Hospital-based surveillance of malaria-relatedpaediatric morbidity and mortality in Kinshasa, ZaireA.E. Greenberg,' M. Ntumbanzondo,2 N. Ntula,3 L. Mawa,3 J. Howell,4 & F. Davachi5

Although Plasmodium falciparum malaria is a leading cause of paediatric morbidity and mortality inAfrica, few quantitative estimates are available about the impact of malaria on childhood health. To quan-tify the impact of the disease in an urban African setting, we reviewed the paediatric ward and mortuaryrecords at Mama Yemo Hospital in Kinshasa, Zaire.

From June 1985 to May 1986, 6208 children were admitted to the hospital, 2374 (38.2%) of whom hadmalaria; 500 of those with malaria died (case fatality rate, 21.1%). During this same period, there were10036 paediatric deaths, 1323 (13.2%) of which were attributed to malaria; 823 (62.2%) of these occurredin the emergency ward prior to hospitalization. Minimum population-based malaria mortality rates werehighest for children aged < 1 year (4.0 per 1000 per year). Over 70% of children admitted with malaria and>80% of children who died from the disease were <5 years old.

The total number of paediatric admissions and deaths remained relatively constant between 1982 and1986; however, the proportional malaria admission rate increased from 29.5% in 1983 to 56.4% in 1986,and the proportional malaria mortality rate, from 48% in 1982 to 15.3% in 1986. These increases weretemporally related to the emergence of chloroquine-resistant Plasmodium falciparum malaria in Kinshasa.Malaria is therefore a major cause of paediatric morbidity and mortality in the city, and this study indi-cates that hospital-based surveillance may be useful in monitoring disease-specific morbidity and mortal-ity elsewhere in Africa.

IntroductionAlthough Plasmodium falciparum malaria is one ofthe leading causes of paediatric morbidity and mor-tality in Africa (1), few quantitative estimates of theimpact of the disease on childhood survival areavailable. In 1954, Bruce-Chwatt wrote that "... ourknowledge of the amount and distribution of malariain tropical Africa is still woefully inadequate" (2),and our understanding of the health impact of thisdisease still remains limited. Despite the importanceof surveillance in monitoring the efficacy of malariacontrol programmes, a multitude of problems haveinhibited the reliable assessment of the incidence ofmalaria cases and death in Africa.

First, it is difficult to formulate a practical casedefinition for malaria because of the complexrelationship between parasitic infection and clinicalillness. In Africa, where basic laboratory equipmentsuch as microscopes may be lacking, diagnosis of thedisease is generally based on clinical criteria without

' Malaria Branch, Division of Parasitic Diseases, Center forInfectious Diseases, Centers for Disease Control, Atlanta, GA30333, USA. Requests for reprints should be sent to this author.2 Projet SIDA, Kinshasa, Zaire.3 Department of Forensic Medicine, Mama Yemo Hospital, Kin-shasa, Zaire.4 Division of Parasitic Diseases, Centers for Disease Control,Atlanta, GA, USA.5Department of Paediatrics, Mama Yemo Hospital, Kinshasa,Zaire.

parasitological confirmation. Conversely, infectionwith P. falciparum is not always associated withclinical disease because of the development ofmalarial immunity by residents in endemic areas.

Second, surveillance activities at centralizedhealth facilities cannot adequately detect all cases ofmalaria because many Africans, especially thoseliving in rural areas, have limited access to medicalcare. Even when the number of cases of the diseasein a region can be ascertained, the rate of malarialillness in a population may be difficult to determine.Accurate census data are often unavailable or subjectto rapid fluctuations because of migration orchanges in the birth or death rate.

To assess the current impact of malaria oninfant and child mortality in an urban Africansetting, we reviewed morbidity and mortality data alMama Yemo Hospital, Kinshasa, Zaire. A similartechnique, used for a study of malnutrition amongKinshasa children in the 1970s, provided a rapid andinexpensive assessment of disease-specific morbidity(3). While recognizing the limitations of retrospectivehospital-based surveillance, we adopted this method-ology to quantify malaria-related morbidity andmortality, detect temporal trends in the number ofcases of severe malaria, and identify patients at highrisk of dying from the disease.

MethodsIn Kinshasa, the capital of Zaire, the transmission ofmalaria is intense and perennial (4). Mama Yemo

Bulletin of the World Health Organization, 67 (2): 189-196 (1989) © World Health Organization 1989 189

A.E. Greenberg et al.

