title: Malaria and HIV among pediatric inpatients in two Tanzanian referral hospitals: A prospective study.
abstract: Malaria remains common in sub-Saharan Africa, but it is frequently over-diagnosed and over-treated in hospitalized children. HIV is prevalent in many malaria endemic areas and may delay parasite clearance and increase mortality among children with malaria. This prospective cohort study enrolled children with suspected malaria between 3 months and 12 years of age hospitalized at two referral hospitals in Tanzania. Both a thick blood smear (BS) and a malaria rapid diagnostic test (mRDT) were performed. If discordant results were obtained, PCR was performed for Plasmodium falciparum. Malaria was confirmed if two out of three tests were positive. Malaria parasite densities were determined for two consecutive days after diagnosis and treatment of malaria. All participants were tested for HIV. Among 1492 hospitalized children, 400 (26.8%) were enrolled with suspected malaria infection. There were 196/400 (49.0%) males, and the median age was 18 [9-36] months. BS was positive in 95/400 (23.8%), and mRDT was positive in 70/400 (17.5%), with moderate agreement (Kappa=0.598). Concordant results excluded malaria in 291/400 (72.8%) and confirmed malaria in 56/400 (14.0%). PCR performed on 53 discordant results confirmed malaria in 1/39 of the BS-positive/mRDT-negative cases, and 6/14 of the BS-negative/mRDT-positive cases. The prevalence of confirmed malaria was 63/400 (15.8%). In multivariable logistic regression, malaria was associated with HIV (OR 3.45 [1.65-7.20], p=0.001). Current breastfeeding (OR 0.25 [0.11-0.56], p=0.001) and higher hemoglobin (OR 0.70 [0.60-0.81], p<0.001 per 1g/dL) were associated with decreased odds of malaria. Malaria parasite clearance was delayed in HIV-infected participants (p<0.001). Malaria is over-diagnosed even at referral centers in high transmission areas. Hospitalized HIV-infected children are more likely to have malaria and exhibit delayed clearance of parasites. Hospitals should consider using mRDTs as a first step for malaria testing among hospitalized children in sub-Saharan Africa.
authors.affiliation: Department of Internal Medicine, Catholic University of Health & Allied Sciences, P.O. Box 1464, Mwanza, Tanzania; Department of Internal Medicine, Bugando Medical Centre, P.O. Box 1370, Mwanza, Tanzania; Center for Global Health, Weill Cornell Medical College, 402 East 67th Street, 2nd Floor, NewYork, NY 10065, USA. Electronic address: smart.luke@gmail.com.
authors.forename: Luke R
authors.initials: LR
authors.lastname: Smart
authors.affiliation: Department of Pediatrics, Catholic University of Health & Allied Sciences, P.O. box 1464, Mwanza, Tanzania.
authors.forename: Neema
authors.initials: N
authors.lastname: Orgenes
authors.affiliation: Department of Parasitology, Catholic University of Health & Allied Sciences, P.O. Box 1464, Mwanza, Tanzania.
authors.forename: Humphrey D
authors.initials: HD
authors.lastname: Mazigo
authors.affiliation: Department of Pediatrics, Bugando Medical Centre, P.O. Box 1370, Mwanza, Tanzania.
authors.forename: Mercy
authors.initials: M
authors.lastname: Minde
authors.affiliation: Department of Pediatrics, Catholic University of Health & Allied Sciences, P.O. box 1464, Mwanza, Tanzania; Department of Pediatrics, Bugando Medical Centre, P.O. Box 1370, Mwanza, Tanzania.
authors.forename: Adolfine
authors.initials: A
authors.lastname: Hokororo
authors.affiliation: Weill Cornell Medical College in Qatar, Qatar Foundation-Education City, P.O. Box 24144, Doha, Qatar.
authors.forename: Muhammad
authors.initials: M
authors.lastname: Shakir
authors.affiliation: Laboratory of Medical Microbiology and Immunology, St. Elisabeth Hospital, Tilburg, The Netherlands.
authors.forename: Jaco J
authors.initials: JJ
authors.lastname: Verweij
authors.affiliation: Department of Internal Medicine, Catholic University of Health & Allied Sciences, P.O. Box 1464, Mwanza, Tanzania; Department of Internal Medicine, Bugando Medical Centre, P.O. Box 1370, Mwanza, Tanzania; Center for Global Health, Weill Cornell Medical College, 402 East 67th Street, 2nd Floor, NewYork, NY 10065, USA.
authors.forename: Jennifer A
authors.initials: JA
authors.lastname: Downs
authors.affiliation: Department of Internal Medicine, Catholic University of Health & Allied Sciences, P.O. Box 1464, Mwanza, Tanzania; Department of Internal Medicine, Bugando Medical Centre, P.O. Box 1370, Mwanza, Tanzania; Center for Global Health, Weill Cornell Medical College, 402 East 67th Street, 2nd Floor, NewYork, NY 10065, USA.
authors.forename: Robert N
authors.initials: RN
authors.lastname: Peck
mesh_terms: D002648:Child; D002675:Child, Preschool; D015331:Cohort Studies; D005260:Female; D015658:HIV Infections / Q000150:complications* / Q000453:epidemiology*; D006776:Hospitals, Pediatric / Q000706:statistics & numerical data; D006801:Humans; D007223:Infant; D007297:Inpatients; D016015:Logistic Models; D008288:Malaria / Q000175:diagnosis* / Q000453:epidemiology* / Q000473:pathology; D008297:Male; D010963:Plasmodium falciparum / Q000472:pathogenicity*; D015995:Prevalence; D011446:Prospective Studies; D012017:Referral and Consultation; D013636:Tanzania / Q000453:epidemiology
keywords: Children; Clearance; Diagnosis; HIV; Malaria; Tanzania