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Estimating the Number of Insecticide-Treated Nets Required by African Households to Reach Continent-wide Malaria Coverage Targets

John M. Miller, MPH; Eline L. Korenromp, PhD; Bernard L. Nahlen, MD; Richard W. Steketee, MD
JAMA. 2007;297(20):2241-2250. doi:10.1001/jama.297.20.2241.
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Context African countries are scaling up malaria interventions, especially insecticide-treated nets (ITNs), for which ambitious coverage targets have been set.

Objective To estimate how many ITNs are available in African households that are at risk of malaria and how many ITNs are needed to reach targets for use by children younger than 5 years and pregnant women.

Data Sources Primary sources of data were the Multiple Indicator Cluster Surveys II, the Demographic and Health Surveys, or other nationally representative or large-scale household surveys that measured household possession and use of nets or ITNs among children younger than 5 years.

Data Extraction Data from 42 household surveys between 1999 and 2006 on net and ITN coverage (either household possession or use) and average numbers of nets and ITNs per household were compared with populations and households at risk. Data are included for 43 sub-Saharan African countries.

Data Synthesis For the median survey year 2003, the population-weighted mean proportion of households possessing at least 1 ITN was 6.7% (range among countries, 0.1%-71.0%) and was 23.8% (range, 5.0%-91.2%) for any type of net. Based on an average of 0.13 ITNs per household, we estimated that 53.6 million nets, of which 16.7 million were ITNs, were available in households at risk of malaria. Between 130 million and 264 million ITNs are required in 2007 to reach the 80% coverage target for about 133 million children younger than 5 years and pregnant women living in 123 million households in risk areas; the exact number depends on usage patterns (best estimate, assuming 55% of owned ITNs are used by the target groups, 192 million ITNs).

Conclusion To achieve the targeted ITN usage rates, numbers of ITNs available to African households must be dramatically increased.

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Figures

Figure 1. Correlation Between the Proportion of Households With at Least 1 Net and Average Number of Nets per Household
Graphic Jump Location

Open circles indicate data points for any nets from available nationally representative surveys separately for both urban and rural areas; filled circles, data points for insecticide-treated nets (ITNs) from available nationally representative surveys for both urban and rural areas; dashed line, best fit for average number of nets per household predicted from the proportion of households with at least 1 net (y = 1.9288x; R2 = 0.95); solid line, best fit for average number of ITNs, including nets obtained or re-treated in the 6 or 12 months before the survey, per household predicted from the proportion of households with at least 1 ITN (y = 1.8199x; R2 = 0.97).

Figure 2. Currently Available and Required Number of ITNs in 43 Countries in Sub-Saharan Africa
Graphic Jump Location

The shaded area represents the required number of insecticide-treated nets (ITNs), where (1) the minimum is the number of households with children younger than 5 years or pregnant women living in risk areas times 80% targeted coverage divided by an estimated 55% use by children younger than 5 years or pregnant women in households possessing 1 or more nets19; (2) the best estimate (solid line) is the total number of households in risk areas times 80% targeted coverage divided by an estimated 55% use given household net possession; and (3) the maximum is 2 ITNs for all households in malaria risk areas, regardless of whether they contain children younger than 5 years or pregnant women. Filled and open circles represent numbers of ITNs and any nets, respectively, that were actually available in households at risk in the respective median survey years (2003: see Table 2 and Table 3; 2000: from a separate analysis, using similar methods, that considered additional older surveys). Dotted line represents the trend in ITNs expected from actual ITNs available in households from the 2000 and 2003 analyses. Dashed line represents the acceleration in ITN distribution required to reach the 2010 target from existing levels in 2003. Required numbers of nets were projected into the future based on estimated annual population growth27 and assuming constant household size, percentages of households with at least 1 child younger than 5 years or pregnant woman, crude birth rates, maternal mortality rates, and populations at malaria risk.

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