Coverage, Adherence and Costs of Intermittent Preventive Treatment of Malaria in Children Employing Different Delivery Strategies in Jasikan, Ghana

BACKGROUND: Intermittent preventive treatment of malaria in children (IPTc) involves the administration of a course of anti-malarial drugs at specified time intervals to children at risk of malaria regardless of whether or not they are known to be infected. IPTc provides a high level of protection against uncomplicated and severe malaria, with monthly sulphadoxine-pyrimethamine plus amodiaquine (SP&AQ) and sulphadoxine-pyrimethamine plus piperaquine being the most efficacious regimens. A key challenge is the identification of a cost-effective delivery strategy. METHODS: A community randomized trial was undertaken in Jasikan district, Ghana to assess IPTc effectiveness and costs using SP&AQ delivered in three different ways. Twelve villages were randomly selected to receive IPTc from village health workers (VHWs) or facility-based nurses working at health centres' outpatient departments (OPD) or EPI outreach clinics. Children aged 3 to 59 months-old received one IPT course (three doses) in May, June, September and October. Effectiveness was measured in terms of children covered and adherent to a course and delivery costs were calculated in financial and economic terms using an ingredient approach from the provider perspective. RESULTS: The economic cost per child receiving at least the first dose of all 4 courses was US$4.58 when IPTc was delivered by VHWs, US$4.93 by OPD nurses and US$5.65 by EPI nurses. The unit economic cost of receiving all 3 doses of all 4 courses was US$7.56 and US$8.51 when IPTc was delivered by VHWs or facility-based nurses respectively. The main cost driver for the VHW delivery was supervision, reflecting resources used for travelling to more remote communities rather than more intense supervision, and for OPD and EPI delivery, it was the opportunity cost of the time spent by nurses in dispensing IPTc. CONCLUSIONS: VHWs achieve higher IPTc coverage and adherence at lower costs than facility-based nurses in Jasikan district, Ghana. TRIAL REGISTRATION: ClinicalTrials.gov NCT00119132

Impact assessment of onchocerciasis through lymphatic filariasis transmission assessment surveys using Ov-16 rapid diagnostic tests in Sierra Leone

Background: Onchocerciasis is endemic in 14 of Sierra Leone's 16 districts with high prevalence (47–88.5%) according to skin snips at baseline. After 11 rounds of mass treatment with ivermectin with good coverage, an impact assessment was conducted in 2017 to assess the progress towards eliminating onchocerciasis in the country. Methods: A cluster survey was conducted, either integrated with lymphatic filariasis (LF) transmission assessment survey (TAS) or standalone with the LF TAS sampling strategy in 12 (now 14) endemic districts. Finger prick blood samples of randomly selected children in Grades 1–4 were tested in the field using SD Bioline Onchocerciasis IgG4 rapid tests. Results: In total, 17,402 children aged 4–19 years in 177 schools were tested, and data from 17,364 children aged 4–14 years (14,230 children aged 5–9 years) were analyzed. Three hundred forty-six children were confirmed positive for Ov-16 IgG4 antibodies, a prevalence of 2.0% (95% CI 1.8–2.2%) in children aged 4–14 years with prevalence increasing with age. Prevalence in boys (2.4%; 95% CI 2.1–2.7%) was higher than in girls (1.6%; 95% CI 1.4–1.9%). There was a trend of continued reduction from baseline to 2010. Using data from children aged 5–9 years, overall prevalence was 1.7% (95% CI 1.5–1.9%). The site prevalence ranged from 0 to 33.3% (median prevalence = 0.0%): &lt; 2% in 127 schools, 2 to &lt; 5% in 34 schools and ≥ 5% in 16 schools. There was a significant difference in average prevalence between districts. Using spatial analysis, the Ov-16 IgG4 antibody prevalence was predicted to be &lt; 2% in coastal areas and in large parts of Koinadugu, Bombali and Tonkolili Districts, while high prevalence (&gt; 5%) was predicted in some focal areas, centered in Karene, Kailahun and Moyamba/Tonkolili. Conclusions:Low Ov-16 IgG4 antibody prevalence was shown in most areas across Sierra Leone. In particular, low seroprevalence in children aged 5–9 years suggests that the infection was reduced to a low level after 11 rounds of treatment intervention. Sierra Leone has made major progress towards elimination of onchocerciasis. However, attention must be paid to those high prevalence focal areas. Graphical Abstract: (Figure presented.)</p

