Usage of insecticide-treated nets in pregnancy.

<p>ITN usage prior to pregnancy (A) and during pregnancy (B) by parity (based on use during night preceding interview and weighted by age to reflect fertility patterns). Grey lines show usage estimates from each of the 26 country-level surveys with sufficient data, black lines show the median estimate of usage across surveys, and red lines show the estimate weighted by country population size, incorporating pixel-level urban and rural patterns. (C) Estimate of ITN usage weighted by population size within all pregnancies, within potentially infected pregnancies, and within pregnancies potentially leading to LBW. ITN, insecticide-treated net; LBW, low birthweight.</p

Impact of IPTp-SP upon low birthweight and effect of resistance.

<p>(A) Comparison between modelled (lines) and observed (circles with bars indicating 95% confidence intervals) 28- and 42-d failure rates in different resistance settings. Solid lines show a setting where the original prevalence at first ANC visit was 45% (replicating the high transmission settings in which these data were collected) [<a href="http://www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.1002243#pmed.1002243.ref022" target="_blank">22</a>]. The dashed green line shows a model simulation from a setting with 20% prevalence at first ANC visit (to reflect the relatively lower prevalence setting of Mansa, Zambia [<a href="http://www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.1002243#pmed.1002243.ref022" target="_blank">22</a>]). Prophylaxis in the model is assumed to last for an average duration of 28 d (low quintuple mutation), 14 d (intermediate quintuple mutation), and 7 d (high quintuple mutation). Recrudescent infections (estimated by the PCR-corrected failure rate, not shown) were assumed to reappear uniformly throughout the observation period. (B) Example simulations of placental prevalence by week of gestation in the absence of intervention, and where sulphadoxine-pyrimethamine is given at 17, 25, and 32 wk gestation at the different levels of resistance. (C) How efficacy of IPTp-SP against LBW is assumed to vary by resistance category and transmission intensity (based on changes in the estimated average time spent infected). ANC, antenatal care; IPTp-SP, intermittent preventive treatment of malaria in pregnancy with sulphadoxine-pyrimethamine; LBW, low birthweight.</p

The current coverage of IPTp-SP and potential impact of scale-up.

<p>(A) Current coverage of IPTp (at least two doses of SP received at some stage during pregnancy) by first administrative unit according to the most recent population-based survey. (B) Current coverage of women visiting an ANC clinic at least three times during pregnancy. (C) Estimate of the current impact of IPTp-SP given current coverage, SP resistance, and transmission intensity (purple areas show settings where the sextuple mutation has become established, where we do not make an estimate of efficacy). (D) Estimate of the impact of IPTp-SP if given to all women visiting an ANC clinic at least three times, with purple areas as in (C). (E) Estimates of the total number of pregnancies receiving IPTp, and the ANC status of those who do not, by resistance category. (F) Equivalent estimates of total infected pregnancies. (G) Equivalent estimates of potential malaria-attributable LBW deliveries. ANC, antenatal care; IPTp, intermittent preventive treatment of malaria in pregnancy; IPTp-SP, intermittent preventive treatment of malaria in pregnancy with sulphadoxine-pyrimethamine; LBW, low birthweight; SP, sulphadoxine-pyrimethamine.</p

Preventable malaria burden and sulphadoxine-pyrimethamine resistance.

<p>(A) Percent of pregnancies infected in the absence of intervention in 2015. (B) Percent of pregnancies leading to malaria-attributable LBW in 2015 in the absence of intervention. (C) Prevalence of the quintuple K540E mutation within infected individuals. (D) Prevalence of the sextuple A581G mutation within infected individuals. (E) Percent of pregnancies leading to malaria-attributable LBW due to infection involving the quintuple mutation. (F) Percent of pregnancies leading to malaria-attributable LBW due to infection involving the sextuple mutation. LBW, low birthweight.</p

Risk and burden of infection in 2015 by level of resistance.

<p>Risk and burden of infection in 2015 by level of resistance.</p

The health-system benefits associated with PMI funding.

<p>PMI investment in malaria interventions reduces caseloads of national health systems with resulting (A) averted spending due to reduced treatments of clinical and severe cases by country. Without PMI investment, these health system gains are lost, potentially resulting in (B) the estimated cumulative malaria-related deaths in addition to those caused directly by removal of interventions due to health systems not being able to respond to increased caseloads. PMI, President’s Malaria Initiative.</p

Summary of PMI support and estimated impact for 19 focus countries (2013–2015).

<p>Summary of PMI support and estimated impact for 19 focus countries (2013–2015).</p

Schematic of the modelling process.

<p>Data inputs and sources (left column) are combined and linked to estimate the contribution of PMI and the impact of funding cuts on national-level intervention coverage (middle column). These estimates are then used as inputs in a dynamic transmission model to estimate the impact of changes in intervention coverage on epidemiological outcomes (right column). ACT, artemisinin combination therapy; DALY, Disability Adjusted Life Year; DHS, Demographic and Health Survey; IRS, indoor residual spraying; LLIN, long-lasting insecticide treated net; MICS, Multiple Indicator Cluster Surveys; NMCP, National Malaria Control Programme; PMI, President’s Malaria Initiative.</p

Map of PMI activities.

<p>Individual countries and regions that have received PMI-funding and support are highlighted to reflect the level of funding from PMI in (A) sub-Saharan Africa and (B) the GMS over the period 2013–2015. The total regional assignment to the 6 GMS countries over this period is US$9.5 million. Estimated funding per population at risk over this period ranged from US$0.54 (Myanmar) to US$8.08 (Liberia). GMS, Greater Mekong Subregion; PMI, President’s Malaria Initiative.</p