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

Background: 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.

Methods: 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.

Findings: 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).

Interpretation: 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.

Funding: US President's Malaria Initiative and Medicines for Malaria Venture.

Figure 1. Frequency plot of surveys included in study, by country and year, with count of febrile children younger than 5 years and whether RDT data were collected in survey

, 103 surveys were included (22 MIS, 61 DHS, and 20 MICS), of which 40 collected RDT data (19 MIS, 20 DHS, and one MICS). DHS=Demographic and Health Survey. MICS=Multiple Indicator Cluster Survey. MIS=Malaria Indicator Survey. RDT=rapid diagnostic test.

Figure 2. Proportions of children younger than 5 years with fever and Plasmodium falciparum infection who received an ACT in sub-Saharan Africa, 2003–15

ACT coverage for sub-Saharan Africa (A), stratified by UN subregion (B), and by presence or absence of an AMFm scheme (C). Southern Africa is not included in the graph because all countries other than Namibia had a mean P falciparum prevalence in children aged 2–10 years of less than 2%. Namibia was included in central Africa because its endemic area is at the same latitude as countries in this region. Dotted lines show 95% CI. ACT=artemisinin-based combination therapy. AMFm=Affordable Medicines Facility, malaria.

Figure 3. Proportions of children younger than 5 years with fever and Plasmodium falciparum infection who received an ACT, per country, in 2005, 2010, and 2015

, Countries with a mean P falciparum prevalence in children aged 2–10 years of less than 2% are in grey. ACT=artemisinin-based combination therapy.

Figure 4. Proportions of children younger than 5 years with fever and a Plasmodium falciparum infection in sub-Saharan Africa who received an ACT in 2003–15, stratified by demographic and clinical variables

, ACT coverage stratified by residence type (A), public or private health-care provider (B), positive or negative RDT results (C), malaria endemicity (D), wealth relative to median country wealth index (E), and treatment seeking (F). ACT=artemisinin combination therapy. RDT=rapid diagnostic test.