Malaria preventive measures in a context of elimination in children under five in Togo: Trends in malaria prevalence, uptake of preventive measures, and associated factors.

Proposal Rationale:

In 2020, the World Health Organization (WHO) estimates that 14 million more malaria cases were reported than in 2019 (241 million compared to 227 million). The WHO African Region continues to bear the greatest burden, with 95% of all malaria cases (228 million); 96% of all malaria deaths (602 000); and 80% of all malaria deaths are in children under five (1). Between 2000 and 2019, incidence rate in this decrease from 368 to 222.9 cases per 1000 population at risk. However, the rate of decrease has stabilized and is even increasing (2). Between 2019 and 2020, total malaria cases increased from 213 million to 228 million. The Global Technical Strategy for Malaria 2016-2030 estimates that, based on trends in malaria cases, the projected 2030 target for malaria control and elimination could be missed by up to 87% (GTS) (3). The magnitude of the problem can be influenced by a number of environment-related factors, vector-related factors, and human-related factors (4).

In Togo, malaria is endemic with an upsurge of cases during the rainy seasons. Malaria is the leading cause of hospitalization and mortality, especially among children under five (5). In 2020, 2,136,877 confirmed cases and 1,275 deaths were recorded on a general population about 7 million inhabitants (6). Children under five years of age represented 31.6% of cases. In the same year, this burden caused about 753,702.17 Disability-Adjusted Life Years (DALYs) among children under five (7). A study using PNLP routine data from 2008 to 2017, showed an average annual increase in malaria cases in children under five of + 13.1%, also with strong heterogeneity ranging from + 6.3% in the Lomé Commune region to + 16.7% in the Centrale region (8). Through the Global Technical Strategy for Malaria Control (2016–2030), Togo is one of the 35 countries committed to eliminate malaria by 2030 (8).

With regard to the epidemiological burden, Core interventions recommended by WHO for malaria control include i) the use of insecticide treated nets (ITNs) and/or ii) indoor residual spraying (IRS) and environmental sanitation for vector control, and iii) prompt access to diagnostic testing of suspected malaria and treatment of confirmed cases. In areas of moderate to high transmission, high risk groups should also be targeted with Intermittent Preventive Treatment in pregnancy (IPTp), and Intermittent Preventive Treatment in infancy (IPTi) and seasonal malaria chemoprevention (SMC) seasonal malaria chemoprevention (SMC) in areas where malaria transmission seasonal (2). SMC consist in the monthly administration of full dose of SP+3AQ to children in areas where malaria is intense and seasonal (9).

Clinical trials and meta-analyses have demonstrated the effectiveness of the SMC among children aged 3 -59 years in West African countries during the pilot stages (10,11). In relation to insecticide-treated nets, systematic reviews have shown that their correct use has beneficial effects against parasite prevalence in all gravidities in the endemic regions of Africa (12,13). Despite the demonstrated benefits of these preventive measures, their use remains sub-optimal (14,15). In 2021, the World Malaria Report indicated that the percentage of children under five who slept under insecticide-treated nets decreased from 55% to 49% between 2017 and 2020 in sub-Saharan African countries. Nationally, in Togo, 58% of households have at least one impregnated mosquito net for two persons, with 60% of children under five reported to have slept the night before the survey. The rate of net use among children varied from 68% in rural areas to 44% in urban areas. In the same study, only 39% of children eligible for SMC received the 3 doses recommended by the WHO (16). In addition to preventive measures, parental care seeking for febrile children is low (17, 18). Fever is known as one of the main symptoms of malaria in endemic countries (18). Nationally, of all children reported with a fever, for 24% care was sought in 2014 and 31 % in 2017 (17). Studies showed that seeking care from a health provider was not frequent while self-medication and reliance on traditional healers during illnesses remain common practice with 85.8% (19) and 80.2% (20) in Togo.

Although Clinical trials and meta-analyses have demonstrated the effectiveness these preventives measures, evidence regarding optimal take up of these preventive measures implemented routinely remains less known (17–20). Parental care-seeking behaviors among febrile children also remain less documented (19,20), especially in a Togolese context characterized by low participation of children's parents in mass sensitization sessions on malaria in health facilities (17). Analysis of malaria infection trends and associated factors remains very important for moving towards a malaria elimination phase.

To the best of our knowledge, very few studies have addressed this problem (21–23), especially in the Togo context. It is therefore important to undertake this research project to examine the trends and factors associated with malaria inflection in children under five in Togo and to provide knowledge on the factors associated with the optimal uptake of preventive measures and behaviours against malaria in children in the context of malaria elimination in children under five. In addition, as international and national efforts are made to combine prevention strategies, their effectiveness will depend in large part on their correct uptake, by linking child parents' knowledge and adherence (21,23,24).

The aims of the research is to contribute to strategies for malaria elimination by understanding the epidemiology and the determinants of uptake of existing preventive measures. Especially:

i To analyze long-term trends of malaria prevalence and associated factors in children under five in Togo;
ii To explore regional variation in malaria prevalence and to assess risk factors for heterogeneity within Togo;
iii To improve understanding of the behaviour of caregivers in seeking care for children under five with fever and to identify associated modifiable risk factors;
iv To analyze long-term trends in use of Insecticide-Treated Bed Nets in children under five in Togo;
v To develop a systematic review of the challenges and possible approaches for the optimal use of Insecticide-Treated Bed Nets in sub-Saharan Africa;
vi To identify factors related to exposure to mass media (Women aged 15-49 who report being exposed to radio, television, newspapers or magazines at least once a week) for malaria-related health care information in Togo.