title: Mortality attributable to Plasmodium vivax malaria: a clinical audit from Papua, Indonesia.
abstract: BACKGROUND
  Plasmodium vivax causes almost half of all malaria cases in Asia and is recognised as a significant cause of morbidity. In recent years it has been associated with severe and fatal disease. The extent to which P. vivax contributes to death is not known.
  
  
  METHODS
  To define the epidemiology of mortality attributable to vivax malaria in southern Papua, Indonesia, a retrospective clinical records-based audit was conducted of all deaths in patients with vivax malaria at a tertiary referral hospital.
  
  
  RESULTS
  Between January 2004 and September 2009, hospital surveillance identified 3,495 inpatients with P. vivax monoinfection and 65 (1.9%) patients who subsequently died. Charts for 54 of these 65 patients could be reviewed, 40 (74%) of whom had pure P. vivax infections on cross-checking. Using pre-defined conservative criteria, vivax malaria was the primary cause of death in 6 cases, a major contributor in 17 cases and a minor contributor in a further 13 cases. Extreme anaemia was the most common primary cause of death. Malnutrition, sepsis with respiratory and gastrointestinal manifestations, and chronic diseases were the commonest attributed causes of death for patients in the latter two categories. There were an estimated 293,763 cases of pure P. vivax infection in the community during the study period giving an overall minimum case fatality of 0.12 per 1,000 infections. The corresponding case fatality in hospitalised patients was 10.3 per 1,000 infections.
  
  
  CONCLUSIONS
  Although uncommonly directly fatal, vivax malaria is an important indirect cause of death in southern Papua in patients with malnutrition, sepsis syndrome and chronic diseases, including HIV infection.
authors.affiliation: Global Health Division, Menzies School of Health Research and Charles Darwin University, PO Box 41096, Casuarina, Darwin, NT 0811, Australia. nicholas.douglas@gmail.com.|Centre for Tropical Medicine, Nuffield Department of Medicine, University of Oxford, Oxford, UK. nicholas.douglas@gmail.com.
authors.forename: Nicholas M
authors.initials: NM
authors.lastname: Douglas
authors.affiliation: Papuan Health and Community Development Foundation, Timika, Papua, Indonesia. gysje_jp@yahoo.com.
authors.forename: Gysje J
authors.initials: GJ
authors.lastname: Pontororing
authors.affiliation: Papuan Health and Community Development Foundation, Timika, Papua, Indonesia. aditimika@yahoo.com.
authors.forename: Daniel A
authors.initials: DA
authors.lastname: Lampah
authors.affiliation: Global Health Division, Menzies School of Health Research and Charles Darwin University, PO Box 41096, Casuarina, Darwin, NT 0811, Australia. Tsin.Yeo@menzies.edu.au.
authors.forename: Tsin W
authors.initials: TW
authors.lastname: Yeo
authors.affiliation: Papuan Health and Community Development Foundation, Timika, Papua, Indonesia. ennykenangalem@yahoo.com.|District Health Authority, Timika, Papua, Indonesia. ennykenangalem@yahoo.com.
authors.forename: Enny
authors.initials: E
authors.lastname: Kenangalem
authors.affiliation: Papuan Health and Community Development Foundation, Timika, Papua, Indonesia. didot2266@yahoo.com.|District Health Authority, Timika, Papua, Indonesia. didot2266@yahoo.com.|Department of Paediatrics, Faculty of Medicine, Gadjah Mada University, Yogyakarta, Indonesia. didot2266@yahoo.com.
authors.forename: Jeanne Rini
authors.initials: JR
authors.lastname: Poespoprodjo
authors.affiliation: Global Health Division, Menzies School of Health Research and Charles Darwin University, PO Box 41096, Casuarina, Darwin, NT 0811, Australia. Anna.Ralph@menzies.edu.au.|Division of Medicine, Royal Darwin Hospital, Darwin, Australia. Anna.Ralph@menzies.edu.au.
authors.forename: Anna P
authors.initials: AP
authors.lastname: Ralph
authors.affiliation: Public Health & Malaria Control Department, International SOS, PT Freeport Indonesia, Kuala Kencana, Papua, Indonesia. Michael_Bangs@fmi.com.|Department of Entomology, Faculty of Agriculture, Kasetsart University, Bangkok, 10900, Thailand. Michael_Bangs@fmi.com.
authors.forename: Michael J
authors.initials: MJ
authors.lastname: Bangs
authors.affiliation: Mitra Masyarakat Hospital, Timika, Papua, Indonesia. sugiartopaulus@gmail.com.
authors.forename: Paulus
authors.initials: P
authors.lastname: Sugiarto
authors.affiliation: Global Health Division, Menzies School of Health Research and Charles Darwin University, PO Box 41096, Casuarina, Darwin, NT 0811, Australia. Nicholas.Anstey@menzies.edu.au.|Division of Medicine, Royal Darwin Hospital, Darwin, Australia. Nicholas.Anstey@menzies.edu.au.
authors.forename: Nicholas M
authors.initials: NM
authors.lastname: Anstey
authors.affiliation: Global Health Division, Menzies School of Health Research and Charles Darwin University, PO Box 41096, Casuarina, Darwin, NT 0811, Australia. rprice@menzies.edu.au.|Centre for Tropical Medicine, Nuffield Department of Medicine, University of Oxford, Oxford, UK. rprice@menzies.edu.au.
authors.forename: Ric N
authors.initials: RN
authors.lastname: Price
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D002648:Child; D002675:Child, Preschool; D054869:Clinical Audit; D005260:Female; D015658:HIV Infections / Q000150:complications; D006801:Humans; D007214:Indonesia / Q000453:epidemiology; D007223:Infant; D016780:Malaria, Vivax / Q000150:complications / Q000453:epidemiology* / Q000401:mortality / Q000517:prevention & control; D008297:Male; D008875:Middle Aged; D010966:Plasmodium vivax; D011446:Prospective Studies; D012189:Retrospective Studies