Abstract
.Insecticide-treated nets (ITNs) have been shown to be highly effective at reducing malaria morbidity and mortality in children. However, there are limited studies that assess the association between increasing ITN coverage and child mortality over time, at the national level, and under programmatic conditions. Two analytic approaches were used to examine this association: a retrospective cohort analysis of individual children and a district-level ecologic analysis. To evaluate the association between household ITN ownership and all-cause child mortality (ACCM) at the individual level, data from the 2010 Demographic and Health Survey (DHS) were modeled in a Cox proportional hazards framework while controlling for numerous environmental, household, and individual confounders through the use of exact matching. To evaluate population-level association between ITN ownership and ACCM between 2006 and 2010, program ITN distribution data and mortality data from the 2006 Multiple Indicator Cluster Survey and the 2010 DHS were aggregated at the district level and modeled using negative binomial regression. In the Cox model controlling for household, child and maternal health factors, children between 1 and 59 months in households owning an ITN had significantly lower mortality compared with those without an ITN (hazard ratio = 0.75, 95% confidence interval [CI] = 0.62–90). In the district-level model, higher ITN ownership was significantly associated with lower ACCM (incidence rate ratio = 0.77; 95% CI = 0.60–0.98). These findings suggest that increasing ITN ownership may have contributed to the decline in ACCM during 2006–2010 in Malawi and represent a novel use of district-level data from nationally representative surveys.
Highlights
The entire population of Malawi, 16.4 million, is at risk of Plasmodium falciparum malaria infection, which remains a significant threat to health and child survival
To evaluate population-level association between Insecticide-treated nets (ITNs) ownership and all-cause child mortality (ACCM) between 2006 and 2010, program ITN distribution data and mortality data from the 2006 Multiple Indicator Cluster Survey and the 2010 Demographic and Health Survey (DHS) were aggregated at the district level and modeled using negative binomial regression
Results are consistent with those of other country-specific observational studies including a cohort study from Kenya in which ITN use was associated with a 44% relative reduction in mortality among children 1–59 months of age,[5] a casecontrol study from Tanzania in which the estimated protective efficacy of ITN use was 27% among children 1 month to 4 years of age,[6] and a postdistribution evaluation in the Gambia in which the protective efficacy (PE) of ITN use among children 1–9 years of age was 25%
Summary
The entire population of Malawi, 16.4 million, is at risk of Plasmodium falciparum malaria infection, which remains a significant threat to health and child survival. According to best available estimates from the National Statistics Office of Malawi, malaria is responsible for a substantial proportion of health-care consumption, accounting for 29% of all outpatient visits and approximately 40% of hospital deaths and 30% of deaths in children less than 5 years of age.[1,2] To address this high burden of disease, global partners have contributed substantial funds to malaria control efforts, including provision of commodities such as insecticide-treated nets (ITNs) and antimalarial drugs. Indoor residual spraying (IRS) of insecticides is another effective intervention funded by international donors and governments. Distribution of ITNs for household use is the major malaria vector control intervention in Malawi. Between 2004 and 2010, two-thirds of the funding for malaria commodities contributed by the Global Fund to Fight AIDS, Tuberculosis, and Malaria (Global Fund) and the President’s Malaria Initiative (PMI) procured ITNs.[3]
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