The document analyzes the cost-effectiveness of epidemic control measures implemented in Guinea during cholera, measles, and meningococcal meningitis outbreaks from 1993-1995. Routine health services alone reduced potential deaths by an estimated 51% on average. Additional interventions further decreased potential deaths by an estimated 28% on average. The marginal cost per death averted was $29 for routine health services and $93 for additional interventions. The analysis found that strengthening health services to control epidemics, as was done in Guinea, was highly cost-effective.
The document discusses dengue fever surveillance in Cuba and Latin America. It provides an overview of dengue virus and mosquito transmission. It summarizes dengue outbreaks in Cuba from 1981-2002, highlighting the large 1981 outbreak and Cuban response. The 1997 outbreak is discussed, questioning why surveillance failed. Barriers to dengue control are outlined. Finally, PAHO's integrated strategy for improved surveillance and community participation is presented.
The risk of communicable disease transmission increases after disasters due to contamination of water supplies, disruption of disease prevention programs, and overcrowding in shelters. Diseases like cholera, typhoid, and hepatitis spread easily in these conditions. Surveillance is important to identify outbreaks early and target control measures. Key responses include epidemiological monitoring of endemic and disaster-related illnesses, investigation of anomalies, and routine preventative treatment of health workers. Mass vaccination or treatment should be avoided without cause. The goal is to curb epidemics through timely response based on surveillance data.
This document discusses a 1979 article from The New England Journal of Medicine titled "Selective Primary Health Care - an Interim Strategy for Disease Control in Developing Countries" by Julia A. Walsh and Kenneth S. Warren. The article proposes selective primary health care as the most cost-effective approach for improving health in developing countries. It recommends prioritizing diseases based on prevalence, mortality, morbidity, and feasibility of control. The highest priorities should target diseases causing the most preventable illness and death, such as diarrhea, malaria, measles, whooping cough, and neonatal tetanus, through low-cost interventions like vaccination programs.
A presentation about Integrated Malaria Management (IMM) an approach to malaria control that has proved successful and sustainable. It has a focus on breaking the link between the parasite, the mosquito and the human host
The document discusses a directed student learning session on vaccines and immunity. The objectives are to understand immunity, vaccination, and the Malaysian immunization schedule. Students are advised to visit several websites to learn about herd immunity, different vaccine types, and the cold chain system for maintaining vaccine integrity.
The document discusses dengue fever surveillance in Cuba and Latin America. It provides an overview of dengue virus and mosquito transmission. It summarizes dengue outbreaks in Cuba from 1981-2002, highlighting the large 1981 outbreak and Cuban response. The 1997 outbreak is discussed, questioning why surveillance failed. Barriers to dengue control are outlined. Finally, PAHO's integrated strategy for improved surveillance and community participation is presented.
The risk of communicable disease transmission increases after disasters due to contamination of water supplies, disruption of disease prevention programs, and overcrowding in shelters. Diseases like cholera, typhoid, and hepatitis spread easily in these conditions. Surveillance is important to identify outbreaks early and target control measures. Key responses include epidemiological monitoring of endemic and disaster-related illnesses, investigation of anomalies, and routine preventative treatment of health workers. Mass vaccination or treatment should be avoided without cause. The goal is to curb epidemics through timely response based on surveillance data.
This document discusses a 1979 article from The New England Journal of Medicine titled "Selective Primary Health Care - an Interim Strategy for Disease Control in Developing Countries" by Julia A. Walsh and Kenneth S. Warren. The article proposes selective primary health care as the most cost-effective approach for improving health in developing countries. It recommends prioritizing diseases based on prevalence, mortality, morbidity, and feasibility of control. The highest priorities should target diseases causing the most preventable illness and death, such as diarrhea, malaria, measles, whooping cough, and neonatal tetanus, through low-cost interventions like vaccination programs.
A presentation about Integrated Malaria Management (IMM) an approach to malaria control that has proved successful and sustainable. It has a focus on breaking the link between the parasite, the mosquito and the human host
The document discusses a directed student learning session on vaccines and immunity. The objectives are to understand immunity, vaccination, and the Malaysian immunization schedule. Students are advised to visit several websites to learn about herd immunity, different vaccine types, and the cold chain system for maintaining vaccine integrity.
2007 Hpp Panorama 4 He Fs In Cambodia Mathieu Czm015wvdamme
The document provides a comparative analysis of four health equity funds in Cambodia that aim to improve access to hospital care for poor patients. The key findings are:
1) The health equity fund model appears superior to traditional waiver systems in improving health service utilization among targeted poor groups.
2) Design aspects essential to the model's performance include the existence of donor funding, the presence of a driving agent, a clear separation of roles, appropriate identification techniques, and consideration of multiple barriers to health service utilization.
3) The comparative framework may be a useful tool for designing, operating, or evaluating similar strategies in other contexts, though early adoption of common documentation would facilitate generating evidence about comparative performance.
2008 Ssm Art&Fhs Scale Up In S Afr Wvd Kk Gk Ssm6213wvdamme
This document discusses the challenges of scaling up antiretroviral treatment (ART) in Southern African countries with human resource shortages. It notes that the continuously growing caseload of people needing lifelong ART, shortages and uneven distribution of health workers, and the labor-intensive nature of current ART delivery models pose significant challenges. The document analyzes different scenarios for how health systems may adapt, including maintaining the status quo, strengthening the overall health system through task shifting and community-based care, or more technocratic reengineering of services. Achieving universal access to ART will require innovative approaches to address human resource constraints.
2008 Pov Ill Book Challenges In Identifying Poor Oddar Meanchey Cambodiawvdamme
This document summarizes a study that assessed household eligibility for a Health Equity Fund (HEF) in Oddar Meanchey, Cambodia four years after an initial pre-identification process. The study evaluated three tools to assess HEF eligibility: 1) a scoring tool used in the original pre-identification, 2) interviewer assessments, and 3) a socioeconomic status index. The results showed high targeting errors across all three tools, suggesting that the original HEF eligibility granted through pre-identification four years prior did not accurately reflect households' current poverty status. Regular updates of pre-identification combined with post-identification are recommended to minimize targeting errors in the future.
2004 Tmih Out Of Pocket Expenditure In Cambodia 1194wvdamme
This document summarizes a study on out-of-pocket health expenditures and debt in poor households in Cambodia during a dengue epidemic. The study found that:
1) Households that exclusively used private providers paid an average of $103 out-of-pocket, while those that combined private and public providers paid $32, and those that only used public hospitals paid $8.
2) Households financed these costs through savings, selling consumables, selling assets, and borrowing money. After treatment, 63% of households were in debt, with those using private providers more likely to borrow or sell assets.
3) A follow-up found that most households with initial debts were unable to pay
Las propagandas criativas son formas ingeniosas de comunicar ideas a través de medios no tradicionales como stickers, grafitis, intervenciones urbanas u otros medios alternativos que atraen la atención del público de manera original. Estas técnicas buscan generar conciencia sobre diversos temas de interés público de una forma atractiva y memorable más allá de los canales convencionales.
The New Deal is an approach used in Cambodia to improve the public health system. It involves providing performance-based bonuses to health staff from resources freed up by donors and user fees. The New Deal has been implemented in Sotnikum district, Thmar Pouk district, and several provincial hospitals with positive results after 2 years in Sotnikum and 1 year in Thmar Pouk. Activities have increased as staff are more motivated. New institutional arrangements like management committees and Health Equity Funds to help the poor access care have also yielded good results. The document analyzes the implementation and lessons learned from the New Deal experiments to help guide further health sector reforms in Cambodia.
This document summarizes the experience of a Health Equity Fund (HEF) managed by a local NGO in Sotnikum, Cambodia. The HEF aimed to improve access to healthcare for the poor by identifying poor patients and paying their user fees. Over its first 25 months, the HEF supported 16% of hospitalized patients. The authors conducted interviews and found that while the HEF effectively improved financial access, poor patients still faced other barriers like geographical, informational, and intra-household constraints. The study concluded that the HEF model showed promising results with minimal benefits leaking to non-poor individuals, but that further research is needed in different contexts.
