Anti-Malarial Interventions in East African Countries: Availability, Compliance and Implications for Control.

Abstract

Effective interventions to prevent and treat malaria have long existed. Insecticide treated nets (ITNs) simultaneously prevent bites by mosquito vectors, reduce vector abundance, and prevent further transmission to community members. Anti-malarial drugs such as artemisinin combination therapies (ACTs) effectively treat disease while minimizing the potential for drug resistance. Contextual, logistical, and household factors in malaria holo-endemic areas, however, threaten the effectiveness of malaria interventions.

Research presented in this dissertation uncovers specific factors which contribute to malaria risk and compromise access, availability and compliance to anti-malarial interventions. Using spatial analytic methods, a household-level survey of Malawian children from 2007 was analyzed to explore associations of urbanicity factors with parasitemia prevalence. The same database was analyzed to evaluate whether proximity to health facilities, which distribute ITNs, was associated with ITN possession and compliance. A comprehensive survey of a community in Kenya was undertaken to assess factors that determine ITN use under a no-cost distribution scheme. Finally, the problem of ACT availability under a large, global, subsidy program was analyzed through a shop-level survey of certified retail shops in Tanzania.

Results indicated that rather than following a sharp divide, malaria risk inversely follows a smooth gradient of urbanicity. ITN possession and use were found to be inversely vary with distance to nearest health facility. In Kenya, a direct to household distribution led to nearly universal ITN use, but heterogenities among age groups persisted. In Tanzania, it was found that demand for malaria medications and market competition factors influenced stocking and early adoption of ACTs in drug shops.

Policy makers must consider the problems of proper classification of target locations when designing intervention plans. Distributional strategies which center of fixed locations will lead to geographic shortfalls in ITN use and possession, particularly among at highest risk for disease. Comprehensive programs which deliver ITNs directly to households can increase ITN possession and use, but inherent age based heterogeneities in use may compromise control efforts. The success of anti-malarial interventions will depend on multi-pronged approaches which account for proper measurement of target areas, logistics, targeting efficiency, and a deep understanding of household and provider factors.