title: Impact of artemisinin-based combination therapy and insecticide-treated nets on malaria burden in Zanzibar.
abstract: BACKGROUND
  The Roll Back Malaria strategy recommends a combination of interventions for malaria control. Zanzibar implemented artemisinin-based combination therapy (ACT) for uncomplicated malaria in late 2003 and long-lasting insecticidal nets (LLINs) from early 2006. ACT is provided free of charge to all malaria patients, while LLINs are distributed free to children under age 5 y ("under five") and pregnant women. We investigated temporal trends in Plasmodium falciparum prevalence and malaria-related health parameters following the implementation of these two malaria control interventions in Zanzibar.
  
  
  RESULTS
  Cross-sectional clinical and parasitological surveys in children under the age of 14 y were conducted in North A District in May 2003, 2005, and 2006. Survey data were analyzed in a logistic regression model and adjusted for complex sampling design and potential confounders. Records from all 13 public health facilities in North A District were analyzed for malaria-related outpatient visits and admissions. Mortality and demographic data were obtained from District Commissioner's Office. P. falciparum prevalence decreased in children under five between 2003 and 2006; using 2003 as the reference year, odds ratios (ORs) and 95% confidence intervals (CIs) were, for 2005, 0.55 (0.28-1.08), and for 2006, 0.03 (0.00-0.27); p for trend < 0.001. Between 2002 and 2005 crude under-five, infant (under age 1 y), and child (aged 1-4 y) mortality decreased by 52%, 33%, and 71%, respectively. Similarly, malaria-related admissions, blood transfusions, and malaria-attributed mortality decreased significantly by 77%, 67% and 75%, respectively, between 2002 and 2005 in children under five. Climatic conditions favorable for malaria transmission persisted throughout the observational period.
  
  
  CONCLUSIONS
  Following deployment of ACT in Zanzibar 2003, malaria-associated morbidity and mortality decreased dramatically within two years. Additional distribution of LLINs in early 2006 resulted in a 10-fold reduction of malaria parasite prevalence. The results indicate that the Millennium Development Goals of reducing mortality in children under five and alleviating the burden of malaria are achievable in tropical Africa with high coverage of combined malaria control interventions.
authors.affiliation: Infectious Diseases Unit, Department of Medicine, Karolinska Institutet, Stockholm, Sweden. achuyt.bhattarai@ki.se
authors.forename: Achuyt
authors.initials: A
authors.lastname: Bhattarai
authors.forename: Abdullah S
authors.initials: AS
authors.lastname: Ali
authors.forename: S Patrick
authors.initials: SP
authors.lastname: Kachur
authors.forename: Andreas
authors.initials: A
authors.lastname: Mårtensson
authors.forename: Ali K
authors.initials: AK
authors.lastname: Abbas
authors.forename: Rashid
authors.initials: R
authors.lastname: Khatib
authors.forename: Abdul-Wahiyd
authors.initials: AW
authors.lastname: Al-Mafazy
authors.forename: Mahdi
authors.initials: M
authors.lastname: Ramsan
authors.forename: Guida
authors.initials: G
authors.lastname: Rotllant
authors.forename: Jan F
authors.initials: JF
authors.lastname: Gerstenmaier
authors.forename: Fabrizio
authors.initials: F
authors.lastname: Molteni
authors.forename: Salim
authors.initials: S
authors.lastname: Abdulla
authors.forename: Scott M
authors.initials: SM
authors.lastname: Montgomery
authors.forename: Akira
authors.initials: A
authors.lastname: Kaneko
authors.forename: Anders
authors.initials: A
authors.lastname: Björkman
mesh_terms: D000293:Adolescent; D000818:Animals; D037621:Artemisinins / Q000627:therapeutic use*; D001512:Bedding and Linens; D002648:Child; D002675:Child, Preschool; D003430:Cross-Sectional Studies; D004359:Drug Therapy, Combination; D005260:Female; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D007306:Insecticides; D016778:Malaria, Falciparum / Q000188:drug therapy / Q000453:epidemiology* / Q000469:parasitology / Q000517:prevention & control; D008297:Male; D009032:Mosquito Control; D018512:Parasitemia / Q000188:drug therapy / Q000453:epidemiology / Q000469:parasitology; D010963:Plasmodium falciparum; D015995:Prevalence; D013636:Tanzania / Q000453:epidemiology
chemical_list: D037621:Artemisinins; D007306:Insecticides; C031327:artemisinin