Epidemiological assessment of malaria in children under five in Kanifing general hospital, The Gambia: analysing seasonality, spatial distribution, and predictors of fatality (2021–2024)

In The Gambia, malaria control has led to significantly lower national prevalence, yet transmission remains spatially heterogeneous. Identifying localized drivers of morbidity is essential for the transition from control to elimination. This study characterized the epidemiology of pediatric malaria at Kanifing General Hospital (KGH), investigating seasonal fluctuations, spatial clustering, and determinants of case fatality in the Western One Health Region. A retrospective cross-sectional analysis was conducted on laboratory-confirmed malaria cases in children under five years (n = 366) at KGH between 2021 and 2024. Spatial distribution was mapped using QGIS based on residential catchments. We utilized multivariable logistic regression to calculate adjusted odds ratios (aOR) for predictors of mortality, focusing on demographic and clinical presentations. A significant bimodal transmission pattern was identified, with peaks occurring during February–May and September–December. The majority of cases (67.8%) originated from the urban Kanifing Municipal Council. The overall case fatality rate (CFR) was 16.7% (n = 61), peaking at 36.0% in 2023. Children aged 0–2 years faced a significantly higher risk of mortality (aOR 4.25; 95% CI 2.01–8.62, p < 0.001). Severe malaria diagnosis was the most potent predictor of death (aOR 166.9; 95% CI 25.66–1554.5, p < 0.001). Interestingly, the presence of vomiting at admission was associated with a 68% reduction in the odds of mortality (aOR 0.32; 95% CI 0.16–0.6). The presence of a “dry season” transmission peak (February–May) suggests that urban micro-environments, such as permanent wetlands in Kanifing, support perennial vector activity. High mortality among children under 24 months underscores a gap in acquired immunity and the need for age-stratified clinical interventions. These findings advocate for a temporal expansion of seasonal malaria chemoprophylaxis (SMC) and targeted larval source management in urban hotspots to disrupt the bimodal transmission cycle.