently with human surveillance and the results reported promptly. Each area of surveillance—impact on human illness, entomologic and parasitologic status, and delivery of services (the process indicators currently emphasized)—requires special expertise.10

CURRENT GOALS, INDICATORS, AND DATA

The current goal of the Global Malaria Programme and the Roll Back Malaria Partnership (RBM) of the WHO is to “halve the malaria burden by 2010” by focusing on treatment, prevention, and epidemic response (Table 1). Recently, the RBM increased the target for correct treatment of patients, distribution and use of bed nets, and preventive treatment of pregnant women from 60% to 80% by 2010. A number of “core” malaria process indicators have been established for tracking the services delivered (http://www.rollbackmalarial.org/merg.html) (Table 2). The Millennium Development Goal (MDG) for malaria is to “halt and begin to reverse the incidence of malaria and other major diseases by the target date of 2015” (http://www.un.org/millenniumgoals/). The United Nations Millennium Project, stating that the MDG goal was difficult to interpret and measure, proposed to “(r)e-duce malaria morbidity and mortality by 75% by 2015 from the 2005 baseline level.”11 However, for virtually all countries and the world, there is no baseline level. As is widely known, countries in sub-Saharan Africa and the Indian subcontinent contribute the greatest burden.2,3,5

The country profiles from the African region of WHO (http://www.afro.who.int/malaria/country-profile/index.html) give the most up-to-date publicly available data on malaria; yet, the most recent information dates to 2002 and before (Table 3). Seventy-seven million cases of malaria and 94 thousand deaths are reported officially; between 20–60% of cases and the vast majority of deaths are in children < 5 years of age. These morbidity and mortality estimations are less than 10% of what occurs even though microscopy is not often used to confirm the diagnosis. Communications with the African regional office of WHO (E. Minkoulou, personal communication, 2007) give cases and deaths from 2001 to 2006 reported by Ministries of Health (Table 4). There are large discrepancies in numbers of cases reported, incidence, hospital admissions, and deaths. Tables 5 and 6 give the 2006 reports from the Eastern Mediterranean office of WHO (EMRO), divided into countries with no or limited transmission and those with widespread transmission (http://www.emro.who.int/rbm/Epidemiology-CurrentData.htm): over 80% of the 3.5 million malaria cases reported from EMRO are from Sudan; EMRO estimates that > 10 million cases occurred in the region. Malaria in Southeast Asian countries of WHO (SEARO) is shown for 2004 in Figure 1. (http://www.searo.who.int/EN/Section10/Section21/Section1370.htm). India reports 76% of the 2.5 million malaria cases; Myanmar reports 53% and India 25% of the 3.8 thousand deaths in SEARO. Table 7 shows the malaria reports from the Western Pacific Region of WHO (WPRO) for 2005 (http://www.wpro.who.int/sites/mvp/data/malaria/2005.htm). The Solomon Islands, Vanuatu, and Papua New Guinea have the highest incidence of confirmed malaria. Relatively little malaria occurs in the Americas (900 thousand laboratory confirmed cases in 2006), mostly reported from Brazil (65%), and other countries in the Amazon basin (Table 8, Figure 2; http://www.paho.org/english/ad/dpc/cd/malaria.htm). Southeast Europe is the area where malaria remains a peril, particularly in newly independent countries of the former Soviet Union and in southern Turkey (Figure 3; http://www.euro.who.int/malaria/ctryinfo/ctryinfotop). Globally all countries are at risk, as many of thousands of malaria cases are imported into malaria-free countries yearly from endemic sites. Plasmodium falciparum causes the major morbidity and mortality globally, but P. vivax is increasingly recognized as an important pathogen, especially in Southeast Asia and the Western Pacific.12

CONUNDRUMS

How can these data collected in different ways in different places be used in current program planning? Apart from delays, the difficulty in diagnosing malaria correctly is the main reason for the imprecision in quantifying the burden.13 This is because reliable and cheap microscopy or rapid diagnostic testing is not generally available or performed properly, microscopy particularly in sub-Saharan Africa. Even when available, the results are often inaccurate. There is a lack of specificity, sensitivity, and predictive values in clinical and laboratory diagnosis, especially when the frequency and density of parasitemias are low.14,15 These confirmatory tests must be standardized and supervised, and those performing the tests should be certified if the quality of diagnosis and patient management are to improve.

