title: Population coverage of artemisinin-based combination treatment in children younger than 5 years with fever and Plasmodium falciparum infection in Africa, 2003-2015: a modelling study using data from national surveys.
abstract: Artemisinin-based combination therapies (ACTs) are the most effective treatment for uncomplicated Plasmodium falciparum malaria infection. A commonly used indicator for monitoring and assessing progress in coverage of malaria treatment is the proportion of children younger than 5 years with reported fever in the previous 14 days who have received an ACT. We propose an improved indicator that incorporates parasite infection status (as assessed by a rapid diagnostic test [RDT]), which is available in recent household surveys. In this study we estimated the annual proportion of children younger than 5 years with fever and a positive RDT in Africa who received an ACT in 2003-15.
  
  
  
  Our modelling study used cross-sectional data on treatment for fever and RDT status for children younger than 5 years compiled from all nationally available representative household surveys (the Malaria Indicator Surveys, Demographic and Health Surveys, and Multiple Indicator Cluster Surveys) across sub-Saharan Africa between 2003 and 2015. Estimates for the proportion of children younger than 5 years with a fever within the previous 14 days and P falciparum infection assessed by RDT who received an ACT were incorporated in a generalised additive mixed model, including data on ACT distributions, to estimate coverage across all countries and time periods. We did random effects meta-analyses to examine individual, household, and community effects associated with ACT coverage.
  
  
  
  We obtained data on 201 704 children younger than 5 years from 103 surveys (22 MIS, 61 DHS, and 20 MICS) across 33 countries. RDT results were available for 40 of these surveys including 40 261 (20%) children, and we predicted RDT status for the remaining 161 443 (80%) children. Our results showed that ACT coverage in children younger than 5 years with a fever and P falciparum infection increased across sub-Saharan Africa in 2003-15, but even in 2015, only 19·7% (95% CI 15·6-24·8) of children younger than 5 years with a fever and P falciparum infection received an ACT. In meta-analyses, children younger than 5 years were more likely to receive an ACT for fever and P falciparum infection if they lived in an urban area (vs rural area; odds ratio [OR] 1·18, 95% CI 1·06-1·31), had household wealth above the national median (vs wealth below the median; OR 1·26, 1·16-1·39), had a caregiver with any education (vs no education; OR 1·31, 1·22-1·41), had a household insecticide-treated net (ITN; vs no ITN; OR 1·21, 1·13-1·29), were older than 2 years (vs ≤2 years; OR 1·09, 1·01-1·17), or lived in an area with a higher mean P falciparum prevalence in children aged 2-10 years (OR 1·12, 1·02-1·23). In the subgroup of children for whom treatment was sought, those who sought treatment in the public sector were more likely to receive an ACT (vs the private sector; OR 3·18, 2·67-3·78).
  
  
  
  Despite progress during the 2003-15 malaria programme, ACT treatment for children with malaria remains unacceptably low. More work is needed at the country level to understand how health-care access, service delivery, and ACT supply might be improved to ensure appropriate treatment for all children with malaria.
  
  
  
  US President's Malaria Initiative and Medicines for Malaria Venture.
authors.affiliation: Malaria Elimination Initiative, Global Health Group, University of San Francisco, San Francisco, CA, USA. Electronic address: adam.bennett@ucsf.edu.
authors.forename: Adam
authors.initials: A
authors.lastname: Bennett
authors.affiliation: Oxford Big Data Institute, Li Ka Shing Centre for Health Information and Discovery, Nuffield Department of Medicine, University of Oxford, Oxford, UK.
authors.forename: Donal
authors.initials: D
authors.lastname: Bisanzio
authors.affiliation: Center for Applied Malaria Research and Evaluation, Tulane University School of Public Health and Tropical Medicine, New Orleans, LA, USA.
authors.forename: Joshua O
authors.initials: JO
authors.lastname: Yukich
authors.affiliation: Oxford Big Data Institute, Li Ka Shing Centre for Health Information and Discovery, Nuffield Department of Medicine, University of Oxford, Oxford, UK.
authors.forename: Bonnie
authors.initials: B
authors.lastname: Mappin
authors.affiliation: World Health Organization, Geneva, Switzerland.
authors.forename: Cristin A
authors.initials: CA
authors.lastname: Fergus
authors.affiliation: World Health Organization, Geneva, Switzerland; US Centers for Disease Control, Atlanta, GA, USA.
authors.forename: Michael
authors.initials: M
authors.lastname: Lynch
authors.affiliation: World Health Organization, Geneva, Switzerland.
authors.forename: Richard E
authors.initials: RE
authors.lastname: Cibulskis
authors.affiliation: Oxford Big Data Institute, Li Ka Shing Centre for Health Information and Discovery, Nuffield Department of Medicine, University of Oxford, Oxford, UK.
authors.forename: Samir
authors.initials: S
authors.lastname: Bhatt
authors.affiliation: Oxford Big Data Institute, Li Ka Shing Centre for Health Information and Discovery, Nuffield Department of Medicine, University of Oxford, Oxford, UK.
authors.forename: Daniel J
authors.initials: DJ
authors.lastname: Weiss
authors.affiliation: Oxford Big Data Institute, Li Ka Shing Centre for Health Information and Discovery, Nuffield Department of Medicine, University of Oxford, Oxford, UK.
authors.forename: Ewan
authors.initials: E
authors.lastname: Cameron
authors.affiliation: Oxford Big Data Institute, Li Ka Shing Centre for Health Information and Discovery, Nuffield Department of Medicine, University of Oxford, Oxford, UK.
authors.forename: Peter W
authors.initials: PW
authors.lastname: Gething
authors.affiliation: Center for Applied Malaria Research and Evaluation, Tulane University School of Public Health and Tropical Medicine, New Orleans, LA, USA.
authors.forename: Thomas P
authors.initials: TP
authors.lastname: Eisele
mesh_terms: D017954:Africa South of the Sahara; D000962:Antimalarials / Q000627:therapeutic use*; D037621:Artemisinins / Q000627:therapeutic use*; D002669:Child Welfare / Q000706:statistics & numerical data*; D002675:Child, Preschool; D003955:Diagnostic Tests, Routine / Q000706:statistics & numerical data; D005260:Female; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D016778:Malaria, Falciparum / Q000188:drug therapy* / Q000453:epidemiology*; D008297:Male; D010963:Plasmodium falciparum / Q000302:isolation & purification
chemical_list: D000962:Antimalarials; D037621:Artemisinins