HIV, Malnutrition and Invasive Bacterial Infection among Children with Severe Malaria

Abstract

Abstract Background—HIV infection, malnutrition and invasive bacterial infections (IBI) are reported among children with severe malaria. However, it is unclear whether their co-occurrence with falciparum parasitization and severe disease is by chance, or by association among children in malaria endemic areas. Methods—We examined 3,068 consecutive paediatric admissions to a Kenyan district hospital with clinical features of severe malaria, and 592 community controls. We performed multivariable regression analysis with each case weighted for their probability of being due to falciparum malaria using estimates of the fraction of severe disease attributable to malaria at different parasite densities derived from cross sectional parasitological surveys from well children in the same community. Results—HIV infection was present in 133/1071 (12%, 95%CI 11 to 15%) consecutive parasitemic admissions. Parasite densities were higher in HIV infected children. The odds of admission associated with HIV infection for admission with true severe falciparum malaria were 9.6 (95%CI 4.9 to 19), however this effect was restricted to children age ≥1 year. Malnutrition was present in 507/2,048 (25%, 95%CI 23 to 27%) consecutive parasitemic admissions. The odds associated with malnutrition for admission with true severe falciparum malaria were 4.0 (95%CI 2.9 to 5.5). IBI was detected in 127/2,048 (6.2%, 95%CI 5.2 to 7.3%) of consecutive parasitemic admissions. All three comorbidities were associated with increased case fatality.Conclusions—HIV, malnutrition and IBI are biologically associated with severe disease due to falciparum malaria rather than being simply alternative diagnoses in co-incidentally parasitized children in an endemic area.