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Malaria trends in Middle East 'worrying'

Malaria is not usually thought of as a major disease in the Middle East. However concerning new research has revealed that severe paediatric malaria is a substantial burden to the health services in Yemen.

Malaria is not usually thought of as a major disease in the Middle East. However concerning new research has revealed that severe paediatric malaria is a substantial burden to the health services in Yemen, displaying a disease pattern similar to that seen in Africa.

Yemen is one of most highly populated countries in the Middle East, and is second only to Afghanistan in having the highest incidence of malaria in the region. The disease accounts for about 40% of hospital admissions during peak malaria seasons.

To investigate the extent of the trend, Dr Abdullah Al-Taiar, from Sana’s University in Yemen, and colleagues carried out a prospective observational study of childhood malaria in the province of Taiz. Study sites were one hospital in the coastal plain (Hodeidah) and one in the mountains (Taiz). The findings were published in the British Medical Journal.

Study subjects were children ages 6 months to 10 years with a positive slide test for Plasmodium falciparum, admitted to hospital between November 2002 and August 2004. Of the 8068 patients admitted to Taiz and 4233 in Hodeidah, 17% in each hospital (total, 2071) were believed to have severe malaria. Eight hundred and eight patients met the WHO criteria for severe malaria.

Younger children were more likely to have severe anaemia (median age 2.0). Cerebral malaria was diagnosed in 8% of cases, who tended to be older (median age 3.3 years). About 40% of patients had respiratory distress.

The case fatality rate was 3.2% (26 children). The mortality rate was 3-fold higher in girls, 5.2% versus 1.9% in boys. None of the patients with severe anemia as their only symptom died. For respiratory distress alone, the mortality rate was 2%. The highest mortality rate occurred among children with neurological complications -- cerebral malaria, coma, and repeated convulsions.

Dr. Al-Taiar and colleagues identified four independent risk factors for mortality: Blantyre coma scale of 2 or less, history of coma, female gender, and hyperlactatemia.

In many ways, the presentation of severe paediatric malaria in Yemen is similar to that in Africa, the authors note. The incidence rate at peak malaria seasons and clinical patterns are nearly the same. However, more of the Yemeni patients were severely anaemic, and more had respiratory distress.

The higher mortality rate among girls had not been encountered before. The investigators suggest that boys may have higher background immunity because they play outside more. Or, more likely, girls present at later stages because of cultural bias. If so, “health education is needed if this reflects a delay in the presentation of girls,” Dr. Al-Taiar and colleagues write.

They conclude: “Malaria control should be a priority in Yemen and lessons could be learnt from other areas of high seasonal malaria.”

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