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Systematic review and meta-analysis of the cost and cost-effectiveness of distributing insecticide-treated nets for the prevention of malaria. Acta Trop 2020; 202:105229. [PMID: 31669182 DOI: 10.1016/j.actatropica.2019.105229] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Revised: 10/21/2019] [Accepted: 10/21/2019] [Indexed: 11/20/2022]
Abstract
Insecticide-treated nets are one of two core vector control interventions recommended by the World Health Organization for deployment in malaria-endemic regions around the world, especially sub-Saharan Africa. Although there are many factors that influence the type of distribution strategy chosen, among the most important considerations for the type of distribution strategy chosen is cost, both in terms of total expenditure required and in terms of relative cost-effectiveness. This research attempted to inform these decisions by conducting a systematic review and meta-analysis of the literature on the cost and cost-effectiveness of ITN distribution. The analysis compared the relative cost and cost-effectiveness of distribution strategies. Findings suggest that mass campaigns have lower average distribution costs per net compared with continuous/health facility distribution or sale/vouchers, although the relationship between distribution channel and cost were not statistically significant in the multivariate regression models. Continuous/health facility distribution channels were found to be more cost-effective than mass campaigns for averting DALYs, death, and cases of malaria. Those who design and budget for malaria programs should base decisions about distribution channels more on operational and epidemiological considerations than on cost per net, as the costs per net between distribution channels are not statistically different.
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Tedrow RE, Rakotomanga T, Nepomichene T, Howes RE, Ratovonjato J, Ratsimbasoa AC, Svenson GJ, Zimmerman PA. Anopheles mosquito surveillance in Madagascar reveals multiple blood feeding behavior and Plasmodium infection. PLoS Negl Trop Dis 2019; 13:e0007176. [PMID: 31276491 PMCID: PMC6663035 DOI: 10.1371/journal.pntd.0007176] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Revised: 07/29/2019] [Accepted: 05/13/2019] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND The Madagascar National Strategic Plan for Malaria Control 2018 (NSP) outlines malaria control pre-elimination strategies that include detailed goals for mosquito control. Primary surveillance protocols and mosquito control interventions focus on indoor vectors of malaria, while many potential vectors feed and rest outdoors. Here we describe the application of tools that advance our understanding of diversity, host choice, and Plasmodium infection in the Anopheline mosquitoes of the Western Highland Fringe of Madagascar. METHODOLOGY/PRINCIPAL FINDINGS We employed a modified barrier screen trap, the QUadrant Enabled Screen Trap (QUEST), in conjunction with the recently developed multiplex BLOOdmeal Detection Assay for Regional Transmission (BLOODART). We captured a total of 1252 female Anopheles mosquitoes (10 species), all of which were subjected to BLOODART analysis. QUEST collection captured a heterogenous distribution of mosquito density, diversity, host choice, and Plasmodium infection. Concordance between Anopheles morphology and BLOODART species identifications ranged from 93-99%. Mosquito feeding behavior in this collection frequently exhibited multiple blood meal hosts (single host = 53.6%, two hosts = 42.1%, three hosts = 4.3%). The overall percentage of human positive bloodmeals increased between the December 2017 and the April 2018 timepoints (27% to 44%). Plasmodium positivity was frequently observed in the abdomens of vectors considered to be of secondary importance, with an overall prevalence of 6%. CONCLUSIONS/SIGNIFICANCE The QUEST was an efficient tool for sampling exophilic Anopheline mosquitoes. Vectors considered to be of secondary importance were commonly found with Plasmodium DNA in their abdomens, indicating a need to account for these species in routine surveillance efforts. Mosquitoes exhibited multiple blood feeding behavior within a gonotrophic cycle, with predominantly non-human hosts in the bloodmeal. Taken together, this complex feeding behavior could enhance the role of multiple Anopheline species in malaria transmission, possibly tempered by zoophilic feeding tendencies.
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Affiliation(s)
- Riley E. Tedrow
- The Center for Global Health and Diseases, Case Western Reserve University, Cleveland, Ohio, United States of America
- Department of Biology, Case Western Reserve University, Cleveland, Ohio, United States of America
| | - Tovonahary Rakotomanga
- Direction de Lutte contre le Paludisme/National Malaria Control Program Madagascar, Ministry of Health, Antananarivo, Madagascar
| | - Thiery Nepomichene
- Unité d’Entomologie Médicale, Institut Pasteur de Madagascar, Antananarivo, Madagascar
| | - Rosalind E. Howes
- The Center for Global Health and Diseases, Case Western Reserve University, Cleveland, Ohio, United States of America
| | - Jocelyn Ratovonjato
- Direction de Lutte contre le Paludisme/National Malaria Control Program Madagascar, Ministry of Health, Antananarivo, Madagascar
| | - Arséne C. Ratsimbasoa
- Direction de Lutte contre le Paludisme/National Malaria Control Program Madagascar, Ministry of Health, Antananarivo, Madagascar
- Faculty of Medicine & Faculty of Sciences, University of Antananarivo, Antananarivo, Madagascar
| | - Gavin J. Svenson
- Department of Biology, Case Western Reserve University, Cleveland, Ohio, United States of America
- Department of Invertebrate Zoology, Cleveland Museum of Natural History, Cleveland, Ohio, United States of America
| | - Peter A. Zimmerman
- The Center for Global Health and Diseases, Case Western Reserve University, Cleveland, Ohio, United States of America
- Department of Biology, Case Western Reserve University, Cleveland, Ohio, United States of America
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McPake B. Inequalities in investment in malaria research in sub-Saharan Africa: are they inequities? LANCET GLOBAL HEALTH 2017; 5:e730-e731. [PMID: 28668231 DOI: 10.1016/s2214-109x(17)30252-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/02/2017] [Accepted: 06/12/2017] [Indexed: 01/22/2023]
Affiliation(s)
- Barbara McPake
- Nossal Institute for Global Health, University of Melbourne, Melbourne, VIC 3010, Australia.
