Abstract
BackgroundMalaria is almost invariably ranked as the leading cause of morbidity and mortality in Africa. There is growing evidence of a decline in malaria transmission, morbidity and mortality over the last decades, especially so in East Africa. However, there is still doubt whether this decline is reflected in a reduction of the proportion of malaria among fevers. The objective of this systematic review was to estimate the change in the Proportion of Fevers associated with Plasmodium falciparum parasitaemia (PFPf) over the past 20 years in sub-Saharan Africa.MethodsSearch strategy. In December 2009, publications from the National Library of Medicine database were searched using the combination of 16 MeSH terms.Selection criteria. Inclusion criteria: studies 1) conducted in sub-Saharan Africa, 2) patients presenting with a syndrome of 'presumptive malaria', 3) numerators (number of parasitologically confirmed cases) and denominators (total number of presumptive malaria cases) available, 4) good quality microscopy.Data collection and analysis. The following variables were extracted: parasite presence/absence, total number of patients, age group, year, season, country and setting, clinical inclusion criteria. To assess the dynamic of PFPf over time, the median PFPf was compared between studies published in the years ≤2000 and > 2000.Results39 studies conducted between 1986 and 2007 in 16 different African countries were included in the final analysis. When comparing data up to year 2000 (24 studies) with those afterwards (15 studies), there was a clear reduction in the median PFPf from 44% (IQR 31-58%; range 7-81%) to 22% (IQR 13-33%; range 2-77%). This dramatic decline is likely to reflect a true change since stratified analyses including explanatory variables were performed and median PFPfs were always lower after 2000 compared to before.ConclusionsThere was a considerable reduction of the proportion of malaria among fevers over time in Africa. This decline provides evidence for the policy change from presumptive anti-malarial treatment of all children with fever to laboratory diagnosis and treatment upon result. This should insure appropriate care of non-malaria fevers and rationale use of anti-malarials.
Highlights
Malaria is almost invariably ranked as the leading cause of morbidity and mortality in Africa
There is a documented decline in Africa of Plasmodium falciparum prevalence rates in children aged 2-10 years from 37% before the year 2000, to 17% after 2000 [6]. This decline is further evidenced in recent Demographic and Health Surveys (DHS) in malaria endemic countries of sub-Saharan Africa: 11 of the 12 national surveys conducted since 2004 showed declines in underfive mortality estimates over the previous five years [7]
Criteria for considering studies for this review Type of studies: observational studies or diagnostic studies Inclusion criteria were i) study conducted in an area of sub-Saharan Africa where P. falciparum is the dominant species, ii) including patients presenting at a health facility with a syndrome of ‘presumptive malaria’, either considered as such by the health worker in charge, or defined on clinical criteria by the investigators, iii) numerator and denominator available or possible to calculate from text, tables, or obtained after request to the authors, iv) good quality microscopy, v) no obvious selection bias of patients
Summary
Malaria is almost invariably ranked as the leading cause of morbidity and mortality in Africa. There is growing evidence of a decline in malaria transmission, morbidity and mortality over the last decades, especially so in East Africa. There is a documented decline in Africa of Plasmodium falciparum prevalence rates in children aged 2-10 years from 37% before the year 2000, to 17% after 2000 [6]. This decline is further evidenced in recent Demographic and Health Surveys (DHS) in malaria endemic countries of sub-Saharan Africa: 11 of the 12 national surveys conducted since 2004 showed declines in underfive mortality estimates over the previous five years (declines of 5% to 30%, median 23%) [7]
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