Objectives To identify social and structural barriers to timely utilisation of qualified providers among children under five years in a high‐mortality setting, rural Mali and to analyse how utilisation varies by symptom manifestation. Methods Using baseline household survey data from a cluster‐randomised trial, we assessed symptom patterns and healthcare trajectories of 5117 children whose mothers reported fever, diarrhoea, bloody stools, cough and/or fast breathing in the preceding two weeks. We examine associations between socio‐demographic factors, symptoms and utilisation outcomes in mixed‐effect logistic regressions. Results Almost half of recently ill children reported multiple symptoms (46.2%). Over half (55.9%) received any treatment, while less than one‐quarter (21.7%) received care from a doctor, nurse, midwife, trained community health worker or pharmacist within 24 h of symptom onset. Distance to primary health facility, household wealth and maternal education were consistently associated with better utilisation outcomes. While children with potentially more severe symptoms such as fever and cough with fast breathing or diarrhoea with bloody stools were more likely to receive any care, they were no more likely than children with fever to receive timely care with a qualified provider. Conclusions Even distances as short as 2–5 km significantly reduced children’s likelihood of utilising healthcare relative to those within 2 km of a facility. While children with symptoms indicative of pneumonia and malaria were more likely to receive any care, suggesting mothers and caregivers recognised potentially severe illness, multiple barriers to care contributed to delays and low utilisation of qualified providers, illustrating the need for improved consideration of barriers.

Background : Seasonal malaria chemoprevention (SMC) is the administration of complete therapeutic courses of antimalarial to all children 3–59 months old during the malaria transmission season. This study measured coverage, impact and cost of adding SMC in children aged 5-10 years. Methods : A non-randomized, pre-post design, with an intervention (Kita) and control (Bafoulabe) district implemented SMC for children 5-10 years old through the health system in 2017 and 2018. SMC implementation consisted of the administration of SP + AQ at monthly intervals in children 5-10 years in July, August, September and October annually. Baseline and endline household surveys were conducted in both districts. Separate surveys to measure adherence and tolerance to treatment occurred annually in the intervention district (200 households) following each of the four treatment rounds. Routine data on malaria cases tested and treated and information on SMC campaign and treatment costs were collected. Results : A total of 310 and 323 children 5 to 10 years were included in Kita and Bafoulabe respectively in the baseline survey in July 2017, plasmodium infection prevalence was comparable in the two districts (p=0.07): 27.7% in the intervention district (Kita) against 21.7% in the comparison district (Bafoulabé). Mild anemia was found in 14.2% of children in Kita vs 10.5% in Bafoulabé. Household survey found 89.1% of SMC coverage rate, child’s mothers were interviewed with 93.3% during the SMC campaign in Kita. The most side effect reported by parents was vomiting with 9.3%. One year after SMC implementation in 5 to 10 years in Kita, three doses coverage was 81.2%, there was a reduction by 40% (OR=0.60, CI:0.41-0.89) of malaria parasite carriage; 21% and 62% reduction of simple malaria and severe malaria prevalence respectively in the pilot district vs control. Mild anemia and severe anemia were comparable in the two districts. The level of malaria molecular resistance rate remains below the threshold. Quintuple mutation (dhfr triple +dhps437+dhps540) remained <5% after intervention in both districts.Conclusion: The SMC strategy contributed to malaria prevention in 5-10 year old children and should be integrated to SMC for children 3-59 months. Keywords : Malaria, Seasonal Malaria Chemoprevention, Sulfadoxine-Pyriméthamine, Amodiaquine, Anemia.

