Malaria In Malawi Research Articles

Assessment of Malawian mothers' malaria knowledge, healthcare preferences and timeliness of seeking fever treatments for children under five.

Malaria is one of the major public health problems in Malawi, contributing to the majority of morbidity and mortality among children under five. Ignorance of malaria symptoms results in delayed treatment, which often degenerates into fatal emergencies. This study analyzed the impact of maternal malaria knowledge on healthcare preferences and timeliness of treating children with reported fever. The Malaria Indicator Survey data for 2012, which were adequately weighted, were analyzed using multinomial logit and Poisson regression models. The results showed low maternal average years of formal education (3.52) and average mothers’ age was 27.97 years. Majority of the women (84.98%) associated fever with malaria, while 44.17% associated it with chilling. Also, 54.42% and 32.43% of the children were treated for fever on the same day and the following day that fever started, respectively. About 9.70% paid for fever treatment from their regular incomes, while 51.38% sought treatment from either public or private health centers. Multinomial Logit regression results showed that relative to using of other treatments, probabilities of selecting private hospitals and public health centers increased with age of the household heads, resident in urban areas, mothers’ years of education, number of days taken off for treatment, paying medical bills from regular, occasional and borrowed incomes, and knowledge of diarrhea and shivering as symptoms of malaria. In the Poisson regression results, timeliness of seeking treatment was significantly enhanced by knowledge of fever as malaria symptom, residence in northern and central regions of Malawi and use of income from sale of assets to pay medical bills (p < 0.10).However, delays in treating children was motivated by age of the household heads, number of days taken off to care for sick child and usage of regular, borrowed and other incomes to pay medical bills. (p < 0.05). It was concluded that efficiency of public sector in treating malaria holds significant prospects for fighting malaria in Malawi. However, adequate efforts should be channeled in enhancing the knowledge of women on malaria symptoms, among others.

Submicrosopic gametocytemia and malaria in Malawi: Molecular identification and implications for transmission

Submicrosopic gametocytemia and malaria in Malawi: Molecular identification and implications for transmission

Relative importance of climatic, geographic and socio-economic determinants of malaria in Malawi

BackgroundMalaria transmission is influenced by variations in meteorological conditions, which impact the biology of the parasite and its vector, but also socio-economic conditions, such as levels of urbanization, poverty and education, which impact human vulnerability and vector habitat. The many potential drivers of malaria, both extrinsic, such as climate, and intrinsic, such as population immunity are often difficult to disentangle. This presents a challenge for the modelling of malaria risk in space and time.MethodsA statistical mixed model framework is proposed to model malaria risk at the district level in Malawi, using an age-stratified spatio-temporal dataset of malaria cases from July 2004 to June 2011. Several climatic, geographic and socio-economic factors thought to influence malaria incidence were tested in an exploratory model. In order to account for the unobserved confounding factors that influence malaria, which are not accounted for using measured covariates, a generalized linear mixed model was adopted, which included structured and unstructured spatial and temporal random effects. A hierarchical Bayesian framework using Markov chain Monte Carlo simulation was used for model fitting and prediction.ResultsUsing a stepwise model selection procedure, several explanatory variables were identified to have significant associations with malaria including climatic, cartographic and socio-economic data. Once intervention variations, unobserved confounding factors and spatial correlation were considered in a Bayesian framework, a final model emerged with statistically significant predictor variables limited to average precipitation (quadratic relation) and average temperature during the three months previous to the month of interest.ConclusionsWhen modelling malaria risk in Malawi it is important to account for spatial and temporal heterogeneity and correlation between districts. Once observed and unobserved confounding factors are allowed for, precipitation and temperature in the months prior to the malaria season of interest are found to significantly determine spatial and temporal variations of malaria incidence. Climate information was found to improve the estimation of malaria relative risk in 41% of the districts in Malawi, particularly at higher altitudes where transmission is irregular. This highlights the potential value of climate-driven seasonal malaria forecasts.