Two-tier charging in Maputo Central Hospital: Costs, revenues and effects on equity of access to hospital services

<p>Abstract</p> <p>Background</p> <p>Special services within public hospitals are becoming increasingly common in low and middle income countries with the stated objective of providing higher comfort services to affluent customers and generating resources for under funded hospitals. In the present study expenditures, outputs and costs are analysed for the Maputo Central Hospital and its Special Clinic with the objective of identifying net resource flows between a system operating two-tier charging, and, ultimately, understanding whether public hospitals can somehow benefit from running Special Clinic operations.</p> <p>Methods</p> <p>A combination of step-down and bottom-up costing strategies were used to calculate recurrent as well as capital expenses, apportion them to identified cost centres and link costs to selected output measures.</p> <p>Results</p> <p>The results show that cost differences between main hospital and clinic are marked and significant, with the Special Clinic's cost per patient and cost per outpatient visit respectively over four times and over thirteen times their equivalent in the main hospital.</p> <p>Discussion</p> <p>While the main hospital cost structure appeared in line with those from similar studies, salary expenditures were found to drive costs in the Special Clinic (73% of total), where capital and drug costs were surprisingly low (2 and 4% respectively). We attributed low capital and drug costs to underestimation by our study owing to difficulties in attributing the use of shared resources and to the Special Clinic's outsourcing policy. The large staff expenditure would be explained by higher physician time commitment, economic rents and subsidies to hospital staff. On the whole it was observed that: (a) the flow of capital and human resources was not fully captured by the financial systems in place and stayed largely unaccounted for; (b) because of the little consideration given to capital costs, the main hospital is more likely to be subsidising its Special Clinic operations, rather than the other way around.</p> <p>Conclusion</p> <p>We conclude that the observed lack of transparency may create scope for an inequitable cross subsidy of private customers by public resources.</p

Isolation of Angola-like Marburg virus from Egyptian rousette bats from West Africa.

Marburg virus (MARV) causes sporadic outbreaks of severe Marburg virus disease (MVD). Most MVD outbreaks originated in East Africa and field studies in East Africa, South Africa, Zambia, and Gabon identified the Egyptian rousette bat (ERB; Rousettus aegyptiacus) as a natural reservoir. However, the largest recorded&nbsp;MVD outbreak with the highest case-fatality ratio happened in 2005 in Angola, where direct spillover from bats was not&nbsp; shown. Here, collaborative studies by the Centers for Disease Control and Prevention, Njala University, University of California, Davis USAID-PREDICT, and the University of Makeni identify MARV circulating in ERBs in Sierra Leone. PCR, antibody and virus isolation data from 1755 bats of 42 species shows active MARV infection in approximately 2.5% of ERBs. Phylogenetic analysis identifies MARVs that are similar to the Angola strain. These results provide evidence of MARV circulation in West Africa and demonstrate the value of pathogen surveillance to identify previously undetected threats

Determinants of the Cost-Effectiveness of Intermittent Preventive Treatment for Malaria in Infants and Children

BACKGROUND: Trials of intermittent preventive treatment in infants (IPTi) and children (IPTc) have shown promising results in reducing malaria episodes but with varying efficacy and cost-effectiveness. The effects of different intervention and setting characteristics are not well known. We simulate the effects of the different target age groups and delivery channels, seasonal or year-round delivery, transmission intensity, seasonality, proportions of malaria fevers treated and drug characteristics. METHODS: We use a dynamic, individual-based simulation model of Plasmodium falciparum malaria epidemiology, antimalarial drug action and case management to simulate DALYs averted and the cost per DALY averted by IPTi and IPTc. IPT cost components were estimated from economic studies alongside trials. RESULTS: IPTi and IPTc were predicted to be cost-effective in most of the scenarios modelled. The cost-effectiveness is driven by the impact on DALYs, particularly for IPTc, and the low costs, particularly for IPTi which uses the existing delivery strategy, EPI. Cost-effectiveness was predicted to decrease with low transmission, badly timed seasonal delivery in a seasonal setting, short-acting and more expensive drugs, high frequencies of drug resistance and high levels of treatment of malaria fevers. Seasonal delivery was more cost-effective in seasonal settings, and year-round in constant transmission settings. The difference was more pronounced for IPTc than IPTi due to the different proportions of fixed costs and also different assumed drug spacing during the transmission season. The number of DALYs averted was predicted to decrease as a target five-year age-band for IPTc was shifted from children under 5 years into older ages, except at low transmission intensities. CONCLUSIONS: Modelling can extend the information available by predicting impact and cost-effectiveness for scenarios, for outcomes and for multiple strategies where, for practical reasons, trials cann be carried out. Both IPTi and IPTc are generally cost-effective but could be rendered cost-ineffective by characteristics of the setting, drug or implementatio