Hospital, with over 2000 beds, is the largest medicalcentre in Kinshasa and serves as a referral centre forpatients with severe malaria who have notresponded to antimalarial therapy either at home orat one of the many clinics in the city. Children pre-senting to the hospital with signs or symptoms thatare suggestive of malaria are initially evaluated inthe paediatric emergency ward, where a clinicalexamination and a malaria blood smear are per-formed routinely. Antimalarial therapy, principallyan intravenous infusion of quinine, is given topatients who are diagnosed as having severe disease.Children who respond adequately to the therapy aredischarged and treated as outpatients, whereas thosewhose clinical status has not sufficiently improvedafter 24-48 hours are admitted to one of the hospi-tal's three paediatric wards. All children who die ineither the emergency ward or paediatric wards areregistered at the hospital mortuary, where a deathcertificate (required for burial in Kinshasa) is issued.

Data sources

Paedltric ward records. Upon admission to the hos-pital from the emergency ward, the child's name, age,sex, address, and diagnosis, made by the physiciansin the emergency or paediatric ward, are recorded.

Mortuary records. Upon receipt of the corpse at thehospital mortuary, the name, age, sex, and address ofthe deceased, together with the cause of death, asreported by the physicians in the emergency or pae-diatric ward, are recorded. Children who did not dieat the hospital but whose corpses were brought tothe mortuary solely to have a death certificate issued,or who were dead on arrival at the hospital, are notgiven a specific diagnosis.

Census data. A census in 1984 estimated that thetotal population of metropolitan Kinshasa was 2.7million (5). Since the age distribution of thosecovered in the census was not available, we used dis-tribution data obtained during a 1978 nutritionalsurvey of Kinshasa (6-7) to approximate the propor-tions of the population that were in the followingstratified age classes: < 1 year (4.3%), 1-4 years(15.1%), 5-9 years (16.3%), and 10-13 years (14.1%).

Validity of the diagnosis ofmalariaAll children diagnosed as having malaria at MamaYemo Hospital are first evaluated in the emergencyward, where both clinical and parasitological dataare used by the physicians to formulate their diag-nosis. Because this evaluation was the basis for thediagnosis registered in the paediatric ward and mor-tuary records and was thus central to this investiga-tion, we conducted the validation studies outlinedbelow.

First, to determine how frequently the diagnosisof malaria in the emergency ward was confirmedparasitologically, we reviewed the medical records of1000 consecutive patients: 824 were diagnosed ashaving malaria, of whom 615 (75%) were confirmedby a positive malaria smear, 118 (14%) had a nega-tive smear, and for 91 (11%) either no slide wasrequested or the results were not recorded. Of the176 patients not diagnosed as having malaria, 14(8%) had a positive malaria smear (8).

Second, to assess the diagnosis of malariaamong hospitalized patients, we reviewed the recordsof all 167 children resident in the paediatric wardson 1 July 1986. Of the 112 children diagnosed ashaving malaria, 83 (74%) had a positive malariaslide, 19 (17%) had a negative slide, and no slideresults were available for 10 (9%) (8). These data aresimilar to those found for the emergency ward.

Patients who are diagnosed as having malariawithout parasitological confirmation are usuallythose with a clinical illness suggestive of the disease,no other identifiable illness, and a history of recentantimalarial drug intake; such patients are diag-nosed as having "paludisme decapite."

Third, to determine the proportion of childrenwho had undergone prior treatment with antima-larials, we collected samples of venous blood from140 malaria patients who presented at the hospital'semergency ward. These samples were analysed byhigh-performance liquid chromatography (HPLC)(9) for chloroquine and quinine, the two most com-monly used antimalarials in Kinshasa. Overall, 129(92%) of the patients had evidence of recent intakeof chloroquine and/or quinine (mean chloroquinelevel among patients pretreated with chloroquine:559 ug/l; mean quinine level among patientspretreated with quinine, 4.3 mg/l) (unpublished data).

Review of hospital recordsOne-year survey. We recorded the age, sex, address,and diagnosis of all paediatric malaria-relatedadmissions (paediatric ward records) and deaths(mortuary records) at the hospital between June1985 and May 1986. The total numbers of paediatricadmissions and deaths (from all causes) were alsonoted, and case-fatality rates (CFRs) for hospitalizedmalaria patients were determined.

