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ABSTRACT: Evaluation of the mortality impact of nationwide disease-prevention efforts is complicated by potential endogeneity: programme recipients may have unobserved characteristics that simultaneously make them both more likely to become recipients and more likely to survive as a result of other health practices. This population-based study assesses the mortality impact of a nationwide programme that distributed insecticide-treated nets (ITNs) to mothers of children aged 9-59 months in Togo. By comparing mortality rates before and after the programme according to households' eligibility status, we demonstrate that a one-time programme that restricts eligibility to households with a surviving child excludes some households with a high risk of child mortality. We then apply simultaneous estimation models to untangle the mortality impact of ITNs from the effects of unobserved confounders and show that among eligible households, living in a household with ITNs significantly reduces mortality for children aged 20-59 months, even after controlling for endogeneity.
Population Studies 03/2011; 65(1):57-71. · 1.08 Impact Factor
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Adam Wolkon,
Jodi L Vanden Eng, Kodjo Morgah,
M James Eliades,
Julie Thwing,
Dianne J Terlouw,
Vincent Takpa,
Aboudou Dare,
Yao K Sodahlon,
Yao Doumanou,
Allen W Hightower,
Marcel Lama,
Neeta Thawani,
Laurence Slutsker,
William A Hawley
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ABSTRACT: In December 2004, Togo was the first country to conduct a nationwide free insecticide-treated net (ITN) distribution as part of its National Integrated Child Health Campaign. Community-based cross-sectional surveys were conducted one and nine months post-campaign as part of a multidisciplinary evaluation of the nationwide distribution of ITNs to children 9-59 months of age to evaluate ITN ownership, equity, and use. Our results demonstrated that at one month post-campaign, 93.1% of all eligible children received an ITN. Household ITN ownership and equity increased significantly post-campaign. Nine months post-campaign, 78.6% of households with a child eligible to participate in the campaign retained at least one campaign net. Use by eligible children was 43.5% at one month post-campaign (during the dry season) and 52.9% at nine months post-campaign (during the rainy season). Household ownership of at least one ITN increased from 8.0% pre-campaign to 62.5% one month post-campaign. Together, these findings demonstrate that in this setting, increased household ITN ownership, equity, and retention can be achieved on a national scale through free ITN distribution during an integrated campaign.
The American journal of tropical medicine and hygiene 11/2010; 83(5):1014-9. · 2.59 Impact Factor
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ABSTRACT: An evaluation of the short-term impact on childhood malaria morbidity of mass distribution of free long-lasting insecticidal nets (LLINs) to households with children aged 9-59 months as part of the Togo National Integrated Child Health Campaign.
The prevalence of anaemia and malaria in children aged zero to 59 months was measured during two cross-sectional household cluster-sample surveys conducted during the peak malaria transmission, three months before (Sept 2004, n=2521) and nine months after the campaign (Sept 2005, n=2813) in three districts representative of Togo's three epidemiological malaria transmission regions: southern tropical coastal plains (Yoto), central fertile highlands (Ogou) and northern semi-arid savannah (Tone).
In households with children<5 years of age, insecticide-treated net (ITN) ownership increased from <1% to >65% in all 3 districts. Reported ITN use by children during the previous night was 35.9%, 43.8% and 80.6% in Yoto, Ogou and Tone, respectively. Rainfall patterns were comparable in both years. The overall prevalence of moderate to severe anaemia (Hb<8.0 g/dL) was reduced by 28% (prevalence ratio [PR] 0.72, 95% CI 0.62-0.84) and mean haemoglobin was increased by 0.35 g/dL (95% CI 0.25-0.45).The effect was predominantly seen in children aged 18-59 months and in the two southern districts: PR (95% CI) for moderate to severe anaemia and clinical malaria: Yoto 0.62 (0.44-0.88) and 0.49 (0.35-0.75); Ogou 0.54 (0.37-0.79) and 0.85 (0.57-1.27), respectively. Similar reductions occurred in children<18 months in Ogou, but not in Yoto. No effect was seen in the semi-arid northern district despite a high malaria burden and ITN coverage.
