Malaria-anemia comorbidity prevalence as a measure of malaria-related deaths in sub-Saharan Africa

Different methods and data sources have been utilized to determine the relationship between malaria and mortality in endemic countries. Most of these efforts have focused on deaths directly attributed to malaria, while they overlooked causes of mortality that might be indirectly related to the disease, for instance anemia. We estimated the association of malaria parasitaemia, anemia, and malaria-anemia comorbidity with all-cause under-five mortality and evaluated the potential of malaria-anemia comorbidity prevalence to quantify malaria-related deaths in sub-Saharan Africa. We analysed data from Demographic and Health Surveys (DHS) and employed Bayesian geostatistical models. Mortality hazard obtained from malaria-anemia comorbidity prevalence was up to 3·5 times higher compared to the hazard related to Plasmodium parasitaemia only. Malaria parasite prevalence alone could not always capture a statistically important association with under-five mortality. Geographical variation of the malaria-anemia comorbidity effect was observed in most, but not all, countries. We concluded that the malaria burden in sub-Saharan Africa is considerably underestimated when anemia in not taken into account and that the malaria-anemia comorbidity prevalence provides a useful measure of the malaria-related deaths.