2007 Bmc H Serv Chi&Che Deva 1472 6963 7 43wvdamme
This document summarizes a study on two Indian community health insurance (CHI) schemes and whether they protect households from catastrophic health expenditures. The two schemes studied were ACCORD, which provides insurance to indigenous people in Tamil Nadu, and SEWA, which insures self-employed women in Gujarat. Both schemes cover hospitalization costs up to a maximum limit. The study reviewed insurance claims from 2003-2004 to analyze out-of-pocket payments and catastrophic expenditures. The results showed that both schemes halved the number of households experiencing catastrophic expenditures compared to having no insurance. However, 4% of ACCORD households and 23% of SEWA households still experienced catastrophic expenditures, related to low incomes, low maximum limits
Fake antimalarial drugs pose a major threat to malaria control in Southeast Asia. A survey of antimalarial drugs purchased in pharmacies and shops across the region found that 53% of artesunate tablets labeled as such did not contain any artesunate. All counterfeit artesunate tablets were labeled as manufactured by Guilin Pharma and had packaging that was increasingly difficult to distinguish from genuine products. The prevalence of counterfeit artesunate increased 15% compared to a previous survey, with the exception of Myanmar which saw an 18% decrease. A small percentage (9%) of mefloquine samples also contained inadequate active ingredients, undermining treatment and confidence in antimalarials. The proliferation of
2006 Aids Real Challenges Art In S Sa Wvd+Kk+Mlwvdamme
This document summarizes the challenges of scaling up antiretroviral therapy (ART) in sub-Saharan Africa. It notes that while the WHO "3 by 5" initiative has made progress expanding ART access, the long-term outlook requires treating millions of people indefinitely. This growing caseload will overwhelm health systems unless new ART delivery models are developed. It also stresses that prevention efforts must be strengthened in parallel to reduce new HIV infections and make treatment sustainable over the long run. New strategies are needed to address both the escalating treatment needs and enhance prevention across communities and healthcare.
2007 Hrh Doctors & Art In Cambodia 1478 4491 5 12wvdamme
1) The study examines the use of doctor time for antiretroviral treatment (ART) delivery in Siem Reap, Cambodia between 2004 and 2005.
2) It finds that the doctor time needed per patient was reduced by 14-33% from 2004 to 2005 due to fewer patient visits and shorter consultations.
3) Extrapolating to 2013, the clinic will need between 2 to 5 full-time doctors to provide ART based on assumptions about patient survival and further reductions in doctor time per patient.
This editorial discusses two dimensions of epidemics - their bio-demographic burden and their psychological impact through fear. It notes that epidemics trigger social perceptions of panic, blame and need for authority response beyond just quantifiable disease impacts. Decision-making for epidemic control aims to balance both dimensions but is complicated by fear, uncertainty and time pressure, often resulting in overreaction. Managing public perception of risk and feeling of control is important for effective and efficient epidemic response.
2008 Aids Community Support & Art Outcomes S Afr Edwin Wouterswvdamme
This study analyzed data from 268 patients enrolled in South Africa's public sector antiretroviral treatment (ART) program to assess the impact of baseline health, patient characteristics, and community support on ART outcomes after 6 and 12 months. The results showed that delayed ART initiation reduced treatment response, while support from treatment buddies, community health workers, and support groups significantly improved outcomes. Community support had a greater positive influence on outcomes over time, suggesting it can help address human resource shortages in scaling up ART programs.
This document discusses the costs associated with increasing access to artemisinin combination therapy (ACT) for malaria treatment in Cambodia. It finds that in addition to the costs of ACT drugs, substantial investments are needed for appropriate delivery systems, including:
- The cost of blister packaging ACT drugs locally, which was higher than estimated due to low production rates.
- The annual costs per capita of $0.44-0.69 for malaria outreach teams and village malaria workers who improved access to diagnosis and treatment in remote communities.
- The total annual costs of $19.31 and $11.28 per patient treated for the outreach teams and village workers respectively, which included costs of rapid diagnostic tests and drugs
2006 Hrh Nurses In Swaziland 1478 4491 4 13wvdamme
population ratio is estimated at around 30 per
100 000.
Nurses
The total number of registered nurses in Swaziland was
estimated at 2317 in 2004. Of the 1484 established posts
for nurses in the public and mission sectors, only 1108
were filled (Table 1). This means that 19% of nursing posts
were vacant. The majority of nurses are employed in the
public sector, with only around 300 nurses working in the
mission sector. Based on the information available, we
estimate that
land in 2004. Of these, only around 80 were actually
employed in the public sector, giving a doctor:population
ratio of around 7 per 100 000. The remaining 102 doctors
This document outlines the principles and steps of statistical analysis, including data, variables, estimation, statistics, and time series versus cross-section data. It discusses key statistical concepts like the mean, standard deviation, variance, range, mode, and graphs. It also covers hypothesis testing using z-tests, t-tests, F-tests, and chi-square tests and how this relates to rejecting or failing to reject the null hypothesis. Finally, it discusses how cross-section data analysis can provide a concise summary of relationships between variables in a survey dataset.
Malaria Control Strategies among Rural Dwellers in a Typical Nigerian Settingasclepiuspdfs
Malaria is a major public health problem in sub-Saharan African, including Nigeria, causing 63% of total outpatient attendance in health facilities, 30% under-five mortality, and 11% of maternal mortality. Malaria control practices remain a major strategy in the combat of this menace. Therefore, the aim of this study is to determine the malaria control strategies utilized among rural dwellers in the Ezza North local government area (LGA) of Ebonyi state.
Malaria infection during pregnancy is a major public health problem- especially in tropical and sub-tropical regions; with substantial risks for the mother, her foetus and the new-born, Pregnant women are particularly susceptible to malaria, and in low transmission settings they have a greater risk of severe Plasmodium falciparum malaria. This study aimed at investigating the rate of parasitaemia amongst pregnant and none pregnant women was conducted among people attending clinics at the University of Calabar Teaching Hospital, Mambo hospital, Nosam medical laboratory services in Calabar Cross River state. They fall within the age group 18 to 60 years. They were pregnant women who came for Antenatal clinic, controls were sampled from patients who came to request for medical examination and blood donors. Thick and thin blood smears were made from finger prick samples of 400 candidates attending Antenatal clinics 200 of them were from established pregnant women and the other 200 were from non-pregnant women to serve as control. The blood films were dried and fixed in absolute methanol dried and stained with 2% Giemsa stain for 30 min. it was then rinse in clean water and allowed to dry in a draining rack. Dried slides were viewed using x100 oil immersion objective. Result revealed a parasitic rate of 132 (55.9 %) among pregnant women and104 (44.1%) parasitaemia among none pregnant women. The difference between pregnant women and none pegnant women were significantly different at p < 0.05. Similarly, the mean parasite density of the pregnant women was higher 28.9 against 14.2 of control none pregnant women. In conclusion there was a significant density of malaria parasitaemia amongst pregnant women in this study.
The epidemiology of tuberculosis in Kenya, a high TB/HIV burden country (2000...Premier Publishers
Interest in the epidemiology of TB was triggered by the re-emergence of tuberculosis in the early 1990’s with the advent of HIV and falling economic status of many people which subjected them to poverty. The dual lethal combination of HIV and poverty triggered an unprecedented TB epidemic. In this study, we focused on the period 2000-2013 and all the notified data in Kenya was included. Data on estimates of TB incidence, prevalence and mortality was extracted from the WHO global Tuberculosis database. Data was analysed to produce trends for each of the years and descriptive statistics were calculated. The results showed that there was an average decline of 5% over the last 8 years with the highest decline being reported in the year 2012/13. TB continues to disproportionately affect the male gender with 58% being male and 42% being female. Kenya has made significant efforts to address the burden of HIV among TB patients with cotrimoxazole preventive therapy (CPT) uptake reaching 98% AND ART at 74% by the end of 2013. Kenya’s TB epidemic has evolved over time and it has been characterised by a period where there was increase in the TB cases reaching a peak in the year 2007 after which there was a decline which began to accelerate in the year 2011. The gains in the decline of TB could be attributed in part to the outcomes of integrating TB and HIV services and these gains should be sustained. What is equally notable is the clear epidemiologic shift in age indicating reduced transmission in the younger age groups.
The document discusses integrated strategies for dengue prevention and control. It outlines the global impact of dengue virus, with 50 million cases each year in over 100 endemic countries. A multi-sectoral approach is needed involving social communication, epidemiological surveillance, entomology, patient care, and laboratories. Key strategies include reducing mosquito breeding sites, using insect repellents, treating patients, and conducting public education campaigns.
Rift Valley fever: Awareness and sensitizationILRI
1) The document discusses a campaign by VSF Germany, MAAIF, MoH and ILRI to increase awareness of Rift Valley fever in five Ugandan districts through engagements with local leaders and community members, distribution of educational materials, and radio programs.
