Review
Malaria in adolescence: burden of disease, consequences, and opportunities for intervention

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Summary

The problem of malaria in adolescence has largely been overshadowed by the huge burden of disease in young children. A substantial number of adolescents are at risk from malaria infection, but the burden of disease and consequences of infection in this age-group have rarely been studied. Our understanding of specific risk factors and beneficial interventions for adolescents is also limited. Data show that, from an adolescent viewpoint, malaria is a common cause of clinical illness and a preventable cause of death, even in areas of stable malaria transmission. Younger adolescents might be at a higher risk than older adolescents, because of immunological and hormonal factors. There are limited data about the adverse consequences of malaria in non-pregnant adolescents. However, in pregnant adolescents, the consequences of malaria are of great concern and simple interventions might lead to a substantial benefit. Malaria infection in adolescents is an under-recognised problem, and the prevention, diagnosis, and treatment of malaria should have a high priority within adolescent health programmes.

Introduction

Malaria is one of the most important infections in the tropics with an estimated 1 to 2·7 million deaths annually.1 The age-groups at highest risk are primarily determined by the intensity of malarial transmission. Where transmission is intense, clinical disease is most common in young children: immunity develops with increasing age and adults are far less affected. In areas of lower transmission, clinical disease occurs throughout life.2 Although much has been learnt about the epidemiology and clinical effects of malaria in children, malaria in adolescence has been relatively neglected. Approximately 914 million adolescents (aged 10–19 years) live in low-income countries, and many of them will be exposed to malaria, but this group has rarely been targeted for malaria control.3 This review was undertaken to collate evidence and observations from different sources to better understand the burden and consequences of malaria in adolescents, and to identify relevant interventions or opportunities for improved control.

Section snippets

Methods

To obtain data for this review, we searched the 26 Cochrane systematic reviews on malaria for data relevant to adolescents (up to December, 2005). The Cochrane clinical trial register was searched for trials by use of the keywords “malaria” and “adolescence” in any field. Abstracts of these trials were examined to identify interventions relevant to adolescents. We also searched the English and French literature by use of PubMed (1966 to December, 2005) for articles containing the words

Clinical illness

Few studies have examined directly rates of clinical illness in adolescents. Observations in younger children indicate that, even within stable transmission areas, the intensity of transmission has a strong influence on the peak age of clinical illness (panel 1).5 This is shown by a comparison of two villages in Senegal with different transmission rates (200 vs 20 infective bites per year): clinical disease was rare in adolescence in the high-transmission area, but did occur in the area of

Clinical presentation of malaria

The clinical presentation of uncomplicated malaria in adolescents seems to be similar to other age-groups, although adolescents may have a stronger correlation of fever to parasite density than do younger children.15 A Senegalese study found no differences in symptoms, duration, or severity of symptoms between age-groups (including 41 adolescents).10

The pattern of severe malaria differs between adults and children; although cerebral malaria occurs in both, severe anaemia and respiratory

Prevention of malaria in non-pregnant adolescents

There are very limited data on the prevention of malaria in male and non-pregnant female adolescents. Although adolescents have been included in studies of bednets,101 detailed data are limited. One study examined the effect of insecticide-treated nets in non-pregnant adolescent girls and showed a reduction in anaemia in 12 and 13-year-olds (OR 0·38 [95% CI 0·21–0·69]) but not in older adolescents; no effect on malaria episodes or morbidity was shown in any age-group.102 Studies in Africa,

Discussion

Most attention in malaria has focused on the young African child because of the huge burden of disease and mortality in this age group. Finding good quality data on the incidence of disease in adolescents is not easy: few published studies specifically investigate malaria in adolescents, and younger adolescents are often not separated from children. However, although the burden of disease and mortality is clearly far less than that in younger children, we have presented evidence that from the

Conclusions

This review has examined all aspects of malaria in adolescence. Although the burden of malaria is far lower than in younger children in areas of stable transmission, malaria should be one of the highest priorities in adolescent health care; in particular, young pregnant women are at high risk and require special attention in all malaria endemic areas. This review has also shown the relative paucity of good data on many aspects of malaria in adolescents. Researchers should be encouraged to

Search strategy and selection criteria

These are described in detail in the Methods section on page 780.

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