Prioritizing Pregnant Women for Long-Lasting Insecticide Treated Nets through Antenatal Care Clinics
Identifieur interne : 002852 ( Pmc/Corpus ); précédent : 002851; suivant : 002853Prioritizing Pregnant Women for Long-Lasting Insecticide Treated Nets through Antenatal Care Clinics
Auteurs : Jenny Hill ; Jenna Hoyt ; Anna Maria Van Eijk ; Feiko O. Ter Kuile ; Jayne Webster ; Richard W. SteketeeSource :
- PLoS Medicine [ 1549-1277 ] ; 2014.
Abstract
Jenny Hill and colleagues discuss the importance of antenatal care services in providing pregnant women with a long-lasting insecticide treated net for the prevention of malaria in both the mother and infant.
Url:
DOI: 10.1371/journal.pmed.1001717
PubMed: 25203846
PubMed Central: 4159114
Links to Exploration step
PMC:4159114Le document en format XML
<record><TEI><teiHeader><fileDesc><titleStmt><title xml:lang="en">Prioritizing Pregnant Women for Long-Lasting Insecticide Treated Nets through Antenatal Care Clinics</title><author><name sortKey="Hill, Jenny" sort="Hill, Jenny" uniqKey="Hill J" first="Jenny" last="Hill">Jenny Hill</name><affiliation><nlm:aff id="aff1"><addr-line>Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom</addr-line></nlm:aff></affiliation></author><author><name sortKey="Hoyt, Jenna" sort="Hoyt, Jenna" uniqKey="Hoyt J" first="Jenna" last="Hoyt">Jenna Hoyt</name><affiliation><nlm:aff id="aff1"><addr-line>Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom</addr-line></nlm:aff></affiliation></author><author><name sortKey="Van Eijk, Anna Maria" sort="Van Eijk, Anna Maria" uniqKey="Van Eijk A" first="Anna Maria" last="Van Eijk">Anna Maria Van Eijk</name><affiliation><nlm:aff id="aff1"><addr-line>Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom</addr-line></nlm:aff></affiliation></author><author><name sortKey="Ter Kuile, Feiko O" sort="Ter Kuile, Feiko O" uniqKey="Ter Kuile F" first="Feiko O." last="Ter Kuile">Feiko O. Ter Kuile</name><affiliation><nlm:aff id="aff1"><addr-line>Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom</addr-line></nlm:aff></affiliation></author><author><name sortKey="Webster, Jayne" sort="Webster, Jayne" uniqKey="Webster J" first="Jayne" last="Webster">Jayne Webster</name><affiliation><nlm:aff id="aff2"><addr-line>Disease Control Department, London School of Hygiene & Tropical Medicine, London, United Kingdom</addr-line></nlm:aff></affiliation></author><author><name sortKey="Steketee, Richard W" sort="Steketee, Richard W" uniqKey="Steketee R" first="Richard W." last="Steketee">Richard W. Steketee</name><affiliation><nlm:aff id="aff3"><addr-line>Malaria Control and Elimination Program, PATH, Seattle, Washington, United States of America</addr-line></nlm:aff></affiliation></author></titleStmt><publicationStmt><idno type="wicri:source">PMC</idno><idno type="pmid">25203846</idno><idno type="pmc">4159114</idno><idno type="url">http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4159114</idno><idno type="RBID">PMC:4159114</idno><idno type="doi">10.1371/journal.pmed.1001717</idno><date when="2014">2014</date><idno type="wicri:Area/Pmc/Corpus">002852</idno><idno type="wicri:explorRef" wicri:stream="Pmc" wicri:step="Corpus" wicri:corpus="PMC">002852</idno></publicationStmt><sourceDesc><biblStruct><analytic><title xml:lang="en" level="a" type="main">Prioritizing Pregnant Women for Long-Lasting Insecticide Treated Nets through Antenatal Care Clinics</title><author><name sortKey="Hill, Jenny" sort="Hill, Jenny" uniqKey="Hill J" first="Jenny" last="Hill">Jenny Hill</name><affiliation><nlm:aff id="aff1"><addr-line>Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom</addr-line></nlm:aff></affiliation></author><author><name sortKey="Hoyt, Jenna" sort="Hoyt, Jenna" uniqKey="Hoyt J" first="Jenna" last="Hoyt">Jenna Hoyt</name><affiliation><nlm:aff id="aff1"><addr-line>Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom</addr-line></nlm:aff></affiliation></author><author><name sortKey="Van Eijk, Anna Maria" sort="Van Eijk, Anna Maria" uniqKey="Van Eijk A" first="Anna Maria" last="Van Eijk">Anna Maria Van Eijk</name><affiliation><nlm:aff id="aff1"><addr-line>Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom</addr-line></nlm:aff></affiliation></author><author><name sortKey="Ter Kuile, Feiko O" sort="Ter Kuile, Feiko O" uniqKey="Ter Kuile F" first="Feiko O." last="Ter Kuile">Feiko O. Ter Kuile</name><affiliation><nlm:aff id="aff1"><addr-line>Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom</addr-line></nlm:aff></affiliation></author><author><name sortKey="Webster, Jayne" sort="Webster, Jayne" uniqKey="Webster J" first="Jayne" last="Webster">Jayne Webster</name><affiliation><nlm:aff id="aff2"><addr-line>Disease Control Department, London School of Hygiene & Tropical Medicine, London, United Kingdom</addr-line></nlm:aff></affiliation></author><author><name sortKey="Steketee, Richard W" sort="Steketee, Richard W" uniqKey="Steketee