Malaria elimination in Malawi: Research needs in highly endemic, poverty-stricken contexts

Malaria control in the impoverished, highly endemic settings of sub-Saharan Africa remains a major public health challenge. Successes have been achieved only where sustained, concerted, multi-pronged interventions have been instituted. As one of the world‘s poorest countries, Malawi experiences malaria incidence rates that have remained high despite a decade of gradually expanding and more intensive prevention efforts. The Malawi International Center for Excellence in Malaria Research (ICEMR) is beginning work to augment the knowledge base for reducing Plasmodium transmission and malaria morbidity and mortality. Among ICEMR goals, we intend to better assess patterns of infection and disease, and analyze transmission by Anopheles vector species in both urban and rural ecological settings. We will evaluate parasite population genetics and dynamics, transmission intensities and vector ecologies, social and environmental determinants of disease patterns and risk, and human–vector–parasite dynamics. Such context-specific information will help to focus appropriate prevention and treatment activities on efforts to control malaria in Malawi. In zones of intense and stable transmission, like Malawi, elimination poses particularly thorny challenges – and these challengers are different from those of traditional control and prevention activities. Working toward elimination will require knowledge of how various interventions impact on transmission as it approaches very low levels. At present, Malawi is faced with immediate, context-specific problems of scaling-up prevention and control activities simply to begin reducing infection and disease to tolerable levels. The research required to support these objectives is critically evaluated here.

Population Pharmacokinetics of Sulfadoxine and Pyrimethamine in Malawian Children With Malaria

In addition to parasite resistance, inadequate levels of exposure to antimalarial drugs may contribute to treatment failure. We developed population pharmacokinetic (PK) models to describe the distribution of sulfadoxine (SDX) and pyrimethamine (PYM) in children with uncomplicated malaria in Malawi. The concentration levels of antimalarial drugs in whole blood were determined using high-performance liquid chromatography. We found no evidence of underdosing in children as compared with adults; the children had drug exposure levels similar to those described in adults. Treatment failure was more likely in children with lower PYM concentrations on day 14 (P = 0.024), and there was a trend for lower SDX concentrations on day 14 (P = 0.061). SDX and PYM concentrations at levels predictive of treatment failure have been identified at day 14. Less than one-third of the children displayed drug concentration levels above these thresholds after receiving the recommended SDX-pyrimethamine (SP) dose. Our findings suggest that PK factors contributed to the observed high rate of treatment failure, and we therefore recommend a higher SP dose for children under the age of 5 years.

Return of Chloroquine‐Susceptible Falciparum Malaria in Malawi Was a Reexpansion of Diverse Susceptible Parasites

The spread of drug-resistant Plasmodium falciparum malaria has been a major impediment to malaria control and threatens prospects for elimination. We recently demonstrated the return of chloroquine-susceptible malaria in Malawi after chloroquine use was abandoned. In this study, we trace the origins of chloroquine-resistant and chloroquine-susceptible parasites in Malawi by sequencing the P. falciparum chloroquine resistance transporter gene (pfcrt) and by genotyping microsatellites flanking this gene in isolates from infections that occurred in Malawi from 1992 through 2005. Malaria parasites from 2005 harbored the expected wild-type pfcrt haplotype associated with chloroquine susceptibility and have maintained high levels of diversity without linkage disequilibrium, which suggests that the return of chloroquine susceptibility is not the result of a back mutation in a formerly resistant parasite or a new selective sweep. Chloroquine-susceptible parasites that predominate in Malawi likely represent a reexpansion of the susceptible parasites that survived in the population despite widespread drug pressure in the region.

Care-seeking behaviour and implications for malaria control in southern Malawi

Although malaria is a controllable and preventable disease, it remains among the leading causes of mortality and morbidity in southern Malawi. The importance of early diagnosis and prompt treatment with hospital prescribed drugs and effective home management to control malaria is well established; however, these in part depend on how households make their decisions when family members have suffered from malaria. This study examines the behaviour of households with regard to decisions they make in managing malaria illness. Using hierarchically built data from a survey of 1,400 mothers nested within 33 communities, a series of two-level logistic regression models with Bayesian estimation was used to determine predictors of care-seeking behaviour towards malaria when a family member or a child was perceived to have malaria. The results show that most families normally visit or use medication prescribed at health facilities for both adult (80%) and child (86%) members when they are perceived to have malaria. The main obstacle to accessing the nearest health facility was distance and transport costs (73%) and the main problems encountered at health facilities were long waiting time or absence of health workers (73%) and shortage of drugs (35%). Among the main predictor variables for choices of treatment for childhood malaria was the absence of a health surveillance assistant for those that visited hospitals [β=0.56; 95% CI:-0.86,-0.26]; bought medication from open markets [β=0.51; 95% CI:0.20,0.82]; and those that used other traditional methods or did nothing [β=0.70; 95% CI:-0.04,1.44; p=0.06].. The results have an important role to play in the control and prevention of malaria in Malawi. The results reveal the need for increased awareness about the dangers of purchasing drugs from non-medical and/or uncertified private institutions and sources such as those found in open markets. They also show the important role of community health workers in the delivery of health systems. The study recommends empowerment of community health workers through rigorous and relevant health promotion programmes to update both their knowledge and their skills in communication and counselling.

