Evaluation of the Togo National Integrated Child Health Campaign

Global Burden of Malaria million cases occur annually 700, million deaths annually, > 75% in African children 41% of the world’s population lives in areas where malaria is transmitted

Millennium Development Goals Address health, poverty, education, gender inequalities, environmental sustainability and development  Include reducing infant and child mortality by half between

Roll Back Malaria (RBM) Goals: To halve malaria mortality by 2010 and again by 2015 The Abuja targets:  At least 60% children under five years of age under an ITN the previous night  At least 60% of pregnant women under an ITN the previous night

Presidential Malaria Initiative Building on the Abuja Targets 15 countries targeted with pop 175 million 85% coverage with select malaria control and prevention interventions Reduction in malaria-related deaths by 50% 1.2 billion USD

Strategies for Control and Prevention of Malaria Prompt diagnosis and treatment Intermittent presumptive treatment in pregnant women Insecticide-treated bed nets (ITNs) Indoor-residual spraying Larval control

Effectiveness of ITNs Western Kenya Insecticide Treated Bed Nets Trial  Reduction in overall childhood mortality by 20%  Averted 1 in 4 infant deaths in areas of intense transmission  A protective effect on compounds lacking ITNs located within 300 meters of compounds with ITNs for child mortality, moderate anemia, high-density parasitemia, and hemoglobin levels.

Strategies to Increase Coverage Largely social marketing in the past  High coverage not achieved  Highest concentration in urban areas and among wealthiest

Strategies to Increase Coverage Linked to routine health services  Extended Program on Immunizations  Antenatal Clinics

Strategies to Increase Coverage Free distribution linked to an immunization campaign  Ghana (2002) and Zambia (2003): first district-level distributions  Achieved high and equitable coverage  Approached or exceeded Abuja targets for use  Togo (2004): first national-level distributions

Togo

Togo National Integrated Child Health Campaign Measles vaccination Polio vaccination Presumptive treatment with anti-helminth Long-lasting insecticide-treated bed net (LLITN)

Togo National Integrated Child Health Campaign December 13-19, 2004 Objective: achieve > 95% coverage of the 866,725 children between 9-59 months with the four interventions Over 930,000 ITNs distributed Approximate total cost for all interventions USD $6.92

Campaign Targets & Resources 870,000 children ages 9-59 months (measles & polio vaccines, mebendazole) 735,000 households with children ages 9-59 months for ITNs 905,000 LLITNS available (RC and GFATM) 1,340 fixed, outreach, mobile posts 20,000 health workers & volunteers.

Multidisciplinary Evaluation of the Campaign Pre- and post-campaign morbidity surveys: anemia, peripheral parasitemia, clinical malaria 1-month (low transmission season) and 9-month (high transmission season) coverage surveys Cost-effectiveness evaluation Social mobilization evaluation

Timeline of Evaluation September 2004: 1st morbidity survey December 2004: Campaign January 2005: 1st coverage survey September 2005: 2nd coverage survey 2nd morbidity survey

One-month Coverage Survey September 2004: 1st morbidity survey December 2004: Campaign January 2005: 1st coverage survey September 2005: 2nd coverage survey 2nd morbidity survey

Study site All six regions of the country  Lome  Maritime  Plateau  Central  Kara  Savannes Urban and rural communities Two districts per region

Study design and sample size Community-based cross-sectional survey Stratified two-stage cluster sample design  District-level sample size  Estimated rise in ITN coverage from 15% to 65%  80% power to estimate the proportion of households (HHs) that received an ITN with a range of 4% with 95% confidence  Assuming 70% of HHs to have children<5yo, 10% of HHs to own and ITN, and 10% non-response rate

Study design and sample size Stratified two-stage cluster sample design  Selection of Enumeration Areas (EAs)  12 per district for total of 144  1998 census provided the sampling frame with defined EAs with populations between 452 and 1440  Selected using probability proportional to size methodology  16 HHs selected within each EA regardless of presence of children to participate (+5 alternates)

Study Procedures All six regions surveyed in 12 working days  One team mapped 2 EAs per day  Census-based maps provided EA borders  Mapping performed with PDA’s equipped with GPS units  Random selection of HHs selected in the field using survey specific program designed by CDC  Selected HHs invited to participate that same day

Methods (Anemia) 3 regions included 2 stage cluster survey  Enumeration Area (30 per region) Simple random sample of EA  GPS mapping (all houses in EA)  PDA selection (25 Households invited per EA)  PDA-based survey, clinical examination, lab evaluation

Enumeration Areas

Not Selected Selected Alternate Each Household Mapped

Study Procedures Questionnaire: all answers entered directly into database on PDAs while in the field (Visual CE)  Household  Campaign  Children in the HH  Bed nets in the HH  Economic questions (World Bank)

Study Procedures Questionnaire shot

Analysis All data downloaded from PDAs into a central database at the end of the survey (Microsoft Access) Analysis performed using SAS (version 9.1)

Study procedures One team mapped all households in two EAs each day using PDA with GPS PIC OF BOTH

N EW S Enumeration Areas Coverage Survey Anemia Survey

PercentageRangeConfidence Intervals HHs with an ITN hanging HHs with a child < 5 sleeping under any net HHs with a child < 5 sleeping under an ITN Pregnant women sleeping under an ITN

Results Coverage of all services

Results Graph of coverage of all services

Results Itn coverage and equity One or two slides? Just graph or test too?

