Spatial Distribution of PCR-Identified Species of Anopheles gambiae senu lato (Diptera: Culicidae) Across Three Eco-Vegetational Zones in Cross River State, Nigeria.

Anopheles gambiae sensu lato complex (An. gambiae s.l.) describes a group of nine morphologically indistinguishable members that vary in their distribution, ability to transmit malaria, and susceptibility to pyrethroids. Here, we recorded the spatial patterns of PCR-identified An. gambiae s.l. complex species collected from four sites in Cross River State, Nigeria that represented three different ecological zones. Trapping was conducted between October 2015 and June 2016. Anopheles gambiae s.l. complex species identification was performed using species-specific primers followed by An. gambiae and An. coluzzii differentiation using the restriction fragment length polymorphism (RFLP) method. Bivariate and multivariate logistic regression models were used to identify ecological and seasonal variables closely associated with An. coluzzii and An. gambiae distribution. Out of 1,388 An. gambiae s.l. successfully amplified, 1,074 (77.4%) were An. coluzzii, 278 (20%) were An. gambiae, and 25 (1.8%) were hybrids (An. coluzzii/An. gambiae). A very small number of An. arabiensis (0.8%, n = 11) were also collected. Statistical analysis indicated that An. coluzzii is predominant in Guinea-savannah and tropical rainforest, and is highly associated with rainy seasons, while, An. gambiae is prevalent in mangrove swamp forest during dry seasons. Only 13 An. gambiae s.l. females were infected with Plasmodium falciparum (P. falciparum). The sporozoite infection rate was higher in mangrove swamp forest (53.8%, n = 7) than in rain forest (38.5%, n = 5) followed by Guinea-savannah (7.7%, n = 1) ecological zones. These results provide important insights for strategic planning of malaria control programs in Nigeria.

Knowledge of hepatitis B virus infection among traders.

INTRODUCTION: Hepatitis B virus (HBV) is a public health problem in Nigeria, with 13% of its general population having evidence of a previous or current infection. Lack of awareness of HBV, its risk factors, and its consequences are recognized as major deterrents to adopting positive preventive behavior including immunization among HBV high-risk groups. OBJECTIVE: The objective of this study is to evaluate the knowledge, attitude, and practice (KAP) of HBV infection among traders. MATERIALS AND METHODS: A structured KAP questionnaire on HBV infection was administered to traders as part of the activities to mark the World Hepatitis Day in 2014. A score was created for the correct answer to 20 questions. RESULTS: A total of 335 traders were interviewed for this study. The mean age was 33.08 ± 13.8 years and the median age was 29 years. There were 165 males and 170 females. Majority of the traders had secondary education (57.1%) and were of the Ibibio and Igbo tribes. Only 10.4% had HBV vaccination. Only 44.2% of the traders reported having any knowledge of HBV. The most common source for the knowledge was television/radio (25%) and hospitals (22%). The median (interquartile range) of the overall KAP score was low (11, 5-16). The score was least in persons aged 35 years and above, but the difference was not statistically significant (P = 0.33). CONCLUSION: The knowledge of HBV is low among traders in Calabar metropolis. There is need to intensify educational campaigns for the general public.

The impact of an intervention to change health workers' HIV/AIDS attitudes and knowledge in Nigeria: a controlled trial.

The aim of the study was to improve health workers' skills and confidence in dealing with patients with HIV disease and increase attention to patients' human rights. A longitudinal controlled trial was carried out in which one Nigerian state served as the intervention site and the adjacent state served as the control site for an intervention and dissemination of training in clinical management, health education, and attitudinal change toward patients with HIV disease. The intervention group n=1072, control group n=480. Following initial questionnaire-defining focus groups, nurses, laboratory technologists and physicians in all base hospitals in the intervention state were trained by influential role models who attended the initial training. Data were collected in all sites pre-training and 1 y later. Hierarchical multiple regression analysis controlling for baseline data, and orthogonal factor analysis to define scales were used. Data showed significant positive changes after 1 y in the intervention group on perception of population risk assessment, attitudes and beliefs about people with HIV disease, less fear and more sympathy for and responsibility toward HIV patients, and an increase in self-perceived clinical skills. There was increased willingness to treat and teach colleagues about people with HIV. Clinician fear and discrimination were significantly reduced, and the climate of fear that was associated with HIV was replaced with a professional concern. There was increased understanding of appropriate psychosocial, clinical and human rights issues associated with HIV treatment and prevention. This intervention, targeting health workers in an entire state and using HIV/AIDS information, role modeling, diffusion of training and discussions of discrimination and human rights, significantly affected the perception of risk groups and behaviors, perceived skills in treatment and counseling, reduced fears and increased concern for people with HIV disease, and improved the climate of treatment and prevention of HIV disease compared with a control state.