Measurement of adherence, drug concentrations and the effectiveness of artemether-lumefantrine, chlorproguanil-dapsone or sulphadoxine-pyrimethamine in the treatment of uncomplicated malaria in Malawi

BackgroundSulphadoxine-pyrimethamine (SP) is the only single dose therapy for uncomplicated malaria, but there is widespread resistance. At the time of this study, artemether-lumefantrine (AL) and chlorproguanil-dapsone (CPD), both multi-dose regimes, were considered possible alternatives to SP in Malawi. The aim of this study was to investigate the impact of poor adherence on the effectiveness of AL and CPD.MethodsChildren ≥12 months and adults with uncomplicated malaria were randomized to receive AL, CPD or SP. Adherence was measured using a questionnaire and electronic monitoring devices, MEMS™, pill bottles that recorded the date and time of opening. Day-7 plasma dapsone or lumefantrine concentrations were measured to examine their relationship with adherence and clinical response.Results841 patients were recruited. The day-28 adequate clinical and parasitological response (ACPR) rates, using intention to treat analysis (missing data treated as failure), were AL 85.2%, CPD 63.7% and SP 50%. ACPR rates for AL were higher than CPD or SP on days 28 and 42 (p ≤ 0.002 for all comparisons). CPD was more effective than SP on day-28 (p = 0.01), but not day-42.Very high adherence was reported using the questionnaire, 100% for AL treated patients and 99.2% for the CPD group. Only three CPD participants admitted missing any doses. 164/181 (90.6%) of CPD treated patients took all their doses out of the MEMS™ container and they were more likely to have a day-28 ACPR than those who did not take all their medication out of the container, p = 0.024. Only 7/87 (8%) AL treated patients did not take all of their doses out of their MEMS™ container and none had treatment failure.Median day-7 dapsone concentrations were higher in CPD treated patients with ACPR than in treatment failures, p = 0.012. There were no differences in day-7 dapsone or lumefantrine concentrations between those who took all their doses from the MEMS™ container and those who did not. A day-7 lumefantrine concentration reported to be predictive of AL treatment failure in Thailand was not useful in this population; only one of 16 participants with a concentration below this threshold (175 ng/ml) had treatment failure.ConclusionThis study provides reassurance of the effectiveness of AL, even with unsupervised dosing, as it is rolled out across sub-Saharan Africa. Self-reported adherence appears to be an unreliable measure of adherence in this population.

Retinal Pathology of Pediatric Cerebral Malaria in Malawi

IntroductionThe causes of coma and death in cerebral malaria remain unknown. Malarial retinopathy has been identified as an important clinical sign in the diagnosis and prognosis of cerebral malaria. As part of a larger autopsy study to determine causes of death in children with coma presenting to hospital in Blantyre, Malawi, who were fully evaluated clinically prior to death, we examined the histopathology of eyes of patients who died and underwent autopsy.Methodology/Principal FindingsChildren with coma were admitted to the pediatric research ward, classified according to clinical definitions as having cerebral malaria or another cause of coma, evaluated and treated. The eyes were examined by direct and indirect ophthalmoscopy. If a child died and permission was given, a standardized autopsy was carried out. The patient was then assigned an actual cause of death according to the autopsy findings. The eyes were examined pathologically for hemorrhages, cystoid macular edema, parasite sequestration and thrombi. They were stained immunohistochemically for fibrin and CD61 to identify the components of thrombi, β-amyloid precursor protein to detect axonal damage, for fibrinogen to identify vascular leakage and for glial fibrillary acidic protein to detect gliosis. Sixty-four eyes from 64 patients were examined: 35 with cerebral malaria and 29 with comas of other causes. Cerebral malaria was distinguished by sequestration of parasitized erythrocytes, the presence and severity of retinal hemorrhages, the presence of cystoid macular edema, the occurrence and number of fibrin-platelet thrombi, the presence and amount of axonal damage and vascular leakage.Conclusions/SignificanceWe found significant differences in retinal histopathology between patients who died of cerebral malaria and those with other diagnoses. These histopathological findings offer insights into the etiology of malarial retinopathy and provide a pathological basis for recently described retinal capillary non-perfusion in children with malarial retinopathy. Because of the similarities between the retina and the brain it also suggests mechanisms that may contribute to coma and death in cerebral malaria.

