Description of the clinical spectrum and outcomes of childhood severe malaria in eastern Uganda

Abstract

Severe malaria remains a major public health problem in Sub-Saharan Africa (SSA).It has a wide spectrum of clinical and laboratory features. Commonly reported are; severe anaemia, respiratory distress, convulsions and impaired consciousness. A number of children experience a febrile illness following a severe malaria episode. However, there are no focused studies on determining the post therapeutic malaria parasitaemia in this area. The overarching aim of this study was to determine the clinical spectrum, posttherapeutic malaria parasitaemia and treatment outcomes of childhood severe malaria in Eastern Uganda. Methodology: I employed a prospective cohort study for 138 children with severe malaria. I studied a population of children aged from 60 days (2 months) to less than12 years admitted to Mbale Regional Referral Hospital (MRRH) with confirmed P.falciparum severe malaria. Follow up of 93 children was done after 28 days to determine post therapeutic malaria parasitaemia. A structured data collection tool was used to capture participant social demographics, current illness history, features of severe malaria, treatment and follow-up details. Laboratory studies included blood slide for malaria, CBC, lactate, glucose, i-STAT, urine dipstick, and biochemistry at day 0. Additional blood slides were carried out at discharge and at follow up to determine malaria parasitaemia at both time points. Data was analysed using STATA V15.0. The univariate, bivariate, and multivariate analyses were carried out. Results: I recruited 138 participants starting from 01/OCT/2021 to 01 /Mar/ 2022 and analysed data for 138 on the social demographics. I analysed complete data sets for 137, 93,115 and 99 children for severe malaria spectrum, post therapeutic parasitaemia, prolonged hospitalisation and mortality respectively. The overall median age was 4.0years, the eldest being 10.7 years and the youngest 2months. A big proportion 84/138 (60.9%) were under 5 years, 76/138 (55.1%) males. Many of the participants were from Budaka district with 41/138 (29.7%), Mbale 34/138 (24.6%) and the least were from Serere, Namisindwa, Manafwa, Kumi and Bugweri districts. A big proportion had prostration 109/137(79.6%), jaundice 84/137(61.3%), and severe malaria anaemia 75/137(54.7%). Post therapeutic malaria parasitaemia was found in 31/93 (33.3%) after day 28 of treatment. Prolonged hospitalisation was in 23/115(20%) and was highly associated with hypoxaemia OR 14.6 95% CI (2.6, 83.0) P=0.002, hyperlactaemia OR 5.3 95% CI (1.6, 17.2) P=0 .005, acidosis OR 6.1 95%CI (1.4, 25.0) P-value=0.002, impaired consciousness OR CI 4.4(1.5, 12.9) p=0.007. The overall mortality was 6/137(4.4%). Case fatality rate was high for severe anaemia. However, impaired consciousness OR 3.0 95% CI (1.1, 4.9) P=0.002, respiratory distress OR 16.1 95% CI (2.9, 89.3) P= 0.001, acidosis OR 13 95% CI (2.5, 172.3) P=0.002, cerebral malaria OR 8.9 95% CI (1.5, 52.5) iP= 0.015, hypoglycemia OR 16.8 95% CI (1.5, 189.4) P= 0.022 and renal impairment OR 9.9 95% CI (1.1, 90.0) P= 0.040. Conclusion: The findings affirm the changing trend in the severe malaria spectrum with increased prevalence in children above 5 years, more cases of prostration, jaundice, haemoglobinuria and less of shock. Post therapeutic parasitaemia in a sizeable proportion of 33.3% could suggest recrudescence, new infection or resistance and calls for further research confirming these possibilities. Prolonged hospitalisation was noted in smaller proportion in upto 20%. Overall mortality appears to have come down to 4.4% compared to a decade ago of 9.5%. This mortality though is still high. Recommendation: Frequent and regular epidemiological and clinical studies on severe and complicated malaria to inform improved case management and aid reduction in mortality. Keywords: severe malaria, children, post therapeutic parasitaemia, prolonged hospitalization, mortality