title: Effect of a fall in malaria transmission on morbidity and mortality in Kilifi, Kenya.
abstract: BACKGROUND
  As efforts to control malaria are expanded across the world, understanding the role of transmission intensity in determining the burden of clinical malaria is crucial to the prediction and measurement of the effectiveness of interventions to reduce transmission. Furthermore, studies comparing several endemic sites led to speculation that as transmission decreases morbidity and mortality caused by severe malaria might increase. We aimed to assess the epidemiological characteristics of malaria in Kilifi, Kenya, during a period of decreasing transmission intensity.
  
  
  METHODS
  We analyse 18 years (1990-2007) of surveillance data from a paediatric ward in a malaria-endemic region of Kenya. The hospital has a catchment area of 250 000 people. Clinical data and blood-film results for more than 61 000 admissions are reported.
  
  
  RESULTS
  Hospital admissions for malaria decreased from 18.43 per 1000 children in 2003 to 3.42 in 2007. Over 18 years of surveillance, the incidence of cerebral malaria initially increased; however, malaria mortality decreased overall because of a decrease in incidence of severe malarial anaemia since 1997 (4.75 to 0.37 per 1000 children) and improved survival among children admitted with non-severe malaria. Parasite prevalence, the mean age of children admitted with malaria, and the proportion of children with cerebral malaria began to change 10 years before hospitalisation for malaria started to fall.
  
  
  CONCLUSIONS
  Sustained reduction in exposure to infection leads to changes in mean age and presentation of disease similar to those described in multisite studies. Changes in transmission might not lead to immediate reductions in incidence of clinical disease. However, longitudinal data do not indicate that reductions in transmission intensity lead to transient increases in morbidity and mortality.
authors.affiliation: Kenya Medical Research Institute, Centre for Geographic Medicine Research-Wellcome Trust Collaborative Program, Kilifi, Kenya; Fogarty International Center, National Institutes of Health, Bethesda, MD, USA.
authors.forename: Wendy P
authors.initials: WP
authors.lastname: O'Meara
authors.forename: Phillip
authors.initials: P
authors.lastname: Bejon
authors.forename: Tabitha W
authors.initials: TW
authors.lastname: Mwangi
authors.forename: Emelda A
authors.initials: EA
authors.lastname: Okiro
authors.forename: Norbert
authors.initials: N
authors.lastname: Peshu
authors.forename: Robert W
authors.initials: RW
authors.lastname: Snow
authors.forename: Charles R J C
authors.initials: CR
authors.lastname: Newton
authors.forename: Kevin
authors.initials: K
authors.lastname: Marsh
mesh_terms: D000293:Adolescent; D017677:Age Distribution; D002391:Catchment Area, Health / Q000706:statistics & numerical data*; D002648:Child; D002675:Child, Preschool; D006753:Hospital Records; D006760:Hospitalization / Q000706:statistics & numerical data / Q000639:trends*; D006801:Humans; D015994:Incidence; D007223:Infant; D007231:Infant, Newborn; D007630:Kenya / Q000453:epidemiology; D008288:Malaria / Q000453:epidemiology / Q000401:mortality / Q000635:transmission*; D011159:Population Surveillance / Q000379:methods*