The association between travel time to health facilities and childhood vaccine coverage in rural Ethiopia. A community based cross sectional study.

BACKGROUND: Few studies have examined associations between access to health care and childhood vaccine coverage in remote communities that lack motorised transport. This study assessed whether travel time to health facilities was associated with childhood vaccine coverage in a remote area of Ethiopia. METHODS: This was a cross-sectional study using data from 775 children aged 12-59 months who participated in a household survey between January -July 2010 in Dabat district, north-western Ethiopia. 208 households were randomly selected from each kebele. All children in a household were eligible for inclusion if they were aged between 12-59 months at the time of data collection. Travel time to vaccine providers was collected using a geographical information system (GIS). The primary outcome was the percentage of children in the study population who were vaccinated with the third infant Pentavalent vaccine ([Diphtheria, Tetanus,-Pertussis Hepatitis B, Haemophilus influenza type b] Penta3) in the five years before the survey. We also assessed effects on BCG, Penta1, Penta2 and Measles vaccines. Analysis was conducted using Poisson regression models with robust standard error estimation and the Wald test. RESULTS: Missing vaccination data ranged from 4.6% (36/775) for BCG to 16.4% (127/775) for Penta3 vaccine. In children with complete vaccination records, BCG vaccine had the highest coverage (97.3% [719/739]), Penta3 coverage was (92.9% [602/648]) and Measles vaccine had the lowest coverage (81.7% [564/690]). Children living ≥60mins from a health post were significantly less likely (adjRR = 0.85 [0.79-0.92] p value < =0.001) to receive Penta3 vaccine compared to children living <30mins from a health post. This effect was not modified by household wealth (p value = 0.240). Travel time also had a highly significant association with BCG (adjRR = 0.95 [0.93-0.98] p value =0.002) and Measles (adjRR = 0.88 [0.79-0.97] p value =0.027) vaccine coverage. CONCLUSIONS: Travel time to vaccine providers in health posts appeared to be a barrier to the delivery of infant vaccines in this remote Ethiopian community. New vaccine delivery strategies are needed for the hardest to reach children in the African region.

Cluster-randomized study of intermittent preventive treatment for malaria in infants (IPTi) in southern Tanzania: evaluation of impact on survival.

BACKGROUND: Intermittent Preventive Treatment for malaria control in infants (IPTi) consists of the administration of a treatment dose of an anti-malarial drug, usually sulphadoxine-pyrimethamine, at scheduled intervals, regardless of the presence of Plasmodium falciparum infection. A pooled analysis of individually randomized trials reported that IPTi reduced clinical episodes by 30%. This study evaluated the effect of IPTi on child survival in the context of a five-district implementation project in southern Tanzania. [ TRIAL REGISTRATION: clinicaltrials.gov NCT00152204]. METHODS: After baseline household and health facility surveys in 2004, five districts comprising 24 divisions were randomly assigned either to receive IPTi (n = 12) or not (n = 12). Implementation started in March 2005, led by routine health services with support from the research team. In 2007, a large household survey was undertaken to assess the impact of IPTi on survival in infants aged two-11 months through birth history interviews with all women aged 13-49 years. The analysis is based on an "intention-to-treat" ecological design, with survival outcomes analysed according to the cluster in which the mothers lived. RESULTS: Survival in infants aged two-11 months was comparable in IPTi and comparison areas at baseline. In intervention areas in 2007, 48% of children aged 12-23 months had documented evidence of receiving three doses of IPTi, compared to 2% in comparison areas (P < 0.0001). Over the three years of the study there was a marked improvement in survival in both groups. Between 2001-4 and 2005-7, mortality rates in two-11 month olds fell from 34.1 to 23.6 per 1,000 person-years in intervention areas and from 32.3 to 20.7 in comparison areas. In 2007, divisions implementing IPTi had a 14% (95% CI -12%, 49%) higher mortality rate in two-11 month olds in comparison with non-implementing divisions (P = 0.31). CONCLUSION: The lack of evidence of an effect of IPTi on survival could be a false negative result due to a lack of power or imbalance of unmeasured confounders. Alternatively, there could be no mortality impact of IPTi due to low coverage, late administration, drug resistance, decreased malaria transmission or improvements in vector control and case management. This study raises important questions for programme evaluation design.

Safety of sulfadoxine/pyrimethamine for intermittent preventive treatment of malaria in infants: evidence from large-scale operational research in southern Tanzania.

Intermittent preventive treatment with sulfadoxine/pyrimethamine (SP) is recommended for malaria prevention in infants (IPTi-SP). Serious adverse events, including Stevens-Johnson syndrome (SJS), have been reported following exposure to SP, but few infant-specific data exist. The safety of IPTi-SP was evaluated as part of a pilot implementation programme in southern Tanzania using three methods: spontaneous adverse event reporting to capture suspected adverse drug reactions (ADR); a census survey documenting rash-related hospital admissions among children < 2 years of age; and verbal autopsies (VA) completed for rash-related deaths in 2-11-month-olds. Approximately 82 000 IPTi-SP doses were administered to approximately 29 000 children. In total, 119 suspected ADRs were reported, 13 in children aged <2 years, only one of whom had received IPTi-SP. The census involved 243 612 households. Only one rash-related admission was reported amongst 1292 children aged 2-11 months, but this child had no history of exposure to SP. Moreover, 30 of 699 deaths in 2-11-month-olds were said to have been associated with a skin rash. The rates of rash-associated death were 0.59/1000 person-years at risk (PYAR) and 1.17/1000 PYAR in intervention and comparison areas, respectively (P = 0.79). VAs did not suggest SJS or any other ADR. We conclude that IPTi-SP is associated with a very low incidence of severe skin reactions. [ClinicalTrials.gov identifier: NCT00152204].

