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Book 12-6.Indb Eastern Mediterranean Health Journal, Vol. 12, No. 6, 2006 783 Clinical and epidemiological features of severe malaria in children in four hospitals in Sudan Z. Zeidan,1 H. Kojal,2 A. Habour,3 K. Nowary,4 F. Hashim5 and M. Awadelkarim1 Á=aÇj¶=L>É«nJjºÍ£Ee?¹>«{Ù=Ïb¶Í»É]Ƕ=>ÈeØ»·¶ÍÉÑ>EǶ=ÆÍÈfÈfj¶=XºØ= ¼Èf³¶=zǢʷ¢b»(¼m>ÂXI>«¶=(ËfÈÇ¿¶=¹>»²(eÇFUÊ·¢(¹>QÇ]=(Á=bÈgÅbF¢Á=bÈg ¸[F®Í[»É]Ƕ=>[ÈeØ=L×>[Í[ÉÑ>EǶ=ÆÍÈfÈfj[¶=X[ºØ=¼É[[ɯJEÍ[i=eb¶=ÅdÂe>{CÁÇNU>F¶=½>®6Í[qØ= °{>[¿º¬[·JL>É«nJjºÍ£Ee?>ÃEÍìFIf=¸º=Ç£¶=ÆÍ>£=SÑ>J¾¼É[ɯIÆ(ΫnJj= Í>£=ƹ>]aÝ= Ϋn[[Jj==Ç[[·]aî?ÀÈd[[¶=¹>[[«{Ù=ab[[¢¨[[·EÆ*ÀáÉ[[í«¶?½>[[¢fÃ[[m?Íj[[Ïb[[ºÎ[[·¢´[[¶cÆ(Á=aÇj[[¶ = median ¬ [ q > ¾ Á > [ ² Æ *L > É « n [ J j = = Ç [ · ] a î? À È d [ ¶ = ¹ > « { Ù = L × > U ¤ É À º !21 ¸ ù³ n È > º Ç Â Æ ( ðØ « { 543 Í[I>ºÝ=ÍFj¾K§·EÆ*fiÙ=Àº!57.5 Ä I d ^ çI = Ð = f Q C ¹ Æ ? Ê Â ¹ h ¿ = Í > £ = K ¾ > ² Æ *ð= f à m 36 ¹ > « { Ù = e > » ¢ ? Î[·¢?K[ìFIe=b[®Æ*f [ » £ ¶ = À [ º Í £ [ i > J ¶ = Á Æ a = Ç I > [ º À È d ¶ = ¹ > « { Ù = À º !93 Á > ² Æ ( ¬ ¶ ? ¸ ² À º 5 L × > = E Á?Í[i=eb¶= K ¿ çÉ E Æ *Î « n J j = x È f = ¹ > ] a C ¸ F ® > ÈeØ=ͺ>]ÆÏbÆÍ>£=l>»J¶=Ö{>FJ¶>EÌ>ªÇ¶=f{> ÍÉ[uf=L×>[=Í[>£ºÐ=aÙ=f[ëmÖºO[ÉUÀ[ºL>É«n[Jj=¸v[ª?Á>[²(½Ç{f=(Á>ºea½?ΫnJjº *L>É«nJj=fÑ>i¤ºÍ¾e>¯>E ABSTRACT We assessed the clinical and epidemiological features of severe malaria cases before ad- mission, management in hospital and outcome and associated factors in 4 hospitals in different areas of Sudan over a 5-month period in 2000. There were 543 children admitted representing 21% of all pae- diatric admissions. Median age was 36 months. Treatment at home was the first action taken by 57.5% of families. Case fatality rate was 5/1000 and 93% of the children who died were under 9 years. Highest risk of death was associated with delay in seeking treatment and severity of illness before admission. Omdurman Hospital in Khartoum had the best case-management performance index compared to the other hospitals. Caractéristiques cliniques et épidémiologiques du paludisme grave chez des enfants dans 4 hôpitaux au Soudan RÉSUMÉ Nous avons évalué les caractéristiques cliniques et épidémiologiques des cas de paludisme grave avant l’admission à l’hôpital, la prise en charge hospitalière et les résultats ainsi que les facteurs associés dans 4 hôpitaux de différentes zones du Soudan sur une période de 5 mois en 2000. Il y avait 543 enfants hospitalisés représentant 21 % de toutes les hospitalisations pédiatriques. L’âge médian était de 36 mois. Le traitement à domicile était la première mesure prise par 57,5 % des familles. Le taux de létalité s’élevait à 5 pour 1000 et 93 % des enfants qui sont décédés avaient moins de 9 ans. Le risque de mortalité le plus élevé était associé au retard dans le recours aux soins et à la gravité de la maladie avant l’admission à l’hôpital. L’hôpital Omdurman de Khartoum avait le meilleur index de performance pour la prise en charge des cas par rapport aux autres hôpitaux. 1Department of Community Medicine, University of Khartoum, Khartoum, Sudan (Correspondence to Z. Zeidan: [email protected]). 2Department of Paediatrics, Omdurman Islamic University, Omndurman, Sudan. 3Department of Paediatrics, University of Gezira, Wad Medani, Sudan. 4Department of Paediatrics, Gedaref Hospital, Gedaref, Sudan. 5Department of Paediatrics, Sennar Hospital, Sennar, Sudan. Received: 02/11/04; accepted: 15/05/05 ﺍﳌﺠﻠﺔ ﺍﻟﺼﺤﻴﺔ ﻟﺸﺮﻕ ﺍﳌﺘﻮﺳﻂ، ﻣﻨﻈﻤﺔ ﺍﻟﺼﺤﺔ ﺍﻟﻌﺎﳌﻴﺔ، ﺍﳌﺠﻠﺪ ﺍﻟﺜﺎﱐ ﻋﺸﺮ، ﺍﻟﻌﺪﺩ ٦، ٢٠٠٦ 784 La Revue de Santé de la Méditerranée orientale, Vol. 12, No 6, 2006 Introduction Omdurman is largest city in the country. It had an estimated total population of 4 A severe malaria patient is defined by the million in 2002. The majority of the people World Health Organization (WHO) as a in Omdurman are workers in the govern- febrile patient with falciparum malaria with ment and informal sectors. Omdurman has some complications of no other obvious 2 major camps for displaced persons around causes who requires emergency hospitaliza- the city with a population of 1 million, who tion treatment [1]. Out of 1.5 to 2.7 million have come mainly from the south and west deaths that occur in the world every year as of Sudan due to war and desertification. a result of malaria, 1 million are children Wad Medani city is in Gezira State, which is [2]. In Africa, malaria kills 1 child in every located in the middle of the country. It is the 20 under the age of 5 years [3]. main agricultural area of the country. Wad In Sudan, malaria remains a major pub- Medani has an estimated total population lic health problem, with a case prevalence of 3.5 million people, the majority of whom of 93 per 1000 