Malaria
According to the 2023 World Malaria Report by the World Health Organization (WHO), nearly 250 million clinical episodes of malaria occurred in 2022 and an estimated 608,000 malaria deaths. (WHO, 2023) The percentage of all malaria deaths that are in children aged 5 years and under remains highs, although the proportion decreased from 87% in 2000 to 76% in 2015.
WHAT IS MALARIA? (wording)
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CHAMPS Sites with endemic malaria.
MALARIA
Quick Facts
Malaria continues to devastate many communities, especially in sub-Saharan Africa, where children under five make up the majority of deaths from malaria. CHAMPS is helping to combat this crisis by accurately identifying deaths from malaria in children and determining what measures are needed to prevent these deaths.
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Global malaria deaths in children under 5
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Under 5 dying of malaria in Sub-Saharan Africa
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Africa’s Rate of global malaria cases
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Malaria deaths in children under 5 in Africa
The CHAMPS Network collects cause of death data for stillbirths and children <5 years of age across seven countries in sub-Saharan Africa and South Asia; Mozambique began enrollment in 2016, South Africa, Kenya, Mali, and Bangladesh began in 2017, and Sierra Leone and Ethiopia began in 2019. Between December 3, 2016, and December 31, 2022, a total of 5894 cases underwent Minimally Invasive Tissue Sampling (MITS), with 4661 cases had a Cause of Death (CoD) determined through a Determination of Cause of Death (DeCoDe) panel across the 7 sites. Malaria relates deaths were concentrated in Sierra Leona, Kenya, Mozambique, and Mali. South Africa recorded a singular Malaria death. There were no malaria deaths recorded in Ethiopia or Bangladesh.
Fig. 1 Proportion of deaths with malaria in causal chain by age group.
Fig. 2 Number of deaths by site and proportion of deaths that had malaria anywhere in the causal chain in infants and children.
Deaths by Infectious Cause: Malaria
CHAMPS Mortality Category
Frequency of Malaria as CHAMPS Mortality Category
Malaria Parasites
Frequency of parasites found for deaths with Malaria as the Underlying Cause of Death.
Characteristics of Malaria Deaths
The data below is from an analysis of post-neonatal deaths from Sierra
Leone, Kenya, Mali, and Mozambique (n = 858, with n = 262 malaria deaths)
Malaria-attributed deaths were found to occur at a significantly older age compared to
non-malaria deaths
More malaria deaths were in boys than in girls.
Healthcare received in children who died from malaria
Reported symptoms in children who died from malaria
Among the 262 malaria cases, 19 (7.3%) were co-infected with HIV, with the majority occurring in Kenya (12/19)
Co-morbid conditions in children who died from malaria (n=249)
Treatments received by children who died from malaria
World malaria Report https://www.who.int/teams/global-malaria-programme/reports/world-malaria-report-2023
Case Examples
A child who died of cerebral malaria complicated by a serious undiagnosed bacterial infection
A child who died of cerebral malaria complicated by a serious undiagnosed bacterial infection
A three year old boy came to a health center after 3 days of fever, severe headache, vomiting and thirst. He was diagnosed with malaria and started on malaria treatment.
However, he kept getting worse over the next day. He was sent from the health center to a referral hospital. When he arrived at the hospital, he was unresponsive and could not be resuscitated.
Uncovering the Cause
CHAMPS laboratory tests confirmed the presence of Plasmodium falciparum malaria. The child’s blood culture after death was positive for three different bacteria, including Streptococcus pneumoniae. Tests of his blood and tissues also showed evidence of several organisms. In this case, pathologists examined the child’s tissues and determined that the true cause of his serious bacterial infection was Streptococcus pneumoniae in addition to confirming the diagnosis of malaria caused by Plasmodium falciparum.
CHAMPS confirmed that this young boy’s cause of death was cerebral malaria along with a serious bacterial infection that complicated his course.