A marked reduction in childhood malaria associated morbidity was observed in the year following mass distribution of free LLINs in two of the three districts in Togo. Sub-national level impact evaluations will contribute to a better understanding of the impact of expanding national malaria control efforts.
Malaria Journal 01/2010; 9:199. · 3.19 Impact Factor
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ABSTRACT: Abstract
Background
An evaluation of the short-term impact on childhood malaria morbidity of mass distribution of free long-lasting insecticidal nets (LLINs) to households with children aged 9-59 months as part of the Togo National Integrated Child Health Campaign.
Methods
The prevalence of anaemia and malaria in children aged zero to 59 months was measured during two cross-sectional household cluster-sample surveys conducted during the peak malaria transmission, three months before (Sept 2004, n = 2521) and nine months after the campaign (Sept 2005, n = 2813) in three districts representative of Togo's three epidemiological malaria transmission regions: southern tropical coastal plains (Yoto), central fertile highlands (Ogou) and northern semi-arid savannah (Tone).
Results
In households with children 65% in all 3 districts. Reported ITN use by children during the previous night was 35.9%, 43.8% and 80.6% in Yoto, Ogou and Tone, respectively. Rainfall patterns were comparable in both years. The overall prevalence of moderate to severe anaemia (Hb < 8.0 g/dL) was reduced by 28% (prevalence ratio [PR] 0.72, 95% CI 0.62-0.84) and mean haemoglobin was increased by 0.35 g/dL (95% CI 0.25-0.45).
The effect was predominantly seen in children aged 18-59 months and in the two southern districts: PR (95% CI) for moderate to severe anaemia and clinical malaria: Yoto 0.62 (0.44-0.88) and 0.49 (0.35-0.75); Ogou 0.54 (0.37-0.79) and 0.85 (0.57-1.27), respectively. Similar reductions occurred in children <18 months in Ogou, but not in Yoto. No effect was seen in the semi-arid northern district despite a high malaria burden and ITN coverage.
Conclusions
A marked reduction in childhood malaria associated morbidity was observed in the year following mass distribution of free LLINs in two of the three districts in Togo. Sub-national level impact evaluations will contribute to a better understanding of the impact of expanding national malaria control efforts.
Malaria Journal. 01/2010;
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ABSTRACT: 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.
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.
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.
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.
Malaria Journal 02/2008; 7:73. · 3.19 Impact Factor
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ABSTRACT: 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.
Malaria Journal. 01/2008;
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Jodi L Vanden Eng,
Adam Wolkon,
Anatoly S Frolov,
Dianne J Terlouw,
M James Eliades, Kodjo Morgah,
Vincent Takpa,
Aboudou Dare,
Yao K Sodahlon,
Yao Doumanou,
William A Hawley,
Allen W Hightower
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ABSTRACT: We introduce an innovative method that uses personal digital assistants (PDAs) equipped with global positioning system (GPS) units in household surveys to select a probability-based sample and perform PDA-based interviews. Our approach uses PDAs with GPS to rapidly map all households in selected areas, choose a random sample, and navigate back to the sampled households to conduct an interview. We present recent field experience in two large-scale nationally representative household surveys to assess insecticide-treated bed net coverage as part of malaria control efforts in Africa. The successful application of this method resulted in statistically valid samples; quality-controlled data entry; and rapid aggregation, analyses, and availability of preliminary results within days of completing the field work. We propose this method as an alternative to the Expanded Program on Immunization cluster sample method when a fast, statistically valid survey is required in an environment with little census information at the enumeration area level.
