标题：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
摘要：SummaryBackground 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.
