title: Distribution of malaria exposure in endemic countries in Africa considering country levels of effective treatment.
abstract: BACKGROUND
  Malaria prevalence, clinical incidence, treatment, and transmission rates are dynamically interrelated. Prevalence is often considered a measure of malaria transmission, but treatment of clinical malaria reduces prevalence, and consequently also infectiousness to the mosquito vector and onward transmission. The impact of the frequency of treatment on prevalence in a population is generally not considered. This can lead to potential underestimation of malaria exposure in settings with good health systems. Furthermore, these dynamical relationships between prevalence, treatment, and transmission have not generally been taken into account in estimates of burden.
  
  
  METHODS
  Using prevalence as an input, estimates of disease incidence and transmission [as the distribution of the entomological inoculation rate (EIR)] for Plasmodium falciparum have now been made for 43 countries in Africa using both empirical relationships (that do not allow for treatment) and OpenMalaria dynamic micro-simulation models (that explicitly include the effects of treatment). For each estimate, prevalence inputs were taken from geo-statistical models fitted for the year 2010 by the Malaria Atlas Project to all available observed prevalence data. National level estimates of the effectiveness of case management in treating clinical attacks were used as inputs to the estimation of both EIR and disease incidence by the dynamic models.
  
  
  CONCLUSIONS
  When coverage of effective treatment is taken into account, higher country level estimates of average EIR and thus higher disease burden, are obtained for a given prevalence level, especially where access to treatment is high, and prevalence relatively low. These methods provide a unified framework for comparison of both the immediate and longer-term impacts of case management and of preventive interventions.
authors.affiliation: Department of Epidemiology and Public Health, Swiss Tropical and Public Health Institute, 4051, Basel, Switzerland. melissa.penny@unibas.ch.|University of Basel, Petersplatz 1, Basel, Switzerland. melissa.penny@unibas.ch.
authors.forename: Melissa A
authors.initials: MA
authors.lastname: Penny
authors.affiliation: Department of Epidemiology and Public Health, Swiss Tropical and Public Health Institute, 4051, Basel, Switzerland. nicolas.maire@unibas.ch.|University of Basel, Petersplatz 1, Basel, Switzerland. nicolas.maire@unibas.ch.
authors.forename: Nicolas
authors.initials: N
authors.lastname: Maire
authors.affiliation: Department of Epidemiology and Public Health, Swiss Tropical and Public Health Institute, 4051, Basel, Switzerland. cbever@intven.com.|University of Basel, Petersplatz 1, Basel, Switzerland. cbever@intven.com.|Institute for Disease Modeling, Bellevue, WA, 98005, USA. cbever@intven.com.
authors.forename: Caitlin A
authors.initials: CA
authors.lastname: Bever
authors.affiliation: Department of Epidemiology and Public Health, Swiss Tropical and Public Health Institute, 4051, Basel, Switzerland. Peter.Pemberton-Ross@unibas.ch.|University of Basel, Petersplatz 1, Basel, Switzerland. Peter.Pemberton-Ross@unibas.ch.
authors.forename: Peter
authors.initials: P
authors.lastname: Pemberton-Ross
authors.affiliation: Department of Epidemiology and Public Health, Swiss Tropical and Public Health Institute, 4051, Basel, Switzerland. olivier.briet@unibas.ch.|University of Basel, Petersplatz 1, Basel, Switzerland. olivier.briet@unibas.ch.
authors.forename: Olivier J T
authors.initials: OJ
authors.lastname: Briët
authors.affiliation: Department of Zoology, University of Oxford, Tinbergen Building, South Parks Road, Oxford, OX1 3PS, UK. david.smith@zoo.ox.ac.uk.|Sanaria Institute of Global Health and Tropical Medicine, Rockville, MD, 20850, USA. david.smith@zoo.ox.ac.uk.
authors.forename: David L
authors.initials: DL
authors.lastname: Smith
authors.affiliation: Department of Zoology, University of Oxford, Tinbergen Building, South Parks Road, Oxford, OX1 3PS, UK. peter.gething@zoo.ox.ac.uk.
authors.forename: Peter W
authors.initials: PW
authors.lastname: Gething
authors.affiliation: Department of Epidemiology and Public Health, Swiss Tropical and Public Health Institute, 4051, Basel, Switzerland. thomas-a.smith@unibas.ch.|University of Basel, Petersplatz 1, Basel, Switzerland. thomas-a.smith@unibas.ch.
authors.forename: Thomas A
authors.initials: TA
authors.lastname: Smith
mesh_terms: D000349:Africa / Q000453:epidemiology; D000962:Antimalarials / Q000627:therapeutic use; D002648:Child; D002675:Child, Preschool; D003140:Communicable Disease Control / Q000379:methods; D018562:Disease Transmission, Infectious / Q000517:prevention & control*; D006801:Humans; D015994:Incidence; D016778:Malaria, Falciparum / Q000188:drug therapy* / Q000453:epidemiology* / Q000517:prevention & control / Q000635:transmission; D015995:Prevalence
chemical_list: D000962:Antimalarials