Minimum malaria mortality rates for Kinshasachildren were calculated by dividing the number ofpaediatric malaria deaths recorded at Mama YemoHospital by the estimated number of children in thecity in the four stratified age classes. Since deathsfrom malaria that occur at other medical facilities orat home are not routinely registered at the MamaYemo Hospital mortuary, the rates calculated areunderestimates.

190

Malaria-related pa.dlatric morbidity and mortality In Zaire

Longitudinal survey. To detect trends in malaria-related morbidity from 1983 to 1986, we recordedthe total number of admissions from all causes, aswell as from malaria, to the largest paediatric wardat Mama Yemo Hospital (pavilion 7; for 3-12-yearolds). Also, to detect trends in malaria-related mor-tality from 1982 to 1986, we recorded the totalnumber of paediatric deaths from all causes and thenumber of deaths attributed to malaria at the hospi-tal mortuary.

Othr causes of paediatrlc mortality. To comparemalaria-related mortality with other leading causesof paediatric mortality at Mama Yemo Hospital, werecorded the number of deaths attributed in the mor-tuary records to measles and gastroenteritis fromJanuary to December 1986. The following were thetwo largest diagnostic categories for children whosecause of death was not routinely recorded: thosewho did not die at the hospital but whose corpseswere brought to the mortuary for a death certificate;and those who died at the hospital during the neo-natal period. The size of these two groups was esti-mated by determining the percentage attributed toeach during a randomly selected month (March1986) and by extrapolating this to the entire 1-yearstudy period.

ResultsOne-year surveyMalaria admissions. A total of 6208 children were

admitted to the three paediatric wards in MamaYemo Hospital from June 1985 to May 1986, ofwhom 2374 (38.2%) had malaria. More than 70% ofthe malaria patients were aged <5 years (Table 1and Fig. 1), and 52.8% were male. Malaria wasrecorded as the only diagnosis for 42.8% of thecases; and the leading associated diagnoses wereanaemia (22.2%), gastroenteritis (10.6%), and pneu-monia (9.8%), indicating that malaria was the prin-cipal diagnosis in most instances.

Of the 2374 hospitalized children with malaria,500 died (CFR: 21.1%). The CFR of males (20.0%)did not differ significantly (X2 test) from that offemales (22.4%). When stratified by age (Table 1), theCFR was highest in children aged < 1 year (31.8%)and decreased progressively with age (P < 0.001,X2 test for trend).

Malarri deaths. A total of 10036 paediatric deathswere registered at the hospital mortuary from June1985 to May 1986, of which 1323 (13.2%) wereattributed to malaria. More than 80% of the child-ren with malaria who died were less than 5 years old(Table 1 and Fig. 2) and 52.3% were male. Overall,34.9% of those who died had no diagnosis otherthan malaria; and the leading associated diagnoseswere anaemia (27.1%), pneumonia (12.3%), and gas-troenteritis (6.1%). Of the 1323 deaths from malaria,823 (62.2%) occurred in the emergency ward prior tohospitalization, while the remaining 500 (38.2%)were among hospitalized patients.

Fig. 1. Age distribution of paediatric malaria admissions at Mama Yemo Hospital, Klnshasa, June 1985 to May 1986.

ac0

Eco

,A5'5

Co.'E0d2

m

I

.c6 6-1 1 1 2 3 4 5 6 7

Lmonths --- years -

Age

191

A.E. Greenberg et al.

Table 1: Results of the 1-year survey of malaria admissions and deaths at Mama Yemo Hospital, Kinshasa, June 1985to May 1986

Age group

<1 year 1-4 years 5-9 years 10-13 years Total (0-13 years)

No. of deaths from malaria 462 (34.9)' 641 (48.5) 183 (13.8) 37 (2.8) 1323b (100)No. of malaria admissions 508 (21.4) 1169 (49.2) 547 (23.0) 133 (5.6) 2374c (100)Case fatality rate for malaria admissions 31.8% 20.4% 14.8% 13.5% 21.1%No. of children in Kinshasa 116867 408984 440406 379874 1346131% of total census 4.3% 15.1% 16.3% 14.1% 49.9%Minimum malaria mortality rate 4.0 1.6 0.4 0.1 1.0

(per 1000 children)

8 Figures in parentheses are percentages.c Distributed thus: 823 (62.2%) in the emergency ward and 500 (37.8%) among hospitalized patients.c Includes 17 (0.7%) patients whose age was not recorded.

