title: Age-patterns of malaria vary with severity, transmission intensity and seasonality in sub-Saharan Africa: a systematic review and pooled analysis.
abstract: BACKGROUND
  There is evidence that the age-pattern of Plasmodium falciparum malaria varies with transmission intensity. A better understanding of how this varies with the severity of outcome and across a range of transmission settings could enable locally appropriate targeting of interventions to those most at risk. We have, therefore, undertaken a pooled analysis of existing data from multiple sites to enable a comprehensive overview of the age-patterns of malaria outcomes under different epidemiological conditions in sub-Saharan Africa.
  
  
  RESULTS
  A systematic review using PubMed and CAB Abstracts (1980-2005), contacts with experts and searching bibliographies identified epidemiological studies with data on the age distribution of children with P. falciparum clinical malaria, hospital admissions with malaria and malaria-diagnosed mortality. Studies were allocated to a 3x2 matrix of intensity and seasonality of malaria transmission. Maximum likelihood methods were used to fit five continuous probability distributions to the percentage of each outcome by age for each of the six transmission scenarios. The best-fitting distributions are presented graphically, together with the estimated median age for each outcome. Clinical malaria incidence was relatively evenly distributed across the first 10 years of life for all transmission scenarios. Hospital admissions with malaria were more concentrated in younger children, with this effect being even more pronounced for malaria-diagnosed deaths. For all outcomes, the burden of malaria shifted towards younger ages with increasing transmission intensity, although marked seasonality moderated this effect.
  
  
  CONCLUSIONS
  The most severe consequences of P. falciparum malaria were concentrated in the youngest age groups across all settings. Despite recently observed declines in malaria transmission in several countries, which will shift the burden of malaria cases towards older children, it is still appropriate to target strategies for preventing malaria mortality and severe morbidity at very young children who will continue to bear the brunt of malaria deaths in sub-Saharan Africa.
authors.affiliation: Disease Control and Vector Biology Unit, Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom. ilona.carneiro@lshtm.ac.uk
authors.forename: Ilona
authors.initials: I
authors.lastname: Carneiro
authors.forename: Arantxa
authors.initials: A
authors.lastname: Roca-Feltrer
authors.forename: Jamie T
authors.initials: JT
authors.lastname: Griffin
authors.forename: Lucy
authors.initials: L
authors.lastname: Smith
authors.forename: Marcel
authors.initials: M
authors.lastname: Tanner
authors.forename: Joanna Armstrong
authors.initials: JA
authors.lastname: Schellenberg
authors.forename: Brian
authors.initials: B
authors.lastname: Greenwood
authors.forename: David
authors.initials: D
authors.lastname: Schellenberg
mesh_terms: D017954:Africa South of the Sahara / Q000453:epidemiology; D000367:Age Factors; D002648:Child; D002675:Child, Preschool; D006801:Humans; D007223:Infant; D016778:Malaria, Falciparum / Q000453:epidemiology* / Q000635:transmission*; D010343:Patient Admission / Q000706:statistics & numerical data; D012621:Seasons