Lack of Decline in Childhood Malaria, Malawi, 2001–2010

Arantxa Roca-Feltrer

, Collins J. Kwizombe, Miguel A. Sanjoaquin, Sanie S.S. Sesay, Brian Faragher, Jim Harrison, Karen Geukers, Storn Kabuluzi, Don P. Mathanga, Elizabeth Molyneux, Maganizo Chagomera, Terrie Taylor, Malcolm Molyneux, and Robert S. Heyderman

Author affiliations: Malawi–Liverpool–Wellcome Trust Clinical Research Program, Blantyre, Malawi (A. Roca-Feltrer, C.J. Kwizombe, M.A. Sanjoaquin, S.S.S. Sesay, M. Molyneux, R.S Heyderman); Liverpool School of Tropical Medicine, Liverpool, UK (A. Roca-Feltrer, M.A. Sanjoaquin, B. Faragher, R.S Heyderman); Beit CURE International Hospital, Blantyre (J. Harrison); McGill University, Montreal, Quebec, Canada (K. Geukers); Ministry of Health, Lilongwe, Malawi (S. Kabuluzi); University of Malawi College of Medicine, Blantyre (D.P. Mathanga, E. Molyneux, M. Chagomera, T. Taylor); Michigan State University, East Lansing, Michigan, USA (T. Taylor); University of Liverpool, Liverpool (R.S. Heyderman)

Abstract

In some areas of Africa, health facility data have indicated declines in malaria that might have resulted from increasingly effective control programs. Most such reports have been from countries where malaria transmission is highly seasonal or of modest intensity. In Malawi, perennial malaria transmission is intense, and malaria control measures have been scaled up during the past decade. We examined health facility data for children seen as outpatients and parasitemia-positive children hospitalized with cerebral malaria in a large national hospital. The proportion of Plasmodium falciparum–positive slides among febrile children at the hospital declined early in the decade, but no further reductions were observed after 2005. The number of admissions for cerebral malaria did not differ significantly by year. Continued surveillance for malaria is needed to evaluate the effects of the increased malaria control efforts.

Malaria is a leading cause of illness and death among children in countries in which it is endemic (1). An increasing number of countries in sub-Saharan Africa are rapidly scaling up malaria control interventions as broad programmatic measures designed to achieve Millennium Development Goal 4 (2). To reduce malaria effectively, countries should reach at least 70% coverage of the 4 main malaria control tools: long-lasting insecticide-treated bed nets, indoor residual spraying, intermittent presumptive treatment for pregnant women, and prompt treatment with artemisinin-based combination therapy for symptomatic uncomplicated malaria for which parasitemia was confirmed (3). As malaria control interventions increase, several reports based on analyses of long-term surveillance data (4–8) have emerged from countries with long-standing programs that showed a substantial drop in malaria-associated hospitalizations.

Malawi, in south-central Africa, has year-round malaria transmission that peaks during the long rainy season (late November–April) (9) and accounts for 30%–40% of all outpatient visits (2,10,11). Since 2005, and with the support of the President’s Malaria Initiative and the Global Fund, Malawi has started to widely scale up malaria control interventions. In 2000, bed net use was 6% nationally; by 2004, a total of 36% of children <5 years of age reportedly had slept under an insecticide-impregnated bed net during the previous night (12). Since 2007, ≈3 million extra nets have been distributed free of charge through health facilities, reaching ≈60% coverage (13). Coverage of indoor residual spraying, however, remained low in 2010, even in urban areas (e.g., 3% in Blantyre city) where it was limited mainly to the private sector (13). Artemisinin-based combination therapies were adopted as the recommended method of treatment in November 2007. Despite increasing efforts, according to the most recent World Malaria Report, no evidence exists of decreased malaria since 2000 in Malawi (14).
Even with the implementation of an improved Health Management Information System in 2002, obtaining complete facility-based routine data remains a challenge in Malawi (15). Time trends in health facility records may show evidence of fewer malaria cases and may provide a useful complementary approach to monitor disease changes in settings where routine surveillance systems are incomplete.

Malaria has been studied extensively since the late 1990s at the Queen Elizabeth Central Hospital (QECH) in Blantyre, Malawi (16–19). In 2001, an improved Pediatric Accident and Emergency Unit (PAEU) was opened, and routine malaria testing of all febrile children in the unit was introduced. A high-dependency research ward in the Department of Pediatrics has been fully functional since 1987 during January–June each year, with the main aim of improving care and undertaking research on severe malaria during the peak malaria season. This arrangement allows monitoring of malaria at a health facility level. We report trends in outpatient visits by malaria parasite–positive children and in admissions for cerebral malaria among children during the past 10 years in the main referral public hospital of Blantyre, Malawi.