Effect of Transmission Setting and Mixed Species Infections on Clinical Measures of Malaria in Malawi

BackgroundIn malaria endemic regions people are commonly infected with multiple species of malaria parasites but the clinical impact of these Plasmodium co-infections is unclear. Differences in transmission seasonality and transmission intensity between endemic regions have been suggested as important factors in determining the effect of multiple species co-infections.Principal FindingsIn order to investigate the impact of multiple-species infections on clinical measures of malaria we carried out a cross-sectional community survey in Malawi, in 2002. We collected clinical and parasitological data from 2918 participants aged >6 months, and applied a questionnaire to measure malaria morbidity. We examined the effect of transmission seasonality and intensity on fever, history of fever, haemoglobin concentration ([Hb]) and parasite density, by comparing three regions: perennial transmission (PT), high intensity seasonal transmission (HIST) and low intensity seasonal transmission (LIST). These regions were defined using multi-level modelling of PCR prevalence data and spatial and geo-climatic measures. The three Plasmodium species (P. falciparum, P. malariae and P. ovale) were randomly distributed amongst all children but not adults in the LIST and PT regions. Mean parasite density in children was lower in the HIST compared with the other two regions. Mixed species infections had lower mean parasite density compared with single species infections in the PT region. Fever rates were similar between transmission regions and were unaffected by mixed species infections. A history of fever was associated with single species infections but only in the HIST region. Reduced mean [Hb] and increased anaemia was associated with perennial transmission compared to seasonal transmission. Children with mixed species infections had higher [Hb] in the HIST region.ConclusionsOur study suggests that the interaction of Plasmodium co-infecting species can have protective effects against some clinical outcomes of malaria but that this is dependent on the seasonality and intensity of malaria transmission.

Estimated financial and human resources requirements for the treatment of malaria in Malawi

Estimated financial and human resources requirements for the treatment of malaria in Malawi

Estimated financial and human resources requirements for the treatment of malaria in Malawi

BackgroundMalaria fever is a common medical presentation and diagnosis in Malawi. The national malaria policy supports self-diagnosis and self-medication for uncomplicated malaria with first line anti-malaria drugs. While a qualitative appreciation of the burden of malaria on the health system is recognized, there is limited quantitative estimation of the burden malaria exacts on the health system, especially with regard to human resources and financial burden on Malawi.MethodsThe burden of malaria was assessed based on estimated incidence rates for a high endemic country of which Malawi is one. Data on the available human resources and financial resources committed towards malaria from official Malawi government documents and programme reports were obtained. The amount of human and financial resources that would be required to treat 65% or 85% of symptomatic malaria cases as per the Roll Back Malaria partnership and the US President's Malaria Initiative targets.ResultsBased on a malaria incidence rate of 1.4 episodes per year per person it was estimated that there would be 3.71 million symptomatic episodes of malaria among children <5 years of age based on mid-2007 census projections. At 0.59 episodes each year per person there would be 2.13 million episodes in the 5 to 14 year age group and 1.02 million episodes in. There would be 761,848 malaria cases when HIV is not factored in among those 15 years of age or above; this figure rose to 2.2 million when the impact of HIV in increasing malaria incidence was considered. The prevalence of HIV has resulted in 42.3% increase in symptomatic malaria cases. Treating 65% to 85% of cases would result in using 8.9% to 12.2% of the national health budget or 22.2% to 33.2% of the national drug budget. Furthermore, having 65% to 85% of cases treated at a health facility would consume 55.5% to 61.1% of full-time equivalents of all the clinicians registered in the country. While this study's estimated time of 5 and 10 minutes per consultation may differ in actual practice, due to time constraints patients may not be seen for longer consultation in resources limited settings.ConclusionMalaria exacts a heavy toll on the health system in Malawi. The national recommendation of self-medication with first-line drug for uncomplicated malaria is justified as there are not enough clinicians to provide clinical care for all cases. The Malawi Ministry of Health's promotion of malaria drug prescription including other lower cadre health workers may be justified.