Background In malaria endemic countries, control interventions are performed during the high malaria transmission season using epidemiological surveillance data. One such intervention, seasonal chemoprevention (SMC), consists of the monthly administration of antimalarial drugs to children under 5 years. This study proposes an anticipating approach for adapting the timing of SMC interventions in Mali and the number of rounds. Our primary objective was to select the best approach for anticipating the onset of the high transmission season in the different health districts of Mali based on epidemiological surveillance and rainfall data. Our secondary objective was to evaluate the number of malaria cases, hospitalisations, and deaths in children under 5 years that could be prevented in Mali using the selected approach and the additional cost associated.Method Confirmed malaria cases and weekly rainfall data were collected for the 75 health districts of Mali for the 2014-2019 period. The onset of the rainy season, the onset of the high transmission season, the lag between these two events and the duration of the high transmission season were determined for each health district. Two approaches for anticipating the onset of the high transmission season in 2019 were evaluated. Results In 2014-2019, the onset of the rainy season ranged from W17 April to W34 August and that of the high transmission season from W25 June to W40 September. The lag between these two events ranged from 5 to 12 weeks. The duration of the high transmission season ranged from 3 to 6 months. The best approach anticipated the onset of the high transmission season 2019 in June in 2 districts, July in 46 districts, August in 21 districts and September in 6 districts. Using this approach over the 2014-2019 period would have led to changing the timing of SMC interventions in 36 health districts and would have prevented 43,819 cases, 1,943 hospitalisations and 70 deaths in children under 5 years. The additional cost of using our proposed approach is less than 5% of the current approach. Conclusion Adapting the timing of SMC interventions using our proposed approach would improve the prevention of malaria cases, hospitalisations, and deaths for a reasonable additional cost.

Introduction: Malaria has been the main cause of morbidity and mortality in Mali, with an increase from 2017 to 2020 (2,884,837 confirmed cases and 1,454 deaths). On the recommendation of the World Health Organization (WHO) and for efficient use of resources, Mali has begun a process of malaria stratification. Method: Malaria, entomological and environmental data were collected through the local health information system, the Demographic and Health Survey 2018, research institutions and MALI-METEO services. The WHO stratification based on malaria incidence was used to present a stratified malaria risk map. Environmental factors associated with malaria were identified using a general additive non-linear regression model. The classification and regression tree method was used to improve the stratification. Interventions were proposed according to the incidence stratification and the different environmental, entomological, access to care maps. Results: From 2017 to 2019, the median incidence across the 75 health districts was 129. cases per 1,000 person-year (IQR=86.48). Stratification resulted in 12 health districts of very low, 19 low, 20 moderates and 24 in high transmission areas. Considering the environmental risk associated to malaria incidence, 6 environmental classes were selected. Four different strategies were proposed, from improving 2 surveillance and response to epidemic in the very low and low zones, to access to care improvement in the moderate and high zone. Conclusion: This stratification in Mali will allow targeting malaria control strategies.

IntroductionMalaria has been the leading cause of morbidity and mortality for several decades in Mali, with an increase from 2017 to 2020 (2,884,837 confirmed cases and 1,454 deaths). On the recommendation of the World Health Organization (WHO) and in the interests of efficient use of resources, Mali has begun a process of stratifying the health districts to target malaria control strategies.MethodMalaria, entomological and environmental data were collected through the local health information system (LHIS), the Demographic and Health Survey (DHS 2018), research institutions and MALI-METEO services. The WHO has recommended stratification at the district level consisted of assigning each district to one of 4 classes according to criteria based on incidence adjusted for attendance rate. Variables associated with monthly malaria incidence at the district level were identified using a general additive non-linear regression model.ResultsFrom 2017 to 2019, the median incidence across 75 health districts of Mali was 129.34 cases per 1,000 person-year (IQR=86.48). The results showed different periods of high malaria transmission in health districts level and durations varying from 2 to 6 months, showing a double peak for some health districts, which were located in the flooded areas. environmental variables such as rainfall, vegetation index (NDVI), maximum temperature and relative humidity were significantly associated at malaria incidence with a lag of around one month. A strata defines a geographical area with similar epidemiological, environmental and socio-economic factors. Stratification resulted in 12 health districts of very low transmission, 19 low transmission, 20 moderate transmission and 24 in high transmission areas. The number of rounds of season malaria chemoprevention will be based on the number of months in the high transmission period.ConclusionThis first stratification in Mali will allow targeting malaria control strategies. This approach will be dynamic and revised yearly in order to integrate information from the national epidemiological surveillance.