The epidemiology of malaria.

Epidemiologists have recently paid greater attention than in the past to the epidemiology of clinical malaria as opposed to the epidemiology of malarial infection. This change of emphasis has been stimulated in part by the need for better clinical definitions of malaria in the evaluation of control measures such as insecticide-treated materials and malaria vaccines. Methods of determining mortality from malaria and of defining severe and uncomplicated malaria have been devised. The limited data available indicate that malaria-attributable mortality and the incidence of severe malaria do not increase with an increase in the entomological inoculation rate above a threshold value, an observation that has important implications for the likely long-term effects of attempts to contain malaria through vector control. Study of the epidemiology of severe malaria in Africa has shown different epidemiological patterns for the two most frequent forms of this condition: cerebral malaria and severe malarial anaemia. Severe malarial anaemia is seen most frequently in areas of very high malaria transmission and most frequently in young children. In contrast, cerebral malaria predominates in areas of moderate transmission, especially where this is seasonal, and it is seen most frequently in older children. Study of patients with uncomplicated malaria has established the relationship between fever and parasite density and has demonstrated ways of defining fever thresholds. Algorithms have been developed to help in the diagnosis of malaria in the absence of parasitological confirmation but this approach has proved difficult because of the overlap in symptoms and signs between malaria and other acute febrile illnesses such as pneumonia.