In contrast, cerebral malaria predominates in areas of moderate transmission, especially where this is seasonal, and it is seen most frequently in older children. Severe malarial anaemia is seen most frequently in areas of very high malaria transmission and most frequently in young children. Study of the epidemiology of severe malaria in Africa has shown different epidemiological patterns for the two most frequent forms of this condition: cerebral malaria and severe malarial anaemia. The limited data available indicate that malaria-attributable mortality and the incidence of severe malaria do not increase with an increase in the entomological inoculation rate above a threshold value, an observation that has important implications for the likely long-term effects of attempts to contain malaria through vector control. Methods of determining mortality from malaria and of defining severe and uncomplicated malaria have been devised. This change of emphasis has been stimulated in part by the need for better clinical definitions of malaria in the evaluation of control measures such as insecticide-treated materials and malaria vaccines. In African children with malaria, the presence of impaired consciousness or respiratory distress can identify those at high risk for death.Įpidemiologists have recently paid greater attention than in the past to the epidemiology of clinical malaria as opposed to the epidemiology of malarial infection. Hence, this simple bedside index identified 84.4 percent of the fatal cases, as compared with the 79.7 percent identified by the current WHO criteria. Of the 64 children who died, 54 were among those with impaired consciousness (n = 336 case fatality rate, 11.9 percent) or respiratory distress (n = 251 case fatality rate, 13.9 percent), or both. Logistic-regression analysis identified four key prognostic indicators: impaired consciousness (relative risk, 3.3 95 percent confidence interval, 1.6 to 7.0), respiratory distress (relative risk, 3.9 95 percent confidence interval, 2.0 to 7.7), hypoglycemia (relative risk, 3.3 95 percent confidence interval, 1.6 to 6.7), and jaundice (relative risk, 2.6 95 percent confidence interval, 1.1 to 6.3). The mortality rate was 3.5 percent (95 percent confidence interval, 2.7 to 4.3 percent), and 84 percent of the deaths occurred within 24 hours of admission.

Not included were 18 children who died on arrival and 4 who died of other causes. We studied 1844 children (mean age, 26.4 months) with a primary diagnosis of malaria. We calculated the frequency and mortality rate for each of the clinical and laboratory criteria in the current World Health Organization (WHO) definition of severe malaria, and then used logistic-regression analysis to identify the variables with the greatest prognostic value. We conducted a prospective study of all children admitted to the pediatric ward of a Kenyan district hospital with a primary diagnosis of malaria. About 90 percent of the deaths from malaria are in African children, but criteria to guide the recognition and management of severe malaria have not been validated in them.

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