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The Effect of Mass Media Campaign on the Use of Insecticide-Treated Bed Nets among Pregnant Women in Nigeria. Malar Res Treat 2014; 2014:694863. [PMID: 24778895 PMCID: PMC3980778 DOI: 10.1155/2014/694863] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2013] [Revised: 02/06/2014] [Accepted: 02/13/2014] [Indexed: 11/17/2022] Open
Abstract
Background. Malaria during pregnancy is a major public health problem in Nigeria especially in malaria-endemic areas. It increases the risk of low birth weight and child/maternal morbidity/mortality. This paper addresses the impact of radio campaigns on the use of insecticide-treated bed nets among pregnant women in Nigeria. Methods. A total of 2,348 pregnant women were interviewed during the survey across 21 of Nigeria's 36 states. Respondents were selected through a multistage sampling technique. Analysis was based on multivariate logistic regression. Results. Respondents who knew that sleeping under ITN prevents malaria were 3.2 times more likely to sleep under net (OR: 3.15; 95% CI: 2.28 to 4.33; P < 0.0001). Those who listened to radio are also about 1.6 times more likely to use ITN (OR: 1.56; 95% CI: 1.07 to 2.28; P = 0.020), while respondents who had heard of a specific sponsored radio campaign on ITN are 1.53 times more likely to use a bed net (P = 0.019). Conclusion. Pregnant women who listened to mass media campaigns were more likely to adopt strategies to protect themselves from malaria. Therefore, behavior change communication messages that are aimed at promoting net use and antenatal attendance are necessary in combating malaria.
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Morel CM, Thang ND, Erhart A, Xa NX, Peeters Grietens K, Xuan Hung L, Thuan LK, Van Ky P, Hung NM, Coosemans M, D'Alessandro U, Mills A. Cost-effectiveness of long-lasting insecticide-treated hammocks in preventing malaria in South-central Vietnam. PLoS One 2013; 8:e58205. [PMID: 23536790 PMCID: PMC3594234 DOI: 10.1371/journal.pone.0058205] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2012] [Accepted: 01/31/2013] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Despite much success in reducing the burden of malaria in Vietnam, pockets of malaria persist and eliminating them remains an important development goal. In central Vietnam, insecticide-treated hammocks have recently been introduced to help counter the disease in the highly forested, mountainous areas, where other measures have so far been unsuccessful. This study assesses the cost-effectiveness of using long-lasting insecticide-treated hammocks in this area. METHODS AND FINDINGS This cost-effectiveness study was run alongside a randomized control trial testing the efficacy of the long-lasting insecticide-treated hammocks. Data were collected through an exit survey, a household survey, expenditure records and key informant interviews. The study estimates that under normal (non-trial) conditions the total net societal cost per malaria episode averted in using long-lasting insecticide-treated hammocks in this area was 126 USD. Cost per hammock, including insecticidal netting, sewing, transport, and distribution was found to be approximately 11.76 USD per hammock. Average savings per episode averted were estimated to be $14.60 USD for the health system and 14.37 USD for households (including both direct and indirect cost savings). The study estimates that the annual financial outlay required of government to implement this type of programme to be 3.40 USD per person covered per year. CONCLUSION The study finds that the use of a hammock intervention could represent good value for money to help prevent malaria in more remote areas, where traditional control measures such as insecticide-treated bednets and indoor residual spraying are insufficient or inappropriate to control malaria. However, the life span of the hammock-the number of years over which it effectively deters mosquitoes-has a significant impact on the cost-effectiveness of the intervention and study results should be interpreted in light of the evidence on effectiveness gathered in the years to come.
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Affiliation(s)
- Chantal M Morel
- LSE Health, London School of Economics & Political Science, London, United Kingdom.
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Meremikwu MM, Donegan S, Sinclair D, Esu E, Oringanje C. Intermittent preventive treatment for malaria in children living in areas with seasonal transmission. Cochrane Database Syst Rev 2012; 2012:CD003756. [PMID: 22336792 PMCID: PMC6532713 DOI: 10.1002/14651858.cd003756.pub4] [Citation(s) in RCA: 79] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND In malaria endemic areas, pre-school children are at high risk of severe and repeated malaria illness. One possible public health strategy, known as Intermittent Preventive Treatment in children (IPTc), is to treat all children for malaria at regular intervals during the transmission season, regardless of whether they are infected or not. OBJECTIVES To evaluate the effects of IPTc to prevent malaria in preschool children living in endemic areas with seasonal malaria transmission. SEARCH METHODS We searched the Cochrane Infectious Diseases Group Specialized Register (July 2011), CENTRAL (The Cochrane Library 2011, Issue 6), MEDLINE (1966 to July 2011), EMBASE (1974 to July 2011), LILACS (1982 to July 2011), mRCT (July 2011), and reference lists of identified trials. We also contacted researchers working in the field for unpublished and ongoing trials. SELECTION CRITERIA Individually randomized and cluster-randomized controlled trials of full therapeutic dose of antimalarial or antimalarial drug combinations given at regular intervals compared with placebo or no preventive treatment in children aged six years or less living in an area with seasonal malaria transmission. DATA COLLECTION AND ANALYSIS Two authors independently assessed eligibility, extracted data and assessed the risk of bias in the trials. Data were meta-analysed and measures of effects (ie rate ratio, risk ratio and mean difference) are presented with 95% confidence intervals (CIs). The quality of evidence was assessed using the GRADE methods. MAIN RESULTS Seven trials (12,589 participants), including one cluster-randomized trial, met the inclusion criteria. All were conducted in West Africa, and six of seven trials were restricted to children aged less than 5 years.IPTc prevents approximately three quarters of all clinical malaria episodes (rate ratio 0.26; 95% CI 0.17 to 0.38; 9321 participants, six trials, high quality evidence), and a similar proportion of severe malaria episodes (rate ratio 0.27, 95% CI 0.10 to 0.76; 5964 participants, two trials, high quality evidence). These effects remain present even where insecticide treated net (ITN) usage is high (two trials, 5964 participants, high quality evidence).IPTc probably produces a small reduction in all-cause mortality consistent with the effect on severe malaria, but the trials were underpowered to reach statistical significance (risk ratio 0.66, 95% CI 0.31 to 1.39, moderate quality evidence).The effect on anaemia varied between studies, but the risk of moderately severe anaemia is probably lower with IPTc (risk ratio 0.71, 95% CI 0.52 to 0.98; 8805 participants, five trials, moderate quality evidence).Serious drug-related adverse events, if they occur, are probably rare, with none reported in the six trials (9533 participants, six trials, moderate quality evidence). Amodiaquine plus sulphadoxine-pyrimethamine is the most studied drug combination for seasonal chemoprevention. Although effective, it causes increased vomiting in this age-group (risk ratio 2.78, 95% CI 2.31 to 3.35; two trials, 3544 participants, high quality evidence).When antimalarial IPTc was stopped, no rebound increase in malaria was observed in the three trials which continued follow-up for one season after IPTc. AUTHORS' CONCLUSIONS In areas with seasonal malaria transmission, giving antimalarial drugs to preschool children (age < 6 years) as IPTc during the malaria transmission season markedly reduces episodes of clinical malaria, including severe malaria. This benefit occurs even in areas where insecticide treated net usage is high.
