Evaluation of the Togo National Integrated Child Health Campaign

1. Evaluation of the Togo National Integrated Child Health Campaign

3. Global Burden of Malaria • 300-500 million cases occur annually • 700,000-2.7 million deaths annually, > 75% in African children • 41% of the world’s population lives in areas where malaria is transmitted

4. Millennium Development Goals • Address health, poverty, education, gender inequalities, environmental sustainability and development • Include reducing infant and child mortality by half between 1990-2015

5. 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

6. 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

7. 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

8. 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.

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

10. Strategies to Increase Coverage • Linked to routine health services • Extended Program on Immunizations • Antenatal Clinics

11. 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

12. Togo

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

14. 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

15. 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.

16. 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

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

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

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

20. 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

21. 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)

22. 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

23. 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

24. Enumeration Areas

25. Not Selected Selected Alternate Each Household Mapped

26. 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)

27. Study Procedures • Questionnaire shot

28. 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)

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

30. N W E S Enumeration Areas Anemia Survey Coverage Survey

32. Results • Coverage of all services

33. Results • Graph of coverage of all services

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

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

37. Results • ITN use • Table of all figures in paper

38. 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

39. 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

40. Follow-up: 9-month Coverage Survey

41. History • 2001 Measles Catch-up Campaign: 95% coverage (by survey). • Synchronized West Africa campaigns: 2 rounds NIDs, 1 measles round. • 2004 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)

42. Partnerships Ministries of Health National Societies

43. 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:

44. 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

45. 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.

46. 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)

47. 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)

48. 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

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

50. Logistics • Battery Charging • Checking Data • Workload Management