Pediatric mortality in Africa: plasmodium falciparum malaria as a cause or risk?

The disability adjusted life year (DALY) approach of defining cause-specific health burdens is becoming the benchmark for international disease control prioritization. For malaria, this categorical approach may not fully capture its burden that includes chronic anemia, low birth weight, and enhancement of the severity of other childhood diseases. We investigated the extent to which malaria acts as a risk factor for all-cause mortality in African children less than five years of age from 1) ecologic associations between Plasmodium falciparum infection prevalence (PR) and under-five mortality, and 2) reductions in all-cause under-five mortality achieved in malaria intervention trials. Across 48 demographic surveillance studies, when adjusted for secular trends, PR more than doubled all-cause mortality (P = 0.0001). Trials of insecticide-treated mosquito nets generally found smaller population-attributable fractions of pediatric mortality to malaria infection, which may relate to their imperfect coverage and efficacy. In conclusion, the disability and death burden due to malaria in African children could be higher than that detectable from cause-specific DALY estimations.