Integrating ITN delivery and mass vaccination

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Integrating ITN delivery and mass vaccination
RBM Board Meeting, Geneva, 1 April 2005 Mark
Grabowsky, MD, MPH CDC Technical Advisor,
American Red Cross
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Recommendations

• This approach represents a potential breakthrough
  to achieve Abuja targets
• Need RBM leadership to refine strategy and
  develop country guidance
• Empower RBM staff for operational coordination
• Harmonize EPI and RBM assessment methods

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MM Partners

• Measles Partnership
• American Red Cross
• United Nations Foundation
• Centers for Diseae COntrol
• UNICEF
• World Health Organization
• Ministries of Health
• Ghana
• Zambia
• Togo
• Red Cross Societies
• Ghana
• Zambia
• Togo
• Canadian
• Danish
• New Zealand
• Norwegian
• Swiss

• RBM
• IFRC/IFRC Foundation
• World Bank
• ExxonMobil
• Vestergaard-Frandsjen
• Rotarians Against Malaria
• Plan Togo
• FUCEC
• CIDA
• NORAD
• PSI
• NetMark
• DHL
• Peace Corps
• Satellife, Inc
• Freedom from Hunger
• Liverpool School of Tropical Med.
• London School of Tropical Med.
• University of Geneva

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MM Evaluation Plan
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Togo Campaign Acknowledgements

• Togo Ministry of Health
• Vincent Takpa, EPI Coordinator
• Kodjo Morgah, Malaria Control Coordinator
• Red Cross
• Jean Roy, IFRC-Geneva
• Nick Farrell, IFRC-Geneva
• Marcy Erskine, Canadian Red Cross
• Norbert Paniah, Togo Red Cross
• Vestergard-Frandsen
• Mikkel Vestergaard

• CDC
• Bill Hawley, Malaria Branch
• Adam Wolkon
• Jamie Eliades
• Jodi Vanden Eng
• Allen Hightower
• Mac Otten, NIP/GMB
• WHO
• Placide Gbedonou, EPI Focal Person

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Potential areas for collaboration during SIAs
Delivery of free treated nets, or vouchers, to
children under 5 years
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"Free mass distribution of malaria bed-nets . . .
for all children in regions of malaria
transmission by the end of 2007. "
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Reaching 100 million children in two
yearsAnnual number of children attending
measles campaigns, WHO/UNICEF Priority Countries,
1999-2004
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Polio vaccination
Mebendazole tablets
Insecticide treated nets
Measles vaccination

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Campaign Overview

• Target Population
• 870,000 children ages 9-59 months
• 735,000 households
• Delivery strategy
• One-week campaign
• 1,340 fixed, outreach, mobile posts
• 20,000 health workers volunteers
• 840,000 ITNs
• Financial Resources - 5.9 million
• Govt contribution CFA 10m (20,500)
• Cold chain 500,000 (Rotary, GAVI, UNICEF)
• ITNs 4.4m (CIDA, IFRC, Rotary, Norwegian RC)
• Measles Initiative 639,000

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

• Registration card
• Polio vaccination
• Mebendazole
• Measles vaccination
• Bednet distribution

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Focus of this Presentation
Procurement
Delivery
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Evaluations

• Anemia surveys pre- and post-campaign
• Pre-campaign survey, September 2004
• Post-campaign survey, September 2005
• Coverage surveys 1 and 6 months post-campaign
• 1 month survey completed February 2005
• 6 month survey planned for June 2005
• Facility-based mortality study ongoing
• Cost effectiveness evaluation ongoing

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Study Methods

• All 6 regions included
• 2 Districts/Region
• 12 Enumeration Areas/District
• Simple random sample of Enumeration Areas
• GPS mapping (all houses in EA)
• PDA selection (16 Households per EA)
• PDA-based survey

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Coverage, Post-Campaign
Denominator Children under 5 years of age
Measles vaccination
Polio vaccination
Mebendazole tablets
Coverage 98.4 94.3 92.7

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ITN Coverage and Equity, Pre- and
Post-Campaign
HHs with lt5 child All HHs
Coverage, pre 10.0 8.0 Coverage,
post 87.0 62.5 Equity
ratio, pre .25 .25 Equity
ratio, post 1.02 1.02
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ITN Coverage Children lt 5 (n2599)
Among eligible children, 90.8 received a
campaign net and 44 slept under the net.
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Eligible Children and Households Receiving ITNs,
by Region
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ITN Retention
Retention, among those receiving an ITN, one
month post-campaign
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Cost Overview, per child, US
Summary Total cost 5.9 million Total children
870,000 6.75 per child for all 4
interventions 0.78 per child vaccinated for
measles
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Summary

• Campaign was completed on schedule and on budget
• ITN coverage was high (90) and equitable
• ITN logistics costs were low (about 0.50/net
  delivered)
• ITN use was modest (40), consistent with known
  seasonal patterns
• Data on efficacy and cost-effectiveness available
  2/2006.

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Procurement
Delivery
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Delivery
Procurement
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Procurement
Delivery
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Global/Regional Activities

Assessment/Assurance
Research
Policy
Financing
In-country activities
Procurement
Delivery
Monitoring
Proper Use
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• there is a huge gap between the current
  understanding at the global (partners') level and
  the likelihood of countries to immediately embark
  on the process.
• from recent RBM/AFRO MM mission report

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Not constraining currently

• Funding
• Partners
• Political will

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Constraints on Integration

• Ambiguous ownership of integration, Measles or
  RBM?
• Lack of consensus on strategy (One ITN per child?
  per HH? per Bed?)
• Mismatch of EPI and RBM staff number, mission,
  support
• Lack of in-country coordination for both MoH and
  UN agencies
• Differences in EPI/RBM indicators, assessment
  methods, and use of data

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Recommendations

• This approach represents a potential breakthrough
  to achieve Abuja targets
• Need RBM leadership to refine strategy and
  develop country guidance
• Empower RBM staff for operational coordination
• Harmonize EPI and RBM assessment methods

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What is science?

• A predictive discipline based on falsifiable
  facts.
• Non-predictive
• Each social marketing effort has a unique country
  context which precludes extrapolation of results
  to other countries.
• Non-scientific
• Social marketing is more sustainable than mass
  distribution. (Non-falsifiable)

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Post-Campaign Survey Denominators

• 2254 households
• 2599 children (all lt5s)
• 2469 total nets
• 2194 ITNs
• 1611 households with at least one ITN

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ITN Use

• Houses hanging net

Children lt5 sleeping under net
Pregnant Women
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Household ITN Coverage (n2254)
Among eligible households, 87 retained a
campaign net.
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Coordination spreadsheet, AFRO/RBM

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Campaign Attendance

• 97 of eligible children attended the campaign