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Rapid Responses: Rapid Responses published:
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Severe falciparum malaria in Yemen: Child case fatality is 4 times higher in highlands compared with endemic areas.
- Salem Banajeh (23 October 2006)
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Why?
- Michael E Reschen (24 October 2006)
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Editor's reply
- Fiona Godlee (25 October 2006)
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Re: Editor's reply
- Michael E Reschen (25 October 2006)
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Importance of neurological presentation of malaria in Africa
- Nicholas AV Beare (1 November 2006)
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Salem Banajeh, Associate Professor-Child Health Sana'a University-Sana'a-Yemen
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Al-Taiar et al reported important data on children admitted with severe malaria in 2 public health facilities. The study populations were residents of well-known malaria-endemic areas 1. Severe malaria accounted for 6.6% (808/12301) of total paediatric admissions and case fatality rate (CFR) 3.2%(26/808). The study did not report on the proportion of malaria deaths of the total hospitals’ child deaths. Counting child death by cause is an important initial step to plan, implement and monitor child survival interventions 2. Six-year period data (2000-2005) of Al-Sabeen hospital, the major paediatric public health facility in Sana’a, the Capital of Yemen, showed that severe falciparum malaria is the 4th important cause of child admission and death outside the neonatal period (after pneumonia, diarrhoea and meningitis). During this period 18780 children were admitted, 746 (4%) had severe falciparum malaria (less severe cases are usually treated on outpatient basis). There were 91 severe malaria deaths (CFR 12.2%), 4 times higher than that reported by Al-Taiar et al (3.2%). The hospital policy is to treat all severe malaria cases with quinine infusion, and other supportive management according to the WHO guidelines. Possible explanation for the wide difference in CFRs may be due to partial immunity maintained by repeated malaria exposure of the study populations. In the highlands, malaria attacks children that have unprepared immune system. During the 6-year period, there were 1612 child deaths in Al-Sabeen and malaria deaths accounted for 5.7%. It accounted for 4.2%(25/591), 4.7%(23/494), and 8.2%(43/527) in 2000-01, 2002-03, and 2004-05 periods, respectively. This may indicate significant rise in malaria deaths at the community level. The national average proportion for child death caused by malaria is estimated at 7.5% in 2000 3. In poor countries, including Yemen, late hospital attendance of children with severe malaria, usually when alarming neurological symptoms appear, is perhaps the most important risk factor for malaria death indicating that simple and cost effective interventions at community level should be adopted. References: 1.Al-Taiar A, Jaffar S, Assabri A, Al-Habori M, Azazy A, Al-Mahdi N, et al. Severe malaria in children in Yemen: two site observational study. BMJ 2006; 333: 827,doi:10.1136/BMJ.38959.368819.BE 2.Bryce J, Boschin-Pinto C, Shibuya K, Black R, and the WHO Child Health Epidemiology Reference Group. WHO estimates of the causes of death in children. Lancet 2005; 365:1147-52. 3.World Health Organization. Core health indicators for Yemen, World Health Statistics 2006. http://www.who.int/whosis/ (accessed October 18, 2006). Competing interests: None declared |
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Michael E Reschen, SHO General Medicine John Radcliffe, Oxford, OX3 9DU
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Dear Editor, Why are you including such utterly uninteresting studies? This study might yield one or two interesting statistics that may be of use to their government but it hardly warrants publication in the British Medical Journal. It is sad to see such a British icon, the BMJ in decline. No wonder its 'impact factor' has been steadily dropping. The BMJ editors seem to be complicit in Britain's anti-intellectual culture. There seems to be some anxiety about including more scientific or detailed articles for fear of alienating GPs. I think this is a mistake and only serves to leave GPs at a slight disadvantage overall. Afterall GPs may be historically rooted in managment tasks which ought to be performed elsewhere, but they also need to treat physical and mental illness. Sadly the most informative sections in the BMJ are the drugs adverts - they're a useful way of keeping up to date on the latest brands being pushed by drugs companies. If i want medical news there are plenty of better resources and if i want serious medical information i look to the New England journal or the Lancet. I'm not convinced the editors of the BMJ have insight into the decline of their journal or perhaps they are just quite happy for it to be a vehicle for English or foreign authors who need to get on the publication ladder. Lamentably every now and then some hapless SHO presents a research article from the BMJ at one of our grand rounds and is instantly torn to shreds over the sheer lunacy of its publication. Perhaps you should attach a warning that BMJ articles are not intended for peer review - although i am puzzled as to the reasoning of your own peer reviewers? I'm sure my words will evoke a swift rebuttal but i believe there is a kernel of truth within my sentiments. I do however like the careers section and the BMA news! kind regards Michael Reschen Competing interests: None declared |
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Fiona Godlee, Editor BMJ
