# A Cox Proportional Hazards Model Approach to Identifying Malaria Risk Factors in Children in South Sudan

## TL;DR

This study identifies risk factors for child mortality from malaria in South Sudan using a statistical model.

## Contribution

The study applies a Cox proportional hazards model to analyze malaria-related child mortality risk factors in South Sudan.

## Key findings

- Older age and comorbidities increase the risk of death in children with malaria.
- Higher body weight and treatment with quinine are associated with lower mortality risk.
- Quinine showed better outcomes than artesunate, contrary to previous findings.

## Abstract

Introduction

Malaria represents a critical public health concern worldwide, with a pronounced impact in tropical and subtropical regions. In South Sudan, it is a primary contributor to illness and death, particularly among children. This study aimed to identify the risk factors that affect the survival of children with malaria in South Sudan.

Methods

This hospital-based retrospective study was carried out at Al Sabah Children’s Hospital in Juba, South Sudan. Data were obtained from the records of children with malaria who were admitted and ranged in age from 1 month to 15 years during the period from January 1 to December 31, 2021. The Cox proportional hazards model was employed to identify the risk factors affecting the survival of children suffering from malaria.

Results

This study included 6,410 children diagnosed with malaria; males constituted 56.08% and females 43.92%. Censored cases were 95.27%, and those who died constituted 4.73%. The average age of the study cohort was 23.66 months (95% CI: 23.01 to 24.32). Results from the Cox proportional hazards model showed that age was associated with an increased hazard of death (hazard ratio 1.0223, 95% CI: 1.0158 to 1.0280), and body weight was associated with a decreased hazard of death (hazard ratio 0.8513, 95% CI: 0.8146 to 0.8896). Treatment with quinine was associated with a lower risk of death (hazard ratio 0.7107, 95% CI: 0.5501 to 0.9183) compared to treatment with artesunate. Children without comorbidity had a lower risk of death (hazard ratio 0.5530, 95% CI: 0.4273 to 0.7157) compared to those with comorbidity. These covariates were statistically significant (p < 0.01).

Conclusion

In this study, increased mortality risk was linked to both age and the presence of comorbidities among children with malaria. In contrast, increased body weight reduces the hazard of death. Also, treatment with quinine is associated with a reduced risk of death compared to artesunate, which is contrary to studies showing that artesunate is superior to quinine. Quinine is still the drug of choice in the treatment of malaria in South Sudan. Enhancing programs aimed at reducing the malaria burden in children, and ensuring the availability of good-quality drugs to improve treatment outcomes, is important for child health.