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Affiliation(s)
- Martin M Meremikwu
- Department of Paediatrics, University of Calabar Teaching Hospital, Calabar, Nigeria.
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White MT, Conteh L, Cibulskis R, Ghani AC. Costs and cost-effectiveness of malaria control interventions--a systematic review. Malar J 2011; 10:337. [PMID: 22050911 PMCID: PMC3229472 DOI: 10.1186/1475-2875-10-337] [Citation(s) in RCA: 179] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2011] [Accepted: 11/03/2011] [Indexed: 11/10/2022] Open
Abstract
Background The control and elimination of malaria requires expanded coverage of and access to effective malaria control interventions such as insecticide-treated nets (ITNs), indoor residual spraying (IRS), intermittent preventive treatment (IPT), diagnostic testing and appropriate treatment. Decisions on how to scale up the coverage of these interventions need to be based on evidence of programme effectiveness, equity and cost-effectiveness. Methods A systematic review of the published literature on the costs and cost-effectiveness of malaria interventions was undertaken. All costs and cost-effectiveness ratios were inflated to 2009 USD to allow comparison of the costs and benefits of several different interventions through various delivery channels, across different geographical regions and from varying costing perspectives. Results Fifty-five studies of the costs and forty three studies of the cost-effectiveness of malaria interventions were identified, 78% of which were undertaken in sub-Saharan Africa, 18% in Asia and 4% in South America. The median financial cost of protecting one person for one year was $2.20 (range $0.88-$9.54) for ITNs, $6.70 (range $2.22-$12.85) for IRS, $0.60 (range $0.48-$1.08) for IPT in infants, $4.03 (range $1.25-$11.80) for IPT in children, and $2.06 (range $0.47-$3.36) for IPT in pregnant women. The median financial cost of diagnosing a case of malaria was $4.32 (range $0.34-$9.34). The median financial cost of treating an episode of uncomplicated malaria was $5.84 (range $2.36-$23.65) and the median financial cost of treating an episode of severe malaria was $30.26 (range $15.64-$137.87). Economies of scale were observed in the implementation of ITNs, IRS and IPT, with lower unit costs reported in studies with larger numbers of beneficiaries. From a provider perspective, the median incremental cost effectiveness ratio per disability adjusted life year averted was $27 (range $8.15-$110) for ITNs, $143 (range $135-$150) for IRS, and $24 (range $1.08-$44.24) for IPT. Conclusions A transparent evidence base on the costs and cost-effectiveness of malaria control interventions is provided to inform rational resource allocation by donors and domestic health budgets and the selection of optimal packages of interventions by malaria control programmes.
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Affiliation(s)
- Michael T White
- MRC Centre for Outbreak Analysis and Modelling, Department of Infectious Disease Epidemiology, Faculty of Medicine, Imperial College London, London, UK.
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Chuma J, Okungu V, Ntwiga J, Molyneux C. Towards achieving Abuja targets: identifying and addressing barriers to access and use of insecticides treated nets among the poorest populations in Kenya. BMC Public Health 2010; 10:137. [PMID: 20233413 PMCID: PMC2847543 DOI: 10.1186/1471-2458-10-137] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2009] [Accepted: 03/16/2010] [Indexed: 11/23/2022] Open
Abstract
Background Ensuring that the poor and vulnerable population benefit from malaria control interventions remains a challenge for malaria endemic countries. Until recently, ownership and use of insecticides treated nets (ITNs) in most countries was low and inequitable, although coverage has increased in countries where free ITN distribution is integrated into mass vaccination campaigns. In Kenya, free ITNs were distributed to children aged below five years in 2006 through two mass campaigns. High and equitable coverage were reported after the campaigns in some districts, although national level coverage remained low, suggesting that understanding barriers to access remains important. This study was conducted to explore barriers to ownership and use of ITNs among the poorest populations before and after the mass campaigns, to identify strategies for improving coverage, and to make recommendations on how increased coverage levels can be sustained. Methods The study was conducted in the poorest areas of four malaria endemic districts in Kenya. Multiple data collection methods were applied including: cross-sectional surveys (n = 708 households), 24 focus group discussions and semi-structured interviews with 70 ITN suppliers. Results Affordability was reported as a major barrier to access but non-financial barriers were also shown to be important determinants. On the demand side key barriers to access included: mismatch between the types of ITNs supplied through interventions and community preferences; perceptions and beliefs on illness causes; physical location of suppliers and; distrust in free delivery and in the distribution agencies. Key barriers on the supply side included: distance from manufacturers; limited acceptability of ITNs provided through interventions; crowding out of the commercial sector and the price. Infrastructure, information and communication played a central role in promoting or hindering access. Conclusions Significant resources have been directed towards addressing affordability barriers through providing free ITNs to vulnerable groups, but the success of these interventions depends largely on the degree to which other barriers to access are addressed. Only if additional efforts are directed towards addressing non-financial barriers to access, will high coverage levels be achieved and sustained.
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Affiliation(s)
- Jane Chuma
- Kenya Medical Research Institute-Wellcome Trust Research Programme, Kilifi, Kenya.