A related conundrum is the challenge of diagnosing and managing co-existing conditions. Is febrile illness and plasmodial parasitemia in an endemic area enough to confirm malaria as the diagnosis? Yes, and it should be recorded as malaria. Is plasmodial parasitemia, acute or repeated, with another condition (e.g., chronic ankylostomiasis and iron deficiency), enough to confirm malaria as a diagnosis for anemia? Again, yes, but the intestinal helminthiasis is a coexisting cause of the anemia and should be recorded as a second condition.16 Is maternal parasitemia during pregnancy or placental parasitemia at delivery enough to confirm malaria as the cause of a newborn with low birth weight? Again, yes, but HIV, syphilis, and other sexually transmitted infections may coexist and merit proper diagnosis and management.17 Frequent existence of multiple pathologies underscores the necessity of improving clinical and laboratory diagnosis and the quality of medical care. When dual or multiple conditions exist, it is difficult if not impossible to parse the attributable fraction contribution of each pathogen or condition to the patient’s clinical status or to the community’s epidemiologic profile. The patient has multiple conditions for which multiple treatments are required, and surveillance data should reflect this. Hence, the concept of malaria as a “direct” or “indirect” cause of morbidity and mortality is not useful for diagnosing and managing patients or for counting cases.

WHAT SHOULD BE DONE?

Clinical measures.

Start with patients. Those in rural and urban malarious areas are becoming severely ill and dying mainly from hematologic (anemia), metabolic (hypoglycemia, acidosis), and neurologic (cytoadherence of red blood cells and cerebral malaria) manifestations4,18; these events often occur together.19 Associated conditions that often go undiagnosed are sepsis and enteritis.20,21 Low birth weight is caused by or associated with maternal parasitemia and placental sequestration of parasites.17 All of these potentially lethal conditions are measurable and treatable. Sequential measurements of how often these conditions occur, their outcomes, and trends will indicate how well we are doing in managing patients and controlling the disease in the community. WHO Expert Committees have met and defined severe malaria and its management.22,23 Monitoring the frequency of severe clinical events associated with malaria is needed to assess the success of control programs. Of particular importance are severe anemia, metabolic complications, hyperparasitemia, and possible sepsis because immediate management is lifesaving (Table 9).24 Birth weight assessment reflects effective prenatal protection from malaria and other causes of prematurity and intrauterine growth retardation, all of which decrease greatly a newborn’s chances of survival.

These indices require laboratory diagnostics, and their assessment should start in public and private hospitals or other places where staff are trained and supervised; reagents and testing equipment must be present in adequate supply and properly refrigerated and conserved. Agreed on standards must be established for measurements, and laboratories and clinical services evaluated periodically and certified to assure that they are meeting these standards.

Integrated management of childhood illness.

The WHO estimates that six disease syndromes account for 73% of the > 10 million deaths of those < 5 years of age; these are pneumonia (19%), diarrhea (18%), malaria (8%), neonatal pneumonia or sepsis (10%), preterm delivery (10%), and birth asphyxia (8%), with under-nutrition being an underlying cause in more than one half of deaths of those < 5 years of age.25 Multiple studies and reports have shown that 25–40% of patients coming to dispensaries and hospitals in malarious areas of Africa are diagnosed with malaria, usually without laboratory confirmation9; fever or recent history of fever is used as the cardinal symptom. With the development of treatment algorithms, the Integrated Management of Childhood Illness (IMCI) program at WHO has greatly helped front-line health workers make accurate clinical judgments on many common clinical conditions including malaria.26 This systematic evidence-based clinical approach is quite rational and facilitates administering and ordering medicines, educating the patient, and establishing criteria for referral. Problems with ICMI have been poor coverage because of a lack of resources, overburdening the peripheral health worker with too many tasks, and poor supervision.27 For instance, in an area with a high level of malaria transmission and parasitemia in young children, a child with fever may receive an antimalarial drug, irrespective of other diagnoses. This would be fully justified where there is no confirmatory test but not if a properly done blood smear was negative for asexual parasites. In areas of Ethiopia and Kenya, researchers found that conjunctival and palmar “pallor” could help to diagnose anemia associated with malaria, but assessment of the hemoglobin (or hematocrit) and parasitemia status promptly would be the best medical practice (Figure 4).28,29 Beyond malaria, all of the local clinical diagnoses should be entered into a computerized database for disease assessment, anticipation of future trends, and rational management of resources at the district level as has been done successfully in Tanzania.30

Access, use, and quality.

For patients with severe malaria, prompt access, correct treatment, and referral is a matter of life and death. Children with severe anemia (hemoglobin < 5 g/dL) and respiratory distress survived more often if they received a transfusion within 1–2 days of admission to a district hospital compared with those who did not.31 Pregnant women with obstetrical complications and anemia have a high risk of dying from hemorrhage during childbirth, particularly when they arrive late to a hospital.32 Patients with severe neurologic and cerebral manifestations having a short duration of onset merit rapid detection and management because they suffer a high mortality rate.33,34 A recent study showed that treating rural African and Bangladeshi children with acute severe malaria (inability to swallow) with artesunate given by rectal suppository in the village before referral decreased mortality by 25%: the delay before arrival to the local health unit where standard parenteral treatment could be given was about 4 hours in Africa and 1.5 hours in Bangladesh (M. Gomes, personal communication, 2007). Time intervals from illness onset to treatment must be assessed routinely in malaria control and other health programs and used as indicators for the success of control programs. The WHO recommendation is treatment within 24 hours and the frequency of how often this occurs is a process indicator.

