Abstract
BackgroundEpidemiologic data on malaria are scant in many high-burden countries including the Democratic Republic of the Congo (DRC), which suffers the second-highest global burden of malaria. Malaria control efforts in regions with challenging infrastructure require reproducible and efficient surveillance. We employed new high-throughput molecular testing to characterize the state of malaria control in the DRC and estimate childhood mortality attributable to excess malaria transmission.Methods and FindingsThe Demographic and Health Survey was a cross-sectional, population-based cluster household survey of adults aged 15–59 years in 2007 employing structured questionnaires and dried blood spot collection. Parasitemia was detected by real-time PCR, and survey responses measured adoption of malaria control measures and under-5 health indices. The response rate was 99% at the household level, and 8,886 households were surveyed in 300 clusters; from 8,838 respondents molecular results were available. The overall prevalence of parasitemia was 33.5% (95% confidence interval [C.I.] 32–34.9); P. falciparum was the most prevalent species, either as monoinfection (90.4%; 95% C.I. 88.8–92.1) or combined with P. malariae (4.9%; 95% C.I. 3.7–5.9) or P. ovale (0.6%; 95% C.I. 0.1–0.9). Only 7.7% (95% CI 6.8–8.6) of households with children under 5 owned an insecticide-treated bednet (ITN), and only 6.8% (95% CI 6.1–7.5) of under-fives slept under an ITN the preceding night. The overall under-5 mortality rate was 147 deaths per 1,000 live births (95% C.I. 141–153) and between clusters was associated with increased P. falciparum prevalence; based on the population attributable fraction, 26,488 yearly under-5 deaths were attributable to excess malaria transmission.ConclusionsAdult P. falciparum prevalence is substantial in the DRC and is associated with under-5 mortality. Molecular testing offers a new, generalizable, and efficient approach to characterizing malaria endemicity in underserved countries.
Highlights
Renewed interest in the eradication of Plasmodium falciparum malaria has galvanized efforts to define its spatial epidemiology, which can guide the allocation of resources to areas in greatest need [1], and facilitate evaluation of the effectiveness of control [2]
Adult P. falciparum prevalence is substantial in the Democratic Republic of the Congo (DRC) and is associated with under-5 mortality
Of 5,524 households with children less than 5 years of age, only 7.7% possessed an insecticide-treated bednet (ITN; cluster median 5%, interquartile range [IQR] 1–15%), and only 7% of under-fives slept under an ITN the preceding night
Summary
Renewed interest in the eradication of Plasmodium falciparum malaria has galvanized efforts to define its spatial epidemiology, which can guide the allocation of resources to areas in greatest need [1], and facilitate evaluation of the effectiveness of control [2] To this end, several countries have recently generated accurate maps through dedicated Malaria Indicator Surveys [3,4], and the Malaria Atlas Project (MAP) has meta-analyzed extant parasite prevalence surveys to produce global estimates of P. falciparum transmission intensity [5]. We employed new high-throughput molecular testing to characterize the state of malaria control in the DRC and estimate childhood mortality attributable to excess malaria transmission
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