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Background: Long-term outcomes following febrile seizures in African children are not well described, but ma- laria-associated seizures are a risk factor for epilepsy. Design/Methods: 107 consecutive children admitted with febrile seizures (FS group) were age-matched to concurrently admitted children with febrile illness and no seizure, or febrile illness only (FIO). Quarterly follow-up assessments deter- mined interim seizures and developmental outcomes. Results: 214 children were enrolled and followed for mean 20.4 months (median 24, mode 27). The most common diag- nosis was clinical malaria. During follow-up, children in the FS group were more likely to have recurrent febrile seizures (29.9 vs. 11.3%; RR1.27; CI 1.10-1.46), an unprovoked seizure (27.1 vs. 1.9%; RR 1.35; CI 1.20-1.52) and epilepsy (11.2 vs. 0.9; RR 1.16; CI 1.04-1.20). Risk factors for unprovoked seizures during follow-up included younger age at enroll- ment (25.5 v. 34.6 months, p=0.04) and developmental delay preceding the index illness (33.3 vs. 13.1%, p=0.009). Within the FS group, children with focal seizures at enrollment were more likely to experience unprovoked seizures (52.9 vs. 20%, p=0.007) and epilepsy (41.7 vs. 7.8%, p=0.03). Conclusions: Children admitted with febrile seizures in rural Zambia have a high risk of subsequent epilepsy. Further re- search is needed to determine if specific infectious etiologies (e.g. malaria) are associated with epilepsy development in such children. Where access to healthcare services are limited, febrile seizure admission may also be a marker for a pre- existing propensity toward later epilepsy. Regardless, follow- up is warranted to facilitate early initiation of treatment if recurrent, unprovoked seizures occur.