2) Pre-campaign assessments found low RVF awareness outside of previously affected areas, with key risks being poor drainage, meat handling and sanitation.
3) The campaign concluded that controlling RVF in Uganda requires coordinated efforts between government, civil society and the private sector on risk communication, prevention and control measures.
2007 Hpp Panorama 4 He Fs In Cambodia Mathieu Czm015wvdamme
The document provides a comparative analysis of four health equity funds in Cambodia that aim to improve access to hospital care for poor patients. The key findings are:
1) The health equity fund model appears superior to traditional waiver systems in improving health service utilization among targeted poor groups.
2) Design aspects essential to the model's performance include the existence of donor funding, the presence of a driving agent, a clear separation of roles, appropriate identification techniques, and consideration of multiple barriers to health service utilization.
3) The comparative framework may be a useful tool for designing, operating, or evaluating similar strategies in other contexts, though early adoption of common documentation would facilitate generating evidence about comparative performance.
2008 Ssm Art&Fhs Scale Up In S Afr Wvd Kk Gk Ssm6213wvdamme
This document discusses the challenges of scaling up antiretroviral treatment (ART) in Southern African countries with human resource shortages. It notes that the continuously growing caseload of people needing lifelong ART, shortages and uneven distribution of health workers, and the labor-intensive nature of current ART delivery models pose significant challenges. The document analyzes different scenarios for how health systems may adapt, including maintaining the status quo, strengthening the overall health system through task shifting and community-based care, or more technocratic reengineering of services. Achieving universal access to ART will require innovative approaches to address human resource constraints.
2008 Pov Ill Book Challenges In Identifying Poor Oddar Meanchey Cambodiawvdamme
This document summarizes a study that assessed household eligibility for a Health Equity Fund (HEF) in Oddar Meanchey, Cambodia four years after an initial pre-identification process. The study evaluated three tools to assess HEF eligibility: 1) a scoring tool used in the original pre-identification, 2) interviewer assessments, and 3) a socioeconomic status index. The results showed high targeting errors across all three tools, suggesting that the original HEF eligibility granted through pre-identification four years prior did not accurately reflect households' current poverty status. Regular updates of pre-identification combined with post-identification are recommended to minimize targeting errors in the future.
2004 Tmih Out Of Pocket Expenditure In Cambodia 1194wvdamme
This document summarizes a study on out-of-pocket health expenditures and debt in poor households in Cambodia during a dengue epidemic. The study found that:
1) Households that exclusively used private providers paid an average of $103 out-of-pocket, while those that combined private and public providers paid $32, and those that only used public hospitals paid $8.
2) Households financed these costs through savings, selling consumables, selling assets, and borrowing money. After treatment, 63% of households were in debt, with those using private providers more likely to borrow or sell assets.
3) A follow-up found that most households with initial debts were unable to pay
Las propagandas criativas son formas ingeniosas de comunicar ideas a través de medios no tradicionales como stickers, grafitis, intervenciones urbanas u otros medios alternativos que atraen la atención del público de manera original. Estas técnicas buscan generar conciencia sobre diversos temas de interés público de una forma atractiva y memorable más allá de los canales convencionales.
The New Deal is an approach used in Cambodia to improve the public health system. It involves providing performance-based bonuses to health staff from resources freed up by donors and user fees. The New Deal has been implemented in Sotnikum district, Thmar Pouk district, and several provincial hospitals with positive results after 2 years in Sotnikum and 1 year in Thmar Pouk. Activities have increased as staff are more motivated. New institutional arrangements like management committees and Health Equity Funds to help the poor access care have also yielded good results. The document analyzes the implementation and lessons learned from the New Deal experiments to help guide further health sector reforms in Cambodia.
This document summarizes the experience of a Health Equity Fund (HEF) managed by a local NGO in Sotnikum, Cambodia. The HEF aimed to improve access to healthcare for the poor by identifying poor patients and paying their user fees. Over its first 25 months, the HEF supported 16% of hospitalized patients. The authors conducted interviews and found that while the HEF effectively improved financial access, poor patients still faced other barriers like geographical, informational, and intra-household constraints. The study concluded that the HEF model showed promising results with minimal benefits leaking to non-poor individuals, but that further research is needed in different contexts.
2007 Bmc H Serv Chi&Che Deva 1472 6963 7 43wvdamme
This document summarizes a study on two Indian community health insurance (CHI) schemes and whether they protect households from catastrophic health expenditures. The two schemes studied were ACCORD, which provides insurance to indigenous people in Tamil Nadu, and SEWA, which insures self-employed women in Gujarat. Both schemes cover hospitalization costs up to a maximum limit. The study reviewed insurance claims from 2003-2004 to analyze out-of-pocket payments and catastrophic expenditures. The results showed that both schemes halved the number of households experiencing catastrophic expenditures compared to having no insurance. However, 4% of ACCORD households and 23% of SEWA households still experienced catastrophic expenditures, related to low incomes, low maximum limits
Fake antimalarial drugs pose a major threat to malaria control in Southeast Asia. A survey of antimalarial drugs purchased in pharmacies and shops across the region found that 53% of artesunate tablets labeled as such did not contain any artesunate. All counterfeit artesunate tablets were labeled as manufactured by Guilin Pharma and had packaging that was increasingly difficult to distinguish from genuine products. The prevalence of counterfeit artesunate increased 15% compared to a previous survey, with the exception of Myanmar which saw an 18% decrease. A small percentage (9%) of mefloquine samples also contained inadequate active ingredients, undermining treatment and confidence in antimalarials. The proliferation of
2006 Aids Real Challenges Art In S Sa Wvd+Kk+Mlwvdamme
This document summarizes the challenges of scaling up antiretroviral therapy (ART) in sub-Saharan Africa. It notes that while the WHO "3 by 5" initiative has made progress expanding ART access, the long-term outlook requires treating millions of people indefinitely. This growing caseload will overwhelm health systems unless new ART delivery models are developed. It also stresses that prevention efforts must be strengthened in parallel to reduce new HIV infections and make treatment sustainable over the long run. New strategies are needed to address both the escalating treatment needs and enhance prevention across communities and healthcare.
2007 Hrh Doctors & Art In Cambodia 1478 4491 5 12wvdamme
1) The study examines the use of doctor time for antiretroviral treatment (ART) delivery in Siem Reap, Cambodia between 2004 and 2005.
2) It finds that the doctor time needed per patient was reduced by 14-33% from 2004 to 2005 due to fewer patient visits and shorter consultations.
3) Extrapolating to 2013, the clinic will need between 2 to 5 full-time doctors to provide ART based on assumptions about patient survival and further reductions in doctor time per patient.
This editorial discusses two dimensions of epidemics - their bio-demographic burden and their psychological impact through fear. It notes that epidemics trigger social perceptions of panic, blame and need for authority response beyond just quantifiable disease impacts. Decision-making for epidemic control aims to balance both dimensions but is complicated by fear, uncertainty and time pressure, often resulting in overreaction. Managing public perception of risk and feeling of control is important for effective and efficient epidemic response.
2008 Aids Community Support & Art Outcomes S Afr Edwin Wouterswvdamme
This study analyzed data from 268 patients enrolled in South Africa's public sector antiretroviral treatment (ART) program to assess the impact of baseline health, patient characteristics, and community support on ART outcomes after 6 and 12 months. The results showed that delayed ART initiation reduced treatment response, while support from treatment buddies, community health workers, and support groups significantly improved outcomes. Community support had a greater positive influence on outcomes over time, suggesting it can help address human resource shortages in scaling up ART programs.
This document discusses the costs associated with increasing access to artemisinin combination therapy (ACT) for malaria treatment in Cambodia. It finds that in addition to the costs of ACT drugs, substantial investments are needed for appropriate delivery systems, including:
- The cost of blister packaging ACT drugs locally, which was higher than estimated due to low production rates.
- The annual costs per capita of $0.44-0.69 for malaria outreach teams and village malaria workers who improved access to diagnosis and treatment in remote communities.
- The total annual costs of $19.31 and $11.28 per patient treated for the outreach teams and village workers respectively, which included costs of rapid diagnostic tests and drugs
2006 Hrh Nurses In Swaziland 1478 4491 4 13wvdamme
population ratio is estimated at around 30 per
100 000.
