Integration of insecticide‐treated net distribution into routine ...

Tropical Medicine and International Health

doi:10.1111/j.1365-3156.2009.02295.x

volume 14 no 7 pp 792–801 july 2009

Integration of insecticide-treated net distribution into routine immunization services in Malawi: a pilot study Don P. Mathanga1, Elizabeth T. Luman2, Carl H. Campbell3, Chimwemwe Silwimba4 and Grace Malenga4 1 Department of Community Health, College of Medicine, Blantyre, Malawi 2 Global Immunization Division, National Center for Immunization and Respiratory Diseases, US Centers for Disease Control and Prevention, Atlanta, GA, USA 3 CDC Malaria Malawi Program, US Centers for Disease Control and Prevention, Blantyre, Malawi 4 Malaria Alert Centre, College of Medicine, Blantyre, Malawi

Summary

objectives To determine the feasibility of distributing insecticide-treated nets (ITNs) through routine immunization services, to increase ownership and use of ITNs among high-risk groups, whereas maintaining or improving timely completion of routine vaccinations. methods Free ITNs were provided with timely completion of routine vaccinations in two intervention districts in southern Malawi for 15 months. Cross-sectional baseline and follow-up household surveys were conducted in the two intervention districts and one control district. results Insecticide-treated nets utilization among children aged 12–23 months roughly doubled in the two intervention districts and did not change in the control district. Timely vaccination coverage increased in all three districts. The percentage of children aged 12–23 months who were both fully vaccinated by 12 months and slept under an ITN the night prior to the interview increased from 10– 14% at baseline to 40–44% at follow-up in the intervention districts (P < 0.001), but did not change significantly in the control district. conclusions This study is the first to evaluate the provision of free ITNs at completion of a child’s primary vaccination series, demonstrating that such a linkage is both feasible and can result in improved coverage with the combined services. Additional studies are needed to determine whether such a model is effective in other countries, and whether integration of other health services with immunization delivery could also be synergistic. keywords integration, malaria, ITN, immunization, vaccination, coverage

Introduction Insecticide-treated nets (ITNs) are universally accepted as an effective malaria control intervention, especially in settings where high use rates are achieved (Hawley et al. 2003). The challenge now faced by national malaria control programmes is rapidly increasing access to and use of ITNs, especially among vulnerable groups such as pregnant women and young children. Currently, most national malaria control programmes in Africa rely on subsidization and social marketing, which is cost-effective (Hanson et al. 2003) and capable of reducing disease (Schellenberg et al. 2001; Mathanga et al. 2005). However, ITN ownership still remains low (Monasch et al. 2004), mainly because many households cannot afford even the highly-subsidized price. Not only is it difficult to increase ownership, but also to ensure that ITNs are slept 792

under, as utilization trails ownership in many settings (WHO 2005c). Low ITN ownership and utilization have led to a call for alternative distribution channels to achieve high and equitable distribution and usage among groups at high risk of malaria (Guyatt et al. 2002; Mathanga & Bowie 2007). One option previously shown to be of low cost is the distribution of free ITNs to under-five children during measles vaccination campaigns, which can reach >95% of the target population (WHO 2007). High ITN ownership among eligible children was achieved through such campaigns in Ghana, Zambia, Togo and Niger (CDC 2005, 2006; Grabowsky et al. 2005a,b), although utilization was variable. This distribution strategy may not be sufficient, however, because vaccination campaigns occur infrequently in most countries, leaving children born after the campaign without access to ITNs (WHO 2005a). Thus,

ª 2009 Blackwell Publishing Ltd

Tropical Medicine and International Health

volume 14 no 7 pp 792–801 july 2009

D. P. Mathanga et al. Integration of ITN distribution into routine immunization services in Malawi

integration of ITN distribution into routine immunization services may be a preferable long-term strategy. Countries continue to explore new ways to improve routine vaccination coverage among young children, to ensure that they and their communities are protected against vaccinepreventable diseases. Giving free ITNs during routine immunization visits could provide an incentive for caregivers to complete their child’s vaccination series in a timely manner. With the goal of increasing ITN utilization and timely completion of routine vaccinations, we linked the provision of free ITNs to the completion of a child’s primary vaccination series by age 12 months in two rural districts of Malawi for a 15-month period, with a similar district serving as control. We evaluate implementation of this programme in this report.

Methods

one dose of Bacille Calmette-Guerin vaccine, three doses of pentavalent vaccine (includes diphtheria, tetanus, pertussis, hepatitis B and Haemophilus influenzae type b vaccines), a birth dose plus three additional doses of oral poliovirus vaccine (OPV) and one dose of measles vaccine. Children were considered fully vaccinated (i.e. completed their primary vaccine series) on time if they had received these vaccine doses (excluding the birth dose of OPV) by age 12 months. Vaccination status among children aged 12–23 months was determined based on the child’s date of birth and vaccination dates recorded on official health passports (i.e. vaccination cards) or another document retained by the household. Children without household vaccination records were considered not fully vaccinated. Because this coverage estimate is dependent on availability and completeness of vaccination records, we also assessed vaccination coverage among children with complete vaccination records (i.e. those for whom parents said that all doses given were written on the vaccination cards).

Study sites In consultation with Malawi’s National Malaria Control Program, we chose two districts (Mwanza and Phalombe) in which to conduct the integrated intervention, as well as a control district (Chiradzulu), based on the similarity of their population demographics, low coverage for routine vaccinations and ITNs, and high malaria burden. Mwanza, Phalombe and Chiradzulu are all rural districts located in the Southern region of Malawi, with estimated under 1-year populations of 7836, 12 246 and 14 867, respectively. The study protocol was approved by College of Medicine Institutional Review Boards at the University of Malawi and the US Centers for Disease Control and Prevention. Definitions Insecticide-treated nets are mosquito nets that repel, disable or kill mosquitoes coming into contact with the insecticide on the netting material. For this study, an ITN was defined as a net that had ever been treated with an insecticide recommended by the World Health Organization. ITNs routinely available at the time of this study were conventional nets that needed to be treated before use at the household level; nets distributed through the intervention were pre-treated long-lasting insecticidal nets (PermaNet; Vestergaard Frandsen, Lausanne, Switzerland). ITN utilization was defined as the percentage of the target group who reported sleeping under an ITN the night prior to the interview. Malawi’s Ministry of Health recommends that all children receive nine vaccination doses by age 12 months:

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Materials Insecticide-treated nets were donated for this study by Exxon Mobil, the Canadian, American and Finnish Red Cross Societies, the American International Women’s Club of Geneva, and private Swiss donors through the International Federation of the Red Cross and Red Crescent Societies. These ITNs were large (160 cm · 180 cm · 150 cm) and rectangular, accommodating several people sleeping on a bed or floor, and were white in colour to distinguish them from green nets normally distributed by Malawi’s National Malaria Control Program. These were the first long-lasting ITNs to be introduced in Malawi. In the two intervention districts, ITNs were distributed to 28 health clinics by Population Services International; existing community health workers were responsible for transporting the ITNs to an additional 129 outreach clinics. At routine immunization sessions, upon completion of a child’s primary vaccination series by age 12 months, health workers gave the caretaker a free ITN. To ensure that children and their mothers or other caretakers had an opportunity to be protected against malaria before completing the child’s vaccination series, free ITNs were also provided to pregnant women at antenatal care clinics and at immunization sessions to mothers of non-vaccinated children aged