Treatment of malaria in north-eastern and south-eastern Nigeria: a population study of mefloquine, sulphadoxine, pyrimethamine combination (MSP) vs chloroquine (CQ).

In a population-based study involving 4019 patients in 20 peripheral health facilities in Nigeria, the outcome of presumptive malaria treatment with MSP was compared to that of CQ. The study was conducted between January 1995 and January 1996. Patients aged 6 months or more with a clinical diagnosis of malaria based on history of fever and axillary temperature > 37.5 degrees C were either treated with MSP (250 mg mefloquine, 500 mg sulphadoxine, and 25 mg pyrimethamine per tablet) or CQ (150 mg chloroquine base per tablet). The clinical cure rate was assessed by the disappearance of clinical signs and symptoms over a 7-day period. Tolerability was assessed by the incidence of adverse events (adverse drug reaction and intercurrent illness). The result shows that the clinical care rate of suspected malaria was 97.6% with MSP and 85.6% with CQ. The incidence of adverse event was 9.5% with MSP and 9.2% with CQ. The withdrawal rate was 2.0% with MSP and 5.0% with CQ; 3.5% of the patients in the CQ group withdrew due to adverse events compared to 0.47% with MSP. In conclusion it was observed that in addition to superior efficacy of MSP over CQ, fever clearance rate with MSP was comparable to that of CQ. The study also demonstrated that two tablets maximum dose of MSP is safe and effective in a large population of Nigeria malaria patients.

Efficacy and tolerability of a low-dose mefloquine-sulfadoxine-pyrimethamine combination compared with chloroquine in the treatment of acute malaria infection in a population with multiple drug-resistant Plasmodium falciparum.

The efficacy and tolerability of single, low-dose mefloquine, sulfadoxine-pyrimethamine (MSP) combination was compared with chloroquine (CQ) for malaria treatment in a malaria-endemic area of Nigeria with multiple drug-resistant Plasmodium falciparum. The two drug regimens (MSP and CQ) were tested in a 12-month prospective population study. The patients were divided into two groups. Group 1 patients were treated presumptively, based on malaria symptoms. Group 2 patients were treated based on a parasitologic diagnosis using the World Health Organization seven-day in vivo test and extended to a 28-day follow-up period. Tolerability was assessed by the incidence and intensity of adverse events. One thousand nine hundred thirty-five patients visiting 10 health facilities, including the University of Calabar Teaching Hospital, were enrolled. The study showed that the low-dose MSP was efficacious, with day 7 response rates of 95% and 91% for (presumptive) Group 1 and (in vivo) Group 2, respectively, while CQ had day 7 response rates of 82% and 66% in Groups 1 and 2, respectively. The low-dose MSP was significantly (P < 0.0001) more efficacious, with faster fever and parasite clearance times than CQ in this area of CQ-resistant P. falciparum malaria. Eight patients treated with CQ, including seven severe cases (RII-RIII) were successfully re-treated with MSP. Adverse events were generally more common among those treated with MSP (29%) than those treated with CQ (17%). However, the adverse events caused by both drugs were mild to moderate and self-limited. The MSP combination appears to be a good substitute for CQ, in view of multiple drug resistance, especially in areas with severe (RII-RIII) malaria.

The pattern of neurological sequelae of childhood cerebral malaria among survivors in Calabar, Nigeria.

