Deborah A. McFarland

The Economic Benefits Resulting from the First 8 Years of the Global Programme to Eliminate Lymphatic Filariasis (2000–2007)

Background Between 2000–2007, the Global Programme to Eliminate Lymphatic Filariasis (GPELF) delivered more than 1.9 billion treatments to nearly 600 million individuals via annual mass drug administration (MDA) of anti-filarial drugs (albendazole, ivermectin, diethylcarbamazine) to all at-risk for 4–6 years. Quantifying the resulting economic benefits of this significant achievement is important not only to justify the resources invested in the GPELF but also to more fully understand the Programmes overall impact on some of the poorest endemic populations. Methodology To calculate the economic benefits, the number of clinical manifestations averted was first quantified and the savings associated with this disease prevention then analyzed in the context of direct treatment costs, indirect costs of lost-labor, and costs to the health system to care for affected individuals. Multiple data sources were reviewed, including published literature and databases from the World Health Organization, International Monetary Fund, and International Labour Organization Principal Findings An estimated US

Antenatal chloroquine chemoprophylaxis in Malawi: chloroquine resistance, compliance, protective efficacy and cost

21.8 billion of direct economic benefits will be gained over the lifetime of 31.4 million individuals treated during the first 8 years of the GPELF. Of this total, over US

Traditional kinship system enhanced classic community-directed treatment with ivermectin (CDTI) for onchocerciasis control in Uganda.

2.3 billion is realized by the protection of nearly 3 million newborns and other individuals from acquiring lymphatic filariasis as a result of their being born into areas freed of LF transmission. Similarly, more than 28 million individuals already infected with LF benefit from GPELFs halting the progression of their disease, which results in an associated lifetime economic benefit of approximately US

The first 500 days of life: policies to support maternal nutrition

19.5 billion. In addition to these economic benefits to at-risk individuals, decreased patient services associated with reduced LF morbidity saves the health systems of endemic countries approximately US

Opportunities for Improving Maternal Nutrition and Birth Outcomes: Synthesis of Country Experiences:

2.2 billion. Conclusions/Significance MDA for LF offers significant economic benefits. Moreover, with favorable program implementation costs (largely a result of the sustained commitments of donated drugs from the pharmaceutical industry) it is clear that the economic rate of return of the GPELF is extremely high and that this Programme continues to prove itself an excellent investment in global health.

Longitudinal analysis of community health workers’ adherence to treatment guidelines, Siaya, Kenya, 1997–2002

The roles of Plasmodium falciparum resistance to chloroquine and compliance in the protective efficacy of the antenatal chloroquine prophylaxis programme in Malawi were evaluated by interviewing pregnant women attending antenatal clinics and examining them for P. falciparum parasites in thick smears and chloroquine metabolites in urine. 36% of 642 women had urine chloroquine metabolite levels compatible with regular compliance to the weekly chloroquine dosage schedule. Among a subgroup of 288 pregnant women who were provided weekly prophylaxis under supervision for 4 consecutive weeks, P. falciparum infection rates were 37%, representing the failure of chloroquine to eliminate P. falciparum in Malawi. Among pregnant women not taking prophylaxis, the P. falciparum infection rate was 48%. Based on the P. falciparum infection rates among these 2 groups of women, the protective efficacy of CQ chloroquine was estimated as 23%. If the 36% of pregnant women who had chloroquine in their urines accurately estimates the proportion of women who comply with the prophylaxis programme in Malawi, the actual protective efficacy of the programme would be 8%. The cost of preventing one P. falciparum infection among pregnant women in the Malawi programme is estimated at US

Exploring the impact of targeted distribution of free bed nets on households bed net ownership, socio-economic disparities and childhood malaria infection rates: analysis of national malaria survey data from three sub-Saharan Africa countries

10.87. This is an unacceptably high cost in much of Africa, and research is required to define more cost-effective interventions, including more effective drugs, and health education programmes to improve compliance among pregnant women.

Is It Time to Change Guidelines for Iron Supplementation in Malarial Areas

The challenges of community-directed treatment with ivermectin (CDTI) for onchocerciasis control in Africa have been: maintaining a desired treatment coverage, demand for monetary incentives, high attrition of community distributors and low involvement of women. This study assessed how challenges could be minimised and performance improved using existing traditional kinship structures. In classic CDTI areas, community members decide upon selection criteria for community distributors, centers for health education and training, and methods of distributing ivermectin. In kinship enhanced CDTI, similar procedures were followed at the kinship level. We compared 14 randomly selected kinship enhanced CDTI communities with 25 classic CDTI communities through interviews of 447 and 750 household members and 127 and 64 community distributors respectively. Household respondents from kinship enhanced CDTI reported better performance (P<0.001) than classic CDTI on the following measures of program effectiveness: (a) treatment coverage (b) decision on treatment location and (c) mobilization for CDTI activities. There were more female distributors in kinship enhanced CDTI than in classic CDTI. Attrition was not a problem. Kinship enhanced CDTI had a higher number of community distributors per population working among relatives, and were more likely to be involved in additional health care activities. The results suggest that kinship enhanced CDTI was more effective than classic CDTI.

