African children with malaria in an area of intense Plasmodium falciparum transmission: Features on admission to the hospital and risk factors for death

Malaria remains the most important parasitic cause of mortality in humans. Its presentation is thought to vary according to the intensity of Plasmodiu m falciparum transmission. However, detailed descriptions of presenting fea tures and risk factors for death are only available from moderate transmiss ion settings. Such descriptions help to improve case management and identif y priority research areas. Standardized systematic procedures were used to collect clinical and laboratory data on 6,624 children admitted to hospital over a 1-year period in an intensely malarious part of Tanzania. Frequenci es of signs and symptoms were calculated and their association with a fatal outcome was assessed using multivariate logistic regression. There were 72 deaths among 2,432 malaria cases (case fatality rate [CFR] = 3.0%); 44% of the cases and 54% of the deaths were in individuals less than 1 year of ag e. There was no association between level of parasitemia and CFR. Increased risk of dying was independently found in all children with hypoglycemia (o dds ratio [OR] = 6.7, 95% confidence interval [CI] = 3.9-11.7), in children 1-7 months of age with tachypnea (OR = 8.8, 95% CI = 2.6-30.5) and dehydra tion (OR = 5.0, 95% CI = 1.9-14.2), and in children 8 months to 4 years of age with chest indrawing (OR = 4.7, 95% CI = 2.0-11.2) and inability to loc alize a painful stimulus (OR = 6.9, 95% CI = 2.9-16.5). Children in the bot tom quartile of weight-for-age were more likely to die (OR = 2.1, 95% CI = 1.3-3.5). Eight percent of the malaria cases had severe anemia (packed cell volume < 15%) but 24% received a blood transfusion. The epidemiology of ma laria disease may be more complex than previously thought. Improved case ma nagement in a wide variety of health facilities may result from adequate id entification and treatment of dehydration and hypoglycemia. Transfusion-req uiring anemia is a major problem and sustainable, effective preventive meas ures are urgently needed.