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Dear Dr Reschen, Thanks for your message. I'm sorry you found the study on malaria in the Yemen uninteresting. I'm sure it cannot have escaped your notice that this was published in the context of a theme issue focussing on health in the Middle East, nor that malaria remains one of the world's greatest killers and is therefore of huge importance to health care in this and other regions of the world. We expected to get flack from UK readers about running this theme issue, given consistent feedback from reader surveys and focus groups that coverage of international health issues is not popular. Tessa Richards and Christiane Rehwagen said as much in their editor's choice. Interestingly, several UK readers have posted responses congratulating us on the issue. We feel that coverage of health in this important region is entirely justified in an international journal, particularly at the current time, and we were pleased to be able to publish this research paper from Yemen. One aim of our theme issues has been to help build research capacity in parts of the world where this is lacking. Thank you for giving me the opportunity to point out that, for what it's worth, the BMJ's impact factor rose this year for the first time in several years, from around 7 to over 9. As for the lunacy of our research publications, we (and I am sure our authors and peer reviewers) would be keen to hear any coherent critiques of the research we publish - this as a crucial part of peer review. I invite the hapless SHOs you mention, yourself included, to pass these onto us via rapid responses. The most interesting of these will be published as letters in the journal. Fiona Godlee Competing interests: I am the editor of the BMJ. |
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Michael E Reschen, SHO General Medicine John Radcliffe, Oxford, OX3 9DU
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Dear Editor, Thank you for your eloquent response to my comments on the research content of the British Medical Journal. It certainly has not 'escaped' my attention that 40% of the world's children live in malaria-endemic conutries or that there are over 1 million deaths from malaria each year, or that the World Health Organisation is running a decade long campaign called 'Roll back Malaria' (www.who.int/). However, given that there is only 1 research paper published fully this week i think the topic alone is not justification enough. Overall i enjoy the 'themed issues' in the BMJ but i think they can be overblown and there is a delicate balance to be struck. Once again i look to the New England journal's own themed issues, usually begining with some excitingly lucid and incisive commentry in the 'perspectives coloumn'. Is it not a fallacy to suggest that a journal is 'international' because it publishes papers authored in foreign countries? Surely a journal is trully international by virtue of publishing papers worthy of the world stage. The altruistic way in which the BMJ helps to give a 'hand-up' to foreign authors is commendable and i would generally support it given that we can only really flourish when we look outwith ourselves. kind regards, Michael Reschen Competing interests: None declared |
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Nicholas AV Beare, Specialist Registrar St Paul's Eye Unit, Royal Liverpool University Hospital, Liverpool, L7 8XP
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It is very misleading of This week in the BMJ to describe the findings of this study of severe malaria from Yemen(1) as "in contrast to Africa, where severe anaemia and respiratory distress are better predictors of fatal outcome [than neurological signs]" . The study itself refers to "some studies in Africa, however, where respiratory distress without neurological signs is a strong predictor of mortality". Two studies are referenced, one did not compare outcomes between these groups.(2) In the other, a large study from Kenya,(3) it is true that respiratory distress alone had a higher mortality rate than impaired consciousness alone, but three times as many children died with impaired consciousness (n=38) than with respiratory distress without coma (n=13). The highest mortality rate was in the group with impaired consciousness and respiratory distress (31%). Those with severe anaemia alone had the lowest mortality rate (1.3%). Other studies from Africa have shown that profound coma, respiratory distress and hypoglycaemia are the most important predictors of death in severe malaria.(4-6) Severe anaemia without the presence of the other two features has a low mortality in units able to promptly correct the anaemia. Anyone who has worked in a paediatric unit in Africa will recognise cerebral malaria as the dreaded presentation of severe malaria, the more so when the child has laboured breathing due to the accompanying acidosis. Nicholas Beare 1. Abdullah Al-Taiar, Shabbar Jaffar, Ali Assabri, Molham Al-Habori, Ahmed Azazy, Nagiba Al-Mahdi, et al. Severe malaria in children in Yemen: two site observational study. BMJ 2006 333: 827. 2. English M, Waruiru C, Amukoye E, Murphy S, Crawley J, Mwangi I, et al. Deep breathing in children with severe malaria: indicator of metabolic acidosis and poor outcome. Am J Trop Med Hyg 1996;55: 521-4. 3. Marsh K, Forster D, Waruiru C, Mwangi I, Winstanley M, Marsh V, et al. Indicators of life-threatening malaria in African children. N Engl J Med 1995;332: 1399-404. 4. Schellenberg D, Menendez C, Kahigwa E, Font F, Galindo C, Acosta C, et al. African children with malaria in an area of intense Plasmodium falciparum transmission: features on admission to the hospital and risk factors for death. Am J Trop Med Hyg. 1999;61:431-8. 5. Waller D, Krishna S, Crawley J, Miller K, Nosten F, Chapman D, et al. Clinical features and outcome of severe malaria in Gambian children. Clin Infect Dis. 1995;21:577-87. 6. Jaffar S, Van Hensbroek MB, Palmer A, Schneider G, Greenwood B. Predictors of a fatal outcome following childhood cerebral malaria. Am J Trop Med Hyg. 1997;57(1):20-4. Competing interests: None declared |
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