MORBIDITY AND MORTALITY

The most important indicator for evaluating the overall impact of malaria control is overall and population-specific mortality rates, particularly those < 5 years of age in heavily endemic areas. Countries can measure this by routine vital statistics collection systems for numerating events that are tied to periodically updated demographic surveys that provide accurate denominators; special prospective disease and demography surveys following representative cohorts over long periods of time; and specialized disease-specific transversal surveys. The INDEPTH network has 38 demographic surveillance sites covering 19 countries in Africa, Southeast Asia, and the Western Pacific (http://www.indepth-network.org/dss_site_profiles/sites.htm). This project provides the best examples of a community-based cohort survey.35,36 Vital statistics and demographic censuses for health remain poorly developed in low-income countries. Innovative surrogate approaches have included assessing the ages of persons buried at cemeteries, reviewing notices of deaths in newspapers (especially for maternal deaths), and interrogations of families (verbal autopsies) for determining deaths and cause of death over time.

Although disease frequencies can be determined during epidemics, malaria-specific death rates are more difficult to define in areas with stable transmission and the presence of other infections causing fever. Strengthening of routine clinical and laboratory diagnosis—first at the state, province, and district level in hospitals and referral centers—will be the most useful if the information is sent and analyzed promptly. The goal of every country should be to assure that reporting includes facilities from the private sector, military, religious, and non-governmental organizations.37

Surveillance authorities should note that many public and private hospitals and university teaching facilities may report to the Ministries of Education, Science, or Defense and not to the epidemiologic and statistical services at the Ministry of Health. Surveillance systems must be expanded to dispensaries when the hospitals are reporting satisfactorily. Monthly or more frequent electronic reporting with precoded diagnoses should be the goal of every country. Information technology and wireless satellite communications are well advanced and being increasingly used at modest cost.38 Surveys performed by groups outside of the country, while independent and unbiased, are usually too delayed in sharing results and often neglect training nationals.

TRACKING MALARIA TRANSMISSION AND CONTROL

The major measures of malaria endemicity and intensity of transmission have been parasitologic (parasite rates by age), clinical/hematologic (spleen rates, anemia rates by age), and entomologic (entomologic inoculation rates (EIRs) by anopheline species). The parasitologic and spleen rates in children 2–9 years of age have been used to describe the classic endemic categories: hypoendemic (< 10%); mesoendemic (11–50%); hyperendemic (51–75%); and holoendemic (> 75%), but no sampling methods generalizable to populations have been advised for these measurements. Those categories are of limited use because the indices can change throughout a year; they are based on parasitologic diagnoses and surveys that are not performed routinely and are often of questionable reliability; the research teams that perform the surveys do not often report the results promptly to the control program. It is recommended that such surveys first be done on children < 5 years of age and pregnant women (or other high-risk groups) coming to outpatient clinics. Outpatient testing would be similar to periodic serologic testing of HIV in pregnant women and other high-risk groups to assess the success of prevention and control programs.39 Anemia results from multiple causes, including repeated attacks of malaria, including episodes of parasitemia resistant to drugs.

Similarly, entomologic indices are not assessed routinely, except in some countries that rely greatly on classic vector control approaches (insecticide residual spray [IRS] of dwellings, larviciding, and other forms of environmental management) as in the Americas, Southeast Asia, and the Western Pacific.9 Entomologic assessments, particularly EIRs, are frequently done by research institutions only and are often unlinked to prevention policies or actions. These measures are crucial for assessing progress in disease elimination and eradication and should now be used in control programs aiming to decrease transmission, especially in Africa. Entomologic studies require skill in collecting and identifying anopheline species and subspecies in larval and adult habitats using sound sampling methods before, during, and after intervention programs.40,41 The EIRs vary considerably depending on temperature, rainfall, humidity, and other environmental and control parameters. As for all malariometric surveys, the quality of the data may vary, based on the rigor of the study, including acumen of the laboratorian. The Africa Network on Vector Resistance has published useful information on standardized testing of mosquito sensitivity to insecticides (http://www.who.int/tdr/topics/mol_entomology/files/anvr_news.pdf).