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McElroy B, Wiseman V, Matovu F, Mwengee W. Malaria prevention in north-eastern Tanzania: patterns of expenditure and determinants of demand at the household level. Malar J 2009; 8:95. [PMID: 19422704 PMCID: PMC2683859 DOI: 10.1186/1475-2875-8-95] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2008] [Accepted: 05/07/2009] [Indexed: 11/24/2022] Open
Abstract
Objective This study aims to provide a better understanding of the amounts spent on different malaria prevention products and the determinants of these expenditures. Methods 1,601 households were interviewed about their expenditure on malaria mosquito nets in the past five years, net re-treatments in the past six months and other expenditures prevention in the past two weeks. Simple random sampling was used to select villages and streets while convenience sampling was used to select households. Expenditure was compared across bed nets, aerosols, coils, indoor spraying, using smoke, drinking herbs and cleaning outside environment. Findings 68% of households owned at least one bed net and 27% had treated their nets in the past six months. 29% were unable to afford a net. Every fortnight, households spent an average of US $0.18 on nets and their treatment, constituting about 47% of total prevention expenditure. Sprays, repellents and coils made up 50% of total fortnightly expenditure (US$0.21). Factors positively related to expenditure were household wealth, years of education of household head, household head being married and rainy season. Poor quality roads and living in a rural area had a negative impact on expenditure. Conclusion Expenditure on bed nets and on alternative malaria prevention products was comparable. Poor households living in rural areas spend significantly less on all forms of malaria prevention compared to their richer counterparts. Breaking the cycle between malaria and poverty is one of the biggest challenges facing malaria control programmes in Africa.
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Valuing climate change impacts on human health: empirical evidence from the literature. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2009; 6:759-86. [PMID: 19440414 PMCID: PMC2672348 DOI: 10.3390/ijerph6020759] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/29/2008] [Accepted: 02/17/2009] [Indexed: 11/17/2022]
Abstract
There is a broad consensus that climate change will increase the costs arising from diseases such as malaria and diarrhea and, furthermore, that the largest increases will be in developing countries. One of the problems is the lack of studies measuring these costs systematically and in detail. This paper critically reviews a number of studies about the costs of planned adaptation in the health context, and compares current health expenditures with MDGs which are felt to be inadequate when considering climate change impacts. The analysis serves also as a critical investigation of the methodologies used and aims at identifying research weaknesses and gaps.
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Mueller DH, Wiseman V, Bakusa D, Morgah K, Daré A, Tchamdja P. Cost-effectiveness analysis of insecticide-treated net distribution as part of the Togo Integrated Child Health Campaign. Malar J 2008; 7:73. [PMID: 18445255 PMCID: PMC2396647 DOI: 10.1186/1475-2875-7-73] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2008] [Accepted: 04/29/2008] [Indexed: 11/29/2022] Open
Abstract
Background To evaluate the cost-effectiveness of the first nationwide delivery of long-lasting insecticide-treated nets (LLITNs) as part of the 2004 measles vaccination campaign in Togo to all children between nine months and five years. Methods An incremental approach was used to calculate the economic costs and effects from a provider perspective. Effectiveness was estimated in terms of malaria cases averted, deaths averted and Disability-Adjusted Life Years (DALYs) averted. Malaria cases were modelled using regional estimates. Programme and treatment costs were derived through reviews of financial records and interviews with key stakeholders. Uncertain variables were subjected to a univariate sensitivity analysis. Results Assuming equal attribution of shared costs between the LLITN distribution and the measles vaccination, the net costs per LLITN distributed were 4.41 USD when saved treatment costs were taken into account. Assuming a constant utilization of LLITNs by the target group over three years, 1.2 million cases could be prevented at a net cost per case averted of 3.26 USD. The net costs were 635 USD per death averted and 16.39 USD per DALY averted, respectively. Conclusion The costs per case, death and DALY averted are well within commonly agreed benchmarks set by other malaria prevention studies. Varying transmission levels are shown to have a significant impact on cost-effectiveness ratios. Results also suggest that substantial efficiency gains may be derived from the joint delivery of vaccination campaigns and malaria interventions.
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Affiliation(s)
- Dirk H Mueller
- Health Economics and Financing Programme, Department of Public Health and Policy, London School of Hygiene and Tropical Medicine, Keppel St., London WC1E 7HT, UK.
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Meremikwu MM, Donegan S, Esu E. Chemoprophylaxis and intermittent treatment for preventing malaria in children. Cochrane Database Syst Rev 2008:CD003756. [PMID: 18425893 DOI: 10.1002/14651858.cd003756.pub3] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND Malaria causes repeated illness in children living in endemic areas. Policies of giving antimalarial drugs at regular intervals (prophylaxis or intermittent treatment) are being considered for preschool children. OBJECTIVES To evaluate prophylaxis and intermittent treatment with antimalarial drugs to prevent malaria in young children living in malaria-endemic areas. SEARCH STRATEGY We searched the Cochrane Infectious Diseases Group Specialized Register (August 2007), CENTRAL (The Cochrane Library 2007, Issue 3), MEDLINE (1966 to August 2007), EMBASE (1974 to August 2007), LILACS (1982 to August 2007), mRCT (February 2007), and reference lists of identified trials. We also contacted researchers. SELECTION CRITERIA Individually randomized and cluster-randomized controlled trials comparing antimalarial drugs given at regular intervals (prophylaxis or intermittent treatment) with placebo or no drug in children aged one month to six years or less living in a malaria-endemic area. DATA COLLECTION AND ANALYSIS Two authors independently extracted data and assessed methodological quality. We used relative risk (RR) or weighted mean difference with 95% confidence intervals (CI) for meta-analyses. Where we detected heterogeneity and considered it appropriate to combine the trials, we used the random-effects model (REM). MAIN RESULTS Twenty-one trials (19,394 participants), including six cluster-randomized trials, met the inclusion criteria. Prophylaxis or intermittent treatment with antimalarial drugs resulted in fewer clinical malaria episodes (RR 0.53, 95% CI 0.38 to 0.74, REM; 7037 participants, 10 trials), less severe anaemia (RR 0.70, 95% CI 0.52 to 0.94, REM; 5445 participants, 9 trials), and fewer hospital admissions for any cause (RR 0.64, 95% CI 0.49 to 0.82; 3722 participants, 5 trials). We did not detect a difference in the number of deaths from any cause (RR 0.90, 95% CI 0.65 to 1.23; 7369 participants, 10 trials), but the CI do not exclude a potentially important difference. One trial reported three serious adverse events with no statistically significant difference between study groups (1070 participants). Eight trials measured morbidity and mortality six months to two years after stopping regular antimalarial drugs; overall, there was no statistically significant difference, but participant numbers were small. AUTHORS' CONCLUSIONS Prophylaxis and intermittent treatment with antimalarial drugs reduce clinical malaria and severe anaemia in preschool children.
