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Opinion — tropical infectious diseases

Urbanization, malaria transmission and disease burden in Africa

Abstract

Many attempts have been made to quantify Africa's malaria burden but none has addressed how urbanization will affect disease transmission and outcome, and therefore mortality and morbidity estimates. In 2003, 39% of Africa's 850 million people lived in urban settings; by 2030, 54% of Africans are expected to do so. We present the results of a series of entomological, parasitological and behavioural meta-analyses of studies that have investigated the effect of urbanization on malaria in Africa. We describe the effect of urbanization on both the impact of malaria transmission and the concomitant improvements in access to preventative and curative measures. Using these data, we have recalculated estimates of populations at risk of malaria and the resulting mortality. We find there were 1,068,505 malaria deaths in Africa in 2000 — a modest 6.7% reduction over previous iterations. The public-health implications of these findings and revised estimates are discussed.

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Figure 1: Population totals from 1950–2050.
Figure 2: Mean population density (persons per km2) in 2000 of the 37 urban agglomerations (UA) in Africa.
Figure 3: Bar plots of APfEIR by land-use category (a) and APfEIR by dry or wet ecozone (b).
Figure 4: Plot of PR by log10APfEIR.
Figure 5: Childhood mortality in Africa.
Figure 6: The MARA model14 of fuzzy climate suitability (FCS) for P. falciparum malaria transmission.
Figure 7: Plot of PR by log10 APfEIR.

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Acknowledgements

We are grateful to C. Fanello and C. Drakeley for discussion and for sharing unpublished reports. C. Mbogo is thanked for providing geo-referencing information from his published APfEIR and PR data. A. Wilson is also acknowledged for help in constructing the Nairobi time-series data. We similarly thank A. Graham, D. Rogers and S. Randolph for comments on earlier drafts of the manuscript. S.I.H. is funded by a Research Career Development Fellowship from the Wellcome Trust. R.W.S. is a Wellcome Trust Senior Research Fellow and acknowledges the support of the Kenyan Medical Research Institute (KEMRI). This paper is published with the permission of the director of KEMRI.

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Glossary

ANNUAL P. FALCIPARUM ENTOMOLOGICAL INOCULATION RATE

The number of P. falciparum positive mosquito bites per person per year.

FUZZY CLIMATE SUITABILITY

The suitability of local climate to support P. falciparum malarial transmission in an average year. It is represented as a value between 1 and 0, where 1 is completely suitable and 0 completely unsuitable.

PARASITE PREVALENCE RATIO

The proportion of a sampled population who have P. falciparum in their blood.

PERI-URBAN

Defined here for Africa as locations with 250–1,000 persons per km2.

RURAL

Defined here for Africa as locations with fewer than 250 persons per km2. This is further subdivided into rural 1 (100–250 persons per km2) and rural 2 (<100 persons per km2).

SPATIAL DEPENDENCE

The tendency for observations close in space to be more highly correlated than those further apart.

URBAN

Defined here for Africa as locations with more than 1,000 persons per km2.

URBAN AGGLOMERATION

An area with population within the contours of contiguous territory inhabited at urban levels of residential density without regard to administrative boundaries of 1 million inhabitants or more in 2003.

VARIOGRAM

A function used to represent spatial dependence.

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Hay, S., Guerra, C., Tatem, A. et al. Urbanization, malaria transmission and disease burden in Africa. Nat Rev Microbiol 3, 81–90 (2005). https://doi.org/10.1038/nrmicro1069

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