Abstract:
Background: Protection against clinical malaria episodes is acquired slowly after frequent
exposure to malaria parasites. This is reflected by a decrease with increasing age in both parasite
density and incidence of clinical episodes. In many settings of stable malaria transmission, the
presence of asymptomatic malaria parasite carriers is common and the definition of clinical malaria
remains uncertain.
Methods: Between February 2002 and April 2003, a country-wide malaria survey was conducted
in 24 districts of Mozambique, aiming to characterize the malaria transmission intensities and to
estimate the proportion of fever cases attributable to malaria infections in order to establish the
malaria case definition. A total of 8,816 children less than ten years of age were selected for the
study. Axillary temperature was measured in all participating subjects and finger prick blood
collections were taken to prepare thick and thin films for identification of parasite species and
determination of parasite density. The proportion of fever cases attributable to malaria infection
was estimated using a logistic regression of the fever on a monotonic function of the parasite
density and, using bootstrap facilities, bootstrapped estimated confidence intervals, as well as the
sensitivity and specificity for different parasite density cut-offs were produced.
Results: Overall, the prevalence of Plasmodium falciparum was 52.4% (4,616/8,816). The prevalence
of fever (axillary temperature ≥ 37.5°C) was 9.4% (766/8,816). Fever episodes peaked among
children below 12 months of life [15.1% (206/1,517)]. The lowest fever prevalence of 5.9% (67/
1,224) was recorded amongst children between five and seven years of age. Among 4,098
parasitized children, 498/4,098 (13.02%) had fever. The prevalence of malaria infections associated
with fever peaked among children in the less than twelve months age group and thereafter
decreased rapidly with increasing age (p < 0.001). High parasite densities were significantly
associated with fever (p < 0.04).
The proportion of fever attributed to malaria was 37.8% (95% CI 32.9% – 42.7%). An age-specific
pattern was observed with significant variations across different regions in the country. In general,
among children less than 12 months of life, the proportion of fever attributed to malaria infection was 43.5% (95% CI 25.8% – 61.2%), in children aged between 12 and 59 months of age was 39.6%
(95% CI 30.3% – 48.9%), and among children aged between 5 and 10 years old was 21.5% (95% CI
11.6% – 31.4%).
Conclusion: This study confirms that malaria remains a major cause of febrile illness during
childhood. It also defines the relation between parasite density and fever and how this varies with
age and region. This may help guide case definition for clinical trials of preventive tools, as well as
provide definitions that may improve the precision of measurement of the burden of disease.
