Cost-effectiveness of community-based distribution of intermittent preventive treatment of malaria in pregnancy in Madagascar, Mozambique, Nigeria, and the Democratic Republic of Congo

Introduction Malaria in pregnancy is a major driver of maternal and infant mortality in sub-Saharan Africa. The WHO recommends the administration of intermittent preventive treatment with sulfadoxine pyrimethamine (IPTp-SP) at antenatal care (ANC) visits. Despite being a highly cost-effective strategy, IPTp-SP coverage and uptake remains low. A pilot project was conducted to assess the cost-effectiveness (CE) of community-based delivery of IPTp (C-IPTp) in addition to ANC delivery to increase IPTp uptake in the Democratic Republic of Congo (DRC), Madagascar (MDG), Mozambique (MOZ) and Nigeria (NGA).Methods Costs and CE estimates of C-IPTp were calculated according to two scenarios: (1) costs in ‘programmatic mode’ (ie, costs if C-IPTp was to be implemented by national health systems) and (2) costs from the pilot project. The effectiveness of C-IPTp was obtained through estimates of the averted disability-adjusted life-years (DALYs) associated with maternal clinical malaria and anaemia, low birth weight and neonatal mortality.Results Net incremental costs of C-IPTp ranged between US$6138–US$47 177 (DRC), US$5552–US$31 552 (MDG), US$10 202–US$53 221 (MOZ) and US$667–US$28 645 (NGA) per 1000 pregnant women, under scenarios (1) and (2), respectively. Incremental cost-effectiveness ratios (ICERs) ranged between US$15–US$119 in DRC, US$9–US$53 in MDG, US$104–US$543 in MOZ and US$2–US$66 in NGA per DALY averted, under scenarios (1) and (2), respectively. ICERs fall below the WHO recommended CE threshold based on the gross domestic product per capita.Conclusion Findings suggest that C-IPTp is a highly cost-effective intervention. Results can inform policy decisions on adopting and optimising effective interventions for preventing malaria in pregnancy

Prevalence and risk factors associated with malaria infection in children under two years of age in southern Togo prior to perennial malaria chemoprevention implementation

Abstract Background Malaria remains the leading cause of mortality and morbidity in young children in sub-Saharan Africa. To prevent malaria in children living in moderate-to-high malaria transmission areas, the World Health Organization has recommended perennial malaria chemoprevention (PMC). Prior to piloting PMC implementation in southern Togo, a household survey was conducted to estimate malaria infection prevalence in children under 2 years of age (U2). Methods A cross-sectional community-based household survey was conducted in the Haho district in the Togo Plateaux region. A three-stage random sampling method was used to select study participants aged 10–23 months whose caretakers gave informed consent. The prevalence of Plasmodium infection, defined as a positive rapid diagnostic test (RDT), was estimated with 95% confidence interval (CI). Clinical malaria was defined as having a positive RDT plus fever (≥ 37.5 °C) or history of fever in the last 24 h. Mixed-effects logistic regression models were used to assess the child’s, caretaker’s, and household’s factors associated with malaria infection. Results A total of 685 children were included in the survey conducted January–February in 2022 (dry season). Median age was 17 months (interquartile range: 13–21). About 80% of the children slept under a bed net the night before the interview. Malaria infection prevalence was 32.1% (95% CI 27.7–37.0) with significant area variation (cluster range: 0.0–73.3). Prevalence of clinical malaria was 15.4% (95% CI 12.2–19.2). Children whose caretakers were animist (aOR: 1.71, 95% CI 1.19–2.46) and those living in mother-headed households (aOR: 2.39, 95% CI 1.43–3.99) were more likely to have a positive RDT. Living more than 5 km away from the nearest health facility (aOR: 1.60, 95% CI 1.04–2.44) and presence of two or more under-5-years children in the household (aOR: 1.44, 95% CI 1.01–2.07) were also associated with increased risk of infection. Conclusion One-third of the children U2 who participated in this survey had malaria infection, thus PMC could be a promising strategy to reduce malaria burden in young children in Plateaux region. Reinforcement of outreach services and targeting the poorest households should be prioritized to reduce the inequity in malaria prevention in children exposed to the infection

Prevalence of molecular markers of resistance to sulfadoxine–pyrimethamine before and after community delivery of intermittent preventive treatment of malaria in pregnancy in sub-Saharan Africa: a multi-country evaluation

International audienceBackground Intermittent preventive treatment of malaria in pregnancy (IPTp) with sulfadoxine–pyrimethamine isrecommended at each antenatal care clinic visit in high-moderate transmission areas. However, its coverage remainsunacceptably low in many countries. Community health workers can effectively deliver malaria preventive interventions.The aim of this study was to assess the effect of community delivery of IPTp (C-IPTp) on antenatal care and IPTpcoverage.Methods A community-based IPTp administration approach was implemented in four sub-Saharan countries: theDemocratic Republic of the Congo (DR Congo), Madagascar, Mozambique, and Nigeria. A quasi-experimental beforeand after evaluation by cluster sampling was designed where C-IPTp was implemented in selected country areas indifferent phases. Baseline (before C-IPTp implementation), midline, and endline household surveys were carried outto assess IPTp intake in pregnant women in 2018, 2019, and 2021. Eligible participants of the household survey werewomen of reproductive age (13–50 years old, depending on the country) that had a pregnancy that ended (anypregnancy regardless of pregnancy outcome) in the 6 months before the interview. For the first baseline surveys, thetarget population was women who had a pregnancy that ended in the 12 months before the interview. The primaryoutcome from the household surveys was the proportion of women who reported having received at least three dosesof IPTp during pregnancy. The trial is registered at ClinicalTrials.gov, NCT03600844.Findings A total of 32 household surveys were conducted between March 15, and Oct 30, 2018, and data from18 215 interviewed women were analysed. The coverage of at least three doses of IPTp (IPTp3+) increased after thefirst year of C-IPTp implementation in all project areas in DR Congo (from 22∙5% [170/755] to 31∙8% [507/1596]),Madagascar (from 17∙7% [101/572] to 40∙8% [573/1404]), and Nigeria (from 12∙7% [130/1027] to 35∙2% [423/1203]),with increases between 145∙6% (Madagascar) and 506∙6% (Nigeria). IPTp3+ coverage increased between baselineand endline in all districts, except for Murrupula (Mozambique) and ranged between 9∙6% and 533∙6%. This patternwas similar in DR Congo, Madagascar, and Nigeria, and in Mozambique, the increase was lower than the othercountries. Antenatal care attendance did not change or increased lightly in all study countries.Interpretation C-IPTp was associated with an increase in IPTp uptake without reducing antenatal care attendance.The strategy might be considered for malaria control in pregnancy