Two Strategies for the Delivery of IPTc in an Area of Seasonal Malaria Transmission in The Gambia: A Randomised Controlled Trial
Two Strategies for the Delivery of IPTc in an Area of Seasonal Malaria Transmission in The Gambia: A Randomised Controlled Trial
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DOI：
10.1371/journal.pmed.1000409
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发表时间：
2011-02-01
期刊：
影响因子：
15.8
通讯作者：
Greenwood, Brian
中科院分区：
文献类型：
--
作者：
Bojang, Kalifa A.;Akor, Francis;Greenwood, Brian
背景资料：扩大免疫方案提供了一种向婴儿提供间歇性疟疾预防治疗的有效途径。然而，尚不确定如何最有效地向年龄较大的儿童提供IPT。因此，我们比较了向冈比亚儿童提供IPT的两种方法：由乡村卫生工作者（VHWs）或通过生殖和儿童健康（RCH）徒步旅行队进行分配。在农村地区，RCH徒步旅行队在婴儿福利诊所为5岁以下的儿童提供大部分医疗保健，并为孕妇提供产前护理。方法和发现：在2006年疟疾传播季节，冈比亚26个RCH徒步诊所的集水人口，每个诊所有400-500名6岁及以下儿童，随机分配接受来自RCH徒步旅行队或VHW的IPT。在疟疾传播季节，每月给予单剂量磺胺嘧啶乙胺嘧啶（SP）加三剂量阿莫地喹（AQ）治疗。在整个疟疾传播季节，对所有儿童的疟疾发病率进行被动监测，并在疟疾传播季节结束时对每个集群的研究儿童进行随机抽样检查。主要研究终点是疟疾的发病率。次要终点包括IPTc覆盖率、平均血红蛋白（Hb）浓度和疟疾传播期结束时无性疟疾寄生虫血症的患病率。收集了与这两种交付战略有关的财政和经济成本，并对增量成本和效果进行了比较。采用巢式病例对照研究评估IPT疗程的疗效。SP加AQ治疗安全且耐受性良好。在通过生殖健康诊所提供IPT的地区有49例寄生虫血症超过5，000/亩的疟疾病例，在由VHWs提供IPT的地区有21例，（发病率分别为2.8和1.2/1，000儿童月，率差为1.6 [95%置信区间（CI）-0.24至3.5]）。通过VHWs提供的三门IPT课程的覆盖率远远高于RCH徒步旅行队的覆盖率（74%对48%，差异为27% [95% CI 16%-38%]）。这两种交付方法的覆盖率与财富指数无关，最贫穷和最富有群体的覆盖率相似。在传播季节结束时，试验两组的贫血患病率均较低。在每个疗程后的一个月内，IPTc对疟疾的有效率为87%（95%CI 54%-96%）。从经济和财务角度来看，由VHWs提供的IPTc比通过RCH徒步旅行队提供的成本更低，分别节省了872美元和1，244美元。每年的经济成本提供至少每个疗程的第一剂的IPTc是US$3.47和US$1.63每名儿童使用徒步旅行队和VHWs.Conclusions：在冈比亚的这种设置，提供IPTc的儿童6岁及以下的VHWs是更有效和更便宜的比通过RCH徒步诊所交付。
Background: The Expanded Programme on Immunisation (EPI) provides an effective way of delivering intermittent preventive treatment for malaria (IPT) to infants. However, it is uncertain how IPT can be delivered most effectively to older children. Therefore, we have compared two approaches to the delivery of IPT to Gambian children: distribution by village health workers (VHWs) or through reproductive and child health (RCH) trekking teams. In rural areas, RCH trekking teams provide most of the health care to children under the age of 5 years in the Infant Welfare Clinic, and provide antenatal care for pregnant women.Methods and Findings: During the 2006 malaria transmission season, the catchment populations of 26 RCH trekking clinics in The Gambia, each with 400-500 children 6 years of age and under, were randomly allocated to receive IPT from an RCH trekking team or from a VHW. Treatment with a single dose of sulfadoxine pyrimethamine (SP) plus three doses of amodiaquine (AQ) were given at monthly intervals during the malaria transmission season. Morbidity from malaria was monitored passively throughout the malaria transmission season in all children, and a random sample of study children from each cluster was examined at the end of the malaria transmission season. The primary study endpoint was the incidence of malaria. Secondary endpoints included coverage of IPTc, mean haemoglobin (Hb) concentration, and the prevalence of asexual malaria parasitaemia at the end of malaria transmission period. Financial and economic costs associated with the two delivery strategies were collected and incremental cost and effects were compared. A nested case-control study was used to estimate efficacy of IPT treatment courses. Treatment with SP plus AQ was safe and well tolerated. There were 49 cases of malaria with parasitaemia above 5,000/mu l in the areas where IPT was delivered through RCH clinics and 21 cases in the areas where IPT was delivered by VHWs, (incidence rates 2.8 and 1.2 per 1,000 child months, respectively, rate difference 1.6 [95% confidence interval (CI) -0.24 to 3.5]). Delivery through VHWs achieved a substantially higher coverage level of three courses of IPT than delivery by RCH trekking teams (74% versus 48%, a difference of 27% [95% CI 16%-38%]). For both methods of delivery, coverage was unrelated to indices of wealth, with similar coverage being achieved in the poorest and wealthiest groups. The prevalence of anaemia was low in both arms of the trial at the end of the transmission season. Efficacy of IPTc against malaria during the month after each treatment course was 87% (95% CI 54%-96%). Delivery of IPTc by VHWs was less costly in both economic and financial terms than delivery through RCH trekking teams, resulting in incremental savings of US$872 and US$1,244 respectively. The annual economic cost of delivering at least the first dose of each course of IPTc was US$3.47 and US$1.63 per child using trekking team and VHWs respectively.Conclusions: In this setting in The Gambia, delivery of IPTc to children 6 years of age and under by VHWs is more effective and less costly than delivery through RCH trekking clinics.