RESISTANCE OF PARASITES TO DRUGS AND MOSQUITOES TO INSECTICIDES

Every malaria control program should track the efficacy and effectiveness of the interventions. Parasite resistance to artemisinin-based combination therapies (ACTs) is not expected in the near future because of their mode of action and pharmacokinetics.42 Regrettably, other drugs are commonly used, to which parasites are resistant. The best assessment of efficacy is the 28-day in vivo test of response in ill patients in priority groups (i.e., children < 5 years of age and pregnant women). If intermittent preventive treatment of infants (IPTi) is given, the drug used should be tested for efficacy in the youngest children. In vitro testing and the newer molecular tests to identify drug-resistant genes in parasites can identify early patterns of resistance but results of these tests do not consider the immune status of the patient.43 Collaboration between control programs and research centers is required. This will assure that in vivo, in vitro, and molecular drug sensitivity surveillance and other important data (e.g., drug availability, use, and costs) are used in developing patient management guidelines, for ordering drugs, and for preparing and updating training and health education material for health staff and caregivers.

Where IRS is employed, bioassay assessment of the sensitivity of Anopheles to the insecticides used must be done periodically using WHO protocols.40 Toxicity monitoring of spray personnel is also needed. Although long-duration treated nets should retain insecticide potency, the materials need to be inspected and assayed for confirmation of quality and amount of the chemical44; nets that require dipping every 6 months require chemical analysis periodically to assure potency. Sham or counterfeit drugs are now a major problem in Asia and Africa, and antimalarials are a target for the counterfeiters. A plan needs to be developed to survey the drugs, nets, insecticides, and other supplies to assure they meet national and international specifications.

CONCLUSION

Current surveillance for malaria is inadequate. The process indicators identified by control programs are important but will not indicate whether the burden of disease has changed along the timelines needed for managing national and international malaria control initiatives45 (Table 10). Burden of disease is reflected in human morbidity and mortality, and measurements of the manifestations of malaria in the clinical setting should be the place to start. The advantages of improving diagnosis and clinical management of patients are evident. Given the amount of “malaria” coming to clinics and hospitals, especially in Africa, and the costs of newer treatments (ACTs), greater emphasis on improving the quality of medical care is required. Emphasis must be on provision of up-to-date diagnostic equipment and reagents, recommended medicines, and supportive care. Most importantly, establishing the highest standards of care for patients with malaria will involve greater pre-service, in-service, and post-service training of laboratory and clinical officers. Granted, most malaria occurs outside of the hospital.4 As the quality of care improves at hospitals, it will be the responsibility of those running the hospitals to assess the needs of populations near peripheral dispensaries and in villages to improve their care, emphasizing quality, training, and supervision, and efficient utilization of resources. Involvement of communities in decision-making and investments of the public and private sectors in rural and urban health will be necessary. Similarly, major investments in epidemiologic surveillance, particularly for proper record keeping, reporting, and analysis at all hospitals and selected dispensaries, will be needed: this too requires training, provision of diagnostic definitions, computer software, and support. Most importantly, supervision, feedback, and backup from central epidemiologic services will be required.

Accurate and complete demographic surveys will give denominators for calculating rates of malaria and other diseases using outpatient visits and inpatient events occurring at hospitals as numerators. Using agreed on definitions of disease and accurate clinical diagnoses, public health officials will be able to follow disease trends monthly or quarterly and make corrections in patient management and prevention programs without delay. Precise assessments of overall mortality and morbidity requires statistically valid surveys that are rarely performed more often than once every several years—usually by outside consultants, researchers, or academics. Funding organizations often request these surveys to see if the stated goals have been achieved. These specialized surveys have a role, but should also include national staff in design, leadership, and managerial roles, so that nationals can do such surveys on their own.

Measurements of the impact of prevention measures aimed toward decreasing transmission and eliminating disease must focus on entomologic and parasitologic indices. This will require large-scale recruitment and training of entomologists, microscopists, and persons skilled in the newer rapid diagnostic tests. Parasite rates (PRs) are one of the best measures of endemicity, but only when the goal of control is to decrease or eliminate transmission. PRs are dependent on immune status and age and human–vector contact. In areas with intense, stable transmission (hyper- or holoendemic malaria), it has been shown that PRs can be reduced greatly—to ~1% as in Garki, Nigeria—but no further, even after chemoprophylaxis, mass drug administration, and periodic household applications of IRS.46 Great reduction in sporozoite-carrying female anopheles can occur with IRS and insecticide-treated nets (ITNs). Although recent control programs in southern Africa and Zanzibar relying on IRS, ACTs and ITNs have been extremely successful, no areas or country in Africa or Asia has shown that malaria-carrying mosquitoes can be eliminated.47,48 A recently published study from Vanuatu indicated that IRS and ITNs were needed to get the best effect in reducing transmission and malarial illness, but ITNs alone were not as effective as both.49

Models for malaria dynamics and the effects of different interventions continue to be valuable in understanding and preventing malaria.46,50 Much recent attention by mathematical modelers has been in defining the impact of malaria vaccines.51 The main purpose of these exercises should be to understand, control, and prevent disease transmission and facilitate logistics; to date, the results have been mainly of academic use. Rainfall, temperature and humidity are excellent predictors of anopheles’ breeding. Parasite prevalence and incidences will help to track the impact of control measures on transmission.52 It is important that reliable morbidity and mortality information be registered at the same time in the same areas where drug sensitivity studies are done, and where vectors, EIRs, and parasite prevalence data are collected.