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Affiliation(s)
- M M Meremikwu
- University of Calabar Teaching Hospital, Department of Paediatrics, PMB 1115, Calabar, Cross River State, Nigeria.
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Costs and effects of the Tanzanian national voucher scheme for insecticide-treated nets. Malar J 2008; 7:32. [PMID: 18279509 PMCID: PMC2279140 DOI: 10.1186/1475-2875-7-32] [Citation(s) in RCA: 63] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2007] [Accepted: 02/15/2008] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The cost-effectiveness of insecticide-treated nets (ITNs) in reducing morbidity and mortality is well established. International focus has now moved on to how best to scale up coverage and what financing mechanisms might be used to achieve this. The approach in Tanzania has been to deliver a targeted subsidy for those most vulnerable to the effects of malaria while at the same time providing support to the development of the commercial ITN distribution system. In October 2004, with funds from the Global Fund to Fight AIDS Tuberculosis and Malaria, the government launched the Tanzania National Voucher Scheme (TNVS), a nationwide discounted voucher scheme for ITNs for pregnant women and their infants. This paper analyses the costs and effects of the scheme and compares it with other approaches to distribution. METHODS Economic costs were estimated using the ingredients approach whereby all resources required in the delivery of the intervention (including the user contribution) are quantified and valued. Effects were measured in terms of number of vouchers used (and therefore nets delivered) and treated nets years. Estimates were also made for the cost per malaria case and death averted. RESULTS AND CONCLUSION The total financial cost of the programme represents around 5% of the Ministry of Health's total budget. The average economic cost of delivering an ITN using the voucher scheme, including the user contribution, was $7.57. The cost-effectiveness results are within the benchmarks set by other malaria prevention studies. The Government of Tanzania's approach to scaling up ITNs uses both the public and private sectors in order to achieve and sustain the level of coverage required to meet the Abuja targets. The results presented here suggest that the TNVS is a cost-effective strategy for delivering subsidized ITNs to targeted vulnerable groups.
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Wiseman V, McElroy B, Conteh L, Stevens W. Malaria prevention in The Gambia: patterns of expenditure and determinants of demand at the household level. Trop Med Int Health 2006; 11:419-31. [PMID: 16553925 DOI: 10.1111/j.1365-3156.2006.01586.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To provide a better understanding of (1) the amounts households in The Gambia spend on a wide variety of malaria prevention measures, (2) how expenditure fluctuates throughout the year and (3) the main determinants of expenditure. METHODS A random sample of 1700 households from the Farafenni region were interviewed about their expenditure on malaria prevention over the past 2 weeks. Interviews were staggered over 12 months. Expenditure was measured for bed nets, treating and repairing bed nets, aerosols, coils, indoor spraying, smoke and other prevention strategies such as drinking herbs and cleaning the outside environment. Results Expenditure on bed nets, including treatment and repair, constituted only 10% of total expenditure on malaria prevention. Every fortnight, households spent an average of 8.40 Dalasis (D) on coils, 4.20 D on indoor sprays, 3.09 D on smoke and 3.06 D on aerosols, together making up 81% of total fortnightly expenditure. Of the 442 households that did not own a bed net, 68% said it was because they could not afford one. Every 2 months, the same households spent an average of US 5 dollars, the equivalent to the cost of an insecticide treated bed net, on other forms of prevention. Total expenditure was 42% higher during the wet season than for the rest of the year. For every month of the year, coils were the dominant form of prevention expenditure. Wealth, age, occupation of household head, location of residence and month of the year were significant determinants of prevention expenditure. CONCLUSIONS Households in The Gambia spend considerable amounts on a range of malaria prevention products and activities throughout the year. Bed nets represent a relatively small proportion of this expenditure even though they are perceived to be the most efficient and effective method of malaria control. A more concerted effort is needed to develop appropriate targeting strategies to encourage bed net use especially for children <5 years of age. Equal emphasis should be given to addressing barriers to purchasing nets such as their relative high upfront cost.
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Affiliation(s)
- V Wiseman
- Gates Malaria Partnership, Gates Malaria Partnership and Health Policy Unit, London School of Hygiene and Tropical Medicine, London, UK.
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Kolaczinski J, Hanson K. Costing the distribution of insecticide-treated nets: a review of cost and cost-effectiveness studies to provide guidance on standardization of costing methodology. Malar J 2006; 5:37. [PMID: 16681856 PMCID: PMC1513388 DOI: 10.1186/1475-2875-5-37] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2005] [Accepted: 05/08/2006] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Insecticide-treated nets (ITNs) are an effective and cost-effective means of malaria control. Scaling-up coverage of ITNs is challenging. It requires substantial resources and there are a number of strategies to choose from. Information on the cost of different strategies is still scarce. To guide the choice of a delivery strategy (or combination of strategies), reliable and standardized cost information for the different options is required. METHODS The electronic online database PubMed was used for a systematic search of the published English literature on costing and economic evaluations of ITN distribution programmes. The keywords used were: net, bednet, insecticide, treated, ITN, cost, effectiveness, economic and evaluation. Identified papers were analysed to determine and evaluate the costing methods used. Methods were judged against existing standards of cost analysis to arrive at proposed standards for undertaking and presenting cost analyses. RESULTS Cost estimates were often not readily comparable or could not be adjusted to a different context. This resulted from the wide range of methods applied and measures of output chosen. Most common shortcomings were the omission of certain costs and failure to adjust financial costs to generate economic costs. Generalisability was hampered by authors not reporting quantities and prices of resources separately and not examining the sensitivity of their results to variations in underlying assumptions. CONCLUSION The observed shortcomings have arisen despite the abundance of literature and guidelines on costing of health care interventions. This paper provides ITN specific recommendations in the hope that these will help to standardize future cost estimates.
