Childhood Malaria Admission Rates to Four Hospitals in Malawi between 2000 and 2010

et al. (2013) Childhood Malaria Admission Rates to Four Hospitals in Malawi between 2000 and 2010. PLoS ONE 8(4): e62214. doi:10.1371/journal.pone.0062214 Childhood Malaria Admission Rates to Four Hospitals in Malawi between 2000 and 2010 Emelda A. Okiro 0 Lawrence N. Kazembe 0 Caroline W. Kabaria 0 Jeffrey Ligomeka 0 Abdisalan M. Noor 0 Doreen Ali 0 Robert W. Snow 0 Lorenz von Seidlein, Menzies School of Health Research, Australia 0 1 Malaria Public Health Department, Kenya Medical Research Institute-Wellcome Trust-University of Oxford Collaborative Programme , Nairobi , Kenya , 2 Centre for Tropical Medicine, Nuffield Department of Medicine, University of Oxford , Oxford , United Kingdom , 3 Department of Mathematical Sciences, Chancellor College, University of Malawi , Zomba , Malawi , 4 Department of Statistics, University of Namibia , Windhoek , Namibia , 5 Records Department, Zomba Central Hospital , Zomba , Malawi , 6 National Malaria control Programme, Ministry of Health , Lilongwe , Malawi Introduction: The last few years have witnessed rapid scaling-up of key malaria interventions in several African countries following increases in development assistance. However, there is only limited country-specific information on the health impact of expanded coverage of these interventions. Methods: Paediatric admission data were assembled from 4 hospitals in Malawi reflecting different malaria ecologies. Trends in monthly clinical malaria admissions between January 2000 and December 2010 were analysed using time-series models controlling for covariates related to climate and service use to establish whether changes in admissions can be related to expanded coverage of interventions aimed at reducing malaria infection. Results: In 3 of 4 sites there was an increase in clinical malaria admission rates. Results from time series models indicate a significant month-to-month increase in the mean clinical malaria admission rates at two hospitals (trend P,0.05). At these hospitals clinical malaria admissions had increased from 2000 by 41% to 100%. Comparison of changes in malaria risk and ITN coverage appear to correspond to a lack of disease declines over the period. Changes in intervention coverage within hospital catchments showed minimal increases in ITN coverage from ,6% across all sites in 2000 to maximum of 33% at one hospital site by 2010. Additionally, malaria transmission intensity remained unchanged between 2000-2010 across all sites. Discussion: Despite modest increases in coverage of measures to reduce infection there has been minimal changes in paediatric clinical malaria cases in four hospitals in Malawi. Studies across Africa are increasingly showing a mixed set of impact results and it is important to assemble more data from more sites to understand the wider implications of malaria funding investment. We also caution that impact surveillance should continue in areas where intervention coverage is increasing with time, for example Malawi, as decline may become evident within a period when coverage reaches optimal levels. - Funding: This study received financial support from The Wellcome Trust, UK and The Kenyan Medical Research Institute. EAO is supported by the Wellcome Trust as a Research Training Fellow (#086166). RWS is supported by the Wellcome Trust as Principal Research Fellow (#079080) that also supports CWK. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Competing Interests: The authors have read the journals policy and have the following conflicts: RWS has received funding from Novartis for chairing meetings of national control programmes in Africa and EAO has received honoraria from Novartis at their regional best practice workshops. RWS has received a research grant from Pfizer. All other authors have no conflicts of interest. This does not alter the authors adherence to all the PLOS ONE policies on sharing data and materials. Malaria poses a major public health challenge in many part of sub-Saharan Africa and is recognized as part of the global health agenda as a significant barrier to achieving the Millennium Development Goal of improving child survival by 2015 [1]. In response, increased overseas development assistance (ODA) for malaria has led to a rapid increase in coverage of interventions aimed at reducing the malaria burden across Africa over the last five years [2,3]. There is a growing body of evidence of the health impact associated with increasing flows of malaria ODA [423] and also modeled predictions on the impact on malaria mortality [2429]. The largest between country evidence comes from observations of hospital admissions [30] and while limited in their geographic coverage they continue to represent a valuable empirical evidenceplatform on changing patterns of disease since the launch of the Roll Back Malaria (RBM) Initiative in 2000. Malawi is a high mortality burden [31], poor country [32], located in South Central Africa. Malawi has a high malaria burden and has received approximately 140 million USD in malaria specific ODA since 2000. Nevertheless a recent examination of malaria admission rates to the Queen Elizabeth Hospital in the south of Malawi was unable to show any changes in severe paediatric malaria between 2001 and 2010 [33]. Here we explore the impact of changing coverage of malaria control in relation to paediatric admission rates across a wider geographical area at hospital settings in four areas of Malawi and site specific changes in malaria intervention coverage. Malawi Malaria Context In comparison to other countries in sub-Saharan Africa, Malawi was slower to realize adequate donor support before 2008 [3] which inevitably resulted in a much slower scale up and lower levels of intervention coverage [34,35]. In 2001 the Malawian Government adopted a policy on insecticide treated nets (ITN) to ensure 60% coverage by 2005. The second Malaria Strategic Plan (MSP) [35], launched in June 2005, sought to scale up interventions to ensure 80% coverage of ITNs in high risk groups and access to appropriate treatment by all those at risk of malaria by 2010. In the most recent MSP launched in 2011 these targets have been revised to achieve universal coverage of the four main malaria control interventions: long-lasting insecticide treated bed nets (LLIN), indoor residual spraying (IRS), intermittent presumptive treatment for pregnant women, and prompt treatment with effect artemisinin-based combination therapy for uncomplicated malaria by 2015 [35]. In 2000 less than 4% of Malawian children were protected by an ITN [36]. The dominant ITN delivery approach before 2007 was a combined full cost recovery retail sector promotion along with subsidized cost ITN distribution through antenatal clinics and through the community [37]. The first integrated free mass distribution of ITNs was in 2007. In July 2008 the Ministry of Health, using funds fr (...truncated)