Climatic Drivers of Malaria risk in Children Under Five: A Large-Scale Analysis of individual-level data for 350,000 children in 26 Sub-Saharan African Countries

Background Malaria risk is influenced by climatic conditions, and children under five are particularly vulnerable due to their limited acquired immunity. We investigate the association between climatic factors and malaria risk in 350,000 children aged 5-59 months in sub-Saharan Africa over 18 years. Methods We included children aged 5-59 months with malaria tests from Demographic and Health Surveys (DHS) in 26 sub-Saharan African countries between 2006 and 2023. We linked these data to high-resolution climate exposures: temperature, precipitation, soil moisture, actual evapotranspiration and specific humidity. We fitted a mixed-effect logistic regression model incorporating Distributed Lag Non-linear Models (DLNM) over 1-6 month lag window for each exposure, controlling for seasonality and long-term trends. We examined effect modification by maternal education, household wealth, residential type, water source, sanitation facility, child age and sex, use of insecticide-treated bed nets (ITNs), and the age of the household head. Results Malaria prevalence was 19.5%. Malaria risk was highest at 24 degrees (OR: 1.45, 95% CI: [1.36, 1.54]), followed by a decline at higher temperatures. This elevated risk was mainly driven by short-term exposures (1-2 months). Precipitation increased risk up to 59 ~ 120 mm (1.10, [1.07, 1.12]), after which heavier rainfall reduced risk, particularly at short- to medium-term lags (1-4 months). Soil moisture was associated with increasing risk up to ~80 mm (1.11, [1.08, 1.14]), with a plateau at higher levels. Evapotranspiration showed a strong, near-linear positive association with malaria risk. Higher specific humidity levels (>14 g/kg) presented a lower risk, reaching a 45% reduction at 17 g/kg (0.55, [0.49, 0.61]), with the strongest protective effects at short-term lags (1-2 months). Elevated malaria risk at low and moderate average temperatures was particularly evident among children who did not sleep under an ITN net. Conclusion Malaria risk in children under five is strongly shaped by climatic factors, with complex and delayed associations. The findings provide evidence to guide targeted interventions and early-warning strategies for vulnerable populations.