IPTi Implementation Experiences in Africa

A de Sousa Operational Research Coordinator

UNICEF

D Schellenberg Prof of Malaria & International Health

LSHTM

WHO SAGE October 2009

Overview

•  Approach to implementation •  Coverage and acceptability •  Safety •  Financial costs •  Applicability tool •  Summary

“Prepare for Action”

Enable prompt program-based application of IPTi if a policy recommendation is made

Development Implementation

Evaluation of IPTi strategy

Pilot implementation

• IPTi-SP administered simultaneously with:

- DTP + Hib + Hep + OPV doses 2 & 3

- Measles +/- YF at 9 months

• 25 districts in seven countries

•  Tanzania (southern Tanzanian collaboration)

•  Benin, Ghana, Mali, Senegal, Madagascar

and Malawi (UNICEF)

•  ~260,000 infants per year since 2005/2007

UNICEF Type your title in this FOOTER area and in CAPS

Wall paintings

Training Guidelines

Job Aid

Dr Msonde, District Medical Officer, Tandahimba

Child Health Card

Vaccination tally

sheet

Reporting Adverse Events (by caregivers or health staff)

Health workers training evaluation

(n = 734 HWs)

At 1 year of implementation, informally and formally trained have similarly high understanding of IPTi

Overview

•  Approach to implementation •  Coverage and acceptability •  Safety •  Financial costs •  Applicability tool •  Summary

IPTi coverage in 1st year

Madagascar

0 20 40 60 80

100

Ghana

0 20 40 60 80

100

Benin

0 20 40 60 80

100

Jan

Mar

s

May

Jul

Sep

t

% o

f cov

erag

e (IP

Ti/E

PI) IPTi1/ DTP2

IPTi2/ DTP3

IPTi3/ Measles

Malawi

0 20

40 60

80 100

Dec

Feb

Apr

Jun

Mali

0

20

40

60

80

100

Dec Feb Apr Jun

Senegal

0

20

40 60

80

100

IPTi is a well accepted intervention

- Increased time at health clinics was well accepted by both caregivers and health workers

- Coupling of IPTi with EPI was welcomed by caregivers and health workers, and easily integrated

- Some confused it with anti-pyretic, brought in to prevent post-vaccination fever

- IPTi often used by health workers as mechanism to increase adherence to EPI

UNICEF Type your title in this FOOTER area and in CAPS

UNICEF Type your title in this FOOTER area and in CAPS

0% 10% 20% 30% 40% 50% 60% 70% 80% 90%

100%

Benin Ghana Madagascar Malawi Mali Senegal Average

Distribution of time in immunization clinics

IPTi time (11%)

EPI time (64%)

% o

f tim

e pe

r ses

sion

Takes 5 min to administer one dose of IPTi

60% of workers time is used preparing a drinkable solution for infants

Drinkable solution

Other

“free” time (25%)

Overview

•  Approach to implementation •  Coverage and acceptability •  Safety •  Financial costs •  Applicability tool •  Summary

Adverse Events after IPTi

53%

29%%

9%

Events reported are the same reported when EPI vaccines are given alone, except for crying and diarrhea

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

SP/ DTP1

SP/ DTP2

SP/ Measles

Not possible to attribute AEs to the specific administration of SP

Overview

•  Approach to implementation •  Coverage and acceptability •  Safety •  Financial costs •  Applicability tool •  Web tool •  Summary

Start up years : 2.3 USD (range 4.15 to 0.77 USD)

Incremental financial costs / infant

Routine years : 30 cents (range 48 to 14 cents)

If one takes into account supervision strengthening

Routine years : 80 cents (range 171 to 25 cents)

Start up years : 3 USD (range 5.71 to 0.91 USD)

IPTi - highly Cost Effective Hutton G et al Bull WHO in press

Conteh L et al Submitted

UNICEF Operational research

Based on Ifakara & Manhica trials

Based on all 6 RCTs of IPTi-SP

Based on data from all 6 countries

Cost/episode averted

1.57 – 4.73 1.36 – 4.03 (0.68 – 2.27*)

0.66

Cost/DALY averted

3.7 – 11.2 2.90

* Based on IPTi efficacy estimates from pooled analysis

Overview

•  Approach to implementation •  Coverage and acceptability •  Safety •  Financial costs •  Applicability tool •  Summary

IPTi Decision-Making Tool www.iptiwebtool.org

•  Inputs – Country – 1st administrative level – Transmission intensity (EIR or prevalence) – Seasonality – DTP immunization schedule – DTP3 coverage

IPTi Decision-Making Tool www.iptiwebtool.org

29

Age Pattern of Malaria Manifestations by Transmission Setting

TI: Transmission intensity

Estimated Impact

Overview

•  Approach to implementation •  Coverage and acceptability •  Safety •  Financial costs •  Applicability tool •  Summary

• IPTi can be delivered by existing EPI/health systems

•  High coverage can be achieved rapidly

• IPTi is well accepted by communities & health workers

• IPTi has a reassuring safety profile

• IPTi is highly cost-effective & affordable

• A paediatric formulation is desirable

Summary

Acknowledgements Southern Tanzania •  Community

•  District, regional and national authorities

•  Health facility staff

•  Ifakara Health Research & Development Centre

•  Centre for International Health, Hospital Clinic, Barcelona, Spain

•  Swiss Tropical Institute, Basle, Switzerland

•  London School of Hygiene & Tropical Medicine, UK

•  The IPTi Consortium - www.ipti-malaria.org

•  Bill & Melinda Gates Foundation

GHANA •  Dr. Ebenezer Inkoom •  Dr. Philippe Adongo •  Mr. Komla Abotsi Anselm •  Dr. Alex Dodoo •  Dr. Ofori Tenkorang •  Dr. Jerry Nee Wang

MADAGASCAR •  Dr. Leon Rabarijaona •  Dr. Issa Coulibaly •  Ms. Mialy Rabarison •  Dr. Hanta Ravelomanantena •  Dr. Didier Menard •  Dr. Jean Rene Randriasamimanana •  Dr. Sabrina Lock

MALAWI •  Dr. Donald Mathanga •  Dr. Kelias Msyamboza •  Dr. Prestor Kubalalika •  Dr. Ketema Bizuneh •  Dr. Jobiba Chimkhumba •  Pr. Charles Mwasambo •  Dr. Edson Dembo

MALI •  Dr. Alassane Dicko •  Dr. Issaka Sagara •  Dr. Mariam Sy •  Dr. Sidi Toure •  Mr. Idrissa Camara

SENEGAL •  Dr. Jean Louis Ndiaye •  Pr. Omar Gaye •  Dr. Dodoo Sow •  Dr. Mouhamed Ndiaye •  Dr. Sylvain Laundry •  Mr. Abdou Diop •  Dr. Babacar Faye

BENIN •  Dr. Jacques Hassan •  Dr. Gninoussa Akadiri •  Dr. Emile Akowanou •  Mr. Paul Adovohekpe •  Mr. Vincent Capo-Chichi •  Dr. Alphonse Apho