OBJECTIVE: To determine the pattern and long term outcome of neurological complications following cerebral malaria (CM) in a group of Nigerian children treated in Calabar. DESIGN: Prospective, follow up study. SETTING: Children's emergency room (CHER) of the University of Calabar Teaching Hospital (UCTH) located in a malaria-holoendemic rainforest belt of south eastern Nigeria. SUBJECTS: Survivors among 45 children with CM treated between February and December, 1991. All received intravenous quinine infusion and supportive care. Survivors (39) were followed up until detected neurological sequelae had resolved. RESULTS: Case fatality rate was 13.3%, 95% CI. Eleven (28.2%) of the survivors developed neurological sequelae. Prolonged coma, focal seizures and abnormal posturing (decorticate/decerebrate) were associated with increased risk of sequelae. Commonest neurological sequelae were cortical blindness (3/11), speech disorders (3/11: aphasia or echolalia) and motor abnormalities (5/11: dyskinesia/hemiplegia). Eight cases recovered completely from the neurological deficits within a mean period of three (1.3) weeks. One persisted with hyperactivity and attention deficit, had a remarkable improvement at the sixth month of follow up but developed secondary dyslexia and other learning disabilities by the third year of follow up. CONCLUSION: Although short lived, neurological sequelae of CM appear common among these Nigerian children. This problem could significantly add to the burden of childhood disability in Nigeria. Early diagnosis, use of appropriate drugs and large scale malaria control programmes can prevent malady.

HIV/AIDS infection control enforcement: a comparison between Nigeria and the United States.

We examined differences in approaches to HIV-related infection control practices in two university teaching hospitals in the United States and Nigeria. Health care workers (n = 202 in Nigeria and 186 in the USA) responded to a previously validated measure of infection control practices. There were significant differences in the estimated probability of treating a person with HIV disease (higher in USA), and a greater probability of peer ridicule as a way of enforcing group norms on infection control in Nigeria. Peer enforcement of norms was significantly lower in the USA. In both countries, more precautions would be taken if it was known that the patient was HIV infected. Infection control practices were more likely to be followed in the USA compared with Nigeria if they were praised for this activity, if appropriate facilities (sharps containers, gloves, etc.) were nearby, and if they felt that infection control procedures were effective. These data point to the importance of normative social pressures in Nigeria and of knowing the patient is HIV infected in the USA and feeling that infection control procedures are effective ways of avoiding occupational HIV infection. The role of normative pressures and assumptions about HIV infection status as well as cues and availability of facilities for infection control appear to differ between these health care workers in Nigeria and the USA.

An open trial of lisinopril ('ZESTRIL') in mild to moderate hypertension in Nigeria.

Fifty-one native Nigerian patients with mild to moderate essential hypertension received Lisinopril ('Zestril') in doses of 10 mg to 40 mg once daily. All patients received an initial dose of 10 mg, which was titrated up to a maximum of 40 mg if normotensive diastolic blood pressure had not been achieved. Reduction in mean diastolic blood pressure, when compared with baseline data, was significant (p < 0.001) following 16 weeks of treatment. Of the 46 evaluable patients, 32 (70%) had their blood pressure controlled (i.e. diastolic blood pressure < or = 90 Hg). Lisinopril ('Zestril') was well tolerated, with 27% of patients reporting adverse reactions of which cough was the most common. In conclusion, this study shows that Lisinopril ('Zestril"), when administered to Nigerian patients, is a clinically effective and well-tolerated for mild to Customer to supply Mss.

Cross-national HIV infection control practices and fear of AIDS: a comparison between Nigeria and the USA.

Fears about occupational transmission of HIV may have a significant impact on the behaviour of health care workers and on infection control practices. We investigated the relationships between fear of AIDS and infection control practices in health care workers in major university teaching hospitals in Nigeria and the USA. Data from the fear of AIDS scale and on a measure of infection control practices and beliefs showed that knowledge of whether the patient was HIV-infected determined infection control practices in Calabar but not Texas. Where the patient was known to be infected, there were no differences between the 2 countries. Fears of AIDS were related to infection control practices significantly more in the USA than in Nigeria where there was almost no relationship. These data may be influenced by the greater availability of disposable equipment in the USA compared with Nigeria.

PIP: HIV infection control practices and fear of AIDS were compared in 388 health care workers (doctors, nurses, nursing aides, and laboratory technologists) at major university teaching hospitals in Houston, Texas (US), and Calabar, Nigeria, in 1994. The mean duration of hospital employment was 9.2 years in Nigeria and 9.1 years in the US sample. The mean probability of treating a patient with AIDS in the next 12 months was estimated at 29.3% in Nigeria and 54.3% in the US. Nigerian hospital workers were as likely as their US counterparts to observe infection control practices such as carrying sharps in puncture-proof containers when they knew a patient had AIDS, but were not as compliant if the patient's serostatus was unknown. Differences in infection control practices were related to cross-national and not demographic or occupational factors. In the US, but not in Nigeria, there was a significant correlation between practices such as recapping of syringes by hand and fear of AIDS, regardless of prior knowledge of HIV status. The significantly stronger association between fear of AIDS and compliance with infection control practices in the US compared to Nigeria may reflect the higher HIV prevalence, more widespread availability of disposable equipment, stricter enforcement of infection control laws, and lower provider-patient ratios in the US setting.