To perform the disease and transmission measurements properly requires a commitment to training and research in surveillance and malariology. Surveillance staff (including modelers) should go to the field to observe how data are collected and train field workers in diagnostics, demography, malariology, and the relationship of the data collected to program planning. All surveillance activities require a long-term commitment. Although the current interventions can have a substantial impact on malaria incidence within a few years, large-scale decreases in mortality may take much longer. Sustainability of programs will be the key to controlling and eliminating malaria. Measuring accurately how well patients are being managed in health units, changes in mortality rates using updated censuses, and hospital and community-based survey data will be the key to understanding the effectiveness of such programs and making changes to improve them.

Table 1

Malaria control goals, strategies, and targets—2000 goal: halve the burden by 2010 (Roll Back Malaria Partnership)

StrategyTargets for 2010 (Abuja Malaria Summit, 2000, revised 2007)
* The original Abuja declaration recommended chemoprophylaxis; current WHO and Roll Back Malaria policy strongly recommends IPT.
Source: WHO 2003b, 2005.
  • Prompt access to effective treatment

  • Provision of insecticide-treated nets (ITNs)

  • Prevention and control of malaria in pregnant women

  • Epidemic and emergency response

  • 80% of patients having access to and using correct and affordable treatment within 24 hours of symptom onset

  • 80% of children < 5 years and pregnant women benefiting from personal and community protection, such as ITNs

  • 80% of pregnant women at risk accessing intermittent preventive treatment*

  • 60% of epidemics detected within 2 weeks of onset

  • 60% of epidemics responded to within 2 weeks of detection

Table 2

Core malaria indicators advised by the Malaria Monitoring and Evaluation Reference Group, 2007: Essential activity indicators as proportions

Reference: Roll Back Malaria website: http://www.rollbackmalaria.org/merg.html. Accessed August 7, 2007.
  • Households with at least one insecticide-treated net (ITN)

  • Children with fever in last 2 weeks who received antimalarial treatment according to national policy within 24 hours of onset of fever

  • Pregnant women who slept under an ITN the previous night

  • Women who received intermittent preventive treatment (IPT) for malaria during their last pregnancy: IPT is two doses of sulfadoxine-pyrimethamine

Table 3

Malaria morbidity and mortality reported by country and priority groups: African region of WHO

Cases reportedHospital admissionsDeaths
Country (year)Population ×103No. (1000s)Incidence/1000Percent < 5 years of age (%)No.Percent < 5 years of age (%)TotalPercent < 5 years of age (%)
Source: http//www.afro.who.int/malaria/country-profile/index.html. – or 0 = no data available.
Algeria (2002)31,5583071
Angola (2002)13,9311,409103411,34456
Benin (2001)6,461779124032,0085467074
Botswana (2002)1,56628214
Burkina Faso (1999)11,25788084534,431503,47968
Burundi (2002)6,7431,80927330
Cameroon (1998)14,2026645
Cape Verde (1999)417297
Central African Republic (1999)3,6371284600048474
Chad (2001)8,1273865019,463431,00160
Comoros (2001)7283,71851137820321631
Congo (1998)2,8411716
Cote D’lvoire (2001)16,38340023340,3752842245
Democratic Republic of Congo (2002)54,408231< 1
Equitorial Guinea (1990)35225673
Eritrea (2001)3,82112632110,8861812935
Ethiopia (2001)64,424151< 12312,7862300
Gabon (1998)1,16580269
Gambia (1999)1,2601281058
Ghana (2002)20,2642,8311434161,062513,53638
Guinea (2000)8,154899113314,9334144156
Guinea–Bisseau (2002)1,257195164866,7036578059
Kenya (2000)30,6697422409,4523468330
Liberia (1998)2,51177831
Madagascar (2002)16,95900
Malawi (2002)11,8481,36211057,6494557,6493
Mali (2001)11,681871341,0565718266
Mauritania (2002)2,8251676197,3121310031
Mauritus (2002)1,182222
Mozambique (2002)19,0351,902100001,9100
Nambia (2002)1,826359200001,0230
Niger (2002)11,6336826494,777301,09674
Nigeria (2000)113,86231,68528422,205535848
Rwanda (2000)7,6099151230123,026312,67843
Sao Tome and Principe (1998)1413626338,1602315494
Senegal (2000)9,4211,120122736,860181,33738
Seychelles (2002)8400
Sierra Leone (1999)4,3364109
South Africa (2002)44,12715,61935000960
Swaziland (1999)90530303,25901480
Tanzania (2001)36,0326732
Togo (2001)4,65243293612,904547910
Uganda (2002)24,8101,878838
Zambia (2000)10,4211,1391161157,8983,26853
Zimbabwe (2002)13,1425995626
Total652,66776,964818,02594,445
Table 4