Nurses
The total number of registered nurses in Swaziland was
estimated at 2317 in 2004. Of the 1484 established posts
for nurses in the public and mission sectors, only 1108
were filled (Table 1). This means that 19% of nursing posts
were vacant. The majority of nurses are employed in the
public sector, with only around 300 nurses working in the
mission sector. Based on the information available, we
estimate that
land in 2004. Of these, only around 80 were actually
employed in the public sector, giving a doctor:population
ratio of around 7 per 100 000. The remaining 102 doctors
This document outlines the principles and steps of statistical analysis, including data, variables, estimation, statistics, and time series versus cross-section data. It discusses key statistical concepts like the mean, standard deviation, variance, range, mode, and graphs. It also covers hypothesis testing using z-tests, t-tests, F-tests, and chi-square tests and how this relates to rejecting or failing to reject the null hypothesis. Finally, it discusses how cross-section data analysis can provide a concise summary of relationships between variables in a survey dataset.
Malaria Control Strategies among Rural Dwellers in a Typical Nigerian Settingasclepiuspdfs
Malaria is a major public health problem in sub-Saharan African, including Nigeria, causing 63% of total outpatient attendance in health facilities, 30% under-five mortality, and 11% of maternal mortality. Malaria control practices remain a major strategy in the combat of this menace. Therefore, the aim of this study is to determine the malaria control strategies utilized among rural dwellers in the Ezza North local government area (LGA) of Ebonyi state.
Malaria infection during pregnancy is a major public health problem- especially in tropical and sub-tropical regions; with substantial risks for the mother, her foetus and the new-born, Pregnant women are particularly susceptible to malaria, and in low transmission settings they have a greater risk of severe Plasmodium falciparum malaria. This study aimed at investigating the rate of parasitaemia amongst pregnant and none pregnant women was conducted among people attending clinics at the University of Calabar Teaching Hospital, Mambo hospital, Nosam medical laboratory services in Calabar Cross River state. They fall within the age group 18 to 60 years. They were pregnant women who came for Antenatal clinic, controls were sampled from patients who came to request for medical examination and blood donors. Thick and thin blood smears were made from finger prick samples of 400 candidates attending Antenatal clinics 200 of them were from established pregnant women and the other 200 were from non-pregnant women to serve as control. The blood films were dried and fixed in absolute methanol dried and stained with 2% Giemsa stain for 30 min. it was then rinse in clean water and allowed to dry in a draining rack. Dried slides were viewed using x100 oil immersion objective. Result revealed a parasitic rate of 132 (55.9 %) among pregnant women and104 (44.1%) parasitaemia among none pregnant women. The difference between pregnant women and none pegnant women were significantly different at p < 0.05. Similarly, the mean parasite density of the pregnant women was higher 28.9 against 14.2 of control none pregnant women. In conclusion there was a significant density of malaria parasitaemia amongst pregnant women in this study.
The epidemiology of tuberculosis in Kenya, a high TB/HIV burden country (2000...Premier Publishers
Interest in the epidemiology of TB was triggered by the re-emergence of tuberculosis in the early 1990’s with the advent of HIV and falling economic status of many people which subjected them to poverty. The dual lethal combination of HIV and poverty triggered an unprecedented TB epidemic. In this study, we focused on the period 2000-2013 and all the notified data in Kenya was included. Data on estimates of TB incidence, prevalence and mortality was extracted from the WHO global Tuberculosis database. Data was analysed to produce trends for each of the years and descriptive statistics were calculated. The results showed that there was an average decline of 5% over the last 8 years with the highest decline being reported in the year 2012/13. TB continues to disproportionately affect the male gender with 58% being male and 42% being female. Kenya has made significant efforts to address the burden of HIV among TB patients with cotrimoxazole preventive therapy (CPT) uptake reaching 98% AND ART at 74% by the end of 2013. Kenya’s TB epidemic has evolved over time and it has been characterised by a period where there was increase in the TB cases reaching a peak in the year 2007 after which there was a decline which began to accelerate in the year 2011. The gains in the decline of TB could be attributed in part to the outcomes of integrating TB and HIV services and these gains should be sustained. What is equally notable is the clear epidemiologic shift in age indicating reduced transmission in the younger age groups.
The document discusses integrated strategies for dengue prevention and control. It outlines the global impact of dengue virus, with 50 million cases each year in over 100 endemic countries. A multi-sectoral approach is needed involving social communication, epidemiological surveillance, entomology, patient care, and laboratories. Key strategies include reducing mosquito breeding sites, using insect repellents, treating patients, and conducting public education campaigns.
Rift Valley fever: Awareness and sensitizationILRI
1) The document discusses a campaign by VSF Germany, MAAIF, MoH and ILRI to increase awareness of Rift Valley fever in five Ugandan districts through engagements with local leaders and community members, distribution of educational materials, and radio programs.
2) Pre-campaign assessments found low RVF awareness outside of previously affected areas, with key risks being poor drainage, meat handling and sanitation.
3) The campaign concluded that controlling RVF in Uganda requires coordinated efforts between government, civil society and the private sector on risk communication, prevention and control measures.
depth and details answer the following discussion board question.docxwrite22
This document discusses vaccine-preventable diseases among refugee and internally displaced populations during humanitarian emergencies. It reviews 50 articles on outbreaks of diseases like measles, polio, and meningitis in these vulnerable groups. Key challenges discussed are the breakdown of health services during crises, overcrowding in camps increasing transmission, and issues providing vaccination due to insecurity or infrastructure damage. Maintaining surveillance and responding quickly to outbreaks with vaccination is important for control. Coordination with partners and vaccination of surrounding communities is also recommended when immunity gaps exist in both displaced and host populations.
depth and details answer the following discussion board question.docx4934bk
This document discusses vaccine-preventable diseases among refugee and internally displaced populations during humanitarian emergencies. It reviews 50 articles on outbreaks of diseases like measles, polio, and meningitis in these vulnerable groups. Key challenges discussed are the breakdown of health services during crises, overcrowding in camps increasing transmission, and issues providing vaccination due to insecurity or infrastructure damage. Maintaining surveillance and responding quickly to outbreaks with vaccination is important for control. Coordination with partners and vaccination of surrounding communities is also recommended when immunity gaps exist in both displaced and host populations.
Am very excited to start the process of writing this research proposal because malaria is one of the most deadly diseases in Africa, especially in Ghana. so the reason behind this research proposal is that I want us to prevent this disease once and for all in our community. But am not done with this research I will continue it someday.
The document discusses vaccine-preventable diseases among refugee and internally displaced populations during humanitarian emergencies. It reviews 50 articles on outbreaks of diseases like measles, polio, meningitis, yellow fever and hepatitis A among displaced communities. Mass population movements, overcrowding and poor sanitation in refugee camps increase risk of disease transmission and outbreaks. Vaccination is critical for protection but humanitarian crises pose challenges to vaccine delivery and can threaten global eradication efforts. The increasing number of emergencies globally requires new approaches to vaccination for vulnerable displaced groups.
When this chapter was written, Drs Roger Glass and Eric Noji were medical epidemiologists at the Centers for Disease Control and Prevention in Atlanta Georgia. Dr. Glass is currently Director of the Fogarty International Center at the National Institutes of Health in Bethesda Maryland. Dr. Noji is currently Chief Executive Officer of Noji Global Health and Security LLC based in Washington DC and Geneva Switzerland
Economic analysis of malaria burden in kenyaNanyingi Mark
This framework uses a cost of illness approach to evaluate the burden of malaria. The evaluation is based on private direct costs (PDC) and private indirect cost (PIC) of malaria attack per episode.
This study summarizes the first outbreak of Chikungunya virus in Suriname in 2014-2015. It followed patients clinically suspected of Chikungunya infection and tested their blood to confirm cases. It found that 68% of symptomatic patients tested positive for Chikungunya virus. It described the symptoms in both adults and children over time. It also conducted household surveys to estimate a cumulative incidence of 249 Chikungunya cases per 1000 people in Paramaribo. A government campaign against mosquitos coincided with a sharp decline in reported cases.
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2004 Tmih Disease Control & Health Services In Guinea 1189
1. Tropical Medicine and International Health
volume 9 no 2 pp 281–291 february 2004
Strengthening health services to control epidemics: empirical
evidence from Guinea on its cost-effectiveness
Wim Van Damme and Wim Van Lerberghe
Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
objective To assess the cost-effectiveness of control measures implemented against epidemics in
Summary
Guinea, West Africa.
methods We collected all routine data available on incidence, mortality, control measures imple-
mented and their cost during epidemics of cholera, measles and meningococcal meningitis in 1993–95.
Then we estimated for one prefecture the effectiveness and cost-effectiveness of epidemic control
measures for three scenarios: (i) ‘natural’ situation, (ii) ‘routine’ health services and (iii) ‘intervention’.