A simple method for defining malaria seasonality.

BACKGROUND: There is currently no standard way of defining malaria seasonality, resulting in a wide range of definitions reported in the literature. Malaria cases show seasonal peaks in most endemic settings, and the choice and timing for optimal malaria control may vary by seasonality. A simple approach is presented to describe the seasonality of malaria, to aid localized policymaking and targeting of interventions. METHODS: A series of systematic literature reviews were undertaken to identify studies reporting on monthly data for full calendar years on clinical malaria, hospital admission with malaria and entomological inoculation rates (EIR). Sites were defined as having 'marked seasonality' if 75% or more of all episodes occurred in six or less months of the year. A 'concentrated period of malaria' was defined as the six consecutive months with the highest cumulative proportion of cases. A sensitivity analysis was performed based on a variety of cut-offs. RESULTS: Monthly data for full calendar years on clinical malaria, all hospital admissions with malaria, and entomological inoculation rates were available for 13, 18, and 11 sites respectively. Most sites showed year-round transmission with seasonal peaks for both clinical malaria and hospital admissions with malaria, with a few sites fitting the definition of 'marked seasonality'. For these sites, consistent results were observed when more than one outcome or more than one calendar year was available from the same site. The use of monthly EIR data was found to be of limited value when looking at seasonal variations of malaria transmission, particularly at low and medium intensity levels. CONCLUSION: The proposed definition discriminated well between studies with 'marked seasonality' and those with less seasonality. However, a poor fit was observed in sites with two seasonal peaks. Further work is needed to explore the applicability of this definition on a wide-scale, using routine health information system data where possible, to aid appropriate targeting of interventions.

Use and misuse of a discount voucher scheme as a subsidy for insecticide-treated nets for malaria control in southern Tanzania.

Since 1997, discount vouchers for insecticide-treated nets (ITNs) have been used in two rural districts of southern Tanzania as a way to target subsidies to children under 5 years and pregnant women. We assessed appropriate use and misuse of discount vouchers through a follow-up study of 104 randomly selected vouchers. We traced these vouchers from their original issue in mother-and-child health (MCH) clinics through to being redeemed at a sales agent. We found that all vouchers that reached the target population (100%, 56/56) were used to buy an ITN. Moreover, 94% of the ITNs bought with vouchers were used by those intended, women and children under 5 years. However, up to 48% (50/104) of the vouchers had been misused at the clinics that issued them. Nevertheless, large-scale misuse occurred only at three of 21 clinics. Although most women slept under a net while pregnant, the use of voucher-subsidized ITNs during pregnancy was low despite widespread knowledge of the scheme. Parents had apparently decided to buy the subsidized ITNs once the child was born and not during pregnancy. Importantly, in 20% of households the only existing net had been bought with a voucher. Our findings suggest that vouchers are properly used by the target population, and that to minimize voucher leakage, control measures are needed at MCH clinics and to a certain extent for commercial sales agents. Increased awareness among the whole community on the right to receive a discount voucher may also help to control misuse at health facilities.

Targeted subsidy for malaria control with treated nets using a discount voucher system in Tanzania.

During the last decade insecticide-treated nets have become a key strategy for malaria control. Social marketing is an appealing tool for getting such nets to poor rural African communities who are most afflicted by malaria. This approach usually involves subsidized prices to make nets and insecticide more affordable and help establish a commercial market. We evaluated a voucher system for targeted subsidy of treated nets in young children and pregnant women in two rural districts of southern Tanzania. Qualitative work involved focus group discussions with community leaders, male and female parents of children under 5 years. In-depth interviews were held with maternal and child health clinic staff and retail agents. Quantitative data were collected through interviewing more than 750 mothers of children under 5 years during a cluster sample survey of child health. The voucher return rate was extremely high at 97% (7720/8000). However, 2 years after the start of the scheme awareness among target groups was only 43% (45/104), and only 12% of women (12/103; 95% CI 4-48%) had used a voucher towards the cost of a net. We found some evidence of increased voucher use among least poor households, compared with the poorest households. On the basis of these results we renewed our information, education and communication (IEC) campaign about vouchers. Discount vouchers are a feasible system for targeted subsidies, although a substantial amount of time and effort may be needed to achieve high awareness and uptake - by which we mean the proportion of eligible women who used the vouchers - among those targeted. Within a poor society, vouchers may not necessarily increase health equity unless they cover a high proportion of the total cost: since some cash is needed when using a voucher as part-payment, poorer women among the target group are likely to have lower uptake than richer women. The vouchers have two important additional functions: strengthening the role of public health services in the context of a social marketing programme and forming an IEC tool to demonstrate the group at most risk of severe malaria.