BackgroundMore than 500 000 young children die from dehydration caused by severe diarrhea each year, globally. Although routine use of oral rehydration solution (ORS) could prevent almost all of these deaths, ORS utilization remains low in many low–income countries. Previous research has suggested that misperceptions among caregivers may be an obstacle to wider use of ORS.MethodsTo better understand the extent of ORS utilization and the reasons for use or non–use in low–resource settings, the project team conducted a semi–structured, quantitative survey of 400 caregivers in Burkina Faso in 2014. All caregivers had a child below the age of five who had diarrhea lasting 2 days or more in the previous 2 months.ResultsAlthough more than 80% of caregivers were aware of ORS, less than half reported using it to treat their child’s diarrhea. Replacing fluids lost due to diarrhea was considered a low priority by most caregivers, and many said they considered antibiotics more effective for treating diarrhea. Users and non–users of ORS held substantially different perceptions of the product, though all caregivers tended to follow recommendations of health care workers. A significant proportion of users reported difficulty in getting a child to drink ORS. Costs and access to ORS were not found to be significant barriers to use.ConclusionsMisperceptions among caregivers and health workers contribute to low utilization of ORS. Better caregiver understanding of diarrheal disease and the importance of rehydration, as well as increased recommendation by health workers, will help to increase ORS utilization. Improving product presentation and taste will also help to increase use.

Background Vector control tools have contributed significantly to a reduction in malaria burden since 2000, primarily through insecticidal-treated bed nets (ITNs) and indoor residual spraying. In the face of increasing insecticide resistance in key malaria vector species, global progress in malaria control has stalled. Innovative tools, such as dual active ingredient (dual-AI) ITNs that are effective at killing insecticide-resistant mosquitoes have recently been introduced. However, large-scale uptake has been slow for several reasons, including higher costs and limited evidence on their incremental effectiveness and cost-effectiveness. The present report describes the design of several observational studies aimed to determine the effectiveness and cost-effectiveness of dual-AI ITNs, compared to standard pyrethroid-only ITNs, at reducing malaria transmission across a variety of transmission settings. Methods Observational pilot studies are ongoing in Burkina Faso, Mozambique, Nigeria, and Rwanda, leveraging dual-AI ITN rollouts nested within the 2019 and 2020 mass distribution campaigns in each country. Enhanced surveillance occurring in select study districts include annual cross-sectional surveys during peak transmission seasons, monthly entomological surveillance, passive case detection using routine health facility surveillance systems, and studies on human behaviour and ITN use patterns. Data will compare changes in malaria transmission and disease burden in districts receiving dual-AI ITNs to similar districts receiving standard pyrethroid-only ITNs over three years. The costs of net distribution will be calculated using the provider perspective including financial and economic costs, and a cost-effectiveness analysis will assess incremental cost-effectiveness ratios for Interceptor® G2, Royal Guard®, and piperonyl butoxide ITNs in comparison to standard pyrethroid-only ITNs, based on incidence rate ratios calculated from routine data. Conclusions Evidence of the effectiveness and cost-effectiveness of the dual-AI ITNs from these pilot studies will complement evidence from two contemporary cluster randomized control trials, one in Benin and one in Tanzania, to provide key information to malaria control programmes, policymakers, and donors to help guide decision-making and planning for local malaria control and elimination strategies. Understanding the breadth of contexts where these dual-AI ITNs are most effective and collecting robust information on factors influencing comparative effectiveness could improve uptake and availability and help maximize their impact.

Background Many US health departments now integrate HIV-related outcomes (e.g., relinkage to HIV care and preexposure prophylaxis [PrEP]) into sexually transmitted disease (STD) partner services (PS) programs. We sought to determine the barriers, facilitators, and cost of integrating these activities into PS. Methods From 2016 to 2018, the Mississippi State Department of Health integrated 3 new activities into STD PS: HIV testing for partners of HIV-negative men who have sex with men with gonorrhea/chlamydia, relinkage to HIV care for STD PS recipients previously diagnosed with HIV, and PrEP referrals. We conducted direct observations and interviews with disease intervention specialists (DIS) in Jackson to assess barriers and facilitators to implementing these activities. We completed time and motion studies with 8 DIS and case tracking forms for 90 unique cases to estimate the incremental staff time and associated personnel cost of added services compared with a standard PS case. Results Disease intervention specialists were optimistic about integrating HIV-related activities but noted disparate data systems, nonsystematic documentation, and lack of training as barriers. The mean time for a standard STD PS case without HIV-related activities was 195 minutes (cost, $77.69/case). The cost to conduct PS for HIV-negative men who have sex with men with gonorrhea/chlamydia was 36% higher than a standard case. Integrating relinkage to care and PrEP referrals resulted in a 44% and 20% increase in cost, respectively. Conclusions Integrating HIV care relinkage and PrEP referrals into STD partner services was generally acceptable by DIS and added marginal cost per case. Coupling these cost metrics with an assessment of the effectiveness of these activities can inform prioritization of partner services activities.

Background Malaria is a major cause of morbidity and mortality globally, especially in sub-Saharan Africa. Widespread resistance to pyrethroids threatens the gains achieved by vector control. To counter resistance to pyrethroids, third-generation indoor residual spraying (3GIRS) products have been developed. This study details the results of a multi-country cost and cost-effectiveness analysis of indoor residual spraying (IRS) programmes using Actellic®300CS, a 3GIRS product with pirimiphos-methyl, in sub-Saharan Africa in 2017 added to standard malaria control interventions including insecticide-treated bed nets versus standard malaria control interventions alone. Methods An economic evaluation of 3GIRS using Actellic®300CS in a broad range of sub-Saharan African settings was conducted using a variety of primary data collection and evidence synthesis methods. Four IRS programmes in Ghana, Mali, Uganda, and Zambia were included in the effectiveness analysis. Cost data come from six IRS programmes: one in each of the four countries where effect was measured plus Mozambique and a separate programme conducted by AngloGold Ashanti Malaria Control in Ghana. Financial and economic costs were quantified and valued. The main indicator for the cost was cost per person targeted. Country-specific case incidence rate ratios (IRRs), estimated by comparing IRS study districts to adjacent non-IRS study districts or facilities, were used to calculate cases averted in each study area. A deterministic analysis and sensitivity analysis were conducted in each of the four countries for which effectiveness evaluations were available. Probabilistic sensitivity analysis was used to generate plausibility bounds around the incremental cost-effectiveness ratio estimates for adding IRS to other standard interventions in each study setting as well as jointly utilizing data on effect and cost across all settings. Results Overall, IRRs from each country indicated that adding IRS with Actellic®300CS to the local standard intervention package was protective compared to the standard intervention package alone (IRR 0.67, [95% CI 0.50–0.91]). Results indicate that Actellic®300CS is expected to be a cost-effective (> 60% probability of being cost-effective in all settings) or highly cost-effective intervention across a range of transmission settings in sub-Saharan Africa. Discussion Variations in the incremental costs and cost-effectiveness likely result from several sources including: variation in the sprayed wall surfaces and house size relative to household population, the underlying malaria burden in the communities sprayed, the effectiveness of 3GIRS in different settings, and insecticide price. Programmes should be aware that current recommendations to rotate can mean variation and uncertainty in budgets; programmes should consider this in their insecticide-resistance management strategies. Conclusions The optimal combination of 3GIRS delivery with other malaria control interventions will be highly context specific. 3GIRS using Actellic®300CS is expected to deliver acceptable value for money in a broad range of sub-Saharan African malaria transmission settings.