The Contributions of Onchocerciasis Control and Elimination Programs toward the Achievement of the Millennium Development Goals

Background From conception to 6 months of age, an infant is entirely dependent for its nutrition on the mother: via the placenta and then ideally via exclusive breastfeeding. This period of 15 months – about 500 days – is the most important and vulnerable in a childs life: it must be protected through policies supporting maternal nutrition and health. Those addressing nutritional status are discussed here. Objective and design This paper aims to summarize research on policies and programs to protect womens nutrition in order to improve birth outcomes in low- and middle-income countries, based on studies of efficacy from the literature, and on effectiveness, globally and in selected countries involving in-depth data collection in communities in Ethiopia, India and Northern Nigeria. Results of this research have been published in the academic literature (more than 30 papers). The conclusions now need to be advocated to policy-makers. Results The priority problems addressed are: intrauterine growth restriction (IUGR), womens anemia, thinness, and stunting. The priority interventions that need to be widely expanded for women before and during pregnancy, are: supplementation with iron–folic acid or multiple micronutrients; expanding coverage of iodine fortification of salt particularly to remote areas and the poorest populations; targeted provision of balanced protein energy supplements when significant resources are available; reducing teenage pregnancies; increasing interpregnancy intervals through family planning programs; and building on conditional cash transfer programs, both to provide resources and as a platform for public education. All these have known efficacy but are of inadequate coverage and resourcing. The next steps are to overcome barriers to wide implementation, without which targets for maternal and child health and nutrition (e.g. by WHO) are unlikely to be met, especially in the poorest countries. Conclusions This agenda requires policy decisions both at Ministry and donor levels, and throughout the administrative system. Evidence-based interventions are established as a basis for these decisions, there are clear advocacy messages, and there are no scientific reasons for delay.Background From conception to 6 months of age, an infant is entirely dependent for its nutrition on the mother: via the placenta and then ideally via exclusive breastfeeding. This period of 15 months - about 500 days - is the most important and vulnerable in a childs life: it must be protected through policies supporting maternal nutrition and health. Those addressing nutritional status are discussed here. Objective and design This paper aims to summarize research on policies and programs to protect womens nutrition in order to improve birth outcomes in low- and middle-income countries, based on studies of efficacy from the literature, and on effectiveness, globally and in selected countries involving in-depth data collection in communities in Ethiopia, India and Northern Nigeria. Results of this research have been published in the academic literature (more than 30 papers). The conclusions now need to be advocated to policy-makers. Results The priority problems addressed are: intrauterine growth restriction (IUGR), womens anemia, thinness, and stunting. The priority interventions that need to be widely expanded for women before and during pregnancy, are: supplementation with iron-folic acid or multiple micronutrients; expanding coverage of iodine fortification of salt particularly to remote areas and the poorest populations; targeted provision of balanced protein energy supplements when significant resources are available; reducing teenage pregnancies; increasing interpregnancy intervals through family planning programs; and building on conditional cash transfer programs, both to provide resources and as a platform for public education. All these have known efficacy but are of inadequate coverage and resourcing. The next steps are to overcome barriers to wide implementation, without which targets for maternal and child health and nutrition (e.g. by WHO) are unlikely to be met, especially in the poorest countries. Conclusions This agenda requires policy decisions both at Ministry and donor levels, and throughout the administrative system. Evidence-based interventions are established as a basis for these decisions, there are clear advocacy messages, and there are no scientific reasons for delay.

Determinants of Bed Net Use in Southeast Nigeria following Mass Distribution of LLINs: Implications for Social Behavior Change Interventions.

Background Undernutrition in women in poor countries remains prevalent and affects maternal, neonatal and child health (MNCH) outcomes. Improving MNCH outcomes requires better policies and programs that enhance womens nutrition. Objective The studies aimed to better understand awareness, perceptions, barriers to intervention, and policy and program priorities and approaches, through different platforms, addressing three related priority problems: anemia, intra-uterine growth retardation (IUGR), and maternal thinness and stunting (including incomplete growth with early pregnancy). Methods Results of a global literature review on program effectiveness, and from case studies in Ethiopia, India, and Nigeria, were synthesized. Results and conclusions Anemia can be reduced by iron-folate supplementation, but all aspects for successful implementation, from priority to resources to local capacity, require strengthening. For IUGR, additional interventions, of food supplementation or cash transfers, may be required for impact, plus measures to combat early pregnancy. Breaking the intergenerational cycle of womens undernutrition may also be helped by child nutrition programs. Potential interventions exist and need to be built on: iron-folate and multiple micronutrient supplementation, food fortification (including iodized salt), food supplementation and/or cash transfer programs, combatting early pregnancy, infant and young child nutrition. Potential platforms are: the health system especially antenatal care, community-based nutrition programs (presently usually child-oriented but can be extended to women), child health days, safety net programs, especially cash transfer and conditional cash transfer programs. Making these more effective requires system development and organization, capacity and training, technical guidelines and operational research, and advocacy (who takes the lead?), information, monitoring and evaluation.