Plasmodium vivax and mixed infections are associated with severe malaria in children: a prospective cohort study from Papua New Guinea

Abstract

Background: Severe malaria (SM) is classically associated with Plasmodium falciparum infection. Little information is available on the contribution of P. vivax to severe disease. There are some epidemiological indications that P. vivax or mixed infections protect against complications and deaths. A large morbidity surveillance conducted in an area where the four species coexist allowed us to estimate rates of SM among patients infected with one or several species.

Methods and findings: This was a prospective cohort study conducted within the framework of the Malaria Vaccine Epidemiology and Evaluation Project. All presumptive malaria cases presenting at two rural health facilities over an 8-y period were investigated with history taking, clinical examination, and laboratory assessment. Case definition of SM was based on the World Health Organization (WHO) criteria adapted for the setting (i.e., clinical diagnosis of malaria associated with asexual blood stage parasitaemia and recent history of fits, or coma, or respiratory distress, or anaemia [haemoglobin < 5 g/dl]). Out of 17,201 presumptive malaria cases, 9,537 (55%) had a confirmed Plasmodium parasitaemia. Among those, 6.2% (95% confidence interval [CI] 5.7%-6.8%) fulfilled the case definition of SM, most of them in children <5 y. In this age group, the proportion of SM was 11.7% (10.4%-13.2%) for P. falciparum, 8.8% (7.1%-10.7%) for P. vivax, and 17.3% (11.7%-24.2%) for mixed P. falciparum and P. vivax infections. P. vivax SM presented more often with respiratory distress than did P. falciparum (60% versus 41%, p = 0.002), but less often with anaemia (19% versus 41%, p = 0.0001).

Conclusion: P. vivax monoinfections as well as mixed Plasmodium infections are associated with SM. There is no indication that mixed infections protected against SM. Interventions targeted toward P. falciparum only might be insufficient to eliminate the overall malaria burden, and especially severe disease, in areas where P. falciparum and P. vivax coexist.

Figure 1. Age-Specific Prevalence of Parasitaemia among Presumptive Malaria Cases

Figure 2. Age-Specific Risk of Severe Disease with P. falciparum, P. vivax, and Mixed Infections in Children <10 y

Figure 3. Mosaic Plot of SM by Species in Children < 5 y

Horizontal, species; vertical, proportion of SM.

Figure 4. Proportion of SM Cases with Each of the Main Defining Clinical or Laboratory Features among Children <5 y Infected with P. vivax, P. falciparum, and Mixed Species (Venn Diagram)

Figure 5. Total Parasite Densities in Uncomplicated and SM by Species (Children <5 y)

Line is median, boxes are 25th and 75th percentile, and whiskers are upper and lower adjacent values.