Where uncertainty was considerable, we used sensitivity analysis and estimated ranges.
findings Routine health services reduced potential deaths by 51% (67%, 37% and 60% for cholera,
measles and meningitis, respectively), and additional interventions further decreased potential deaths by
28% (28%, 27% and 30% for cholera, measles and meningitis, respectively). The marginal cost-
effectiveness of epidemic control measures in routine health services was US$29 per death averted. The
marginal cost-effectiveness of additional interventions was US$93 per death averted.
conclusion Even with the data weaknesses that characterize situations of epidemics it is possible to
show that strengthening health services to control epidemics as was performed in Guinea was highly
cost-effective. Moreover, sensitivity analysis over a range of assumptions confirms that (i) well-func-
tioning health services averted the major part of avoidable deaths, (ii) combining existing health services
with additional interventions minimizes the health impact of epidemics and (iii) case management should
be a cornerstone of control of epidemics of cholera, measles and meningococcal meningitis.
keywords epidemics, cost-effectiveness, health services, cholera, measles, meningococcal meningitis
‘interventions’ are more a question of choice and judge-
Introduction
ment. To a large extent, the choice of response package and
Large-scale epidemics of infectious diseases, such as the balance between working through routine services and
measles, cholera and meningococcal meningitis, are fre- additional interventions are questions of cost-effectiveness.
quent throughout sub-Saharan Africa and cause substantial But the fear, urgency and time pressure during epidemics
excess mortality. A rational choice of measures to reduce may blur rational decision-making and complicate sound
the impact of an epidemic would have to consider not only judgement (Van Damme & Van Lerberghe 2000).
potential effectiveness, but also the cost, the feasibility and The evidence base for many emergency health interven-
the acceptability of implementing the control measures tions remains weak (Sondorp et al. 2001). Except for work
envisaged. on meningococcal meningitis (Veeken et al. 1998), the
Measures to be taken in response to a particular cost-effectiveness of measures to control epidemics in sub-
epidemic threat are often within the reach – and remit – of Saharan Africa has not been documented systematically.
‘routine’ health service activities (e.g. pre-emptive measles This is not surprising given the operational difficulties of
vaccination, or case management of patients with diar- collecting such documentation in the often-chaotic cir-
rhoea, meningitis or measles); other measures may have to cumstances that characterize epidemics (Banatvala & Zwi
be organized separately, as specific additional ‘interven- 2000).
tions’ (e.g. a mass emergency vaccination campaign) (Bres This paper examines the marginal cost-effectiveness
`
1986). of epidemic control measures by ‘routine’ health services
Case management, and particularly the involvement and additional, specially set-up ‘interventions’ as they
therein of the ‘routine’ health services, is an impera- were organized for the control of cholera, measles and
tive during an epidemic, not a choice. Additional meningococcal meningitis in the Forest Region of Guinea,
281
ª 2004 Blackwell Publishing Ltd
2. Tropical Medicine and International Health volume 9 no 2 pp 281–291 february 2004
W. Van Damme & W. Van Lerberghe Cost-effectiveness of controlling epidemics in Guinea
West-Africa, in the early nineties. With all their weaknes- collections of Institute of Tropical Medicine, Antwerp, and
ses, the Guinea data are sufficiently sound to allow for a London School of Hygiene and Tropical Medicine, on
robust assessment. cholera, measles and meningococcal meningitis.
Epidemic control measures
Methods
Measles vaccination and case management for cholera,
Study area and data sources
measles and meningitis were part of the routine functioning
of the health services. The only change in the routine
Guinea, West Africa, is one of the poorest countries in the
during epidemics was a decision to provide care, free of
world. Between 1990 and 1996 some 500 000 refugees
charge for all patients with cholera and meningitis, even in
from Liberia and Sierra Leone arrived in the Forest Region
facilities functioning on a cost-recovery basis. Additional
of Guinea (Van Damme 1995). Most settled among the
‘interventions’ aimed at further reducing the impact of
host population, <20% in refugee camps (Van Damme
epidemics were implemented. From 1990, with the arrival
1999). The basic reaction of the Forest Region’s health
of Liberian refugees in Macenta, mobile measles vaccin-
authorities after the influx of the refugees in their area was
ation teams were launched. When cholera and meningo-
to strengthen and expand the development of the network
coccal meningitis epidemics broke out, additional mobile
of health centres and health posts, and to set up a disease
surveillance system. With the help of the refugee-assistance support teams started to implement the control activities
programme, the health system was well established by that are listed in Table 1. For the purpose of this study,
three scenarios are distinguished: (i) a ‘natural’ situation, in
1991, assuring access to health care throughout the region
the absence of any health care, which served as the
for refugees and the local population alike (Van Damme
baseline; (ii) a ‘routine’ situation where routine health
et al. 1998). This study concerns the prefecture of
services are functioning, without any additional epidemic
Macenta, with a population of 355 000 inhabitants.
control measures and (iii) an ‘intervention’ situation, as
Macenta was the prefecture worst hit by epidemics:
was the case in Guinea, where routine health services were
between 1993 and 1995 – the period covered in this study –
strengthened and additional epidemic control measures
it experienced one epidemic each of cholera, measles and
implemented (Table 1).
meningococcal meningitis. It was also the prefecture with
the best health care network and the best routine data.
These routine data are complemented with (i) vaccination
Effectiveness
coverage surveys; (ii) relevant documents from Ministry of
We did the assessment of the effectiveness of the epidemic
Health and ‘Medecins Sans Frontieres’, including their
´ `
control measures in three steps, using the sources men-
bookkeeping for costing purposes; (iii) in-depth interviews
tioned above. The first step was to estimate the number of
with health authorities, health workers, ‘Medecins Sans
´
cases and of deaths during the various epidemics as they
Frontieres’ staff and key informants from Ministry of
`
occurred, in the ‘intervention’ scenario. These estimates are
Health, UNHCR and other agencies and (iv) an extensive
based on notification data, completed with data from the
literature search in Medline and through the library
Table 1 Overview of epidemic control scenarios (and total estimated marginal cost), Macenta, 1993–95
Scenario Cholera control activities Measles control activities Meningococcal meningitis control activities
‘Natural’ None None None
‘Routine’ Case management of diarrhoea Routine A: case management Case management in hospitals (US$14 980)
in health centres and hospitals in health centres (US$7400)
(US$17 500) and routine B: pre-emptive
vaccination in health centres
(US$20 780 – 63 080)
‘Intervention’ Improved case management Pre-emptive vaccination by Intervention A: improved case management
(actual scenario) in cholera treatment centres mobile teams (US$31 080) in health centres with intensive training
linked to existing health facilities, support (US$11 235) and intervention B:
with intensive support from mass reactive vaccination campaign
specialised teams (US$53 350) (US$52 000)
282 ª 2004 Blackwell Publishing Ltd
3. Tropical Medicine and International Health volume 9 no 2 pp 281–291 february 2004
W. Van Damme & W. Van Lerberghe Cost-effectiveness of controlling epidemics in Guinea
literature and expert opinion, to infer the number of deaths
that actually occurred from those that were notified. The
Cost of basic Cost of basic
second step consisted of estimating what that burden health care health care
would have been in the ‘natural’ situation. We used system system
different methods, either extrapolation from the interven-
Marginal cost Marginal cost
tion scenario doing backward adjusting using intervention for ‘routine’ for ‘routine’
effectiveness and coverage information; or natural history Marginal cost for
data from primary and secondary sources, combined with ‘intervention’
case-fatality rates (CFRs) available in the literature.