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Affiliation(s)
- Jan Kolaczinski
- Disease Control and Vector Biology Unit, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK
| | - Kara Hanson
- Health Policy Unit, Department of Public Health and Policy, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK
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Meremikwu MM, Omari AAA, Garner P. Chemoprophylaxis and intermittent treatment for preventing malaria in children. Cochrane Database Syst Rev 2005:CD003756. [PMID: 16235340 DOI: 10.1002/14651858.cd003756.pub2] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Malaria causes repeated illness in children living in endemic areas. Policies of giving antimalarial drugs at regular intervals (prophylaxis or intermittent treatment) are being considered for preschool children. OBJECTIVES To evaluate chemoprophylaxis and intermittent treatment with antimalarial drugs to prevent malaria in young children living in malaria endemic areas. SEARCH STRATEGY We searched the Cochrane Infectious Diseases Group Specialized Register (April 2005), CENTRAL (The Cochrane Library Issue 1, 2005), MEDLINE (1966 to April 2005), EMBASE (1974 to April 2005), LILACS (1982 to April 2005), and reference lists of identified trials. We also contacted researchers. SELECTION CRITERIA Randomized and quasi-randomized controlled trials comparing antimalarial drugs given at regular intervals (prophylaxis or intermittent treatment) with placebo or no drug in children aged one month to six years or less living in an area where malaria is endemic. DATA COLLECTION AND ANALYSIS We independently extracted data and assessed methodological quality. We used relative risk (RR) or weighted mean difference with 95% confidence intervals (CI) for meta-analyses. Where we detected heterogeneity and considered it appropriate to combine the trials, we used the random-effects model (REM). MAIN RESULTS Nineteen trials (14,393 participants) met the inclusion criteria. Children receiving antimalarial drugs as prophylaxis or intermittent treatment had fewer clinical malaria episodes (RR 0.52, 95% CI 0.35 to 0.77, REM; 4051 participants, 8 trials), and severe anaemia was less common (RR 0.54, 95% CI 0.42 to 0.68; 2727 participants, 8 trials). We did not detect a difference in the number of deaths from any cause (RR 0.82, 95% CI 0.65 to 1.04; 7929 participants, 9 trials), but the confidence intervals do not exclude a potentially important difference. None of the trials reported serious adverse events. Three trials measured morbidity and mortality six months to two years after stopping regular antimalarial drugs; overall, there was no statistically significant difference, but participant numbers were small. AUTHORS' CONCLUSIONS Prophylaxis and intermittent treatment with antimalarial drugs reduce clinical malaria and severe anaemia in preschool children. There is insufficient evidence to detect an effect on mortality.
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Affiliation(s)
- M M Meremikwu
- University of Calabar, Department of Paediatrics, Calabar, Cross River State, Nigeria, PMB 1115.
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Bhatia MR, Fox-Rushby J, Mills A. Cost-effectiveness of malaria control interventions when malaria mortality is low: insecticide-treated nets versus in-house residual spraying in India. Soc Sci Med 2004; 59:525-39. [PMID: 15144762 DOI: 10.1016/j.socscimed.2003.11.005] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Malaria is one of the leading causes of morbidity and mortality in the developing world and a major public health problem in India. Disillusioned by in-house residual spraying (IRS), and increasingly aware that insecticide-treated nets (ITNs) have proved to be effective in reducing malaria mortality and morbidity in various epidemiological settings, policy-makers in India are keen to identify which is the more cost-effective malaria control intervention. A community randomised controlled trial was set up in Surat to compare the effectiveness and efficiency of IRS and ITNs. Both control strategies were shown to be effective in preventing malaria over the base-case scenario of early diagnosis and prompt treatment. The mean costs per case averted for ITNs was statistically significantly lower (Rs. 1848, 1567-2209; US$ 52) than IRS (Rs. 3121, 2386-4177, US$ 87). The incremental cost-effectiveness ratio for ITNs over IRS was Rs. 799 (US$ 22). The conclusions were robust to changes in assumptions. This study expands the scope of recent comparative economic evaluations of ITNs and IRS, since it was carried out in a low mortality malaria endemic area.
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Affiliation(s)
- Mrigesh R Bhatia
- Department of Social Policy, London School of Economics, Houghton Street, London WC2A 2AE, UK.
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18
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Goodman CA, Mnzava AE, Dlamini SS, Sharp BL, Mthembu DJ, Gumede JK. Comparison of the cost and cost-effectiveness of insecticide-treated bednets and residual house-spraying in KwaZulu-Natal, South Africa. Trop Med Int Health 2001; 6:280-95. [PMID: 11348519 DOI: 10.1046/j.1365-3156.2001.00700.x] [Citation(s) in RCA: 62] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Residual house-spraying (RHS) has been the mainstay of South African malaria prevention for more than 50 years, but it has been argued that insecticide-treated bednets (ITBN) could be a more effective and appropriate method of control. To provide a rational basis for choosing between the interventions, a trial was conducted during 1998 and 1999 in northern KwaZulu-Natal to collect comparable data on the effectiveness, acceptability and cost of the two interventions. The current practice of house-spraying once a year was compared with ITBN, distributed free to households and retreated annually at several specific centres. The base case results show ITBN to be significantly more effective in preventing malaria cases than RHS (overall adjusted rate ratio of 0.69), and also more costly, with an incremental economic cost per person of ITBN compared with RHS of R8.68 (US$1.42) per year, giving a gross incremental cost per case averted of R111 ($18) (1999 prices). Estimating the number of deaths averted, based on the average case fatality rate, gave a gross incremental cost per death averted of R11 718 ($1915). The additional cases averted were estimated to lead to drug cost savings of around R1 ($0.16) per capita per year, giving a net cost per case averted of R98 ($16), and net cost per death averted of R10 377 ($1696). Although the finding that the economic costs of ITBN were higher than those for RHS was relatively robust to parameter variations, the extent of the cost margin was sensitive to changes in the price and useful life of the net, and the price of the insecticide. Moreover, a switch to ITBN could lead to net financial savings if the price per net fell below $3.57 (R21.85), or if a change in policy allowed a significant reduction in the number of permanent full-time malaria control staff. In view of the greater effectiveness of ITBN, policy makers may view ITBN as a cost-effective use of resources, even if the economic costs are higher. If ITBN are implemented, close monitoring will be required of use, retreatment and useful life of nets, and resistance to insecticides, to assess any change over time in relative cost-effectiveness, and any threat to the role of the programme as a barrier to the spread of malaria transmission to other areas.
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Affiliation(s)
- C A Goodman
- Health Policy Unit, Department of Public Health and Policy, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK.
