title: Impact of health facility-based insecticide treated bednet distribution in Malawi: progress and challenges towards achieving universal coverage.
abstract: BACKGROUND
  High levels of insecticide treated bednet (ITN) use reduce malaria burden in countries with intense transmission such as Malawi. Since 2007 Malawi has implemented free health facility-based ITN distribution for pregnant women and children <5 years old (under-5s). We evaluated the progress of this targeted approach toward achieving universal ITN coverage.
  
  
  METHODS
  We conducted a cross-sectional household survey in eight districts in April 2009. We assessed household ITN possession, ITN use by all household members, and P. falciparum asexual parasitemia and anemia (hemoglobin <11 grams/deciliter) in under-5s.
  
  
  RESULTS
  We surveyed 7,407 households containing 29,806 persons. Fifty-nine percent of all households (95% confidence interval [95% CI]: 56-62), 67% (95% CI: 64-70) of eligible households (i.e., households with pregnant women or under-5s), and 40% (95% CI: 36-45) of ineligible households owned an ITN. In households with at least one ITN, 76% (95% CI: 74-78) of all household members, 88% (95% CI: 87-90) of under-5s and 90% (95% CI: 85-94) of pregnant women used an ITN the previous night. Of 6,677 ITNs, 92% (95% CI: 90-94) were used the previous night with a mean of 2.4 persons sleeping under each ITN. In multivariable models adjusting for district, socioeconomic status and indoor residual spraying use, ITN use by under-5s was associated with a significant reduction in asexual parasitemia (adjusted odds ratio (aOR) 0.79; 95% CI: 0.64-0.98; p-value 0.03) and anemia (aOR 0.79; 95% CI 0.62-0.99; p-value 0.04). Of potential targeted and non-targeted mass distribution strategies, a campaign distributing 1 ITN per household might increase coverage to 2.1 household members per ITN, and thus achieve near universal coverage often defined as 2 household members per ITN.
  
  
  CONCLUSIONS
  Malawi has substantially increased ITN coverage using health facility-based distribution targeting pregnant women and under-5s, but needs to supplement these activities with non-targeted mass distribution campaigns to achieve universal coverage and maximum public health impact.
authors.affiliation: Malaria Branch, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America. jskarbinski@cdc.gov
authors.forename: Jacek
authors.initials: J
authors.lastname: Skarbinski
authors.forename: Dyson
authors.initials: D
authors.lastname: Mwandama
authors.forename: Madalitso
authors.initials: M
authors.lastname: Luka
authors.forename: James
authors.initials: J
authors.lastname: Jafali
authors.forename: Adam
authors.initials: A
authors.lastname: Wolkon
authors.forename: David
authors.initials: D
authors.lastname: Townes
authors.forename: Carl
authors.initials: C
authors.lastname: Campbell
authors.forename: John
authors.initials: J
authors.lastname: Zoya
authors.forename: Doreen
authors.initials: D
authors.lastname: Ali
authors.forename: Don P
authors.initials: DP
authors.lastname: Mathanga
mesh_terms: D000293:Adolescent; D000328:Adult; D000740:Anemia / Q000453:epidemiology; D019352:Censuses; D002648:Child; D002675:Child, Preschool; D005191:Family Characteristics; D005260:Female; D005843:Geography; D019538:Health Care Surveys / Q000706:statistics & numerical data; D006268:Health Facilities / Q000706:statistics & numerical data*; D006801:Humans; D057148:Insecticide-Treated Bednets; D008295:Malawi / Q000453:epidemiology; D008297:Male; D018512:Parasitemia / Q000453:epidemiology / Q000469:parasitology; D011247:Pregnancy; D015995:Prevalence; D012111:Residence Characteristics