R" first="Richard W." last="Steketee">Richard W. Steketee</name><affiliation><nlm:aff id="aff3"><addr-line>Malaria Control and Elimination Program, PATH, Seattle, Washington, United States of America</addr-line></nlm:aff></affiliation></author></analytic><series><title level="j">PLoS Medicine</title><idno type="ISSN">1549-1277</idno><idno type="eISSN">1549-1676</idno><imprint><date when="2014">2014</date></imprint></series></biblStruct></sourceDesc></fileDesc><profileDesc><textClass></textClass></profileDesc></teiHeader><front><div type="abstract" xml:lang="en"><p>Jenny Hill and colleagues discuss the importance of antenatal care services in providing pregnant women with a long-lasting insecticide treated net for the prevention of malaria in both the mother and infant.</p><p><italic>Please see later in the article for the Editors' Summary</italic></p></div></front><back><div1 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<front><journal-meta><journal-id journal-id-type="nlm-ta">PLoS Med</journal-id><journal-id journal-id-type="iso-abbrev">PLoS Med</journal-id><journal-id journal-id-type="publisher-id">PLoS</journal-id><journal-id journal-id-type="pmc">plosmed</journal-id><journal-title-group><journal-title>PLoS Medicine</journal-title></journal-title-group><issn pub-type="ppub">1549-1277</issn><issn pub-type="epub">1549-1676</issn><publisher><publisher-name>Public Library of Science</publisher-name><publisher-loc>San Francisco, USA</publisher-loc></publisher></journal-meta><article-meta><article-id pub-id-type="pmid">25203846</article-id><article-id pub-id-type="pmc">4159114</article-id><article-id pub-id-type="publisher-id">PMEDICINE-D-14-01265</article-id><article-id pub-id-type="doi">10.1371/journal.pmed.1001717</article-id><article-categories><subj-group subj-group-type="heading"><subject>Policy Forum</subject></subj-group><subj-group subj-group-type="Discipline-v2"><subject>Medicine and Health Sciences</subject><subj-group><subject>Parasitic Diseases</subject><subj-group><subject>Malaria</subject></subj-group></subj-group><subj-group><subject>Public and Occupational Health</subject><subj-group><subject>Global Health</subject></subj-group></subj-group><subj-group><subject>Women's Health</subject><subj-group><subject>Maternal Health</subject><subj-group><subject>Antenatal Care</subject></subj-group></subj-group></subj-group></subj-group></article-categories><title-group><article-title>Prioritizing Pregnant Women for Long-Lasting Insecticide Treated Nets through Antenatal Care Clinics</article-title></title-group><contrib-group><contrib contrib-type="author"><name><surname>Hill</surname><given-names>Jenny</given-names></name><xref ref-type="aff" rid="aff1"><sup>1</sup></xref><xref ref-type="corresp" rid="cor1"><sup>*</sup></xref></contrib><contrib contrib-type="author"><name><surname>Hoyt</surname><given-names>Jenna</given-names></name><xref ref-type="aff" rid="aff1"><sup>1</sup></xref></contrib><contrib contrib-type="author"><name><surname>van Eijk</surname><given-names>Anna Maria</given-names></name><xref ref-type="aff" rid="aff1"><sup>1</sup></xref></contrib><contrib contrib-type="author"><name><surname>ter Kuile</surname><given-names>Feiko O.</given-names></name><xref ref-type="aff" rid="aff1"><sup>1</sup></xref></contrib><contrib contrib-type="author"><name><surname>Webster</surname><given-names>Jayne</given-names></name><xref ref-type="aff" rid="aff2"><sup>2</sup></xref></contrib><contrib contrib-type="author"><name><surname>Steketee</surname><given-names>Richard W.</given-names></name><xref ref-type="aff" rid="aff3"><sup>3</sup></xref></contrib></contrib-group><aff id="aff1"><label>1</label><addr-line>Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom</addr-line></aff><aff id="aff2"><label>2</label><addr-line>Disease Control Department, London School of Hygiene & Tropical Medicine, London, United Kingdom</addr-line></aff><aff id="aff3"><label>3</label><addr-line>Malaria Control and Elimination Program, PATH, Seattle, Washington, United States of America</addr-line></aff><author-notes><corresp id="cor1">* E-mail: <email>j.hill@liv.ac.uk</email></corresp><fn fn-type="COI-statement"><p>The authors have declared that no competing interests exist.</p></fn><fn fn-type="con"><p>Conceived and designed the experiments: JHi. Performed the experiments: JHi JHo. Analyzed the data: JHi JHo AMvE FOtK JW RWS. Wrote the first draft of the manuscript: JHi. Contributed to the writing of the manuscript: JHi JHo. <ext-link ext-link-type="uri" xlink:href="http://www.icmje.org/">ICMJE</ext-link> criteria for authorship read and met: JHi JHo AMvE FOtK JW RWS. Agree with manuscript results and conclusions: JHi JHo AMvE FOtK JW RWS.