Abstract
BackgroundHigh 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.MethodsWe 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.ResultsWe 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.ConclusionsMalawi 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.
Highlights
Insecticide treated bednets (ITNs) have been shown to reduce malaria-associated morbidity and mortality [1]
Malawi distributes ITNs through three main mechanisms: 1) routine free distribution of ITNs for children born in health facilities, children attending their first visit under the Expanded Program on Immunization (EPI) if an ITN was not received at birth, and pregnant women at their first visit to an antenatal care (ANC) clinic; 2) periodic mass campaigns targeted at households in ‘hard to reach areas’; 3) traditional social marketing through private sector outlets
Household bednet and ITN possession In the eight surveyed districts, 68% of all households owned at least one bednet, 59% owned at least one ITN, and 57% owned at least one ITN obtained through health facility-based distribution (Table 2)
Summary
Insecticide treated bednets (ITNs) have been shown to reduce malaria-associated morbidity and mortality [1]. Increasing ITN coverage has been done using a variety of distribution strategies including, the development of commercial markets, social marketing interventions, and distribution through health facilities, community groups and mass distribution campaigns [2,3,4,5,6,7,8,9,10,11,12,13]. Between 2007 and 2009, PMI and the Global Fund have purchased approximately 4.5 million ITNs, the majority of which have been distributed through health facilities to pregnant women and children ,5 years old [20]. We evaluated the progress of this targeted approach toward achieving universal ITN coverage
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