Annex 3
MALARIA EPIDEMIC IN CHILDREN UNDER 5 ADMITTED
AT ST. KIZITO-MATANY HOSPITAL 1988 – 1998
Summary
The morbidity of malaria has dramatically increased in the last few years and therefore the number of deaths related to malaria. This has increased the workload of children ward and in 1998, malaria admissions account for 50% of the total admissions in children ward. The case fatality rate in under 5 is apparently stable or in slight reduction as well as the severity of anaemia associated to malaria showing a good case management of these condition in the Hospital. Nevertheless the increased morbidity has increase the costs for the Hospital in term of number of staff, drugs and surgical sundries and requirement of blood, increasing the risk of HIV/Hepatitis transmission.
Introduction
Malaria has for the last 11 years, been among the five top causes of admission in Paediatric ward: the 3rd in 1988, the 2nd in 1989 and always the first cause of admission since 1990.
The number of cases admitted have been around 4 -500 per year up to 1993 since then the number of cases have increased up to last year with 1739 of cases in under 5.
Methods
A retrospective analysis of the Hospital inpatients and laboratory database was done from 1988 to 1998. The Database files were analysed with Microsoft Excell and presented in a descriptive form as graphics. The analysis was done in children under 5, concerning the number of patients admitted per year, the relative case fatality rate per malaria, the total mortality rate, the number of blood transfusions. The number of malaria cases were calculated counting all the 1st diagnosis that were malaria plus the cases of anaemia as 1st diagnosis and malaria as 2nd diagnosis, considering that this could affect mostly the case fatality rate.
Results and Discussion
All the data results are presented in a graphic way to give better view of the trends over these 11 years.
Therefore the presentation of the results will go along with the discussion of the data and where possible the interpretation as well.
The number of under 5 admitted with malaria has increased especially from 1994 and in 1998 has more than tripled what was up to 1993. This trend is clearly showed in the following chart:
This unexpected increase in morbidity appears as a general trend in Uganda, and in 1998 the Country experienced a malaria epidemic in most of the south western district (1), probably related to an increase in malaria transmission due to deforestation, cultivation of wetlands, poor environmental sanitation or other man breeding sites such as construction works, brick pits or fish ponds (1).
The increased morbidity of malaria is the cause of the increased workload of paediatric ward and in 1998 malaria accounted for 58% of the causes of admission in under 5, while it was only 15% in 1988; this is clearly shown in the following chart:
The increased workload due to the main complication of malaria, severe anaemia, is also reflected by the increase in the number of blood transfusions required; the number of blood transfusions has almost doubled in the last 3 years as shown in the following chart:
Despite the fact of this increase of severe anaemia and the blood needed related to it, no increase in the case
fatality rate was noticed, as instead these factors could have suggested. The trend of the case fatality rate appears
to be
decreasing as shown in the following chart:
The C.F.R appears to change over the years; the reasons of these changes are not clear and probably difficult to explain.
The apparent great differences maybe related to the different diagnosis made (due to changes in medical officers), especially as cause of death: Eg.the patient has died because of malaria or severe anaemia? Because of malaria with severe anaemia or severe pneumonia (not always easy to differentiate on the clinical ground)? This sounds reasonable if we analyse the overall mortality rate in under 5, where these differences are much less. Therefore the great difference in the C.F.R. of malaria may be the result of the “different diagnosis”. The trend of the overall mortality rate in under 5 is shown in the following chart:
This apparent not worsening of the severity of malaria is also noticed if we analyse the trend of the ratio of the number of blood transfusions to the number of malaria cases admitted that, as shown in the following chart, is reducing. This can be interpreted as if the malaria cases are increasing but they require less blood transfusion or in other words the anaemia associated to malaria is less severe:
Conclusions
No clear conclusion can be made interpreting these data. The overall impression is that malaria morbidity is increasing but not so the severity of malaria that on term of severe anaemia associated seems reducing.
How to esplain this is very difficult and need further analysis and data collection for example on the drugs resistance and on the overall morbidity/ mortality in the population.
However some ipotesis can be made:
· The in patient case management has improved along these years.
· The malaria endemicity has change and from a probably medium or low endemicity (Karamoja has very short and erratic rain season and therefore a long dry season with very few mosquito), where more likely there are “epidemic” with higher mortality rate to a highly endemic situation with a lower mortality rate; this last anyway appears in contradiction with an increase of morbidity as it happened.
· The increase of self medication with underdosage cloroquine lead to prolong the parasitemia and results in an increase of severe anaemia and more under 5 that require hospitalisation (self medication is often denied by the mothers).
Whatever are the reasons, what appears
clear is that the morbidity has encrease and therefore the need of blood , with the related increase
costs for the Hospital (for personnel ,
drugs and supplies) and the related
increase risk of HIV transmission.
Bibliography:
1) National Malaria Control Programme: Institutional Frame Work and Draft Plan of Action For 1999. Ministry of Health.