ABSTRACT

Corresponding Author:
Nasreen Ali,
D/o. Dr. M. F. Ali,
1st Military Lane,
Berhampur-760001,
Odisha.
E-mail: nasreenurfriendmbbs@gmail.com

ABSTRACT

BACKGROUND

Malaria is a major cause of morbidity and mortality in the tropical and subtropical regions of the world. Our state Odisha alone accounts for 27% of all malaria cases and 18% of all malaria deaths. Since severe malaria is associated with high mortality, a scoring system for predicting the outcome (like GCRBS) will be of great help for a treating clinician in identifying the patients needing more intensive medical care and prognosticate chances of survival.

MATERIALS AND METHODS

A hospital-based descriptive study was conducted to include all cases of severe malaria in patients <14 years of age admitted to the Paediatric Department of MKCG Medical College and Hospital during the study period from October 2014-September 2016. The exclusion criteria included cases which were suspected malaria cases having negative lab diagnosis. The diagnosis of malaria was confirmed by blood tests (microscopic and RD test). Then a detailed clinical evaluation of each patient and laboratory investigations were done following which GCRBS scoring was given to each patient. Clinical findings, haematological and biochemical investigations were analysed in SPSS V24 software, and Chi Square analysis along with Odds ratio were calculated to know the statistical significance and the sensitivity and specificity of the GCRBS score was calculated.

RESULTS

A total of 185 cases of severe malaria as per WHO criteria were included in the study. In which, 107 (58%) were male and 78 (42%) were female. The age of the patients ranged from 3 months to 14 years. Majority were in <5 years age group (51.9%). Fever is the most common presenting symptom (97.8%). The most common clinical manifestation was severe anaemia (69.7%). The causative agent was P. falciparum in 81.1%. The overall mortality in the study was 9.7%. Higher the GCRBS score poorer was the outcome. As the scores increase, sensitivity of predicting mortality is decreasing and specificity is increasing. GCRBS has a good discriminatory ability between survivors and non-survivors.

CONCLUSION

The GCRBS score seems to be a very good working tool as it is very easy to calculate and easy to remember. Like GCS score system which is popular among doctors, this too will help in predicting outcome of severe malaria in children and indirectly reducing the mortality.

KEYWORDS

Severe Malaria, Outcome, GCRBS Score.

BACKGROUND

Malaria is a major cause of morbidity and mortality in the tropical and subtropical regions of the world. 52% of all confirmed cases in South East Asia region are reported in India, where 5 states (Odisha, Chhattisgarh, MP, Jharkhand and WB) account for 60% of these cases. Our state Odisha alone accounts for 27% of all malaria cases and 18% of all malaria deaths.^[1] Since severe malaria is associated with high mortality, a scoring system for predicting the outcome (like GCRBS) will be of great help for a treating clinician in identifying the patients needing more intensive medical care and prognosticate chances of survival. GCRBS score adopted by Mohapatra B N et al has a possible score of 0-10, with higher the score poorer the outcome. 5 parameters are required for its calculations namely GCS, Creatinine, Respiratory rate, Bilirubin and systolic BP (pneumonic GCRBS). Out of these creatinine and bilirubin are laboratory parameters and the rest three are clinical parameters. The score is given to each parameter and the summation of all will give the total score. At a cut-off score of 5, the prediction of mortality has a sensitivity of 85.3% and specificity of 95.6%.^[2] The greatest advantage of this scoring is that, all the parameters are objective and has very minimal to none observer bias.

DISCUSSION

The GCRBS score by Mohapatra BN et al is a new scoring system for predicting the outcome in severe malaria. Glasgow Coma Scale (GCS<11), Creatinine (>3 mg/dL), Respiratory rate (>24/min.), Bilirubin (>10 mg/dL) and Systolic BP (<90 mmHg) are taken into account. The GCRBS score has a possible score of 0-10.^[2] In the present study, male outnumbered female with the ratio of 1.37:1. In a study by Sathpathy et al, it was found to be 1.6:1.^[3] This can be explained by the fact that more outdoor activity of the males and better clothing of females in India may favour this trend. In the series reported by Bhave S Y et al, maximum cases were observed in the age group of 0-5 years^[4] which is similar to our study. This may be due to differential parasite organ sequestration in young children as compared to older children and also because of low complementary regulatory protein. Cerebral malaria was responsible for maximum number of deaths. This finding was similar to Tripathy R et al^[5] but less than African studies by Mockenhaupt FP et al.^[6] The relationship between higher GCRBS and poorer outcome was similar to Mohapatra BN et al.^[2]

CONCLUSION

The severe cases are likely to be only the ‘tip of the iceberg’. Many children living far from the health care units may die at some local hospital due to delay in the referrals, hence early diagnosis and classification of severe malaria would allow appropriate management and early referrals. The GCRBS score seems to be a very good working tool as it is very easy to calculate and easy to remember. Like GCS score system which is popular among doctors, this too will help in predicting outcome of severe malaria in children and indirectly reducing the mortality.