In vivo efficacy of chloroquine, halofantrine, pyrimethamine-sulfadoxine and qinghaosu (artesunate) in the treatment of malaria in Calabar, Nigeria.

We used the WHO in vivo seven day test, extended to 14 day follow up to evaluate the efficacy of the alternative antimalarial drugs in Nigeria (1992), where chloroquine resistant P. falciparum (CRPD) has been confirmed. One thousand and four patients were screened. Those fulfilling recruitment criteria were randomly treated with chloroquine (CQ), n = 50, halofantrine (H), n = 53, pyrimethamine-sulfadoxine (P-S), n = 52 and qinghaosu (Q), n = 53. Parasitological treatment failures were found with all drugs i.e. CQ-53.6pc, H-9.5pc, P-S-28.5pc and Q-2.0pc. H and Q were significantly more efficacious than CQ and P-S, p < 0.003 and p < 0.006, respectively. similarly symptom clearance after 48 hours by H and Q, was 76.3pc and 94pc respectively, better than CQ. P-S was not significantly better than CQ, 64.4pc and 63.3pc, respectively, p > 0.05. The symptom clearance rate of CQ has markedly reduced from 97.7pc to 67.7pc, and in increased proportion of RIII, from 5.9pc to 14.3pc, are signs of increase in chloroquine resistant Plasmodium falciparum. Drug resistant P. falciparum in Nigeria constitutes a serious problem to malaria chemotherapy.

Perception of malaria infection in two rural communities in Nigeria.

This investigation was concerned with how and when parents and other members of two rural communities (Awi and Ikot Edem Odo) in Cross River State, Nigeria, recognized malaria infection, what they do to prevent the disease, and what triggers their treatment seeking behaviour (cue to action). The psychological and sociocultural contexts of these complex factors were considered. Focus group discussion (FGD) techniques were employed. A total of eight groups selected using theoretical sampling matrix method were categorized. A thirty-three-item FGD battery of guide questions was used. Information and data on knowledge, attitude, and practice (KAP) and the perception of malaria infection were generated. Analysis showed that both communities recognized the symptoms, morbidity and mortality of malaria infection in both adults and children. The mosquito vector was identified among numerous other causes of malaria. The pervasive role of ethnomedical sociocultural, and belief systems on KAP and perception of malaria were revealed. Both communities will likely benefit from health education interventions which recognize the belief systems of the two communities.

Hyperventilation in febrile Nigerian children without pneumonia: an evaluation of the influence of anaemia.

A total of 225 pre-school Nigerians were studied to evaluate the effect of anaemia on the respiratory rate of febrile children, and the influence of this on the reliability of the WHO criteria for the clinical diagnosis of pneumonia in the primary health care setting. Malaria was the commonest cause of febrile illness (63.1 pc). The prevalence of severe anaemia was 28.0 pc. The mean respiratory rate of anaemic children (53.9 +/- 12.8/min) was significantly higher than that of the non-anaemic (48.4 +/- 12.7/min; p = 0.011). Mean body temperature was not significantly different in both groups. Haematocrit was negatively correlated with respiratory rate. The positive correlation observed between temperature and respiratory rate was enhanced by decreasing haematocrit. More of the severely anaemic children (68.6 pc) exceeded the WHO respiratory rate threshold for diagnosis of pneumonia than the moderately anaemic (55.4 pc) or non-anaemic (36.1 pc). The specificity of the WHO criteria for clinical diagnosis of pneumonia decreased with decreasing haematocrit.

New trends in chloroquine efficacy in the treatment of malaria: significance of low (scanty) parasitaemia in an endemic area, with emerging chloroquine-resistant P. falciparum.