Public Health Implications
Malaria remains an important cause of child mortality for previously healthy children in much of the world. Efforts are ongoing to prevent children from getting malaria. When children do get malaria,the World Health Organization (WHO) recommends that those who have signs of severe malaria receive antibiotics for the possible complication of serious bacterial infection in addition to malaria medication. Children with severe malaria may also need faster transfer of their care to a referral facility if they are stable. This case shows the importance of rapid recognition of severe malaria so that appropriate care can be given.
A severely malnourished child who died from overwhelming bacterial infection complicated by malaria and anemia
A severely malnourished child who died from overwhelming bacterial infection complicated by malaria and anemia
A one-year, eight-month-old female was referred to a regional hospital after two weeks of fever, cough, restlessness, loss of appetite, mouth ulcers, diarrhea, and skin rash. Four days prior, her parents had taken her to a small community health facility where she was treated with antibiotics and pain medication. The mother reported that the child was not brought immediately to the regional hospital because they did not have money for admission and she had hoped to see improvement from treatment received at the community facility. The mother also said she purchased tablets at a pharmacy before visiting the facility to treat the child but could not recall the name of the medication. Unfortunately, neither the community health facility treatment nor the tablets improved the child’s symptoms.
Within the first few hours of hospital admission, the child tested positive for malaria via a Rapid Diagnostic Test. Hemoglobin testing indicated that she was anemic. She was subsequently treated for both conditions but ultimately succumbed to multiple contributing factors just 12 hours after hospital admission.
Uncovering the Causes
CHAMPS laboratory tests revealed presence of a lung infection caused by Klebsiella pneumoniae. This bacterium was also found in samples of the child’s blood and cerebrospinal fluid. Liver specimens showed an accumulation of extra fat cells, which is often indicative of malnutrition. Severely malnourished children are at greater risk of infection which, when affecting organs like the lungs, can lead to death. This child’s underlying malaria and anemia also further weakened her immune system and the ability to fight off bacterial infection.
The CHAMPS team confirmed severe malnutrition as the main underlying cause of death as supported by anthropometric measurements. Malaria and K. pneumoniae were found to be contributing causes of death in this case.
Public Health Implications
- Malnutrition Screening: CHAMPS findings underscore the need for early identification and management of nutrition. There was likely a gap in this screening program, as the child was fully vaccinated but was not identified as malnourished at 6.5kg and 1 year 8 months old; the child should have been referred for treatment based on low weight measurements, and monitoring should be able to pick up any children who are missed. There are also free programs for nutrition to which this child could have been referred.
- Traditional Feeding Practices: Aspiration pneumonia is common in this low-income context because, when children are sick, their parents will often force-feed small children a mix of traditional herbs and a local cereal type food called Pap. CHAMPS provides education to healthcare workers and community members about the risks of force-feeding and sharing alternative ways to improve Pap, such as fortifying cereals with locally available nutrients. This kind of fortification is essential to help undernourished children to build strength.
- Malaria Prevention: Education about malaria is critical. This mother lived in a city and her child was fully vaccinated and visited health care facilities often. Nevertheless gaps in general knowledge about malaria and prevention often delay parents from seeking appropriate health care for their children. This could be mitigated by training nurses and patient navigators to provide helpful information about malaria while families are waiting in health care facilities, before and after seeking care. This is a low-cost intervention for an already captive audience.
- Klebsiella pneumoniae: The presence of Klebsiella pneumoniae in several CHAMPS specimens raised alarm about a possible outbreak in this area. This informed a decontamination exercise in the Special Care Baby Unit (SCBU) and involvement of infection prevention control teams, both at country-level and locally. CHAMPS supported the Ministry of Health efforts in a general supervised cleaning of the SCBU unit including disinfecting beds and equipment. Staff were also trained in proper handwashing techniques and glove usage. This message was relayed to all the other SCBUs at quarterly meetings to improve and sustain rigorous cleaning regimens. Random environmental samples were taken at these units that proved the effectiveness of the new infection prevention and control cleaning measures.