Minimum malaria mortality rates. The overallminimum malaria mortality rate was 1.0 per 1000children per year (Table 1), with the highest age-specific mortality rate among those aged <1 year(4.0 per 1000) and decreasing progressively with age(P < 0.001, x2 test for trend).

Longitudinal survey

Malaria admissions. While the total number of pae-diatric admissions from all causes remained rela-tively constant (182 per month in 1983, 184 permonth in 1984, 177 per month in 1985, and 193 permonth in 1986), the proportional malaria admissionrate increased significantly from 29.5% in 1983,41.7% in 1984 and 45.6% in 1985 to 56.4% in 1986(P < 0.001, x2 test for trend) (Fig. 3).

Malaria deaths. The total number of deaths from allcauses among 0-13-year olds remained relativelyconstant (835 per month in 1982, 924 per month in1983, 815 per month in 1984, 828 per month in 1985,and 981 per month in 1986); however, the pro-portional malaria mortality rate increased signifi-cantly from 4.8% in 1982, 7.0% in 1983, 7.9% in1984 and 8.9 in 1985 to 15.3% in 1986 (P < 0.001, x2test for trend) (Fig. 4).

Other causes of paedlatrlc mortalityFrom January to December 1986, a total of 11 773paediatric deaths were recorded at the hospital mor-tuary, 1803 (15.3%) of which were attributed tomalaria, 674 (5.7%) to measles, and 376 (3.2%) togastroenteritis (Fig. 5).

Fig. 2. Age distribution of paediatric malaria deaths at Mama Yemo Hospital, Kinshasa, June 1985 to May 1986.

.aa

E

z

Age

192

Malaria-related psediatric morbidity and mortality In Zaire

Fig. 3. (a) Total number of paodlatric admissions and ofpaedlatric malaria and (b) proportional malaria admis-sion rate, pavilion 7, Mama Yemo Hospital, Kinshasa,1983-86.

soor()

\Total admissionst-TMalaria admissions

lti, l lil

Fig. 4. (a) Total number of paediatric deaths from allcauses and from malaria and (b) proportional malariamortality rate, Mama Yomo Hospital, Klnshasa, 1982486.

400or (a)

3000

X 20006

2

1 2 3 4 _34 1 2 3 1I 2 a 4 1 2 3 4 1 z 3 4 l z

1983 1984 1985 1986Ab)

601

46

20 1-

I . - - - - - - - - - - - -

-1

.X

2

_ Malaria admission rate

10001

20

IS

10

a

I 2 3 4 1 2 3 4 1 2 3 4 l 21983 1984 1985 1986

Year (by quarters)

Malariaotadeaths

Malaria deaths ,lilltilillill,..1f I,tI,,l ,tltilllmi lllllllt l IIII lllMII III l llJIII |1

1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 41982 1983 1984 1985 1986

.(b)

- Malaria mortality rate

I I I I I -

1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 3 41982 1983 1984 1985 1986

Year (by quarters)

In March 1986, 1082 paediatric deaths were

recorded at the mortuary, of which 28.5% did notoccur in Mama Yemo Hospital and 25.4% involvedneonates. By extrapolation, we therefore estimatethat of the 11 773 paediatric deaths in 1986, a total of3355 (28.5%) occurred outside the hospital and 2990(25.4%) were neonatal deaths.

DiscussionThe study demonstrates that malaria is a majorcause of paediatric morbidity and mortality in Kin-shasa and is of value in quantifying the impact of thedisease on overall childhood survival in the city.Since malaria transmission patterns are hetero-geneous in Africa, great caution must be exercised inextrapolating the data we have reported here toother populations. The total number of paediatricdeaths reviewed in the study (52 606) is much largerthan those reviewed in previous investigations ofmalaria-related mortality in Africa (1, 10, 11).However, the proportional malaria mortality ratesfound are similar to those reported in investigationsthat employed a variety of data sources and which

were conducted in geographically and temporallydiverse situations (Tables 2 and 3).

Perhaps the most important finding is the strik-ing increase in the malaria morbidity and mortalityrates that occurred at Mama Yemo Hospitalbetween 1982 and 1986. During this period there

Fig. 5. Distribution of causes of paedlatric mortality,Mama Yemo Hospital, Klnshasa, January to December196.

