The effect of malaria on childhood anemia in a quasi-experimental study of 7,384 twins from 23 Sub-Saharan African countries

Tim Starck*, Peter Dambach, Toussaint Rouamba, Halidou Tinto, Faith Osier, Catherine E. Oldenburg, Maya Adam, Till Bärnighausen, Thomas Jaenisch, Caroline A. Bulstra

*Corresponding author for this work

Research output: Contribution to journalArticleAcademicpeer-review


Background: Young children in Sub-Saharan Africa (SSA), particularly those from resource-limited settings, are heavily burdened by anemia and malaria. While malaria infected children frequently become anemic (hemoglobin < 110 g/L), anemia is a strongly multifactorial disease with many other risk factors than malaria. Due to the complex and often overlapping contributors to anemia, it remains challenging to isolate the true impact of malaria on population level hemoglobin concentrations. Methods: We quantified the malaria-induced effect on hemoglobin levels in children under 5 years of age, leveraging data from 7,384 twins and other multiples, aged 6 to 59 months, from 57 nationally representative Demographic and Health Surveys (DHSs) from 23 SSA countries from 2006 to 2019. The quasi-experimental twin fixed-effect design let us minimize the impact of potential confounders that do not vary between twins. Results: Our analyses of twins revealed a malaria-induced hemoglobin decrease in infected twins of 9 g/L (95% CI -10; -7, p<0.001). The relative risk of severe anemia was higher (RR = 3.01, 95% CI 1.79; 5.1, p<0.001) among malaria positive children, compared to malaria negative children. Conversely, malaria positive children are only half as likely to be non-anemic (RR = 0.51, 95% CI 0.43; 0.61, p<0.001). Conclusion: Even after rigorous control for confounding through a twin fixed-effects study design, malaria substantially decreased hemoglobin levels among SSA twins, rendering them much more susceptible to severe anemia. This effect reflects the population-level effect of malaria on anemia.

Original languageEnglish
Article number1009865
JournalFrontiers in Public Health
Publication statusPublished - 6 Dec 2022

Bibliographical note

Funding Information:
For the publication fee we acknowledge financial support by Deutsche Forschungsgemeinschaft within the funding programme Open Access Publikationskosten as well as by Heidelberg University and the Heidelberg Institute of Global Health.

Publisher Copyright:
Copyright © 2022 Starck, Dambach, Rouamba, Tinto, Osier, Oldenburg, Adam, Bärnighausen, Jaenisch and Bulstra.


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