Abstract
BackgroundThe precise nature of the relationship between malaria mortality and levels of transmission is unclear. Due to methodological limitations, earlier efforts to assess the linkage have lead to inconclusive results. The malaria transmission intensity and mortality burden across Africa (MTIMBA) project initiated by the INDEPTH Network collected longitudinally entomological data within a number of sites in sub-Saharan Africa to study this relationship. This work linked the MTIMBA entomology database with the routinely collected vital events within the Rufiji Demographic Surveillance System to analyse the transmission-mortality relation in the region.MethodsBayesian Bernoulli spatio-temporal Cox proportional hazards models with village clustering, adjusted for age and insecticide-treated nets (ITNs), were fitted to assess the relation between mortality and malaria transmission measured by entomology inoculation rate (EIR). EIR was predicted at household locations using transmission models and it was incorporated in the model as a covariate with measure of uncertainty. Effects of covariates estimated by the model are reported as hazard ratios (HR) with 95% Bayesian confidence interval (BCI) and spatial and temporal parameters are presented.ResultsSeparate analysis was carried out for neonates, infants and children 1–4 years of age. No significant relation between all-cause mortality and intensity of malaria transmission was indicated at any age in childhood. However, a strong age effect was shown. Comparing effects of ITN and EIR on mortality at different age categories, a decrease in protective efficacy of ITN was observed (i.e. neonates: HR = 0.65; 95% BCI:0.39-1.05; infants: HR = 0.72; 95% BCI:0.48-1.07; children 1–4 years: HR = 0.88; 95% BCI:0.62-1.23) and reduction on the effect of malaria transmission exposure was detected (i.e. neonates: HR = 1.15; 95% BCI:0.95-1.36; infants: HR = 1.13; 95% BCI:0.98-1.25; children 1–4 years: HR = 1.04; 95% BCI:0.89-1.18). A very strong spatial correlation was also observed.ConclusionThese results imply that assessing the malaria transmission-mortality relation involves more than the knowledge on the performance of interventions and control measures. This relation depends on the levels of malaria endemicity and transmission intensity, which varies significantly between different settings. Thus, sub-regions analyses are necessary to validate and assess reproducibility of findings.
Highlights
The precise nature of the relationship between malaria mortality and levels of transmission is unclear
A total of 8,528 children entered in the course of the study and 831 deaths were registered for the entire study period
This study found rather small relationships between estimated malaria transmission and child mortality, that were not statistically significant, insecticide-treated nets (ITNs) appeared to have a large impact, suggesting that malaria was a major cause of death in this population
Summary
The precise nature of the relationship between malaria mortality and levels of transmission is unclear. The malaria transmission intensity and mortality burden across Africa (MTIMBA) project initiated by the INDEPTH Network collected longitudinally entomological data within a number of sites in sub-Saharan Africa to study this relationship. For instance in the Rufiji demographic surveillance system (DSS), changing of the first-line drug for malaria treatment from chloroquine to sulphadoxine-pyrimethamine and increasing coverage of ITNs were followed by a sharp decline in mortality and malaria transmission [13,14]. The traces on the possible relationship between mortality and fluctuation in malaria transmission exists, lack of vital registration in developing countries, unreliable information on specific causes of deaths, problems related to disease diagnosis e.g. malaria, lack of appropriate data to track changes in malaria transmission complicate efforts to understand the transmission-mortality relationship [15,16,17,18]. Progress towards malaria eradication as the long-term vision of Roll Back Malaria (RBM) partnership, requires accurate knowledge of the transmission-mortality relation [15,21,22,23]
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