Severe childhood malaria in two areas of markedly different falciparum transmission in east Africa.

Malaria remains a major public health challenge in sub-Saharan Africa, yet our knowledge of the epidemiology of malaria in terms of patterns of mortality and morbidity is limited. We have examined the presentation of severe, potentially life-threatening malaria to district hospitals in two very different transmission settings: Kilifi, Kenya with low seasonal transmission and Ifakara, Tanzania with high seasonal transmission. The minimum annual rates of severe disease in children below five years in both populations were similar (46 per 1000 children in Kilifi and 51 per 1000 children in Ifakara). However, there were important differences in the age and clinical patterns of severe disease; twice as many patients were under one year of age in Ifakara compared with Kilifi and there was a four fold higher rate of cerebral malaria and three fold lower rate of malaria anaemia among malaria patients at Kilifi compared with Ifakara. Reducing malaria transmission in Ifakara by 95%, for example with insecticide-treated bed nets, would result in a transmission setting comparable to that of Kilifi and although this reduction may yield early successes in reducing severe malaria morbidity and mortality in young, immunologically naive children, place these same children at increased risk at older ages of developing severe and potentially different manifestations of malaria infection hence producing no net cohort gain in survivorship from potentially fatal malaria.

Maternal recall of symptoms associated with childhood deaths in rural east Africa.

Verbal autopsies (VA) are frequently used to determine causes of death for individuals for whom there is no reliable clinical information regarding the terminal illness. VA interviews are used to note key symptoms and signs recalled by relatives of the deceased and diagnoses ascribed according to the symptom complexes. The VA technique assumes that individual disease entities have discrete symptom complexes and that these can be accurately recognized and recalled by the interviewees. We have examined the accuracy with which specific symptoms are recalled over time by mothers or normal guardians of 491 children who died on the paediatric wards of two district hospitals in East Africa. Kwashiorkor, measles, trauma, generalized convulsions and neonatal tetanus were all reported with a high degree of accuracy for children who died of these conditions and had low false positive rates for children without these conditions. Recall was similar within 1 month of death compared to recall after 6 months for most symptoms and signs except neonatal tetanus where false positive reports by mothers increased with time since death. Symptoms and signs commonly used to describe malaria, respiratory tract and diarrhoea-related deaths were reported by mothers to have been present during the terminal illness in 43% of cases where these features were absent. Recall abilities differed between the two communities studied for some symptoms and signs highlighting the importance of such studies in every setting where VA are applied.

PIP: Verbal autopsies (VA) are widely used by population and health scientists to determine individual causes of death in areas where most deaths occur at home and well-documented clinical data on cause of death are usually unavailable. VA interviews are based upon key symptoms and signs recalled by relatives of the deceased. In order to assess the reliability of the technique, the accuracy with which mothers and normal guardians recognize and recalled specific symptoms and clinical signs over time was assessed in the cases of 491 children who died on the pediatric wards of 2 district hospitals in Ifakara, Tanzania, and Kilifi, Kenya. The bereaved were interviewed 3 days to 24 months after child death. Recall after 1 month was similar to recall after 6 months for most signs and symptoms except neonatal tetanus for which false positives reported by mothers increased with time after death. Kwashiorkor, measles, trauma, generalized convulsions, and neonatal tetanus were reported with a high degree of accuracy. Symptoms and signs commonly used to describe malaria, respiratory tract and diarrhea- related deaths, however, were reported by mothers to have been present during terminal illness in 43% of cases where the features were absent. Finally, recall abilities differed between the 2 communities studied.