Vulnerability, access to health services and impact: a gender lens on TB, HIV and malaria in Malawi

This paper synthesises the different research findings in Malawi to explore how gender roles and relations affect the way in which key diseases related to poverty are experienced at the community level. We highlight background information on Malawi with an overview of the three diseases: HIV/AIDS, tuberculosis and malaria, and of the methods used; and provide a conceptual framework on how gender shapes (1) vulnerability to TB, HIV/AIDS and malaria, (2) access and adherence to services and (3) the impact of being ill on individuals and households Malawi Medical Journal Vol. 18 (2) 2006: pp. 80-83

Economic costs of epidemic malaria to households in rural Ethiopia

To estimate the direct and indirect costs of malaria morbidity among communities in an epidemic area in rural Southcentral Ethiopia. Community-based cross-sectional study of 2195 households in Adami Tulu district from October to November 2003. Treatment-seeking behaviour, expenditure on treatment and transportation, interruption of normal activities, time lost from working and household expenditure on preventive methods were ascertained through interview. Of 12,225 surveyed individuals, 1748 (14.3%) reported perceived malaria during the preceding 2 weeks. 77.1% sought any form of care and 70% had recovered at the time of interview. The average treatment cost per patient at private clinics was Birr 24.00 ($2.76) and Birr 12.50 ($1.44) at public facilities. The average estimated direct cost of malaria per patient was Birr 14.00 ($1.60); the average indirect cost, Birr 35.26 ($4.08). Only 5% of all households reported any preventive expenditure in the preceding month, with a mean of Birr 0.76 ($0.09). Malaria poses a significant economic burden on rural households and individuals both through out-of-pocket payment and person-days lost. The promotion and implementation of insecticide-treated nets would alleviate the economic consequences of the disease.

Geographical disparities in core population coverage indicators for roll back malaria in Malawi

BackgroundImplementation of known effective interventions would necessitate the reduction of malaria burden by half by the year 2010. Identifying geographical disparities of coverage of these interventions at small area level is useful to inform where greatest scaling-up efforts should be concentrated. They also provide baseline data against which future scaling-up of interventions can be compared. However, population data are not always available at local level. This study applied spatial smoothing methods to generate maps at subdistrict level in Malawi to serve such purposes.MethodsData for the following responses from the 2000 Malawi Demographic and Health Survey (DHS) were aggregated at subdistrict level: (1) households possessing at least one bednet; (2) children under 5 years who slept under a bednet the night before the survey; (3) bednets retreated with insecticide within past 6–12 months preceding the survey; (4) children under 5 who had fever two weeks before the survey and received treatment within 24 hours from the onset of fever; and (5) women who received intermittent preventive treatment of malaria during their last pregnancy. Each response was geographically smoothed at subdistrict level by applying conditional autoregressive models using Markov Chain Monte Carlo simulation techniques.ResultsThe underlying geographical patterns of coverage of indicators were more clear in the smoothed maps than in the original unsmoothed maps, with relatively high coverage in urban areas than in rural areas for all indicators. The percentage of households possessing at least one bednet was 19% (95% credible interval (CI): 16–21%), with 9% (95% CI: 7–11%) of children sleeping under a net, while 18% (95% CI: 16–19%) of households had retreated their nets within past 12 months prior to the survey. The northern region and lakeshore areas had high bednet coverage, but low usage and re-treatment rates. Coverage rate of children who received antimalarial treatment within 24 hours after onset of fever was consistently low for most parts of the country, with mean coverage of 4.8% (95% CI: 4.5–5.0%). About 48% (95% CI: 47–50%) of women received antimalarial prophylaxis during their pregnancy, with highest rates in the southern and northern areas.ConclusionThe striking geographical patterns, for example between predominantly urban and rural areas, may reflect spatial differences in provider compliance or coverage, and can partly be explained by socio-economic and cultural differences. The wide gap between high bed net coverage and low retreatment rates may reflect variation in perceptions about malaria, which may be addressed by implementing information, education and communication campaigns or introducing long lasting insecticide nets. Our results demonstrate that DHS data, with appropriate methodology, can provide acceptable estimates at sub-national level for monitoring and evaluation of malaria control goals.