Neonatal(25.4%)

Malaria(15.3%)

| Measles(5.7%)

G2troenteritis(3.2%)

Not in hospitl(diagnosis unknowr

(28.5%)

Other(pneumonia, meningitis, etc.)

(21.9%)

193

- 600C

E 400-

0

200

a.

0

'UI

as

42

*0

C91aC

-. r. _Z ........ |_ - - - - - z .O- . . . . .

I II I

I I I I

01 vci c-i

_ae~

_s

0

cm cm. r,s

r-c uI

4c6 16 to

_00 CM

co O CD m co

I

10

0 0 0

CC 0. -

0

CO

o 0

0o 01 E

Z E0O

° N'@@

:1Ym

s

co

01

0

0

61

D_

C

0

as

0

0

010

C0.00

0aiCO0

,0CO

0.

0

0100

0m

co.

0

S

U

0Ea

U

IC

E

la

Ia

-I

c

0

iFL

..

0

.CS

0

0I-

V

0-0

-00

0

.0.c

00

*C 01.0

0. C

O o

0.._ CM

0 0V 0I LEas 0

4'

CD._

r- LLe la

4D._

co

0

01

0

CL0CD

co

0:

000L%10

0

asvD0

0

0

L.

co0

7%

0

0

000

a

UD

0

7%

0

0

co

V0

w0v-

v

0

-

0

c0

01

0

0

o

._

CS,C o

Coc o(0

10 CV, 0(60

V

Co

0 5

10 Z 0

00

01

c 0

C C C4

N

CS,01

enberg et al.A.E. Gre

aaI

EU

U

.Z.E

0

E

a0a.

'i0

.0:EI06

N

0

0L.

000

2c010

D 0D

0_ _

E_0

0

00

0DsLIZ0Z

0D0

0

0- 01

oC=

0

0.

ai-

0

co

IL)

co

0

L.

co

00

00

.2

0 * 0|0 E

oL-co 4 U-

194

0

9

Malaria-related paedlatric merbidity and mortality In Zaire

were no significant changes in diagnostic capabilitiesor in medical personnel at the hospital that couldaccount for these results. However, the rapid devel-opment and intensification of chloroquine-resistantP. falciparum malaria in Kinshasa during the 5-yearstudy interval may be related to the observedincrease in the number of cases of severe malaria inthe city. A similar trend was noted previously amongchildren in Malawi upon the emergence ofchloroquine-resistant malaria (12).

In 1982, no case of in vivo or in vitrochloroquine-resistant malaria was detected in Kins-hasa (13). The first evidence of in vivo chloroquineresistance in the city was observed in 1984 (14), andby 1985 a total of 56% of P. falciparum infections inKinshasa children were not cured by a standardregimen of 25 mg/kg chloroquine (15). By 1986, atotal of 82% of P.falciparum parasites isolated fromchildren at Mama Yemo Hospital exhibited in vitroresistance to the drug (16).

Kinshasa children who develop symptoms thatare suggestive of malaria are often treated by theirmothers or at local clinics with chloroquine. If,however, the children are infected with chloroquine-resistant strains of P. falciparum, their parasitaemiamay increase with a consequent deterioration inclinical status; studies of the natural history ofchloroquine-resistant malaria at the community levelwould therefore be useful in assessing this hypo-thesis. Additionally, prospective monitoring ofmalaria-related mortality in West Africa, where chlo-roquine resistance has only recently emerged (17),might indicate whether increases in malaria mortal-ity reflect the changing drug-sensitivity patterns of P.falciparum.

In the 1-year review of malaria deaths at MamaYemo Hospital, young children were identified asbeing at particularly high risk of malaria-relatedmortality. Of the paediatric malaria deaths, 83.4%occurred among children aged < 5 years: 34.9%among infants aged < 1 year and 48.5% amongchildren aged 1-4 years. The case-fatality rate amonghospitalized malaria patients was highest for infants(31.9%) and young children (20.4%). Since acquiredimmunity to malaria is least developed amongyounger age groups, these findings were not unex-pected; however, the data emphasize the importanceof the prompt diagnosis and management of malariain young children.

