Are we missing millions of children in Africa?

On October 16, 2009, in malaria, research, by Karen Grepin

During the last couple of weeks some variant of the following catchy headlines have been making their way around twitter and in the media: “Not enough malaria nets for children” or “School-age children found to be least protected from malaria“. The headlines suggest that bed net efforts have been suboptimal in protecting children in Africa.

The headlines were in response to a new research article in BMC Public Health published by Abdisalan Noor and co-authors which has shown that coverage of bed nets is quite high among children under the age of five and again among adults, but is lowest among children aged 5-19. The authors conclude that universal coverage of bed nets will require new strategies, not just targeting of nets through antenatal programs, which have apparently been successful at raising coverage among children under the age of 5.

Maybe I missed this…but when did Universal Coverage of all children become the accepted goal? The Abuja Declaration, which was signed by the participants of the African Summit on Roll Back Malaria in the Spring of 2000 set out as a goal to ensure that a least 60% of the most vulnerable children, specifically those under the age of 5, should sleep under an insecticide impregnated bed net. The logic for targeting children under the age of 5 is that at younger ages children are immunologically most vulnerable to infection and that is, by far, where most deaths from malaria are concentrated. While significant progress has been made to date against this goal, it has not yet been achieved.

The logic for extending coverage to children over the age of 5 could also make sense for a number of reasons: since children in that age group are also exposed to infection and do incur some mortality it could further reduce mortality and there is evidence that at really high levels of bed net coverage (probably well beyond the levels seen in most places today) bed nets can have an effect on malaria transmission in communities. But changing the focus on young children to all children would significantly affect the cost-effectiveness of the intervention and would have massive implications for the funding envelope required. The data from the study mentioned above is that there are 2-3 times the number of school aged children in Africa than children under the age of 5. Are they advocating purchasing 2-3 times as many bed nets (in lieu of perhaps most cost effective environmental modifications)?

So while I thought this study was well done and contributed to our knowledge of the rollout of bed nets in Africa, its advocacy efforts were perhaps unfounded. I am actually quite pleased to see that efforts to date have actually focused on children under the age of 5. A more appropriate conclusion could have been “bed net rollouts appear to be targeting those most in need” and left it at that.

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