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Walker D, Fox-Rushby JA. Economic evaluation of communicable disease interventions in developing countries: a critical review of the published literature. HEALTH ECONOMICS 2000; 9:681-698. [PMID: 11137950 DOI: 10.1002/1099-1050(200012)9:8<681::aid-hec545>3.0.co;2-x] [Citation(s) in RCA: 45] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Abstract
Limited health care budgets have emphasized the need for providers to use resources efficiently. Accordingly, there has been a rapid increase in the number of economic evaluations of communicable disease health programmes in developing countries, as there is a need to implement evidence-based policy decisions. However, given the prohibitive cost of many economic evaluations in low-income countries, interest has also been generated in pooling data and results of previously published studies. Yet, our review demonstrated that very few published economic evaluations have been performed during 1984-1997 (n=107). Certain diseases and geographical areas have also been neglected. Of those studies published, appropriate analytic techniques have been inconsistently applied. In particular, there are four immediate concerns: the narrow perspective taken-dominance of the health care provider viewpoint and reliance on intermediate outcomes measures; bias-some costs were excluded from estimates; the lack of transparency-sources of data not identified; and the absence of a critical examination of findings-many papers failed to perform a sensitivity analysis. The usefulness of previously published economic evaluations to help make resource allocation choices on an individual basis and, therefore, for the purpose of international comparisons, pooling or meta-analysis, has to be questioned in light of the results from this study.
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Affiliation(s)
- D Walker
- Health Economics and Financing Programme, Health Policy Unit, London School of Hygiene and Tropical Medicine, London, UK.
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20
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Guyatt HL, Snow RW, Evans DB. Malaria epidemiology and economics: the effect of delayed immune acquisition on the cost-effectiveness of insecticide-treated bednets. Philos Trans R Soc Lond B Biol Sci 1999; 354:827-35. [PMID: 10365407 PMCID: PMC1692554 DOI: 10.1098/rstb.1999.0434] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
An understanding of the epidemiology of a disease is central in evaluating the health impact and cost-effectiveness of control interventions. The epidemiology of life-threatening malaria is receiving renewed interest, with concerns that the implementation of preventive measures such as insecticide-treated bednets (ITNs) while protecting young children might in fact increase the risks of mortality and morbidity in older ages by delaying the acquisition of functional immunity. This paper aims to illustrate how a combined approach of epidemiology and economics can be used to (i) explore the long-term impact of changes in epidemiological profiles, and (ii) identify those variables that are critical in determining whether an intervention will be an efficient use of resources. The key parameters for determining effectiveness are the protective efficacy of ITNs (reduction in all-cause mortality), the malaria attributable mortality and the increased malaria-specific mortality risk due to delays in the acquisition of functional immunity. In particular, the analysis demonstrates that delayed immune acquisition is not a problem per se, but that the critical issue is whether it occurs immediately following the implementation of an ITN programme or whether it builds up slowly over time. In the 'worst case' scenario where ITNs immediately increase malaria-specific mortality due to reduced immunity, the intervention might actually cost lives. In other words, it might be better to not use ITNs. On the other hand, if reduced immunity takes two years to develop, ITNs would still fall into the category of excellent value for money compared to other health interventions, saving a year of life (YLL) at a cost of between US$25-30. These types of calculations are important in identifying the parameters which field researchers should be seeking to measure to address the important question of the net impact of delaying the acquisition of immunity through preventive control measures.
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Affiliation(s)
- H L Guyatt
- Wellcome Trust Centre for the Epidemiology of Infectious Disease, University of Oxford, UK
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Aikins MK, Fox-Rushby J, D'Alessandro U, Langerock P, Cham K, New L, Bennett S, Greenwood B, Mills A. The Gambian National Impregnated Bednet Programme: costs, consequences and net cost-effectiveness. Soc Sci Med 1998; 46:181-91. [PMID: 9447642 DOI: 10.1016/s0277-9536(97)00145-7] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Clinical trials have indicated that treating mosquito nets with insecticide could be a potentially cost-effective method of preventing malaria. As malaria is one of the most common causes of death in children under five in developing countries, there has been substantial interest in whether such findings can be replicated for a country's control programme in practice. The cost-effectiveness of the Gambian National Insecticide-impregnated Bednet Programme (NIBP), from the viewpoint of providers (government and non-governmental agencies) and the community, has been calculated. Information was collected from existing records, interviews with NIBP personnel, observation and household surveys. Information is provided on the resource use consequences of the NIBP in terms of reduced expenditure on anti-malaria preventive measures, treatment in government health services, household financed treatment and "charity" (burial, funeral and mourning activities), as well as cash income lost as a result of child death. The annual implementation cost of the NIBP was D757,875 (US$91,864), of which 86% was recurrent cost. The estimated number of death averted was 40.56. The net implementation cost-effectiveness ratio per death averted and discounted life years gained were D3884 (US$471) and D260 (US$31.5), respectively. Adding the cost of all mosquito nets would increase the cost-effectiveness ratios by over five times, which is an important consideration for countries with a lower coverage of mosquito nets per capita. It is concluded that insecticide-impregnated mosquito nets are one of the more efficient ways of reducing deaths in children under 10 years in rural Gambia.
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Affiliation(s)
- M K Aikins
- National Population Council Secretariat, Accra, Ghana
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Binka FN, Mensah OA, Mills A. The cost-effectiveness of permethrin impregnated bednets in preventing child mortality in Kassena-Nankana district of Northern Ghana. Health Policy 1997; 41:229-39. [PMID: 10170091 DOI: 10.1016/s0168-8510(97)00035-3] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Permethrin impregnated bednets are now being widely promoted as an effective means of protecting African children against malaria, but there is little evidence of their cost-effectiveness. The impact on child mortality of introducing permethrin impregnated bednets was evaluated in a rural district of northern Ghana in a controlled trial. The cost-effectiveness of the intervention is reported in this paper. The total cost of the intervention over the 2 years of follow-up was US $148,245. Cost per impregnated bednet per year and per person protected per year was US $2.4 and 1.2, respectively. Approximately 16,800 child years were protected and 74 child deaths averted at an estimated cost of US $8.8 per child year protected and US $2003 per death averted. In this rural community, where life expectancy at the mean age of death of trial children was 57.5 years, the estimated cost per discounted healthy life-year gained was US $73.5. Sensitivity analysis suggested that this cost-effectiveness ratio might be reduced substantially by feasible changes in programme implementation. This study supports the argument that the cost-effectiveness of bednet impregnation is sufficiently attractive to make it part of a package of high priority interventions for children. Issues of how to finance the provision of nets and insecticide, and especially the relative contribution of governments, households and donors, need urgently to be addressed.