Range
Numbers of deaths averted thus become sensitive not only
to errors in counting how many actually occurred, but also Deaths Deaths
in estimating ‘what would have occurred if…’. One way to averted by averted by
deal with such an amount of uncertainty is to use ‘routine’ ‘routine’
Potential
sensitivity analysis over a range of assumptions to test the
Range
number of
robustness of any conclusions (Briggs et al. 1994; deaths Deaths
due to Residual
Campbell & Torgerson 1997). We calculated effectiveness averted by
Range
epidemic number of ‘intervention’
of interventions with low-end and high-end estimations, deaths Residual
where the range of uncertainty was large. We only report number of
deaths
the extrapolations over the full range of uncertainty in
those instances where they might invalidate conclusions or Baseline Baseline Baseline
add useful qualifications. Else we report only the extra- mortality mortality mortality
polations on the most likely data points. The third step
consisted of apportioning the difference between the
estimates of step 1 and step 2 to either the impact of the ‘Natural’ ‘Routine’ ‘Intervention’
situation: situation:
situation:
routine health services or to the additional specific
interventions, resulting in number of deaths averted Only routine Routine services +
Absence of any
health services additional
health care
because of ‘routine’ health services or ‘intervention’. This interventions
allowed for assessing the potential of relying only on
Figure 1 Excess mortality of an epidemic in ‘natural’, ‘routine’
routine health services to react to (the threat of) epidemics,
and ‘intervention’ scenarios, with corresponding marginal effects
and the marginal effectiveness of organizing ‘additional’
and costs of control efforts.
interventions alongside the work through the ‘routine’
services. These various categories are summed up in
Figure 1.
population, but has the advantage of being feasible and
straightforward (World Bank 1993b). The total marginal
Cost and cost-effectiveness
cost of the epidemic control measures in the ‘routine’ and
‘intervention’ scenarios is then divided by the effect of the
The economic analysis took the health service perspective,
strategy, in terms of number of deaths averted, to calculate
assessing only the direct costs for service provision during
the marginal cost per death averted in each of the
the epidemics. We did not attempt to estimate opportunity
scenarios.
costs. All costs are estimated in US$, with 1995 as the
reference year. The total cost of the basic health care
system in Macenta has been estimated at US$3 per capita
per year (Van Damme 1998). The marginal cost, or sunk Results
cost, of dealing with the epidemics was defined as the
Cholera control
additional direct cost of vaccines, drugs, material, vehicles,
Cases, deaths and deaths averted. In 1995 in Macenta
extra staff, etc. incurred because of the activities through
6340 cases of cholera were recorded, of which 111 died, a
the routine health services (marginal cost for ‘routine’) plus
reported CFR of 1.8%. We estimate that most cases were
the marginal cost of additional control interventions
reported: the population perceived cholera as a major
(marginal cost for ‘intervention’). This definition takes the
threat, and the health authorities took special measures to
existence of the basic health service for granted, and does
improve access to health services. It is unlikely that cases of
not take into consideration opportunity costs for the health
cholera would occur without the patients and their
system nor the direct and opportunity costs for the
283
ª 2004 Blackwell Publishing Ltd
4. Tropical Medicine and International Health volume 9 no 2 pp 281–291 february 2004
W. Van Damme & W. Van Lerberghe Cost-effectiveness of controlling epidemics in Guinea
Table 2 Efficacy and effectiveness of epidemic control activities used
Community effectiveness in the
Efficacy, as documented in the literature field situation in Guinea
Vaccine efficacy: Efficacy of case management: Reduction in Reduction
Epidemic control activities reduction in attack rate reduction in CFR* attack rate in CFR
Cholera case management: oral and 50% fi 1–2% 50% fi 10–20%(?)
intravenous rehydration
(Bres 1986; Hanquet et al. 1997)
`
Pre-emptive measles vaccination 85% 60%
(Halsey et al. 1985; Bennett et al. 1990)
Measles case management: 5% fi 1.25%à 5% fi 2.5%(?)
prevention and treatment of 10% fi 2.50% 10% fi 5%(?)
complications (Foster et al. 1993;
Aaby 1995)
Reactive meningococcal meningitis 90% 50%(?)
vaccination (Moore et al. 1990)
Meningococcal meningitis case 50% fi 5–10% 50 fi 20%(?)
management: antibiotherapy (Bres 1986)
`
CFR, case fatality rate; (?), order of magnitude.
* Estimation of the reduction in CFR from the ‘natural’ CFR to the lowest possible CFR with timely and optimal treatment.
Measles vaccine efficacy is 85% when administered at 9 months of age; it is only 60–70% when administered at 6 months of age,
but increases to 95–98% at 15 months of age.
à CFR differs widely, probably depending on intensity of transmission (Aaby 1995). The efficacy of excellent case management was
reported to be 78% (Foster et al. 1993).
environment at least attempting to reach a treatment facilities to get the ‘natural’ CFR of 50% down to 20% or
centre. Rather, given the prevailing fear of cholera and the to 10%. The number of deaths averted by ‘routine’ services
sensitive case-definition used, the figure of 6340 cases most is then estimated between 951 and 2536. The ‘intervention’
probably contains a substantial number of false positives, averted additionally between 184 and 1157 deaths.
possibly even up to 50%. A total of 6340 is therefore a
high-end estimate of the range of the actual number of Cost and cost-effectiveness. The total direct cost of the
cases of cholera that occurred during the epidemic – cholera control programme in Macenta was US$70 850.
intervention scenario – and 3170 a low-end estimate. The We can estimate that exclusive reliance on routine health
number of deaths, however, 111, is probably an services would only have cost US$17 500, i.e. the marginal
underestimate, as a number of patients may actually have cost for the medical supplies for the extra case-load. The
died before reaching a treatment centre. The actual number ‘intervention’ required an extra US$53 350 for setting up,
may have been up to 20% higher, which gives a range for staffing and supervising the cholera treatment centres. The
number of deaths of (111–133), a CFR between 2% and resulting marginal cost per death averted was US$11 (range
4% (Table 3). between US$7 and US$18) for routine case management
The case-fatality rate of untreated cholera is of the order and US$80 (range between US$46 and US$290) for
of magnitude of 50% (Table 2). In the ‘natural’ scenario, improved case management during the intervention
one could therefore have expected between 1585 and 3170 (Table 3).
deaths from cholera in Macenta among the cases that
actually occurred. Deaths averted by a possible reduction
Measles control
of incidence are not taken into account; they are probably
negligible. Cases, deaths and deaths averted. Measles epidemics
With routine services alone one could have expected follow a triennial cycle in the Forest Region of Guinea.
between 317 and 1268 deaths among the 6340 cases, With a simple mathematical model it is possible to make an
depending on whether (i) one considers all cases as true estimate of the measles attack rate (Black 1982; Anderson
cholera cases, and whether (ii) one expects unassisted health & May 1992; Foster et al. 1993). In a ‘natural’ situation,
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5. Tropical Medicine and International Health volume 9 no 2 pp 281–291 february 2004
W. Van Damme & W. Van Lerberghe Cost-effectiveness of controlling epidemics in Guinea
Table 3 Effectiveness and cost-effectiveness of cholera control
Deaths midpoint Deaths averted Marginal Marginal cost per
Scenario Activities Cases (range) [range] midpoint [range] cost death averted (range)
Natural None 4755 (3170–6340) 2378 (100%)* 0 0 0
[1585–3170]
Routine Case management 4755 (3170–6340) 793 (33%)* 1585 (67%)* +US$17 500 US$11 (7–18)
in health centres [317–1268] [951–2536]
and hospitals
Intervention Improved case 4755 (3170–6340) 122 (5%)* +671 (28%)* +US$53 350 US$80 (46–290)
management in [111–133] [184–1157]
cholera treatment
centres
* Proportion of potential deaths in ‘natural’ scenario.
Table 4 Effectiveness and cost-effectiveness of measles control
Deaths Deaths averted Marginal Marginal cost per
Scenario Activities Cases midpoint [range] midpoint [range] cost (range) death averted (range)
Natural None 37 000 2775 (100%)* 0 0 0
[1850–3700]
Routine A Case management 37 000 2497 (90%)* 278 (10%)* [185–370] US$7400 US$27 (20–40)
in health centres [1665–3330]
Routine B +vaccination in 25 900 1748 (63%)* +749 (27%)* [499–999] +US$41 930 US$56 (21–126)
health centres [1165–2331] (20 780–63 080)
Intervention +vaccination by 14 800 999 (36%)* +749 (27%)* [499–999] +US$31 080 US$41 (31–62)
mobile teams [666–1332]
* Proportion of potential deaths in ‘natural’ scenario.
i.e. without vaccination, 10.4% of the total population, i.e. these assumptions the ‘intervention’ (i.e. routine case
some 37 000 children in Macenta, would get measles management + vaccination in health centres + vaccination
during one 3-year cycle. In the absence of any case- by mobile teams) would have averted 22 200 measles
management the CFR would be between 5% and 10% cases and 666 to 1332 deaths.
