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The Gambia: treated bednets
THE LANCET The Gambia: treated
bednets
Treatment of presumptive malaria attacks by village health workers (VHWs), chemoprophylaxis given by VHWs, and bednets have all been investigated as possible malaria control measures in The Gambia. Early studies demonstrated a marked reduction in mortality among children aged 1-4 years who slept under insecticide-treated bednets. This suggested that bednets treated with the insecticide permethrin might prove to be a useful malaria control measure. In 1992 the Gambian Ministry of Health, supported by WHO, initiated a national impregnated bednet programme. The objectives were to introduce treated bednets into all primary health care (PHC) villages in The Gambia over a two-year period, and to set up a system of cost recovery that would allow this intervention to be sustained. During the first year (1992) insecticide delivered through the primary health care system was provided free to half the villages. A high level of coverage was obtained and total mortality in children aged 1-9 years who lived in villages where insecticide had been provided fell by 25%. During the second year, charges were introduced for the villages that had been given insecticide; coverage fell to 14% and the mortality difference in children disappeared. When Gambian villages were asked to pay to have their bednets treated few did so, despite knowledge of
the benefit. This knowledge had been reinforced by intensive advertising on radio and by posters and local meetings, directed equally at villages where charges were made and at those which they were not charged. Lack of funds was cited by heads of households during a post-treatment survey as the main reason why they could not produce the cash needed to treat the four or five nets for which they were responsible. Weekly cash expenditure for an average household was only about $3 on staple items and 70 cents on luxury items. So the $2-3 needed to treat all bednets in a large household represented a substantial outlay for a family with little disposable income. Radio broadcasts, leaflets, letters, and the use of shops and mother-and-child clinics as alternatives to the PI~C system were tried. Coverage improved but the results were still disappointing. Treated bednets have been shown to work in Kenya and Ghana, where significant reductions in childhood mortality have also been obtained, and they are the most promising method for malaria control in tropical Africa. However, in most studies the nets and/or the insecticide have been provided free. Experience from The Gambia indicates that innovative ways of funding bednet programmes will be required.
Mohammadou Kabir Cham MRC Laboratories, Fajara, The Gambia
Syndromic approaches to disease management David Mabey, Theo Vos The 1993 World Development Report' suggested that priority should be given to the treatment of certain common and life-threatening conditions at the primary health care level. An economic analysis had shown that treating these conditions was one of the most cost-effective health interventions available (on a par with childhood immunisation) in terms of cost per disability-adjusted lifeyear (DALY) saved. The conditions identified included acute respiratory infections (ARI), malaria, a n d diarrhoea, which are estimated to kill up to 5 million children under the age of 5 every year. The report also pointed out that treatment of the bacterial sexually transmitted diseases (STD) could be highly cost-effective and might save much illness and many deaths in areas where HIV infection was prevalent. There was evidence that STDs facilitated the transmission of HIV by heterosexual contact. Most health centres and dispensaries in developing countries do not have access to reliable laboratory facilities, and it is not possible to make an aetiological diagnosis. Treatment, therefore, has to be based on a syndromic assessment--the patient has watery diarrhoea, a cough, a genital ulcer, or a urethral discharge, and is treated for the likely causes of that syndrome. W H O has been promoting syndromic management for STD. 2 Even where laboratory facilities are available, it is
Lancet 1997; 349 (suppt Ill): 26-28 London School of Hygiene and Tropical Medicine, London WCIE 7HT, UK (Prof D Mabey FRCP,T VOSMD) Correspondence t(~: Prof David Mabey
SlII26
advisable to give treatment for these conditions at the first visit (when test results are often not available) since this will prevent sequelae and reduce the risk of further transmission. Several other conditions are usually treated syndromically too, even in better equipped health-care settings. Pneumonia, for example, may be diagnosed clinically and radiologically but a reliable aetiological diagnosis can seldom be made at the first visit--yet no-one would argue that treatment should be delayed pending the results of serology and culture. Since the early 1980s W H O has been helping to teach health workers at the most peripheral level to treat acute watery diarrhoea and ARI in children syndromicaUy, using simple algorithms. There is considerable overlap in the presentation of the major childhood illnesses, and severe illness is often associated with more than one lifethreatening condition (figure 1); W H O and U N I C E F have therefore developed an integrated approach3 Since 1993, materials have been developed to train health workers at first-level outpatient facilities to manage sick children following standard guidelines (panel) with the basic structure of the earlier ones for diarrhoea and ARI. Colourcoded triage algorithms require just a few key symptoms and signs to classify the severity of the condition and to point to appropriate treatment and advice for the child's mother. Syndromic treatment must be based on sound knowledge of the likely aetiology of the syndrome in a particular group and geographical location and of the
