Date Published: July 01, 2012
Publisher: The American Society of Tropical Medicine and Hygiene
Author(s): Siti Nurleila, Din Syafruddin, Iqbal R. F. Elyazar, J. Kevin Baird.
Records of 3,449 patients admitted to Karitas Hospital at Waitabula in eastern Indonesia with microscopy-confirmed malaria through 2008 and 2009 were systematically reviewed. Falciparum, vivax, and mixed species malaria occurred among 1,541, 1,837, and 71 admissions, respectively. Among these, 400 (26%), 199 (11%), and 15 (21%) had serious illness. Fatalities occurred in 46 (12%), 18 (9%), and 2 (13%) of these patients, respectively. Although patients with a diagnosis of falciparum malaria were more likely to have serious illness compared with those with vivax malaria (odds ratio [OR] = 2.9; 95% confidence interval [CI]: 2.4–3.5), this diagnosis nonetheless was associated with 32% of serious illness and 27% of fatalities. Among the seriously ill with a diagnosis of falciparum or vivax malaria, no significant difference in risk of death occurred (OR = 1.3; 95% CI: 0.7–2.5). Serious and fatal illness was predominantly anemia or altered mental state syndromes among patients with either of the species diagnoses. Plasmodium vivax was associated with a substantial share of the burden of morbidity and mortality caused by malaria in this hypo- to meso-endemic community.
Plasmodium vivax malaria has long been considered only rarely fatal.1 Recent studies, however, have revitalized the argument that P. vivax may often become pernicious and directly threaten life.2 As the causal agent in 100–400 million clinical attacks each year,3 and threatening almost three billion people exposed to endemic risk,4 this parasite obviously bears consideration as a major global health concern.
Figure 2 illustrates monthly admissions to the hospital for malaria over the 24 months of analysis by species of diagnosis. Table 1 lists the distribution of admissions, serious illness, and death with a diagnosis of P. falciparum, P. vivax, or mixed infections of these two species among demographic groups. Among the 3,449 patients admitted with a diagnosis of malaria, 614 (18%) were classified as having serious disease, and 66 (11%) of those patients died. Falciparum malaria occurred among 45% of admissions, 65% of serious disease, and 70% of deaths, whereas vivax malaria occurred in 53%, 32%, and 27% of these, respectively. No significant differences appeared between rates of serious illness with a diagnosis of P. falciparum versus mixed species infection (26% versus 23%; P = 0.527), and the same was true of case fatality rates (12% versus 13%; P = 0.905). Mixed infections were excluded from further analyses comparing trends in morbidity and mortality between species.
This study analyzed trends in morbidity and mortality among patients admitted to a tertiary care referral hospital at West Sumba in eastern Indonesia with a microscopic diagnosis of malaria during 2008 and 2009. The relatively compact and well-resourced Karitas Hospital provided access to remarkably thorough and complete patient files, coupled with systematic and certifiably competent microscopic diagnoses of malaria. Like most retrospective hospital-based analyses of illness associated with malaria, this one applied an improvised and simplified definition of serious illness with malaria. Although this requirement imposes uncertainty with respect to comparability of the risk findings with those in other hospitals, the uniform application of this definition to patients at Karitas Hospital nonetheless provides useful comparisons of risk of serious illness associated with infection by the species of plasmodia. Examining the relative burdens of risk of serious and fatal illness associated with P. falciparum and P. vivax malaria was the primary objective of this study.