In a continuous malaria therapy surveillance, using in vivo (WHO) seven-day-test, extended to 14 days follow up, we evaluated the significance of low (scanty) parasitaemia, in an area with chloroquine resistance P. falciparum (CRPF), where self-medication is widely practised. We found that 30.9 pc of the patients screened had Plasmodium species, and 71.4 pc of these had low parasite counts of less than 500 parasites/mm3, whole blood. Eight pc of these were febrile and 41.7 pc of the parasite strains were not susceptible to chloroquine. Parasite strains from four of the patients were also resistant to other antimalarials. These patients gave psychosomatic symptoms, and were seen by a psychiatrist. We conclude that 41 pc of the patients with low parasite counts consist of patients with CRPF and/or multiple-drug resistant P. falciparum in this area. These do not only cause chronic anaemia, but also may be responsible for moderate psychosomatic symptoms in all ages.

Malaria parasite density and body temperature in children under 10 years of age in Calabar, Nigeria.

1,188 children under 10 years of age who attended the children's Emergency Clinic were examined from January to December 1988. Their axillary temperatures were recorded and thick and thin blood smears made to determine the malaria prevalence rate and the parasite density. The results show a high prevalence rate (44.8%) for malaria and this was stable throughout the year. The number of subjects with parasite densities of 100,000/mm3 and over, increased progressively with increase in body temperature such that 74.9% of the parasitemic subjects had high grade temperatures of 38 degrees C and over, while only 11.8% had moderate temperatures of 37.5-37.9 degrees C. The ratio of parasitemic afebrile to parasitemic febrile patients was in the order of 1:6, suggesting that parasitaemia is usually accompanied by fever. There was a steady rise in temperature with parasite density up to 39.5 degrees C, when further increase in parasite density apparently caused no further rise in temperature, suggesting a self-protective efficient feed back mechanism.

PIP: Fever due to malaria may be continuous , intermittent, remittent, irregular, or absent. This study, therefore, investigates whether a relationship exists between body temperature and parasitemia, which could prove helpful in diagnosing and treating children with febrile illness. 1188 children under age 10 attending the children's Emergency Clinic in Calabar, Nigeria, throughout 1988 were examined. The malaria prevalence rate and parasite density were found from measuring axillary temperatures and analyzing thick and thin blood smears. The malaria prevalence rate was found to be stable at 44.8% over the year. The number of children with parasite density of 100,000/sq. mm and higher increased progressively with body temperature. 74.9% of parasitemic children had high-grade temperatures of 38 degrees Celsius and over, while 11.8% had a moderate temperature of 37.5-37.9 degrees Celsius. These results suggest that parasitemia is usually accompanied by fever. Further, temperature increased steadily with parasite density, up to 39.5 degrees Celsius, beyond which point increases in parasite density failed to produce additional rises in temperature.

New trends in chloroquine efficacy in the treatment of malaria: chloroquine-resistant Plasmodium falciparum in Anambra and Benue States of Nigeria.

Increasing malaria treatment failures with chloroquine (C25) and reports of chloroquine resistant Plasmodium falciparum (CRPF) led to the field survey of two sites (Agbani and Jato-Aka) both in Primary Health Zone A, using WHO--in vivo seven-day test, modified to 14-day follow-up period. Of the 922 children studied, high transmission rates of 40 pc and 59.2 pc were found in Agbani and Jato-Aka respectively. Varying degrees of parasitologic failures (CRPF), 52 pc in Agbani and 60 pc in Jato-Aka were confirmed. However, chemotherapy with C25 significantly reduced the clinical symptoms of malaria infection, even in the CRPF-cases. The clinical success in the two study sites were 69 pc ad 94 pc respectively.

Correlation between in vivo and in vitro response of chloroquine-resistant Plasmodium falciparum in Calabar, south-eastern Nigeria.

Since chloroquine-resistant Plasmodium falciparum (CRPF) has emerged in Nigeria, we monitored the susceptibility of the parasite strain to a standard chloroquine (C25) dose in our Children's Emergency Unit. Chloroquine (CQ) is the drug of choice for malaria chemotherapy in Nigeria. The WHO 7-day in vivo evaluation and Rieckmann's microtitre technique (in vitro test) were used. 33 children of mean age 4.9 years were enrolled in the study. 27 (81.8%) of the in vitro cultures were successful. 16 (59.3%) of the successful isolates still showed schizogony at CQ concentration of 5.7 pmol/well and above. 28 (84.8%) of the children completed the in vivo study. 15 (53.6%) were parasitaemic on day 7 and/or day 14 and were regarded as parasitologic failures. The isolates from 14 of these children showed corresponding in vitro resistance of CQ concentrations equal to or above 5.7 pmol/well. The proportion of RIII (= 13.3%) appears to have increased as compared to 5.9% recorded in 1987. We conclude that there appears to be a good correlation between in vivo evaluation of parasitologic failures (53.6%) and in vitro resistance (59.3%). It thus appears that CRPF is definitely increasing in South-Eastern Nigeria. This can be expected not only to complicate malaria chemotherapy in the Children's Emergency Unit of the University of Calabar Teaching Hospital, but will contribute immensely to the deterioration of malaria therapy and control in Nigeria.