Ownership of an ITN by economic quintile before and after the campaign

Results ITN use Table of all figures in paper

Advantages Data quality procedures such as skip patterns and validity checks included Ability to rapidly aggregate data, perform additional data checks and preliminary analysis Presenting preliminary results Rapidly map entire EA Use geospatial information in reports and analyses Statistically valid

Follow-up: Pre- and Post- campaign Morbidity Surveys Performed in September of 2004 and 2005 in the same three districts (high transmission season) Hemoglobin levels, peripheral parasitemia, clinical malaria Similar rainfall pattern significant post-campaign reductions of the prevalence of multiple anaemia and malaria markers in the pooled group of children under 5 years in 2 out of the 3 evaluated districts

Follow-up: 9-month Coverage Survey

History 2001 Measles Catch-up Campaign: 95% coverage (by survey). Synchronized West Africa campaigns: 2 rounds NIDs, 1 measles round Follow-up Campaign: first nationwide integrated campaign. Integrated campaigns with measles and malaria Conducted in selected districts of two countries  Ghana (1 district 2002)  Zambia (5 districts 2003) Scale-up to national level  Togo (26 districts 2004)

Ministries of Health National Societies Partnerships

Campaign Costs USD $6.75 per child for all 4 interventions. USD $0.78 per child vaccinated for measles. Gov’t contribution: CFA 10m ($20,500) Cold chain: $500,000 (Rotary, GAVI, UNICEF) CIDA: Measles Initiative: Other:

Social Mobilization Greater than 7,400 Red Cross volunteers trained, monitored, and engaged 5,000 TRC volunteers received ITNs 2 weeks before the campaign, demonstrated use

What worked well? Smooth post organization (improved with supervision. Good injection technique, cold chain. Adverse Events Following Immunization (AEFI) surveillance: 25 minor, none severe. High motivation for bednets.

What was a challenge? Lack consensus on denominator. Target age groups. Mebendazole problems. Late arrival funds at operational level. Partner coordination in field (RC, MOH, WHO). Targets for ITN (per child vs. per household)

Task Assist Togolese Ministry of Health (MOH) and Togolese Red Cross in community-based coverage survey Assist partners in assessing anemia levels in children less than 5 years old Assist MOH in assessing ITN retention and utilization Gather data and report results as quickly as possible (Days, not months)

Evaluation Local supervisors, external monitors for campaign Anemia surveys pre- and post-campaign  Pre-campaign survey completed September 2004  Post-campaign survey planned for September 2005 Coverage surveys 1 month (all interventions) and 6 months post-campaign (Bednets)  1 month survey completed February 2005  6 month survey planned for June 2005 Facility-based mortality study - ongoing Economic/ cost effectiveness evaluation - ongoing

Logistics of Evaluation Two groups of 6 teams  GPS (Advance team)  Evaluation Daily data synchronization Daily supply restocking

Logistics Battery Charging Checking Data Workload Management

Training Supervisors - 6 GPS staff - 12 Field staff - 24/district  2 interviewers/team  1 laboratorian/team  1 clinician/team

Multiple Stations with Multiple Children Each PDA can record data for each child <5 in a household Mother takes PDA from station to station Data is entered by trained staff

Preliminary Results Anemia Survey

Denominators 1924 households 2677 children (all <5s)

Indicators Rapid Diagnostic Test for P. faliciparum 74% positive (n=2642) Hemoglobin levels (n=2677) Severe (<5) 0.75% Moderate(5-7.9) 20% Mild(8-10.9) 63% Normal (>=11) 16%

Indicators (2) Houses owning at least one bed net (any type) 10% (n=1924) Houses with at least one bed net hanging (any type) 8% (n=1924)

Methods (Coverage) All 6 regions included 2 stage cluster survey  District (2 per Region)  Enumeration Area (12 per District) Simple random sample of EA  GPS mapping (all houses in EA)  PDA selection (16 Households per EA)  PDA-based survey

Logistics of Evaluation Six teams  Supervisor  3 Interviewers Daily data backup Recharging PDAs

Preliminary Results Coverage Survey

Denominators 2254 households 2599 children (all <5s) 2469 total nets 2194 ITNs 1611 households with at least one ITN

What was the Draw?

Households With At Least One Child Less Than 5 Years Old 77.23%

Campaign Attendance 97.1% of eligible children attended the campaign

Oral Polio Vaccine National Coverage Estimates Before Campaign: 93.37% Of those who attended the Campaign: 98.56%

55% verified by immunization card Eligible Children Receiving Polio Vaccine 67% verified by campaign card

Measles Vaccine National Coverage Estimates Before Campaign: 80.81% Of those who attended the Campaign: 97.88% Campaign Administrative coverage: 100.4% EPI cluster survey: 98.4%

57% verified by immunization card Eligible Children Receiving Measles Vaccine 67% verified by campaign card

Mebendazole National Coverage Estimates Of those who attended the Campaign: 97.12% Noticed Worms Exiting: 3.88%

Eligible Children Receiving Mebendazole 68% verified by campaign card

Eligible Children Who Received an ITN from the Campaign National Coverage Estimates Of those who attended the Campaign: 94.87% Households with at Least One Eligible Child: 97.82%

Eligible Children and Households Receiving ITNs

% of Campaign Eligible Children Under a Campaign Net the Previous Night 94.94%

Equity in ITN Ownership

ITN Ownership (All Households) National Coverage Estimates Not From Campaign: 5.90% After Campaign: 62.43%

Household ITN Ownership

Households ITN Ownership by Wealth Quintile

ITNs (All Households) Hanging: 36.2% Retention among HH that received at least one ITN: 90%

RBM Indicators

Under ITNs National Coverage Estimates Children Less Than 5 Years Under an ITN Previous Night: 59.98% Pregnant Women Under an ITN Previous Night: 35.8%

% All Children Less Than 5 Years and Bednets

Summary of Campaign