Date Published: July 6, 2010
Publisher: Public Library of Science
Author(s): Philip Bejon, Thomas N. Williams, Anne Liljander, Abdisalan M. Noor, Juliana Wambua, Edna Ogada, Ally Olotu, Faith H. A. Osier, Simon I. Hay, Anna Färnert, Kevin Marsh, Thomas A. Smith
Abstract: Philip Bejon and colleagues document the clustering of malaria episodes and malarial parasite infection. These patterns may enable future prediction of hotspots of malaria infection and targeting of treatment or preventive interventions.
Partial Text: Many infectious disease show marked heterogeneity of transmission . Mathematical models predict that this heterogeneity reduces the efficacy of disease control strategies , and intensifying control measures on foci of high transmission is predicted to be very effective in reducing overall transmission . Marked spatial heterogeneity of malaria transmission on the household level is consistently detected when analysed –, and results from both genetic and environmental factors ,. It is unclear how stable hotspots are in longitudinal data.
The approval for human participation in these cohorts was given by Kenya Medical Research Institute Scientific committee and National Review and Ethical Committee of Kenya Medical Research Institute, and was conducted according to the principles of the declaration of Helsinki.
Data were analysed from 256 homesteads in three study cohorts, where 5,600 episodes of febrile malaria were recorded over 32,452 person years of observation. The average incidence of malaria was 0.49 per child per year (cpy) in the lowest incidence cohort, and 0.82 per cpy in the highest incidence cohort (Table 1). Behind these summary statistics was substantial heterogeneity, with individual homestead incidences of febrile malaria ranging from zero to two episodes per cpy over the 3–11 y of monitoring (Figures S1 and S2).
We identified stable hotspots of asymptomatic parasitaemia, and unstable hotspots of febrile disease in each of three cohorts in Kilifi District. The hotspots of asymptomatic parasitaemia were characterized by nonsignificantly higher mean antibody titres, a lower mean age at febrile episodes, and lower overall incidences of febrile disease. There may have been an increase in the incidence of febrile malaria in the penumbra around the perimeter of the hotspots of asymptomatic parasitaemia (Figure 5). Furthermore, hotspots of asymptomatic parasitaemia were stable over the full 7 y of monitoring, whereas hotspots of febrile malaria were not stable past 3 y of monitoring. Taken together, these observations suggest the following explanation: that a rapid acquisition of immunity in stable high transmission hotspots offsets the high rates of febrile malaria that would otherwise result. Instead, a high prevalence of asymptomatic parasitaemia is seen . Unstable hotspots are not associated with prior exposure, and hence relatively low levels of immunity, and therefore produce higher incidences of febrile disease. Although the unstable hotspots are directly associated with more febrile disease, hotspots of asymptomatic parasitaemia may be critical in maintaining transmission .