(Assaad 1983), resulting in between 1850 and 3700 deaths ‘Routine’ case management alone would have averted
(Table 4). 185–370 deaths among the 7400 children reached. The
In Guinea, only some 20% of children with measles are total contribution of health centres – case management +
seen in health facilities (Van Damme 1998). Conse- vaccination – would have averted 11 100 cases and
quently, for the ‘intervention’ scenario, we could not between 185 + 499 and 370 + 999 deaths.
assess the actual number of measles cases or deaths from
the cases notified. As an alternative we used guesstimates Cost and cost-effectiveness. The unit cost of ambulatory
on the basis of vaccine coverage, the effectiveness of treatment of a case of measles in a health centre in
vaccination and of case management. In Macenta, overall Guinea has been estimated at US$1 (Soucat et al. 1997).
coverage with measles vaccine was around 70%, with In Guinea, routine vaccination by health centres cost
health centres and mobile teams each accounting for US$8.80 per fully vaccinated child (which requires five
about half of this. We estimate vaccine effectiveness at encounters) (Soucat et al. 1997). This includes investment
85%, assuming that factors decreasing vaccine effective- in cold chain and transport. If one attributes one-fifth of
ness in field conditions (Kenya 1990; Luthi et al. 1997) this cost to measles vaccination, the unit cost of measles
were balanced by a considerable proportion of children vaccination is US$1.76. If one, however, considers the
being vaccinated after 9 months of age. For the 20% of full investment cost, the cost is approximately US$5 per
measles cases managed in health centres, we assume a measles vaccination. The total cost for measles
reduction by 50% of the baseline CFR of (5–10%). Under vaccinations carried out by the health centres over the
285
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6. Tropical Medicine and International Health volume 9 no 2 pp 281–291 february 2004
W. Van Damme & W. Van Lerberghe Cost-effectiveness of controlling epidemics in Guinea
3-year period was US$23 000 or 65 300 (depending on Total cost
the assumptions used). The total cost of vaccinations by
$90 000
the mobile teams amounted to US$33 300
$80 000
(approximately 30% for the vaccines, and the rest for the
mobile teams). Vaccination by mobile teams and by $70 000
health centres saved some US$2220 each in treatment $60 000
costs (Table 4 and Figure 2).
$50 000
The marginal cost for measles case management
$40 000
amounted to US$7400; for measles vaccination in ‘routine’
health services to between US$20 780 and 63 080; and for $30 000
measles vaccination by mobile teams to US$31 080. Using $20 000
these cost estimates, the cost per measles death averted
$10 000
ranges between US$20 and 40 for case management in
$0
health centres, between US$21 and 126 for vaccination in
health centres, and between US$31 and 62 for vaccination CM CM + VHC CM + VHC +
VMT
by mobile teams.
Deaths averted
Meningococcal meningitis control 2000
Cases, deaths and deaths averted. In 1993 in Macenta 1800
539 cases of meningococcal meningitis were registered, 1600
with 35 deaths, a CFR of 6.5%. We consider that 1400
registration was near exhaustive, both for cases and for 1200
deaths, and thus use these data for the ‘intervention’
1000
scenario. To establish the number of deaths in a ‘natural’
800
epidemic, one has to estimate the attack rate and the
600
CFR that would have occurred without vaccination
campaign or case management. In Macenta, vaccination 400
was undoubtedly late and some might argue that it 200
hardly prevented any cases (Veeken et al. 1998). 0
However, assuming 90% protection among the 28% of CM CM + VHC CM + VHC +
the population that was vaccinated (the most optimistic VMT
hypothesis), the upper-end estimate of the ‘natural’
incidence would be 749, some 210 more cases than the Cost per death averted
registered 539. It is indeed unlikely that vaccination $60
would have stopped transmission or influenced the
dynamics of the epidemic (Greenwood 1984; Begg 1995): $50
not only the coverage but also the timing of vaccination
plays a major role. The number of cases averted is $40
therefore more likely to be <210 (Table 5).
In the absence of any treatment one would expect about $30
half of the expected 749 cases of meningitis to die. We
$20
estimate that in Guinea, case management in ‘routine’
health services would have brought the CFR down from
$10
50% to 20%, averting 225 of the likely 375.
It is worthwhile to make an additional simulation to
$0
understand the relative contribution of improved case
CM CM + VHC CM + VHC +
management and reactive vaccination for meningococcal
VMT
meningitis. Accepting the high-end estimate of the impact
of vaccination – 210 cases prevented – improved case Figure 2 Effectiveness and cost-effectiveness of measles control
management alone would have had to deal with a total of strategies (midpoint estimates). CM, case management; VHC,
749 cases, but could have reduced the CFR from 20% to vaccination in health centres; VMT, vaccination by mobile teams.
286 ª 2004 Blackwell Publishing Ltd
7. Tropical Medicine and International Health volume 9 no 2 pp 281–291 february 2004
W. Van Damme & W. Van Lerberghe Cost-effectiveness of controlling epidemics in Guinea
Table 5 Effectiveness and cost-effectiveness of control of meningococcal meningitis
Deaths Marginal cost
Scenario Activities Cases Deaths averted Marginal cost per death averted
Natural None 749 375 (100%)* 0 0 0
Routine Case management in hospitals 749 150 (40%)* 225 (60%)* +US$14 980 US$67
Intervention A Improved case management in health centres 749 48 (13%)* +102 (27%)* +US$11 235 US$110
Intervention B + mass reactive vaccination campaign 539 35 (9%)* +13 (3%)* +US$47 800 US$3677
* Proportion of potential deaths in ‘natural’ scenario.
6.5% – the CFR observed – averting 102 deaths, leaving
Cost-effectiveness of control of epidemics
48. Adding reactive vaccination to improved case man-
agement further reduces the number of deaths to 35, All routine activities together roughly halved potential
averting 13 additional deaths. deaths from epidemics: 51% for the three diseases combined
(67% by cholera case management, 37% by measles case
Cost and cost-effectiveness. The marginal cost of case management and measles vaccination by health centres
management in ‘routine’ services, can be equated to the combined and 60% by meningitis case management;
cost of medicines for meningococcal meningitis: Figure 3 and Table 6). Additional interventions roughly
approximately US$20 per patient, or a total cost of halved again the residual deaths: a further 28% for the three
US$14 980. For improved case management, including diseases combined (28% by improved cholera case man-
extra supervision and support, the cost was estimated at agement, 27% by measles vaccination by mobile teams and
US$35 per patient, similar to the cost documented in 30% by improved meningitis case management and menin-
Nigeria (Veeken et al. 1998), US$15 per patient more gitis vaccination combined). Figure 4 summarizes the cost-
than ‘routine’ or a total marginal cost of US$11 235 effectiveness of the different epidemic control activities
(Table 5). The total cost of the 104 000 vaccinations in studied. Meningitis vaccination is clearly less cost-effective
Macenta prefecture was US$52 000 (Varaine et al. than any of the other measures.
1997). But vaccination may have saved up to US$4200 The three epidemics – in the absence of adequate control
of drugs, leaving a total marginal cost of US$47 800 for measures – would have added a considerable number of
13 additional deaths averted, US$3677 per death deaths to the annual death toll in Macenta (Figure 3). As it
averted. was performed, the intervention to control a cholera
7000
Deaths averted by ‘routine’
Deaths averted by ‘intervention’
6000
Residual deaths
5000
2837
4000
Deaths
6390
3000
1027
2000 1535
1585
749
1000
Figure 3 Deaths averted and residual
1156
deaths of the three epidemics, compared 999
671
225
122 115
with the annual baseline mortality in 35
0
Macenta (mid point estimates). Baseline mortality (annual) Three diseases combined Cholera Measles Meningitis
287
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8. Tropical Medicine and International Health volume 9 no 2 pp 281–291 february 2004
W. Van Damme & W. Van Lerberghe Cost-effectiveness of controlling epidemics in Guinea
Table 6 Effectiveness and cost-effective-
Marginal cost ness of control of cholera, measles and
Scenario Deaths Deaths averted Marginal cost per death averted meningitis combined (midpoint estimates)
Natural 5528 (100%)* 0 0 0
Routine 2691 (49%)* 2837 (51%)* +US$81 810 US$29
Intervention 1156 (21%)* +1535 (28%)* +US$143 465 US$93
* Proportion of potential deaths in ‘natural’ scenario.