Malaria cases, deaths, and percent deaths, African region of The World Health Organization, 2000–2006

2000200120022003200420052006
CountryCasesDeathsPercent deathsCasesDeathsPercent deathsCasesDeathsPercent deathsCasesDeathsPercent deathsCasesDeathsPercent deathsCasesDeathsPercent deathsCasesDeathsPercent deaths
Source: Ministries of Health and African Regional Office of WHO, January 4, 2007.
–, no report.
* Data from Sao Tome & Principe from 2000 through 2002 are incomplete compared to later years.
Algeria156001960086005500
Angola1,635,8841,124,5579,2550.8409,2943,4880.91,880,67918,8001.02,282,46112,4330.5
Benin708,4447400.1779,0416700.1782,8187070.1819,2565600.1853,0349440.1803,462323045,503620.1
Botswana71,55530049,619590.128,971150.148,237290.122,4040010,117100.110,357130.1
Burkina Faso1,008,4413,2620.31,176,4604,2330.41,434,0534,0570.31,797,7885,1590.31,814,6844,2050.21,818,6905,6450.3426,6041,2390.3
Burundi3,057,2392,855,86857901,808,5881,2890.11,861,3541,3410.11,304,0851,0710.1568,9584670.1674,1035680.1
Cameroon41,3483050.776,1921520.2277,4138360.3
Cape Verde10010010022004524.470811.4
Central African Republic89,6145390.6140,7425410.495,6444170.4152,3648590.6
Chad
Comoros9,619410.43,71880.237,8430029,14820
Congo
Cote D’Ivoire34,4136441.9400,4024460.11,153,5811,2420.11,393,1209460.11,582,0751,2890.11,812,6001,7570.1
Democratic Republic of Congo964,6233,8560.42,199,24711,5970.52,640,1687,5530.34,555,05616,4980.44,028,95012,9990.36,697,77817,1030.32,766,697
Eritria119,155940.1125,7461290.168,783850.155,193980.223,665160.126,665380.111,135290.3
Ethiopia7,951,5791,15908,516,0581,26309,274,7812,324010,906,8024,662010,244,5873,5500918,2749870.1
Gabon
Gambia77,5841370.2
Ghana294,9981900.1651,6613800.1228,2421620.1
Guinea3,349,5284,0950.13,383,0253,7260.11,458,0153,3370.21,486,2363,0940.22,790,3492,6880.13,921,2002,7180.1
Guinea Equatorial1,736,4178310851,8775170.1850,1474400.1731,9115860.1876,8375280.1850,3094900.1
Guinea-Bissau194,976241,0897140.3151,2153710.2148,5263910.3
Kenya186,6596830.4133,78487,9142,149,3222,002,82460,372
Lesotho
Liberia83,869208,08862,415400.1
Madagascar1,383,23959101,429,4917420.11,598,91975702,198,1971,00001,358,4088660.1
Malawi3,566,2777,1390.23,756,7984,2860.12,687,9275,7750.23,268,5544,7870.12,776,7373,0390.11,739,3144050
Mali99,2171530.286,5121820.269720,879290.138,455440.144,86622044,34890
Mauritania259,0934910.2243,9423370.1211,8701000140,926310110
Mauritus62006600390040002617
Mozambique3,446,2202,0390.13,947,3354,7000.14,592,7994,2140.15,182,5553,5620.15,610,8844,1500.15,813,7254,2090.12,315,7772,1290.1
Namibia494,8671,0310.2538,5121,7280.3445,8031,5040.3468,2591,1060.2610,7991,1850.2348,3851,3250.4
Niger1,203,2942,4390.2723,9504,0180.6681,7092,4330.4817,0714,2870.5822,6943,1810.4732,0593,0830.4621,7071,1500.2
Nigeria2,508,2985,7250.22,253,5194,3170.22,710,4074,1220.23,740,8035,9260.23,109,1665,1190.22,610,7303,4170.1
Rwanda475,1061,9230.4989,9252,5890.31,061,3671,8580.21,190,5161,4340.11,271,6741,0760.1991,6126290.1
Sao Tome & Principe*1741811,9481728.836718144,5201450.336,8701240.321,633700.3
Senegal1,120,0941,3370.1927,8701,5630.2987,8681,2570.11,425,3061,6070.11,154,3501,5240.1995,9071,2860.1
Seychelles
Sierra Leone266,808
South Africa64,6224590.726,5061190.415,649960.613,4591421.113,290890.77,141600.88,580610.7
Swaziland45,581600.119,799130.114,86380.112,670170.16,952120.27,099510.7838
Tanzania205,4294950.2336,6838380.2266,5194410.29,754,38114,8420.29,288,45719,5500.25,955,7167,7360.11,964,3032,5970.1
Togo457,4251,2090.3472,5051,3560.3557,6481,6630.3490,2561,1300.2516,9421,1830.2
Uganda8,7451461.75,211,8457,545,44914609,657,332897010,712,6012,57304,487,0691,0540573,9634350.1
Zambia3,602,5648,9520.24,150,0969,3910.24,101,1699,0230.24,642,7749,1780.24,329,6688,2890.24,339,0287,6970.2
Zimbabwe1,533,9601,0120.11,564,3421,6070.11,348,1371,8930.1638,9061,1390.21,830,1811,5870.1644,5915690.1371,9863810.1
Total33,445,85950,1970.247,935,05071,0140.148,262,76958,9470.168,495,78883,4890.172,992,931102,5880.158,521,46377,6880.111,081,4259,6680.1
Table 5

