Rachel Brim: Cognitive outcomes and psychiatric symptoms following cerebral malaria in Malawi

Read proposals by Rachel Brim, Lindsey Retterath & Sara VanBronkhorst Schaafsma, the MSU College of Human Medicine students who were selected to receive Blake W.H. Smith, PhD, Scholarships for 2012.

The Proposal


Background and Significance:

Rachel Brim

In 2009, there were an estimated 225 million cases of malaria worldwide with nearly 781,000 deaths attributed to the disease. The majority of these deaths occurred in young children in sub-Saharan Africa. The severity of the disease ranges from a febrile illness to severe, cerebral malaria (CM) caused exclusively by Plasmodium falciparum. The child mortality rate with CM ranges from 12-25%, and the survivors of CM represent a neurologically vulnerable group. An estimated 30% of CM survivors develop neurological sequelae including epilepsy, behavioral changes, cognitive dysfunction, and gross neurologic deficits.

This project attempts to further characterize the long term neurologic changes in a defined CM cohort in Malawi. This area of interest emerged in 2006 as an unexpected outcome in Dr. Gretchen Birbeck’s case-control study linking CM and the onset of epilepsy in children of sub-Saharan Africa. This project will utilize a long standing study cohort coordinated by Dr Terrie Taylor, which characterizes a population of CM survivors through clinical observations, EEG findings, opthalmoscopic data, and acute and convalescent magnetic resonance imaging.

Specific Aims/Objectives:

This study will further define the connection between CM and long term neurological sequelae with a focus on behavioral change.

  • To characterize the attention, memory, and other cognitive changes in a defined cohort of CM survivors in Malawi
  • To utilize culturally relevant screening tools in the assessment of Malawian children
  • To utilize structured interviews and focus groups to establish the effects these behavioral changes have on the survivors quality of life and overall morbidity
  • To compare CM survivors with non-CM malaria survivors with regard to neurological function over time

Using culturally relevant screening tools, I will have the opportunity to assess CM survivors in a variety of settings (home and school) to characterize any neurologic changes after the onset of CM. I will work to further identify and define behavioral changes in this population especially in regards to memory and attention. I will focus on specific behavior patterns that are deemed disruptive by parents and teachers, and behaviors that may decrease the child’s quality of life. Focus groups or structured interviews may be held with parents, teachers, and children to develop an understanding of the cultural and societal impact of these behaviors.

I will play a role in coordinating the research team at a local level (currently a team of two nurses, a manager, and a driver). This includes aiding in the participant enrollment process, assisting with data management, and addressing the team’s general needs and concerns. I will also have the opportunity to participate in the care of children with acute CM, which will help broaden my understanding of this disease process.

Prior to departure, I will work with Dr. Jed Magen (child psychiatry) and Dr. Margaret Semrud-Clikeman (pediatric neuropsychologist) to develop an understanding of how to conduct the necessary behavior observations, focus groups, and structured interviews.

Preliminary studies:

Birbeck G, et al. Blantyre Malaria Project Epilepsy Study (BMPES) of neurological outcomes in retinopathy-positive paediatric cerebral malaria survivors: A prospective cohort study. Lancet 2010;9:1173-81.

Boivin M, et al. The neurocognitive effects of retinopathy-confirmed cerebral malaria in school-age Malawian children. Malawi Mental Health Research and Practice Development Conference. Blantyre, Malawi, 2011.

Magen J, et al. Adapting the Achenbach Child Behavior Checklist (CBCL) as a psychiatric screening tool for DSM IV diagnosis in Malawian children. Malawi Mental Health Research and Practice Development Conference. Blantyre, Malawi, 2011.

Boivin MJ, Gladstone MJ, Vokhiwa M, et al. Developmental outcomes in Malawian children with retinopathy-confirmed cerebral malaria. Annual meeting of the Pediatric Academic Societies. Vancouver, BC Canada, 2010.

Vroman L, Semrud-Clikeman M, Taylor TE, Seydel K. Corpus Callosum Morphology in Retinopathy-Confirmed and Retinopathy-Negative Malawian Children Diagnosed with Cerebral Malaria. National Academy of Neuropsychology. Marco Island, FL, 2011.