$200 $4000
Marginal cost per death averted
Marginal cost per death averted
by meningitis vaccination $3677
$180
$3500
$160
$3000
$140
$2500
$120 $110
$100 $2000
$93
$80
$80
$1500
$67
$56
$60
$1000
$41
$40
$29
$27
$500
$20 $11
$0 $0
Cholera case Measles case Measles Meningitis All routine Cholera Measles Meningitis All Meningitis
management management vaccination in case activities improved vaccination improved intervention mass
Figure 4 Cost-effectiveness of different
health centres management case by mobile case activities vaccination
management teams management campaign
epidemic control activities (mid point
‘Routine’ ‘Intervention’ estimates).
epidemic adds US$0.15 per capita per year to the annual further 28% at an average marginal cost of US$93 per
average expenditure of US$3 per capita per year; and death averted.
controlling measles US$0.09 per capita. In the case of One should, however, treat these findings with caution,
meningitis US$0.13 per capita per year was spent for for several reasons. First, marginal costs per death averted
vaccination – with a very small yield in deaths averted – as calculated are approximate at most. We had to use
while the cost for improved case management was only different primary and secondary sources for cost estimates,
US$0.03 per capita per year. The routine health care of varying reliability and degree of detail. A systematic
system in the region, with its facilities, staff, vehicles and ingredient approach was thus impossible. Moreover, costs
cold chain, was already functioning and funded: donor were estimated as marginal to the routine health system.
inputs and official user fees amounted to a total of about Activities developed within existing facilities have a lower
US$3 per capita per year (Van Damme 1998). The total marginal cost than activities for which an additional
cost of the interventions was US$145 685. This adds 4.6% intervention was organized. However, this approach to
to the total cost of the routine health system, estimated at cost estimation was the best one could do with the
US$3195 000 for the triennial period. available data, and is widely used (Mills 1985; World Bank
1993b). Our data did not allow applying more recent
guidelines on cost-effectiveness analysis (Johannesson &
Discussion
Meltzer 1998; Murray et al. 2000; Hutubessy et al.
In Guinea, reducing the burden of the epidemics was 2001a,b).
mainly the work of the routine health services: they Second, effectiveness estimates also lack precision,
avoided some 51% of the potential excess mortality, at an because the assumptions used for attack rates and case
average marginal cost of US$29 per death averted. The fatality rates (CFRs) are imprecise. For instance, the
additional intervention to help control the epidemics, such 50% natural CFR often quoted for cholera and meningo-
as mobile teams and cholera treatment centres, averted a coccal meningitis (Table 2) may not be universally valid.
288 ª 2004 Blackwell Publishing Ltd
9. Tropical Medicine and International Health volume 9 no 2 pp 281–291 february 2004
W. Van Damme & W. Van Lerberghe Cost-effectiveness of controlling epidemics in Guinea
in anxiety are difficult to measure and were not taken into
However, we accepted them for our analysis. Reported or
account for the cost-effectiveness analysis in this paper.
estimated attack rates and CFRs are already imprecise
Nevertheless, the bio-demographic burden and the psy-
(‘intervention’ situation), but attack rates and CFRs in the
chological impact are both integral parts of what is
absence of any health care (‘natural’ situation), or in the
perceived as an epidemic, both by health professionals and
absence of additional epidemic control measures (‘routine’
by the population. In Guinea, the psychological impact
situation) are by necessity based on extrapolation. How-
seemed influenced by factors such as the degree of
ever, despite these limitations, sensitivity analysis showed
acquaintance with the diseases; the speed of transmission
that the conclusions are robust over a wide range of
and the fear of further spread; the age groups involved; the
assumptions.
perception of certain epidemics as being an ‘invasion from
Third, cost per death averted is very sensitive to potential
outside’; and the history of the disease in the area
number of deaths estimated. In environments with lower
(VanDamme 1998). These factors may explain why chol-
measles CFR, such as southern Africa, or with higher
era and meningococcal meningitis were perceived as major
meningitis attack rates, such as areas within the core of the
threats, while measles was not, its higher mortality
Sahelian meningitis belt, cost-effectiveness estimates may
notwithstanding.
differ significantly from Guinea.
If epidemic control measures are as much a response to
On the basis of its cost-effectiveness ratio, relying on
fear as an attempt to avert surplus mortality, it seems
routine health services for controlling epidemics is an
inadequate to measure the cost-effectiveness of epidemic
obvious first choice, with its 51% reduction of excess
control measures exclusively in terms of cost per death
mortality (Figure 3) at US$29 per death averted
averted (Van Damme & Van Lerberghe 2000). To spend
(Figure 4). One would presume, however, that in most
US$47 800 in Macenta for meningitis vaccination to
countries, as in Guinea, the residual death toll of solely
prevent 13 deaths is not cost-effective, in terms of deaths
relying on routine services would be humanely unaccept-
prevented. If, however, one also considers this from the
able and politically unfeasible. Complementing the con-
viewpoint of society, it may well have been worthwhile to
trol efforts of routine health services with specific
spend that money to alleviate its fear through a highly
additional interventions, be it at a lower cost-effectiveness
visible operation. After all, to allocate resources in this
ratio – a marginal cost of US$93 per death averted –
(irrational) way is also the society’s choice. Health
eventually proved useful and affordable. This is partic-
authorities in Guinea acknowledged that the impact of
ularly obvious in the case of measles (Figure 2). Although
meningitis vaccination on the course of the epidemic would
case management alone was highly cost-effective (US$27
be limited, but political pressure was so high that ‘not
per death averted), it would have reduced measles
vaccinating was not an option’.
mortality only by 10%, clearly ‘unacceptable’. The best
Well-functioning health services can play a prominent
strategy was undoubtedly the combination of all three
role in handling complex emergencies, even of the scale of
activities.
the refugee crisis in east Congo (Porignon et al. 1998). The
An extra health budget of 4.6%, or US$0.14 per capita
experience from Guinea shows that they can also be the
per year, to control such devastating epidemics seems a
mainstay of the control of epidemics, even in severely
very reasonable amount. It represents only a very small
resource-constrained situations. In Macenta, existing ser-
share of the US$12 per capita per year estimated necessary
vices were functioning reasonably well – all things
by the World Bank for a minimum package of health
considered – in part because the staff were paid decent
services (World Bank 1993a; World Bank 1993b), the
wages and supply channels were adequate. In these
US$34 per capita per year judged necessary by the
circumstances, relatively little extra support – targeted
Commission on Macroeconomics and Health (Commission
supplies and training – was enough to further increase the
on Macroeconomics and Health 2001), or the cost of
performance of the health system.
treating AIDS patients with antiretroviral drugs. For
However, these obvious minimum conditions are often
managers or policy makers it provides good value for
not met in sub-Saharan Africa, where health services
money; all the more as action on their part is usually taken
usually lack the means and experience to tackle epidemics
on the basis of an overestimation of the epidemic’s threat.
adequately. They may run out of stock of the necessary
Public health interventions tend to anticipate worst-case
drugs, and may have difficulties coping with the increased
scenarios, with decisions made under considerable time-
workload. But when they do function and get the means
constraints and on the basis of uncertain information
to respond to an emergency situation they have the
(Van Damme & Van Lerberghe 2000).
comparative advantage of providing case management,
Moreover, epidemics do not only cause death, disease
which is an essential part of addressing fear and panic,
and disability. They provoke fear and anxiety. Reductions
289
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10. Tropical Medicine and International Health volume 9 no 2 pp 281–291 february 2004
W. Van Damme & W. Van Lerberghe Cost-effectiveness of controlling epidemics in Guinea
and one of the most cost-effective interventions in various Geographical Medicine (eds KS Warren & AAF Mahmoud)
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Briggs A, Bland R, Cheetham J & Lapsey I (1994) Uncertainty in
ment – as previously shown in Nigeria for meningococcal the economic evaluation of healthcare technologies: the role of
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than commonly assumed. But even for additional inter- Campbell M & Torgerson D (1997) Confidence intervals for cost-
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nomics and Health: Investing in Health for Economic Devel-
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diarrhoeal diseases. In: Refugee Health. An Approach to
The authors thank field staff of the Ministry of Health and
Emergency Situations (ed. G. Hanquet) Macmillan, London and
of Medecins sans Frontieres in Guinea for their collabora-
´ ` Basingstoke, pp. 154–171.
tion during the fieldwork. We also thank R. Eeckels and Hutubessy RC, Baltussen RM, Evans DB, Barendregt JJ & Murray
M. Boelaert for useful comments on previous drafts. CJ (2001a) Stochastic league tables: communicating cost-
This study was made possible by a research grant of effectiveness results to decision-makers. Health Economics 10,
the Fund for Scientific Research – Flanders, Belgium 473–477.
Hutubessy RC, Bendib LM & Evans DB (2001b) Critical issues in
(F.W.O. – S2/5 – AV – E62).
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Authors
Wim Van Damme (corresponding author) and Wim Van Lerberghe, Institute of Tropical Medicine, 155 Nationalestraat,
2000 Antwerp, Belgium. E-mail: wvdamme@itg.be, isa@itg.be
291
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