Malaria morbidity and mortality for the Eastern Mediterranean region countries having interrupted or limited transmission, 2006

Cases
CountriesPopulationTotalAutochthonousSpecies transmitted locally
* Endemic areas mainly in the southeast.
† Endemic areas mainly in the southwest.
‡ Introduced falciparum cases.
>, predominance of one species.
Bahrain688,345700Nil
Egypt78,887,007290Nil
Iran, Islamic Republic of*65,400,00015,90913,127P. vivax >
 P. falciparum
Iraq27,499,6382423P. vivax
Jordan5,630,0001162‡Nil
Kuwait3,182,9602350Nil
Lebanon3,874,050420Nil
Libyan Arab Jamahiriya6,036,914100Nil
Morocco33,757,175830Nil
Oman3,200,0004430Nil
Palestine20Nil
Qatar907,2291980Nil
Saudi Arabia†27,600,0001,278269P. falciparum
 >P. vivax
Syrian Arab Republic18,600,000340Nil
Tunisia10,216,000360Nil
United Arab Emirates4,400,0001,6630Nil
Total289,879,31820,14213,421
Table 6

Malaria morbidity and mortality for the Eastern Mediterranean region countries with continuing widespread transmission, 2006

Cases
CountriesPopulationReportedConfirmedEstimatedSpecies transmitted
Since 2004 in heavily endemic conditions.
* Estimated figures in 2005.
NA, not available; >, predominance of one species.
Afghanistan31,056,997329,15482,6921,500,000P. vivax > P. falciparum
Djibouti650,0007,7081,79660,000P. falciparum > P. vivax
Pakistan164,741,924NA124,0001,600,000P. vivax > P. falciparum
Somalia8,800,00049,25616,4301,300,000P. falciparum > P. vivax
Sudan40,200,0002,888,943589,1385,000,000P. falciparum > P. vivax
Yemen19,800,000217,27055,000900,000P. falciparum > P. vivax
Total265,248,9213,492,331569,05610,360,000
Table 7

Malaria morbidity and mortality for the Western Pacific Region of WHO, 2005

CountryPopulation (in thousands)No. of confirmed malaria casesPercent falciparum casesNo. of malaria deathsIncidence (confirmed malaria cases per 1,000)Mortality rate (per 100,000)
WHO, Regional Office for the Western Pacific.
Cambodia14,82549,436822963.332.00
China1,322,27521,93516480.020
Lao People’s Democratic Republic5,91813,60296772.31.30
Malaysia23,3255,56940330.220.13
Papua New Guinea5,95998,7626572516.5712.17
Philippines82,80946,485631450.560.18
Republic of Korea48,1821,323000.030.00
Solomon Islands50476,7627138152.317.54
Vanuatu2229,83443044.330.00
Vietnam83,58519,49773180.230.02
Total1,589,602343,2055491,3800.000.09
Table 8

Malaria morbidity trend in the Americas: 2000, 2005, 2010, and 2015 annual data (no. of cases)

Table 8
Table 9

Selected severe clinical malaria conditions requiring diagnosis, assessment, and reporting