Quantitative Outcomes of a One Health Approach to Investigate the First Outbreak of African Swine Fever in the Republic of Sierra Leone

African swine fever (ASF) outbreaks have been reported in Sub-Saharan countries, including West Africa states, but has never been notified in the Republic of Sierra Leone. This is the first report describing field epidemiological and laboratory investigations into the outbreak of fatal pig disease in western rural and urban districts, Freetown. A preliminary finding indicated that pigs exhibited clinical and necropsy signs suggestive of ASF. Serological (ELISA) and molecular (qRT-PCR) methods used to confirm and investigate the outbreak yielded three positive results for the ASF antibody and all negative for Swine flu; thus, confirming ASF as the etiology agent

Cost-effectiveness of intermittent preventive treatment of malaria in infants (IPTi) for averting anaemia in Gabon: a comparison between intention to treat and according to protocol analyses

ABSTRACT: BACKGROUND: In Gabon, the impact of intermittent preventive treatment of malaria in infants (IPTi) was not statistically significant on malaria reduction, but the impact on moderate anaemia was, with some differences between the intention to treat (ITT) and the according to protocol (ATP) trial analyses. Specifically, ATP was statistically significant, while ITT analysis was borderline. The main reason for the difference between ITT and ATP populations was migration. METHODS: This study estimates the cost-effectiveness of IPTi on the reduction of anaemia in Gabon, comparing results of the ITT and the ATP clinical trial analyses. Threshold analysis was conducted to identify when the intervention costs and protective efficacy of IPTi for the ATP cohort equalled the ITT cost-effectiveness ratio. RESULTS: Based on IPTi intervention costs, the cost per episode of moderate anaemia averted was US$12.88 (CI 95$11.30 (CI 95% 4.56, 26.66) using the ATP analysis. In order for the ATP results to equal the cost-effectiveness of ITT, total ATP intervention costs should rise from US$118.38 to US$134 or the protective efficacy should fall from 27% to 18.1%. The uncertainty surrounding the cost-effectiveness ratio using ITT trial results was higher than using the ATP results. CONCLUSIONS: Migration implies great challenges in the organization of health interventions that require repeat visits in Gabon. This was apparent in the study as the cost-effectiveness of IPTp-SP worsened when drop out from the prevention was taken into account. Despite such challenges, IPTi was both inexpensive and efficacious in averting cases of moderate anaemia in infant

Tracking Official Development Assistance for Reproductive Health in Conflict-Affected Countries

Preeti Patel and colleagues report inequity in the disbursement of official development assistance for reproductive health between countries affected by conflict and those unaffected

Connecting children’s worlds: Creating a multilingual syncretic curriculum through partnership between complementary and mainstream schools

Children from minority-language backgrounds have multiple sites of learning: home, community, mainstream school, and in some cases complementary school where they study their mother tongue after school or at weekends. However, due to the institutional constraints of an education system based on monolingual principles, mainstream teachers are often unaware of the contribution that complementary classes make to children’s learning, or unsure of how to draw on their pupils’ linguistic knowledge in the curriculum. Children’s multilingual identities and their other worlds of learning therefore remain invisible in mainstream school. This paper describes an action research study with teachers from complementary and mainstream schools in East London, in which they jointly planned lessons around topics that were then taught in both settings. The complementary teachers brought a holistic perspective based in the linguistic and cultural knowledge of their communities, which enabled these resources to be brought into mainstream learning, thus creating a syncretic curriculum that led to an increase in agency of children and their families as well as teachers themselves. We argue that collaboration between complementary and mainstream teacher colleagues can play a crucial role in constructing a space for multilingual learning in a monolingualizing society