The results of the surveys conducted one month and nine months, respectively, after the Togo National Integrated Child Health Campaign demonstrated that integrating ITN delivery into the vaccination campaign throughout the six regions of Togo rapidly achieved high levels of ITN ownership and equity, and that this was maintained nine months post-campaign.
The September 2004 pre-campaign survey established that in rural districts, net ownership was positively associated with higher wealth quintile, suggesting possible competition for limited funds to supply other basic needs.6
The Togo National Integrated Health Campaign appears to have been an effective strategy to achieve high, equitable ITN coverage reaching > 90% coverage for all eligible children. In a study by Noor and others, free mass distribution campaigns were found to achieve the highest coverage among the poorest children compared with heavily subsidized and commercially available nets.4
Moreover, a similar free distribution integrated campaign carried out in Niger, which used a voucher system, achieved 73.4% coverage compared with 90.8% coverage in Togo among children less than five years of age, suggesting that apart from the cost of nets, eliminating additional layers of complexity during distribution campaigns may contribute to greater success.12
The rate of use was significantly lower than the rate of possession, and use by children less than five years of age did not meet the 2000 RBM target set at 60%.1
Nevertheless, use by all households, including households that did not have an eligible child during the campaign and therefore did not receive a net at that time, increased from 43.5% (January) to 52.9% (September). Similarly, in all households, the proportion that hung an ITN the night before increased in the September survey compared with the January survey. During that same period, there was no significant change in the level of household ownership between the January and September surveys. Korenromp and others demonstrated that net use is markedly higher in the rainy season than in the dry season in surveys that reported on seasonal use patterns; the higher usage and hanging of ITNs in the September survey coincided with the high-transmission season towards the end of the rainy season.13
Furthermore, there was an increase in net use in children less than five years of age observed across all regions and wealth quintiles. This increase included children born after the campaign and those who were too young to receive a net during the campaign. Both children less than 18 months of age (at the time of the peak malaria season and second coverage survey) and pregnant women, despite not being targeted by the campaign, saw increases in ITN use. It is possible that these households had an eligible child at the time of the campaign that was more than five years of age by the time the September survey was conducted. In that case, it may appear that a household without a campaign eligible child received an ITN from the campaign. It should be noted that we did not directly measure this in these surveys.
High coverage with ITNs has been shown to reduce malaria morbidity and all-cause mortality in malaria-endemic areas.14,15
Togo Ministry of Health data, the September 2004 anemia survey, and the January 2005 coverage survey indicate that ITN coverage in Togo was low before the integrated campaign.6,16
Although we have shown that coverage was high after the campaign, use still failed to reach contemporary RBM goals, indicating than additional strategies are needed to achieve these use goals. Assuming that all areas received the same mass media messages before and after the campaign (although reach/access may vary), it should be noted that use differed somewhat on the basis of visits to households by community-based volunteers. A significant difference between ITN use rates between houses that received follow-up visits after the campaign and those that did not suggests that this may be a useful strategy to increase overall ITN use after a mass distribution campaign in some settings. Despite a number of free re-impregnation stations in the community to re-treat existing nets (set up by the Togo Ministry of Health with support from the World Health Organization), in September 2004, less than 10% of the nets had been treated with insecticide in the previous six months.6
This low rate of re-treatment highlights the need for long-lasting ITNs as a feasible, long-term malaria control tool.
Expanded Program on Immunization campaigns typically reach more than 90% of targeted children, and this is the first time that ITN distribution has been integrated with a vaccination campaign on a national scale. A cost-effectiveness study conducted by the London School of Hygiene and Tropical Medicine on the Togo National Integrated Health Campaign found that integrating ITN delivery into health campaigns is as cost-effective as other malaria intervention strategies when averted treatment costs are taken into consideration.17
Moreover, the study found that many costs were shared by the ITN and vaccination components of the campaign underlining the economic gains of merging health campaigns. Conversely, there are potential limitations of this type of campaign.
Vaccination campaigns can be disruptive to the routine delivery of health care services because of increased demand on health care workers to plan, organize, mobilize, and conduct the campaign, and impose an additional burden on limited logistic capabilities. Although it seems unlikely that the addition of ITNs to vaccination campaigns would cause significantly greater disruption than a vaccination campaign, further investigation of these potentially deleterious outcomes may be warranted. In addition, the target groups for vaccination campaigns may differ from those targeted for ITNs. In this survey the vaccination target group was children 9–59 months of age, whereas the ideal ITN target for a child-oriented distribution would have been all children less than five years of age. This finding may require additional planning and logistics to ensure the desired target groups are appropriately covered for ITN and vaccination delivery.
In conclusion, there have been considerable efforts using various methods to increase ITN ownership and use across Africa.17
The results of these surveys reinforce previous findings that integrating ITN distribution with measles campaigns is an effective way to rapidly increase ITN ownership and use, and represents an important route towards attaining the Abuja and RBM targets for ITN use in children.7,8
In addition, these findings demonstrated the potential capability of this strategy when scaled up to a national level and was the pioneering effort upon which several other countries (Niger, Mozambique, Kenya, Sierra Leone, Madagascar) built their campaigns. Integrated campaigns continue to present an important opportunity for reaching malaria control goals and merit continued large-scale implementation. Future campaigns should include efforts to maintain coverage for children less than nine months of age born since the campaign because these children are among the most vulnerable. Increasing household ownership of ITNs and efforts to promote increased use rates among vulnerable populations will provide Togo with an effective tool in their efforts to control malaria.