ConditionManifestationsRequired EquipmentManagement*
* In addition to antimalarial drugs; referral to a secondary or temporary care facility for patients requiring parenteral therapy and intensive supportive care.
† Essential measurement.
‡ Consider exchange transfusion for parasitemia > 10
Coma†Unable to respond to stimuliBlantyre coma scale scoreParenteral therapy
ConvulsionsConvulsions (grand and petit mal)—can be subtle signsObservationAnticonvulsants, protection from injury
Renal failureUrine output in 24 hours < 400 mL (adults); or < 12 mL/kg (children)Biochemical analysisRehydration (no overhydration)
Serum creatinine > 265 3mol/L (> 3.0 mg/dL)Urine collectionsHemofiltration if needed
Other: sepsis†Febrile, hypotensive, shocked (after malaria treatment)Blood culture, complete blood countAntibiotics, supportive care, rehydration
Low birth weight†< 2,500 < 1,500 g (severe)Scale (calibrated)Resuscitation, breast feeding, food supplements, warmth (incubator)
Hematologic: anemia†Hematocrit < 15%
 Hemoglobin < 5 g/dLHematocrit equipment HemoglobinometerBlood transfusion with whole blood or packed cells
Biochemical: hypoglycemia†Plasma glucose < 2.2 mmol/L (< 40 mg/dL)Analytic equipment GlucosometerGlucose infusion
    AcidosisArterial pH < 7.25 or plasma bi-carbonate < 15 mmol/LBlood gas analysisCorrect hypovolemia Hemofiltration
    Parasitologic: Hyper-parasitemia†> 100,000 parasites/mLMicroscopy (or Rapid Diagnostic Test)
 Microscope, slides, reagentsConsider parenteral treatment with artemisinins, quinine or quinidine
Table 10

Indicators of the impact of malaria control programs

Morbidity
* This and several other morbidity indicators are not expressed as proportions, as is desirable. The most useful denominator would be “the population served by the health facilities”; however, in most malaria-endemic countries, population estimates are unavailable or outdated, utilization rates for health facilities may vary over times, and the resulting proportion would be imprecise.
† This indicator can be difficult to interpret because changes may be caused mainly by a change in the denominator, which may be unrelated to malaria.
‡ More complete reporting is often available from public sector than private sector facilities. This may vary by country, and program managers using this indicator will need to define the types of facilities to sample for indicator measurement.
§ In this example, measurement of the indicator is limited to referral health facilities because they are most likely to have microscopes available and receive a major share of severe malaria cases.
¶ ”Malaria-like” can be defined regionally or at country level, but might include fever alone, seizure, coma, or anemia without other apparent cause.
** This indicator may reflect community beliefs and attitudes related to health system utilization, health worker performance, or quality.
Patients diagnosed with malaria in public-sector facilities over 1year.*
Proportion of children diagnosed with malaria among patients seen at public-sector clinics†‡
Proportion of population reporting a febrile episode in the previous 2 weeks
Patients with microscopically confirmed severe malaria seen in referral facilities over 1 year§
Proportion of children with severe anemia among pediatric admissions in health facilities†
Proportion of babies delivered in health facilities who have low birth weight (< 2500 g)
Mortality
Deaths after a malaria-like illness¶ occurring in facilities over 1 year
Deaths after a malaria-like illness, confirmed microscopically, occurring in referral facilities over 1 year
Proportion of all deaths in health facilities that follow a malaria-like illness
Proportion of patients hospitalized with a malaria-like illness who die in the hospital**
Number of children dying with severe anemia in health facilities over 1 year
Figure 1.
Figure 1.

Malaria cases and death in South East Asia region of WHO, 2004.

Citation: The American Journal of Tropical Medicine and Hygiene 77, 6_Suppl

Figure 2.
Figure 2.

Regional malaria morbidity trend in the Americas: 2000, 2005, 2010, 2015.

Citation: The American Journal of Tropical Medicine and Hygiene 77, 6_Suppl

Figure 3.
Figure 3.

Number of autochthonous cases of malaria in the European region of WHO, 2005.

Citation: The American Journal of Tropical Medicine and Hygiene 77, 6_Suppl

Figure 4.
Figure 4.

Conjunctival pallor in patient with severe anemia.

Citation: The American Journal of Tropical Medicine and Hygiene 77, 6_Suppl

*

Address correspondence to Joel G. Breman, 16 Center Drive, Fogarty International Center, Bethesda, MD 20892. E-mail: jbreman@nih.gov

Authors’ address: Joel G. Breman and Cherice N. Holloway, Building 16, Room 214, 16 Center Drive, MSC 6705, Bethesda, MD 20892. Tel: 301-496-0815, Fax: 301-496-8496, E-mail: jbreman@nih.gov.

Acknowledgments: The authors thank Dr. Richard Cibulskis, Dr. Colin Mathers, Dr. Ellis McKenzie, Mr. Etienne Minkoulou, Dr. Magda Robalo, and Dr. Nicholas White for useful comments. Dr. Martin Weber kindly contributed the photo of a patient with conjunctival pallor, Figure 4.

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