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Müller O, Cham K, Jaffar S, Greenwood B. The Gambian National Impregnated Bednet Programme: evaluation of the 1994 cost recovery trial. Soc Sci Med 1997; 44:1903-9. [PMID: 9194251 DOI: 10.1016/s0277-9536(96)00299-7] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Following the success of a controlled trial of insecticide-impregnated bednets in reducing mortality in children. The Gambia started a National Impregnated Bednet Programme (NIBP) in 1992. The objectives of this programme were to introduce impregnated bednets into all primary health care (PHC) villages and to establish a system of cost recovery over a three-year period. During the initial phase of the programme, when insecticide was given out free, a high uptake was achieved. However, after small user charges were introduced in 1993, coverage dropped to a low level. In 1994, different systems of insecticide distribution and permethrin formulations were tried in an attempt to improve coverage. A nationwide cross-sectional survey carried out during the 1994 rainy season measured coverage by distribution channel, as well as the knowledge, attitudes and practices of health workers and villagers during the intervention. Overall, only 16% of bednets were impregnated in 1994, compared to 80% when the insecticide was offered free of charge in previous years. Lack of money was the major reason given by villagers for not impregnating their bednets in 1994. Use of impregnated bednets was higher in areas where the sale of permethrin emulsion by village health workers was supplemented by the sale of insecticide in individual packages through shops. In villages where insecticide was distributed free to women with small children through governmental mother and child health (MCH) services, higher levels of coverage were achieved among women and young children than in villages where other distribution systems were used. We conclude that the sale of insecticide through the private sector may increase bednet impregnation rates in African communities, and that the free distribution of insecticide through MCH services may be an effective way of targeting young children, the group most at risk of malaria.
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Affiliation(s)
- O Müller
- Medical Research Council (MRC) Laboratories, Banjul, The Gambia, West Africa
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David KP, Marbiah NT, Lovgren P, Greenwood BM, Petersen E. Hyperpigmented dermal macules in children following the administration of Maloprim for malaria chemoprophylaxis. Trans R Soc Trop Med Hyg 1997; 91:204-8. [PMID: 9196770 DOI: 10.1016/s0035-9203(97)90225-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
The occurrence of an unexpected side effect following the use of Maloprim (pyrimethamine/dapsone) for malaria chemosuppression in 3-59 months old children in Sierra Leone is reported. As part of a trial of chemoprophylaxis and insecticide-impregnated bed nets, 2000 children received either Maloprim or placebo; 4% of children who received Maloprim fortnightly for more than 3 months developed hyperpigmented macules, whereas none of the children who received placebo did so. Histopathological examination of full thickness skin biopsies showed macrophages containing melanin in the dermal layer. Clustering of cases was noted among siblings, suggesting the possible involvement of genetic factors in the pathogenesis of these skin reactions. One child was accidentally re-exposed to Maloprim after the drug had been withdrawn and he developed a severe reaction. No other serious side effect was noted. Hyperpigmented lesions similar to those reported in this study have been described previously in patients with leprosy treated with dapsone, and the dapsone component of Maloprim is the likely cause of the skin reactions seen in children given this drug for malaria chemoprophylaxis.
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Affiliation(s)
- K P David
- EC Malaria Project, Bo, Sierra Leone
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Fox-Rushby JA, Foord F. Costs, effects and cost-effectiveness analysis of a mobile maternal health care service in West Kiang, The Gambia. Health Policy 1996; 35:123-43. [PMID: 10156650 DOI: 10.1016/0168-8510(95)00774-1] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
The costs, effects and cost-effectiveness of a new mobile maternal care service offered in The Gambia at a government-run health centre in Karantaba were compared with the usual pattern of maternal care offered (at Ngayen Sanjal). Routinely collected data were supplemented by research on time allocation of staff by activity, use of drugs, medical consumables and vehicles, out-of-pocket payments by patients and a range of effectiveness indicators. To account for a differential effect on hospital referrals, maternity care at the main referral hospital was assessed. In 1991, the annual total cost of maternity care at Karantaba was US$64 800 compared with US$25 300 at Ngayen Sanjal. The largest proportion of this difference was attributed to training. Whilst average cost/attendance was higher at Karantaba, the marginal cost of expanding the service to other villages was lower than the marginal cost at Ngayen Sanjal. Incremental cost-effectiveness of the mobile service at Karantaba was calculated according to best and worst case scenarios which showed that the extra cost/extra death averted per year ranged between US$459 and US$2134. Using discounted life years gained reduced the figures to US$42.9 and US$206.3. Various suggestions are offered for reducing the cost of the new service, and a number of methodological points are raised for discussion.
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Abstract
Drug-resistant falciparum and vivax malaria will continue to be an increasing problem. The incidence of drug-resistant malaria has been increasing at a rate that exceeds new drug development. Plasmodium falciparum has rapidly developed resistance to new synthetic antimalarials, including mefloquine and halofantrine. P. vivax malaria resistant to chloroquine and primaquine is now widespread in parts of Oceania; the optimal therapy for this infection is unknown. At present, a combination of qinghaosu derivatives and mefloquine appears to be the most active drug regimen against multidrug-resistant falciparum malaria from Southeast Asia. However, qinghaosu compounds are not yet licensed and widely available. The capacity of P. falciparum to rapidly develop drug resistance and the growing evidence that other plasmodia can evolve resistance suggests that within the next 10 years, we face the real prospect of untreatable malaria. Ultimately, control of malaria may require more creative approaches than additional inhibitory drugs. These might include: the identification of biochemical pathways unique to the parasite (such as drug efflux and heme polymerase), making it possible to design new classes of antimalarial agents that are selectively toxic to the parasite; methods to block parasite development in the mosquito vector; and multistage vaccines against both asexual and sexual stages in order to block both the pathophysiology and transmission of disease.
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Affiliation(s)
- K C Kain
- Department of Medicine, University of Toronto, The Toronto Hospital, Canada
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Affiliation(s)
- D B Evans
- United Nations Development Program-World Bank-WHO Special Programme for Research and Training in Tropical Diseases, Geneva, Switzerland
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