Beyond child mortality: paediatric neurorehabilitation and the long-term impacts of cerebral malaria in sub-Saharan Africa

The World Health Organisation’s (WHO) most recent world malaria report estimates that there were 282 million new cases of malaria in 2024, an increase of 9 million (+3.19%) from 2023 (1). Cerebral malaria, caused by infection of the cerebrum by Plasmodium falciparum, is the deadliest subtype of severe malaria and is disproportionately prevalent in sub-Saharan Africa, notably among children under five years (1-2). While survival rates of infection are increasing globally, the risk of developing a neurological deficit (ND) remains (2).

An ND is an impairment to regular function of the nervous system. Epilepsy, hemiplegia, ataxia and paresis are typical in cerebral malaria patients post-discharge (3), with implications for movement, function and speech. The literature is clear on the impact of NDs – a 2021 systematic review by Abuga and colleagues found that childhood-onset of ND increased the risk of premature mortality by 2-3 times, with risks even higher in low- and middle-income countries (LMICs) (4). This increased risk of mortality is likely due to inadequate medical facilities and resources, as well as a lack of education regarding NDs and their long-term effects, both among healthcare workers, as well as patients’ families (5-6). The impact of NDs is further exemplified in survivors of childhood cerebral malaria – one study found significant deficits in survivors’ math skills and overall cognition up to 15 years post-infection (7).

Neurorehabilitation is a leading long-term treatment for NDs, both congenital and acquired. Neurorehabilitation is led by physiotherapists and often aided by a multidisciplinary team, working with patients to improve their physical and mental function through exercises and real-life practice. In sub-Saharan Africa, the need for neurorehabilitation is great – a 2021 global burden study found that the region exhibited the highest rates globally of both prevalence of and years lived with neurological disability per person (8). Adjuncts or complimentary treatments as simple as Constraint Induced Movement Therapy (9) and as complex as virtual reality or other computerised simulations (10) have found success in the neurorehabilitation of NDs in Europe and could be adapted to the African context. The more complex or technologically advanced an adjunct is, the higher its potential for effective rehabilitation. However, these adjuncts also require more resources and education for their continued use, making them less accessible to remote and resource poor communities. The issue, then, lies in both the accessibility of these adjuncts and the education of healthcare professionals regarding their use.

When resources are allocated to children, the impact is clear – survivors of cerebral malaria in sub-Saharan African countries, such as Uganda have experienced life-changing rehabilitation by way of computerised cognitive rehabilitation (11-13), with brilliant advancements by researchers like Paul Bangirana of Makerere University in Uganda. These rehabilitation programmes leverage computer software which immerses the user into an altered sensory environment. This is relatively costly in sub-Saharan Africa, the region with the lowest proportion of internet users per capita at 36% (14). However, scaling-up is not insurmountable with greater investments in internet infrastructure, especially in rural areas (15).

Reducing the burden of malaria needs to move beyond simply preventing deaths—there is a need to find approaches that enable survivors to flourish as children, adolescents and into early adulthood. Neurorehabilitation via digital adjuncts is one such pathway and is worthy of adequate investment.

Hero image: Image courtesy of Awesome Nervous System Wallpapers. https://wallpaperaccess.com/neural-system

References

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