An unexpected finding was that 62.2% of allpaedatric deaths from malaria at Mama Yemo Hos-pital occurred among patients in the emergencyward. Since the hospital is a referral centre forpatients with severe malaria in Kinshasa, a largeproportion of children presenting to the emergencyward have not responded to therapy at other clinics

or medical centres, and it is, therefore, essential thatthey receive rapid and intensive clinical managementsoon after their arrival. Subsequent to this investiga-tion, a separate room and a team of medical per-sonnel were designated to provide more intensivecare to patients requiring intravenous therapy orblood transfusions (the majority of whom havemalaria). Ongoing surveillance of paediatric deathsat the hospital would help to determine whether thisintervention will reduce malaria-related mortality.

We conclude that in Africa hospital-based sur-veillance of malaria at selected health care facilities,particularly those where the clinical diagnosis ofmalaria can be confirmed parasitologically, may beuseful in monitoring whether improvements inhealth-care delivery programmes will have an impacton malaria-related mortality. Furthermore, this pro-cedure could readily be adapted for the surveillanceof other infectious and noninfectious diseases,thereby providing local health officials with data thatcould be used in the development of rational inter-vention programmes.

AcknowledgementsWe thank Dr Joel G. Breman, Dr Paola Baudoux, and DrPhuc Nguyen-Dinh for their assistance in developing thisproject; Dr Alan Y. Huong, Ms Walo Olangi, Ms JacquelinM. Roberts, and Ms Kristine Campbell for their statisticalsupport; Mr Michael Lorenz and Ms Monica Overman fortheir laboratory assistance; Dr Hans Lobel and Dr CarlosC. Campbell for their editorial comments; and Dr Jona-than M. Mann, Dr Robert W. Ryder, Dr Kapita Bila, andDr Ngandu Kabeya for their support.

Resume

Surveillance en milieu hospitalier de lamorbidite et de la mortalite dues aupaludisme chez l'enfant a Kinshasa, ZaireLe paludisme a Plasmodium falciparum est l'unedes causes majeures de morbidite et de mortalitechez l'enfant en Afrique. On ne dispose toutefoisque de rares estimations quantitatives de sonimpact. Afin d'evaluer l'impact actuel du palu-disme sur la mortalite infanto-juvenile en Afriqueurbaine, nous avons examine les registres duservice de pediatrie et de la morgue a l'hopitalMama Yemo, Kinshasa, Zaire.

De juin 1985 a mai 1986, 6208 enfants au totalont ete admis a l'h6pital; sur les 2374 enfants(38,2%) qui etaient atteints de paludisme, 500 sontd'c6d6s (taux global de letalite, 21,1%; taux deletalite chez les nourrissons de moins d'un an:

195

A.E. Greenberg et al.

30,8%). Au cours de la meme periode, la morguede l'hopital a enregistre 10036 d6ces pediatriques,dont 1323 (13,2%) etaient attribues au paludisme;parmi ces derniers, 823 (62,2%) ont et6 enregis-tres au service des urgences, avant hospita-lisation. Plus de 70% des enfants hospitalises pourpaludisme et plus de 80% des enfants d6cedes decette maladie etaient ages de moins de 5 ans. Letaux global minimal de mortalite par paludismechez les enfants de Kinshasa 6tait de 1,0 pour1000 par an, le taux le plus 6leve s'observant chezles nourrissons (4,0 pour 1000).

D'apr6s les resultats d'une enqu6te longitudi-nale, que nous avons r6alis6e afin de d6celer lestendances du paludisme grave, le nombre totald'admissions et de d6c6s pediatriques est resterelativement constant entre 1982 et 1986. Toute-fois, la proportion de cas admis pour paludismeest passee de 29,5% en 1983 a 56,4% en 1986, etle taux proportionnel de mortalite palustre estpasse de 4,8% en 1982 I 15,3% en 1986.

Afin d'identifier d'autres causes de mortalitepediatrique, nous avons examine les registres dela morgue de l'h6pital pour la periode s'etendantde janvier a decembre 1986. Pendant cette pe-riode, 11 773 dec6s pediatriques ont ete enregis-tres, dont 1803 (15,3%) attribues au paludisme, 674(5,7%) a la rougeole, 376 (3,2%) a une gastro-enterite, 3355 (28,5%) d6c6s survenus en dehorsde l'h6pital, et 2990 (25,4%) d6ces de nouveau-nes.