MALARIAL RETINOPATHY: A NEWLY ESTABLISHED DIAGNOSTIC SIGN IN SEVERE MALARIA

Severe malaria is commonly misdiagnosed in Africa, leading to a failure to treat other life-threatening illnesses. In malaria-endemic areas, parasitemia does not ensure a diagnosis of severe malaria because parasitemia can be incidental to other concurrent disease. The detection of malarial retinopathy is a candidate diagnostic test for cerebral malaria. Malarial retinopathy consists of a set of retinal abnormalities that is unique to severe malaria and common in children with cerebral malaria. Its presence and severity are related to risk of death and length of coma in survivors. A large, prospective autopsy study of children dying with cerebral malaria in Malawi found that malarial retinopathy was better than any other clinical or laboratory feature in distinguishing malarial from non-malarial coma. However, visualization has to date relied on specialist examination techniques. Further studies are planned to evaluate the usefulness of funduscopy by general clinicians in a variety of settings across Africa. Studies of the retina and retinal blood vessels provide an unparalleled opportunity to visualize an infected microvasculature and its effect on neural tissue in vivo. This report reviews current knowledge of malarial retinopathy, including its use as a diagnostic test in the comatose child, and its value as a tool for research into the pathophysiology of cerebral malaria.

Spatial analysis and mapping of malaria risk in Malawi using point-referenced prevalence of infection data

BackgroundCurrent malaria control initiatives aim at reducing malaria burden by half by the year 2010. Effective control requires evidence-based utilisation of resources. Characterizing spatial patterns of risk, through maps, is an important tool to guide control programmes. To this end an analysis was carried out to predict and map malaria risk in Malawi using empirical data with the aim of identifying areas where greatest effort should be focussed.MethodsPoint-referenced prevalence of infection data for children aged 1–10 years were collected from published and grey literature and geo-referenced. The model-based geostatistical methods were applied to analyze and predict malaria risk in areas where data were not observed. Topographical and climatic covariates were added in the model for risk assessment and improved prediction. A Bayesian approach was used for model fitting and prediction.ResultsBivariate models showed a significant association of malaria risk with elevation, annual maximum temperature, rainfall and potential evapotranspiration (PET). However in the prediction model, the spatial distribution of malaria risk was associated with elevation, and marginally with maximum temperature and PET. The resulting map broadly agreed with expert opinion about the variation of risk in the country, and further showed marked variation even at local level. High risk areas were in the low-lying lake shore regions, while low risk was along the highlands in the country.ConclusionThe map provided an initial description of the geographic variation of malaria risk in Malawi, and might help in the choice and design of interventions, which is crucial for reducing the burden of malaria in Malawi.

Sustained clinical efficacy of sulfadoxine-pyrimethamine for uncomplicated falciparum malaria in Malawi after 10 years as first line treatment: five year prospective study

Objective To measure the efficacy of sulfadoxine-pyrimethamine treatment of falciparum malaria in Malawi from 1998 to 2002, after a change from chloroquine to sulfadoxine-pyrimethamine as first line treatment in that...

Reemergence of chloroquine-sensitive Plasmodium falciparum malaria after cessation of chloroquine use in Malawi.

In 1993, Malawi became the first African country to replace chloroquine with sulfadoxine-pyrimethamine nationwide in response to high rates of chloroquine-resistant falciparum malaria. To determine whether withdrawal of chloroquine can lead to the reemergence of chloroquine sensitivity, the prevalence of the pfcrt 76T molecular marker for chloroquine-resistant Plasmodium falciparum malaria was retrospectively measured in Blantyre, Malawi. The prevalence of the chloroquine-resistant pfcrt genotype decreased from 85% in 1992 to 13% in 2000. In 2001, chloroquine cleared 100% of 63 asymptomatic P. falciparum infections, no isolates were resistant to chloroquine in vitro, and no infections with the chloroquine-resistant pfcrt genotype were detected. A concerted national effort to withdraw chloroquine from use has been followed by a return of chloroquine-sensitive falciparum malaria in Malawi. The reintroduction of chloroquine, ideally in combination with another antimalarial drug, should be considered in areas where chloroquine resistance has declined and safe and affordable alternatives remain unavailable.

Correlation of retinal haemorrhages with brain haemorrhages in children dying of cerebral malaria in Malawi

Retinal haemorrhages increase in number with severity of Plasmodium falciparum malaria and occur in 35–40% of children with cerebral malaria. We performed clinical retinal examinations and histopathological examinations of retina, and parietal and cerebellar sections of the brains, in 33 children in Malawi who died with cerebral malaria, severe malaria anaemia, or coma of other causes. Haemorrhages were counted in a standardized fashion: the Spearman correlation coefficient between the number of haemorrhages in retina and brain was 0·741 for parietal tissue and 0·703 for cerebellar ( P < 0·01 for both). Severity of haemorrhage in the retina correlates well with that in the brain. Retinal examination in cerebral malaria is a useful tool in predicting some of the pathophysiological processes occurring in the brain.