Estimated under-five deaths associated with poor-quality antimalarials in sub-Saharan Africa

Abstract

Many antimalarials sold in sub-Saharan Africa are poor-quality (falsified, substandard, or degraded), and the burden of disease caused by this problem is inadequately quantified. In this article, we estimate the number of under-five deaths caused by ineffective treatment of malaria associated with consumption of poor-quality antimalarials in 39 sub-Saharan countries. Using Latin hypercube sampling our estimates were calculated as the product of the number of private sector antimalarials consumed by malaria-positive children in 2013; the proportion of private sector antimalarials consumed that were of poor-quality; and the case fatality rate (CFR) of under-five malaria-positive children who did not receive appropriate treatment. An estimated 122,350 (interquartile range [IQR]: 91,577-154,736) under-five malaria deaths were associated with consumption of poor-quality antimalarials, representing 3.75% (IQR: 2.81-4.75%) of all under-five deaths in our sample of 39 countries. There is considerable uncertainty surrounding our results because of gaps in data on case fatality rates and prevalence of poor-quality antimalarials. Our analysis highlights the need for further investigation into the distribution of poor-quality antimalarials and the need for stronger surveillance and regulatory efforts to prevent the sale of poor-quality antimalarials.

Figure 1.

Estimated annual under-five malaria deaths due to treatment with poor-quality antimalarials. The median (of 10,000 samples) number of under-five malaria deaths caused by treatment with poor-quality antimalarials (radius) is plotted for 39 sub-Saharan countries for which antimalarial sales data were available. The y-axis depicts the poor-quality-antimalarial death estimates as a proportion of total 2010 under-five malaria death estimates made by World Health Organization (WHO) (Supplemental Table 4). The x-axis depicts the fraction of antimalarial recipients who are treated in the private sector. The color code depicts the proportion of private sector under-five antimalarial demand made by malaria-positive children. Darker shades reflect higher levels of overtreatment (i.e., febrile disease is presumptively treated as malaria). * Data were obtained from Cohen and others.

Figure 2.

Estimated annual under-five malaria deaths due to treatment with poor-quality antimalarials. The median (derived from 10,000 simulations) number of under-five malaria deaths due to treatment with poor-quality antimalarials is plotted for 39 sub-Saharan countries. The error bars depict the interquartile range. Nigeria is plotted on a separate scale (Uganda is plotted twice for comparison).

Figure 3.

Deaths due to treatment with poor-quality antimalarials as proportion of under-five malaria deaths. The median (derived from 10,000 simulations) number of 2013 under-five malaria deaths due to treatment with poor-quality antimalarials is plotted for 39 sub-Saharan countries as a proportion of 2010 World Health Organization (WHO) under-five malaria death estimates (Supplemental Table 4). The error bars depict the interquartile range.

Figure 4.

Under-five deaths due to treatment with poor-quality antimalarials as proportion of all-cause deaths. The median (derived from 10,000 simulations) number of 2013 under-five malaria deaths due to treatment with poor-quality antimalarials is plotted for 39 sub-Saharan countries as a proportion of 2012 World Health Organization (WHO) under-five all-cause death estimates (Supplemental Table 5). The error bars depict the interquartile range.