Cette etude demontre que le paludisme estune cause majeure de morbidite et de mortaliteinfanto-juveniles a Kinshasa. Le risque de decesdO au paludisme est particulierement eleve chezles tr6s jeunes enfants et les enfants admis dansles services d'urgence. L'augmentation frappantede la morbidit6 et de la mortalite palustres obser-vee a l'h6pital Mama Yemo entre 1982 et 1986 peutetre liee a l'apparition et a l'intensification rapidesdu paludisme A P. falciparum choroquino-resistanta Kinshasa pendant cette m6me p6riode. Nousconcluons que la surveillance hospitali6re dansdes 6tablissements selectionnes peut etre utilepour surveiller la morbidite et la mortalite infanto-juveniles dues au paludisme en Afrique.

References1. Bruce-Chwaft, L.J. Malaria in African infants and

children in southern Nigeria. Annals of tropical medi-cine and parasitology, 46: 173-200 (1952).

2. Bruce-Chwatt, L.J. Problems of malaria control intropical Africa. British medical journal, 1: 169-174(1954).

3. Franklin, R.R. et al. Rapid assessment of urban nutri-tional status using hospital pediatric records: a case

study from Zaire. Nutrition reports international, 30:1027-1040 (1984).

4. Ngimbl, N.P. et al. Aper,u de la situation epid6miolo-gique du paludisme a Kinshasa (Republique duZaire) en 1980. Annales de la Societe Belge de M6di-cine Tropicale, 62: 121-137 (1982).

5. Institut National de Ia Statlstique, Secretarlat Nation-al du Recensement. R6sultats provisoires du recen-sement scientifique de la population. R6publique duZaire. Volume 19. Kinshasa, 1984.

6. Nkamany, K. et al. Zaire National Nutrition PlanningCenter 1979: Appendix B.

7. Franklin, R.R. et al. A cross-sectional study ofwasting and stunting in Kinshasa, Zaire. Annales dela Soci6t6 Belge de Medicine Tropicale, 64: 403-411(1984).

8. Greenberg, A.E. et al. The association betweenmalaria, blood transfusions, and HIV seropositivity ina pediatric population in Kinshasa, Zaire. Journal ofthe American Medical Association, 259: 545-549(1988).

9. Patchen, L.C. et al. Analysis of filter-paper absorbed,fingerstick blood samples for chloroquine and itsmajor metabolite using high-performance liquidchromatography with fluorescence detection. Journalof chromatography, 278: 81-89 (1983).

10. Duren, A.N. Essai d'6tude sur l'importance du palu-disme dans la mortalite au Congo Beige. Annales dela Soci6t6 Belge de M6dicine Tropicale, 31: 129-147(1951).

11. Greenwood, B.M. et al. Mortality and morbidity frommalaria among children in a rural area of theGambia, West Africa. Transactions of the RoyalSociety of Tropical Medicine and Hygiene, 81:478-486 (1987).

12. Khoromana, C.O. et al. In vivo efficacy of chloroquinetreatment for Plasmodium falciparum in Malawianchildren under five years of age. American journal oftropical medicine and hygiene, 35: 465-471 (1986).

13. Nguyen-Dlnh, P. et al. In vivo and in vitro suscepti-bility to chloroquine of Plasmodium falciparum inKinshasa and Mbuji-Mayi, Zaire. Bulletin of theWorld Health Organization, 63: 325-330 (1985).

14. Ngimbi, N.P. et al. Reponse in vivo a la chloroquineau cours du traitement du paludisme a Plasmodiumfalciparum en region suburbaine de Kinshasa, Zaire.Annales de la Soci6t6 Belge du M6dicine tropicale,65: 123-125 (1985).

15. Paluku, K.M. et al. Response of children with Plas-modium falciparum to chloroquine and developmentof a national malaria treatment policy in Zaire.Transactions of the Royal Society of Tropical Medi-cine and Hygiene, 82: 353-357 (1988).

16. Nguyen-Dlnh, P. et al. Plasmodium falciparum inKinshasa, Zaire: In vitro drug susceptibility studies.American journal of tropical medicine and hygiene,37: 217-219 (1987).

17. Centers for Disease Control. Chloroquine-resistantPlasmodium falciparum malaria in West Africa. Mor-bidity and mortality weekly report, 36: 13-14 (1987).

Reprint No. 4966

16