Vo1349 • June • 1997
bednets
Treatment of presumptive malaria attacks by village health workers (VHWs), chemoprophylaxis given by VHWs, and bednets have all been investigated as possible malaria control measures in The Gambia. Early studies demonstrated a marked reduction in mortality among children aged 1-4 years who slept under insecticide-treated bednets. This suggested that bednets treated with the insecticide permethrin might prove to be a useful malaria control measure. In 1992 the Gambian Ministry of Health, supported by WHO, initiated a national impregnated bednet programme. The objectives were to introduce treated bednets into all primary health care (PHC) villages in The Gambia over a two-year period, and to set up a system of cost recovery that would allow this intervention to be sustained. During the first year (1992) insecticide delivered through the primary health care system was provided free to half the villages. A high level of coverage was obtained and total mortality in children aged 1-9 years who lived in villages where insecticide had been provided fell by 25%. During the second year, charges were introduced for the villages that had been given insecticide; coverage fell to 14% and the mortality difference in children disappeared. When Gambian villages were asked to pay to have their bednets treated few did so, despite knowledge of
the benefit. This knowledge had been reinforced by intensive advertising on radio and by posters and local meetings, directed equally at villages where charges were made and at those which they were not charged. Lack of funds was cited by heads of households during a post-treatment survey as the main reason why they could not produce the cash needed to treat the four or five nets for which they were responsible. Weekly cash expenditure for an average household was only about $3 on staple items and 70 cents on luxury items. So the $2-3 needed to treat all bednets in a large household represented a substantial outlay for a family with little disposable income. Radio broadcasts, leaflets, letters, and the use of shops and mother-and-child clinics as alternatives to the PI~C system were tried. Coverage improved but the results were still disappointing. Treated bednets have been shown to work in Kenya and Ghana, where significant reductions in childhood mortality have also been obtained, and they are the most promising method for malaria control in tropical Africa. However, in most studies the nets and/or the insecticide have been provided free. Experience from The Gambia indicates that innovative ways of funding bednet programmes will be required.
Mohammadou Kabir Cham MRC Laboratories, Fajara, The Gambia
Syndromic approaches to disease management David Mabey, Theo Vos The 1993 World Development Report' suggested that priority should be given to the treatment of certain common and life-threatening conditions at the primary health care level. An economic analysis had shown that treating these conditions was one of the most cost-effective health interventions available (on a par with childhood immunisation) in terms of cost per disability-adjusted lifeyear (DALY) saved. The conditions identified included acute respiratory infections (ARI), malaria, a n d diarrhoea, which are estimated to kill up to 5 million children under the age of 5 every year. The report also pointed out that treatment of the bacterial sexually transmitted diseases (STD) could be highly cost-effective and might save much illness and many deaths in areas where HIV infection was prevalent. There was evidence that STDs facilitated the transmission of HIV by heterosexual contact. Most health centres and dispensaries in developing countries do not have access to reliable laboratory facilities, and it is not possible to make an aetiological diagnosis. Treatment, therefore, has to be based on a syndromic assessment--the patient has watery diarrhoea, a cough, a genital ulcer, or a urethral discharge, and is treated for the likely causes of that syndrome. W H O has been promoting syndromic management for STD. 2 Even where laboratory facilities are available, it is
Lancet 1997; 349 (suppt Ill): 26-28 London School of Hygiene and Tropical Medicine, London WCIE 7HT, UK (Prof D Mabey FRCP,T VOSMD) Correspondence t(~: Prof David Mabey
SlII26
advisable to give treatment for these conditions at the first visit (when test results are often not available) since this will prevent sequelae and reduce the risk of further transmission. Several other conditions are usually treated syndromically too, even in better equipped health-care settings. Pneumonia, for example, may be diagnosed clinically and radiologically but a reliable aetiological diagnosis can seldom be made at the first visit--yet no-one would argue that treatment should be delayed pending the results of serology and culture. Since the early 1980s W H O has been helping to teach health workers at the most peripheral level to treat acute watery diarrhoea and ARI in children syndromicaUy, using simple algorithms. There is considerable overlap in the presentation of the major childhood illnesses, and severe illness is often associated with more than one lifethreatening condition (figure 1); W H O and U N I C E F have therefore developed an integrated approach3 Since 1993, materials have been developed to train health workers at first-level outpatient facilities to manage sick children following standard guidelines (panel) with the basic structure of the earlier ones for diarrhoea and ARI. Colourcoded triage algorithms require just a few key symptoms and signs to classify the severity of the condition and to point to appropriate treatment and advice for the child's mother. Syndromic treatment must be based on sound knowledge of the likely aetiology of the syndrome in a particular group and geographical location and of the
Vo1349 • June • 1997