Progression of Frequency and Lethality of Severe Malaria from 2017 to 2020 in the Pediatric Unit of CHUD-Parakou (Benin)

Background: The latest WHO report shows a decline in the performances achieved concerning the fight against malaria since 2017. This research work aimed to investigate the progression of frequency and lethality due to severe malaria from 2017 to 2020 in the pediatric unit of the Borgou University Teaching Hospital in Parakou (CHUD-Parakou). Patients and Methods: This research work is a descriptive and analytical case-control study focused on all the children aged 1 month and more, hospitalized in the pediatric unit of CHUD-Parakou from January 1, 2017, to December 31, 2020. Recruitment criteria were the following: be admitted to hospital during the period specified above; have a usable medical record containing the diagnosis and type of dis-charge, and the findings of thick smear examination and/or of a rapid diagnostic test. Sampling was complete and takes into account all the medical records of children meeting the inclusion criteria. Epi Info 7.2.2 was the software used to perform data processing. Results: The frequencies of severe malaria in the unit were estimated at 19.89%, 22.65%, 29.65% and 27.51% respectively in 2017, 2018, 2019 and 2020. Lethality rates varied from 7.76% to 8.68 from 2017 through 2020. The death risk associated with severe malaria was 3.08 times higher in children suffering from severe acute undernutrition. Conclusion: Despite all the efforts made by the health authorities and the technical and financial part-ners, the frequency and lethality of severe malaria are increasing in the pediatric unit of the B/A Regional University Teaching Hospital (CHUD-B/A). It is therefore worth investigating the determinants of this situation.


Introduction
Malaria is the leading cause of morbidity and mortality among children in Sub-Saharan Africa in the post-neonatal period. The last WHO report indicates decreased performances in the domain of the fight against the malarial scourge since 2017 [1]. The purpose of this research work was to investigate the progression of frequency and lethality due to children's severe malaria in the pediatric unit of CHUD-Parakou from 2017 to 2020.

Patients and Methods
This research work is a descriptive and analytical case-control study centered on all the children aged 1 month and above, hospitalized in the said pediatric unit from January 1, 2017, to December 31, 2020. Recruitment criteria were the following: be hospitalized during the period specified above, have a usable medical record containing the diagnosis and type of discharge, and the findings of thick smear examination and/or of a rapid diagnostic test (RDT). Child death was the dependent variable, and the independent variables were sociodemographic, clinical and epidemiological. Severe malaria was diagnosed according to the WHO criteria [2] i.e. have a positive thick blood smear or RDT to Plasmodium falciparum with at least one sign of danger or severity. The forms of severe malaria were adopted according to the following definitions:

Anemic Form of Severe Malaria
• Any case of malaria with thick blood smear or RDT positive to Plasmodium falciparum and hemoglobin rate below 5 g/dL or hemoglobin rate oscillating between 5 and 7 which required blood transfusion on medical prescription when faced with signs of anemic decompensation. • Neurological form of severe malaria: any case of malaria with thick smear or RDT positive to Plasmodium falciparum and characterized by a neurological sign other than a coma of more than 30 minutes.

Ethical and Professional Considerations
The authors have adhered to data anonymity and confidentiality. The head of the unit issued authorizations for conducting this study.

Results
All in all, 11568 children were hospitalized from January 1, 2017, to December 31, 2020. Among those children, 8296 were admitted to the hospital for severe malaria i.e. an overall frequency of 71.71%. Among the children suffering from severe malaria, 3831 were female subjects (46.18%) and 4465 male subjects (53.82%) i.e. a sex ratio of 1. 16

Forms of Severe Malaria
The anemic form of severe malaria involved 71.43% of cases of severe malaria if the mixed forms are taken into account i.e. anemic and neurological form of severe malaria (see Table 2)

Overall Lethality
Among those children, 695 died, i.e. a lethality rate of 08.38%. Figure 1 and Figure 2 show how distributed the frequency of severe malaria cases and lethality were distributed respectively according to age groups and years.

Discussion
This case-control study had some shortfalls in terms of missing data, particularly

On the Progression of Frequency
The study has pointed out that the frequency of severe malaria cases has in-

On the Progression of Lethality
According to the findings of this study, the trend in lethality due to malaria among children is the same as the one of frequency. This situation may be due to the lack of equipment and inputs necessary for the management of cases of the disease most commonly suffered by the populations. Even though malaria is the Open Journal of Pediatrics disease most known by the specialists, the latter may be facing a shortage of the most basic essential drugs to solve the emergency cases generated by this scourge. In addition, the problem of shortage of labile blood products is recurring despite the goodwill of authorities at various levels knowing that, the first form of severe malaria is the anemic one with up to 50.48% (927) cases of anemic severe malaria out of 1838 cases of severe malaria in all, according to Adédémy et al. in Parakou (Benin) [12]. When considering the age structure of dead children it is noted in Figure 1 that lethality is higher in infants under six months of age and in children above 5 years compared to those aged 6 to 60 months. Regarding infants under 6 months, lethality may result from the immaturity of their defense system but concerning children above five years who in

Lethality and Nutritional Status
The results show that one out of four children suffering from severe malaria had acute malnutrition. The meaning of that association is difficult to discern knowing that, according to the conceptual framework of the causes of malnutrition developed by UNICEF, infections, including chronic parasitic infections, are all part of the immediate causes of acute malnutrition [14]. In the same way, the Plasmodium falciparum would find breeding grounds in an undernourished body. It is therefore a very morbid association. This is all the more true as the relationship between nutritional status and lethality is expressly shown in this research work with a death risk 3.08 times higher in the case of association of severe malaria and severe acute malnutrition. In two publications in 1993 and 2001, authors had reported that more than half of children under 5 years would have not died if they had not been malnourished [15] [16]. As a result, the fight against malaria also consists in improving children's nutritional status.

Conclusion
Despite all the efforts undertaken by the health authorities and the technical and financial partners, the frequency and lethality of severe malaria are on the rise in the CHUD-B/A pediatric unit. It is necessary to reinforce means and resources for case management on the one hand and to investigate the determinants of that situation on the other hand.