The American journal of tropical medicine and hygiene 09/2007; 77(2):393-9. · 2.59 Impact Factor
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ABSTRACT: Virtually all previous empirical cost-effectiveness analyses of disease control interventions have concentrated on the delivery of single interventions, despite the fact that the joint delivery of multiple interventions may elicit large efficiency gains. We here report results of a cost-effectiveness analysis of the Togo Integrated Child Health Campaign carried out in December 2004. This was the first nationwide campaign with combined delivery of measles vaccine and distribution of a long-lasting insecticide treated bednet (LLITN) to each eligible household ¿ an approach now widely advocated for other countries. Both net and gross cost-effectiveness was measured in terms of cost per LLITN distributed and per vaccination administered, cost per death averted, cost per case averted and cost per DALY averted. The analysis was undertaken from a provider perspective. The total costs of the campaign were estimated at 6.45 million USD. Assuming equal attribution of shared costs between the measles and malaria components of the campaign, 5.38 million USD or 83.5% could be attributed to the malaria component and 1.03 million USD or 16% to the measles component. 1.05 million USD or 16.3% of total campaign costs represent shared expenditure between the malaria and measles components. The gross cost per LLITN distributed reached 5.95 USD. Assuming a constant utilisation of LLITN by the target group over three years, 6,285 malaria deaths could be prevented, as well as 1.2 million malaria cases and 243,472 DALYs. The gross cost per malaria death; per case; and per DALY averted amounted to 856 USD; 4.40 USD; and 22.10 USD, respectively. The net cost-effectiveness per LLITN distributed; death averted; case averted; and DALY averted were estimated at 0.81 USD; 118 USD; 0.61 USD; and 3.00 USD, respectively. The gross cost per measles vaccination administered was calculated at 1.16 USD. The gross costs per measles death and case averted amounted to 224.47 USD and 29.59 USD, respectively. The net cost per measles case averted ranged from 6.59 USD to 26.32 USD depending on the ratio of cases treated as inpatients vs. outpatients. As part of the sensitivity analysis, we varied the attribution of shared costs from a 50%/50% split between the malaria and the measles components to a full attribution of shared costs to either component. Assuming that all shared costs were borne by the measles component, the gross cost-effectiveness ratios per malaria death; case; and DALY averted change from 856; 4.40; and 22.10 USD to 772; 3.96; and 19.93 USD, respectively. If shared costs were borne solely by the malaria component, the gross cost-effectiveness ratios would change to 941; 4.83; and 24.28 USD, respectively. The cost-effectiveness results from this analysis are well within commonly agreed benchmarks set by other malaria prevention studies. Varying transmission levels and the attribution of shared costs have a significant impact on cost-effectiveness ratios. This analysis also suggests that substantial efficiency gains can be achieved through the joint delivery of measles vaccinations and LLITNs by means of a campaign approach.
HEN: Women's & Children's Health (Topic). 06/2007;
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ABSTRACT: A community-based baseline cross-sectional survey was conducted in three districts in Togo in September 2004 as part of a multidisciplinary evaluation of the impact of the Togo National Integrated Child Health Campaign. During this campaign, long-lasting-insecticide-treated bed nets (LLITNs) were distributed to households with children between 9 months and 5 years of age throughout the country in December 2004. The pre-intervention survey provided baseline malaria and anemia prevalence in children < 5 years of age during peak malaria transmission. Of 2,532 enrolled children from 1,740 households, 62.2% (1,352/2,172) were parasitemic and 84.4% (2,129/2,524) were anemic (hemoglobin < 11 g/dL). Moderate-to-severe anemia (< 8.0 g/dL) was found in 21.7% (543/2,524), with a peak prevalence in children 6-17 months of age and was strongly correlated with parasitemia (OR = 2.3, 95% CI: 1.8-2.5). Net ownership (mainly untreated) was 225/2,532 (8.9%). Subsequent nation-wide introduction of LLITNs and the introduction of artemisinin-based combination therapy have the potential to markedly reduce this burden of malaria.
The American journal of tropical medicine and hygiene 11/2006; 75(4):622-9. · 2.59 Impact Factor
