Using sentinel surveillance system data to characterize severe malaria illness and quality of malaria case management among hospitalized patients in Kenya, 2017–2024

Abstract Background In Kenya, limited clinical data on hospitalized malaria patients restricts insights into disease severity and care quality. Using data from the Integrated Facility-based Surveillance (IFBS) system—a sentinel surveillance platform for febrile illnesses across twelve facilities—the assessment focused on risk factors for severe illness and mortality, diagnostic accuracy of microscopy, and adherence to severe malaria treatment guidelines. Methods Analysis of IFBS data obtained from June 2017 to July 2024 was performed using bivariable logistic regression to identify factors linked to severe illness and deaths. Microscopy results were compared with PCR results to assess diagnostic concordance. Evaluation also included whether patients received parasitological confirmation before treatment and if severe cases received IV artesunate followed by artemether-lumefantrine (AL), per standard guidelines. Results Among 8,487 inpatients, 2,197 (25.9%) tested positive for malaria by either microscopy or rapid diagnostic test; among malaria cases, 713 (32.5%) had severe disease and 16 (0.7%) died. Infants had greater odds of severe illness compared to older ages (odds ratio [OR] was < 1.0 for other age groups compared to ≤ 1 year-old). Both severe illness and death were associated with fever duration of ≥ 5 days compared to ≤ 1 day (ORs: 3.67 and 8.00, respectively) and having been referred from another facility (ORs: 3.01 and 3.15, respectively). Positive microscopy at the health facility was PCR negative in 21% of patients. Only 15% of severe cases were documented to have received both IV artesunate and AL, while 17% received IV quinine. Conclusions Modifiable factors that suggested delayed care-seeking were associated with worse malaria outcomes in Kenya. Furthermore, gaps in diagnostic accuracy and adherence to treatment protocols for severe malaria were observed during chart review. These findings point to the importance of behaviour change strategies as well as messaging in the community that promote timely care-seeking, referrals and follow-up, especially for the youngest children. Potential malaria over-diagnosis underscores the need for strengthening quality assured microscopy programs with adequate training of microscopists and properly functioning microscopes and reagents, as well as an external quality assurance programme that routinely provide feedback on performance and identify areas for improvement.