in 2002 [4]. It represented are farmers. Sennar is located to the south- 25% of hospital admission in children. east of the country. It is also an agricultural Although severe malaria is life-threaten- area that has one of the main dams in the ing to children, there is limited information country which irrigates the Gezira agricul- available on the severity of the disease, tural scheme. Sennar has an estimated total management, deaths and associated factors population of 1.2 million people, the major- in Sudan; therefore there is an urgent need ity of whom are farmers. Gedaref is also an for reliable clinical and epidemiological agricultural area located in the east of the information on severe malaria as a killing country. The agriculture in Gedaref is based disease in children. mainly on rain irrigation. It has an estimated The objective of this study was to assess population of 1.5 million. As it is located the clinical and epidemiological features on the border with Ethiopia in the east of of the disease before and on admission to Sudan, Gedaref has witnessed a great influx hospital, management in hospital, outcome of refugees from Ethiopia due to drought of the disease and associated risk factors and war. The refugees are scattered in many for death. camps around the town. The majority of people in Gedaref are also farmers [4]. Children under 15 years of age of both Methods sexes admitted to the above-mentioned hos- We conducted a cross-sectional study in 4 pitals with severe malaria, based on WHO district paediatric hospitals in Sudan in the criteria, were included in the study [5]. 5-month period of the rainy season August The daily records of paediatric admissions to December 2000. The hospitals were lo- to the 4 selected hospitals and of children cated in Omdurman in Khartoum state, Wad admitted because of malaria were reviewed. Medani and Sennar in central Sudan and Those of the children diagnosed as severe Gedaref in eastern Sudan. They are located malaria were checked. in areas with a wide range of endemicity, Interviews with the mothers or carers from urban in Omdurman to mesoendemic of the children admitted and diagnosed as and hyperendemic in Wad Medani, Gedaref severe malaria during the study period were and Sennar. conducted and a questionnaire completed. ﺍﳌﺠﻠﺔ ﺍﻟﺼﺤﻴﺔ ﻟﺸﺮﻕ ﺍﳌﺘﻮﺳﻂ، ﻣﻨﻈﻤﺔ ﺍﻟﺼﺤﺔ ﺍﻟﻌﺎﳌﻴﺔ، ﺍﳌﺠﻠﺪ ﺍﻟﺜﺎﱐ ﻋﺸﺮ، ﺍﻟﻌﺪﺩ ٦، ٢٠٠٦ Eastern Mediterranean Health Journal, Vol. 12, No. 6, 2006 785 Clinical information and procedures Sennar followed by Wad Medani 99 cases that were relevant to the cases and case (18.2%), Omdurman 75 cases (13.8%) and management of severe malaria in children Gedaref 65 cases (12.0%). were recorded. Data on age, sex, occupa- Table 1 summarizes the important epi- tion of father, educational level of parents, demiological features with regard of the accessibility to care at the local level, early cases in the selected hospitals. Of the cases, symptoms and signs, action taken before 56% were males and 44% were females. admission, treatment before and after ad- The median age of children with severe mission, duration of illness and clinical malaria was 36 months, 75th percentile was presentation were collected. Diagnostic 72 months. The median age of children who tests (blood film, parasite count, haemo- died of severe malaria was 66 months, 75th globin count, blood glucose, white blood percentile was 108 months. count, haemoglobin in urine, cerebrospinal A total of 34.8% of the cases reported fluid analysis, and outcome (hospital case- availability of health units at the local level fatality rate of severe malaria in children) in all areas, while only 23.8% reported were analysed. availability of pharmacies at their local Hospital management performance was level. Of the children for whom early action compared between the study hospitals using was taken, the majority 195/339 (57.5%) a scoring system developed by the authors had received treatment at home before ad- using 6 essential criteria which are consid- mission. Wad Medani reported the highest ered optimum care performance for severe percentage for those who took action at malaria in children. These criteria were: home before admission, 63/81 (77.8%), fol- performance of thick and thin blood film for lowed by Sennar 124/183 (67.8%), Gedaref malaria, white blood count, haemoglobin 7/37 (18.9%) and Omdurman 5/37 (13.5%). count, blood glucose, lumbar puncture and There was a significant difference between administration of intravenous quinine. taking action at home in the capital (Omdur- Data were analysed using SPSS, version man) compared to the districts Wad Medani, 2 10.
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