Problems of chloroquine-resistant P. falciparum in Nigeria: one antimalaria drugs' utilisation in metropolitan Calabar.

We studied the antimalarial drugs utilisation pattern in urban Calabar, with a view to determining what drugs people take when they have malaria attack and who diagnoses and prescribes the drugs. We used a standard questionnaire data sheet to record the results of the interview carried out by the authors. Malaria symptoms and the drugs consumed were diagnosed and prescribed respectively by self (54pc), qualified medical doctor (32pc) and others including paramedical staff (2pc). The rest (12pc) took traditional remedies. The antimalarial drugs (chloroquine, fansidar, camouqin) were chosen because of their efficacy/popularity (21pc), cheapness (43pc) and availability (34pc). Among those interviewed, only 21.2pc took the adequate curative dose of 25 mg/kg chloroquine for 3 days according to WHO recommendations. Majority of the consumers took their drugs orally, but some (17pc) had chloroquine injections, administered, in some cases, by ill-qualified patient medicine dealer. The results show that there is an association between the level of education and the pattern of remedy sought by the respondents (p less than 0.05). Self-medication was practised significantly more by those with formal education than by those without (p less than 0.05). The trend of consulting patent medicine dealers for prescription decreased with acquisition of more formal education. Conversely, significantly more of the respondents with higher education consulted qualified medical doctors or paramedical staff (P less than 0.05). Two aspects of drug abuse observed here, i.e. the utilisation of sub-curative doses of chloroquine and monotherapy are believed to be two of the factors that lead to the several chloroquine treatment failures which have been recently reported in Calabar, and other areas of Nigeria.

Malaria and its treatment in rural villages of Aboh Mbaise, Imo State, Nigeria.

We examined the malaria situation among 489 children under 5 years of age in the rural villages of Aboh Mbaise, Nigeria, using a combination of a standard questionnaire technique and laboratory diagnosis to confirm clinical observations. The results show a high prevalence rate of 52.8% for Plasmodium falciparum in this area. The geometric mean parasite density (GMPD) was 19,361.4/mm3. The proportion of children with fever and/or parasitaemia was not related to age, although the numbers in the febrile group appeared to increase with age. Using 37.5 degrees C as the threshold for fever, 48.7% of the heavily infected group (more than 1000/mm3) were afebrile while 51.3% were febrile. High grade temperatures above 38 degrees C were associated with high parasitaemia above 10,000 parasites/mm3. Of the 911 children who died in the area within the last five years, 22.4% died of fever of unknown origin, 39.7% from malaria, 22.5% from convulsion, 10.5% from diarrhoea and 4.6% from cough. Chloroquine is the drug of choice for the treatment of malaria and there were many cases of drug abuse, and use of sub-curative doses prescribed by non-medically qualified staff.

A retrospective study of malaria and malnutrition in the University of Calabar Teaching Hospital, Calabar, Nigeria.

Morbidity and mortality due to malaria and marasmic kwashiorkor were determined from hospital records in the University of Calabar Teaching Hospital over five years. Malaria was found to be a significant cause of morbidity but was responsible for only 3.5% of the deaths that occurred during the period. This represents 0.3% of all infant deaths and 2.0% of deaths in children aged 1-4 years. The percentage of malaria deaths, 4.4% (1983), 5.2% (1984), 3.0% (1985) and 1.9% (1986), respectively showed a downward trend but went up again to 2.8% (1987), probably due to the treatment failures ascribed to chloroquine in the area. Malnutrition on the other hand, resulted in 174 deaths as opposed to 42 deaths due to malaria in children under six years of age. More of these deaths due to malnutrition (40.8%) occurred in children aged 2-3 years, just as the case with malaria (33.3%). 20.7% of these deaths occurred in infants. These results suggest that the pride of place, as a number one killer, goes to malnutrition while malaria is a serious cause of morbidity.