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Seasonality and malaria in a west African village: does high parasite density predict fever incidence?

In this cohort study, the authors studied the effect of blood malaria parasite density on fever incidence in children in an endemic area with 9 days' follow-up of 1- to 12-year-old children during two time periods: the end of the dry season (May 1993: n = 783) and the end of the rainy season (October 1993: n = 841) in Bougoula, West Africa (region of Sikasso, Mali). The cumulative incidence of fever (temperature > 38.0 degrees C) was 2.0% in the dry season and 8.2% in the rainy season (p < 0.0001). In the rainy season, the risk of fever was increased in children of ages 1-3 years (relative risk (RR) = 2.5, 95% confidence interval (CI) 1.6-4.1); in those with an initial parasitemia > 15,000/microliter (RR = 2.7, 95% CI 1.4-5.4); in children with an enlarged spleen (RR = 2.0, 95% CI 1.2-3.3); or in those with anemia (hematocrit < 30%: RR = 1.8, 95% CI 1.1-2.9). In the dry season, anemia was the only predictor of fever incidence. In the rainy season, the best predictors of fever were, in order, age (< 4 years), enlarged spleen, and high parasite density. Even in the higher risk groups, the cumulative incidence was < 20%. The authors conclude that most children with high parasite density do not develop fever subsequently. The association between parasite density and fever varies according to age and season. Since even high levels of parasite density do not reliably predict fever incidence, parasite density should be considered as just one of a group of indicators that increase the probability of a fever of malarial origin.