When severe malaria is called sepsis, and why African artemisinin resistance may be invisible

The edition in brief

Eighty-five per cent of sepsis cases and deaths occur in low-income and middle-income countries, and the global burden estimates that establish this have absorbed deaths from malaria, leptospirosis, tuberculosis and gastroenteric illness into the sepsis category. A Lancet Infectious Diseases Personal View argues that this conflation is both useful and harmful: useful because it makes preventable deaths visible, harmful because these illnesses follow different trajectories, arrive after long prehospital courses, and need disease-specific diagnosis and treatment rather than a generic bundle. The authors propose a separate label, sepsis from an endemic and emerging infectious disease, with its own severity stratification. A systematic review of 96 studies of Plasmodium falciparum finds that the parasite clearance half-life thresholds used to define artemisinin partial resistance were derived in southeast Asia and may not detect it in Africa: in east Africa and the Horn of Africa, independently emergent kelch13 mutations generally cleared faster despite raised ring-stage survival, so surveillance built on clearance half-life alone risks missing spread until it is fixed. In a pilot randomised trial of 57 parents in two Tennessee clinics, a tailored pre-visit web app was followed by HPV vaccine initiation in 48% versus 17% with attention control, though the knowledge and concern measures did not separate significantly. The practice-changer is a meta-analysis of 25 observational studies of infection after total knee replacement, which puts numbers on the modifiable risks — preoperative anaemia, drains left for 24 hours or more, postoperative urinary tract infection, smoking, obesity and diabetes — and so on what a pre-operative clinic can actually change.