</p></fn></author-notes><pub-date pub-type="collection"><month>9</month><year>2014</year></pub-date><pub-date pub-type="epub"><day>9</day><month>9</month><year>2014</year></pub-date><volume>11</volume><issue>9</issue><elocation-id>e1001717</elocation-id><permissions><copyright-statement>© 2014 Hill et al</copyright-statement><copyright-year>2014</copyright-year><copyright-holder>Hill et al</copyright-holder><license xlink:href="http://creativecommons.org/licenses/by/4.0/"><license-p>This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly credited.</license-p></license></permissions><abstract abstract-type="toc"><p>Jenny Hill and colleagues discuss the importance of antenatal care services in providing pregnant women with a long-lasting insecticide treated net for the prevention of malaria in both the mother and infant.</p><p><italic>Please see later in the article for the Editors' Summary</italic></p></abstract><funding-group><funding-statement>This article was made possible by the generous support of the American people through the United States Agency for International Development (USAID) under the terms of USAID/JHU Cooperative Agreement No. GHS-A-00-09-00014-00 for the NetWorks Project. The contents are the responsibility of the authors and do not necessarily reflect the views of USAID or the United States Government. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.</funding-statement></funding-group><counts><page-count count="4"></page-count></counts></article-meta></front><body><boxed-text id="pmed-1001717-box001" position="float" orientation="portrait"><sec id="s1a"><title>Summary Points</title><list list-type="bullet"><list-item><p>Long-lasting insecticide treated nets (LLINs) are a powerful public health tool and, when used by pregnant women, contribute to improving maternal, neonatal, and infant health, with lasting benefits to the developing child.</p></list-item><list-item><p>Use of LLINs among pregnant women is well below national and international targets; the median use of an insecticide treated net (ITN) the previous night among pregnant women across 37 countries for 2009–2011 was 35.3% (range, 5.2%–75.5%); ITN use was higher in areas with both a high disbursement of funds for malaria control and a lower per-head gross domestic product.</p></list-item><list-item><p>Routine antenatal care (ANC) services constitute an important delivery channel that ensures pregnant women who attend an ANC clinic at least once (77% in sub-Saharan Africa) are covered with a LLIN from their first ANC visit in each pregnancy and plays an important role in maintaining population-level coverage between campaigns, particularly for women who become pregnant between campaigns and for infants born outside of campaign years.</p></list-item><list-item><p>The majority of LLINs delivered from 2010–2012 in sub-Saharan Africa were through mass campaigns as countries sought to reach the 80% coverage target, and some of the LLINs used in these campaigns were re-allocated from routine ANC delivery.</p></list-item><list-item><p>Going forward, national malaria programmes and donors alike will have to make difficult decisions to balance costs with the benefits and impact of investments in LLINs. Where choices must be made, high-risk groups (pregnant women and children under 5 years of age) should be prioritized for the same reason these groups were targeted under the pre-universal coverage WHO strategy.</p></list-item></list></sec></boxed-text><p>The use of insecticide treated nets (ITNs), and subsequently the new generation of long-lasting insecticide treated nets (LLINs), has been a core malaria prevention strategy for more than two decades <xref rid="pmed.1001717-World1" ref-type="bibr">[1]</xref>, and until 2010, distribution of LLINs targeted biologically vulnerable groups such as pregnant women and children aged less than 5 years <xref rid="pmed.1001717-World2" ref-type="bibr">[2]</xref>,<xref rid="pmed.1001717-World3" ref-type="bibr">[3]</xref>. In 2008, due largely to increased funding for malaria control leading to impressive gains in LLIN coverage, the Roll Back Malaria (RBM) Partnership set a more ambitious target of universal coverage of LLINs, defined as universal access to, and use of, LLINs <xref rid="pmed.1001717-Roll1" ref-type="bibr">[4]</xref>,<xref rid="pmed.1001717-World4" ref-type="bibr">[5]</xref>.</p><p>The strategy for achieving and maintaining universal coverage outlined by the RBM Partnership involves a combination of strategies based on mass campaigns, either target-specific or population-wide, to rapidly scale up coverage (“catch up”), complemented by continuous distribution through routine health services, including antenatal clinics, child health clinics, and expanded programme on immunisation (EPI) services (“keep up”) <xref rid="pmed.1001717-World5" ref-type="bibr">[6]</xref>. The choice of the combination is generally based on existing coverage and status of available distribution mechanisms in a given country. It is well recognised that, individually, each mechanism is suboptimal to maintain universal coverage and will leave some gaps.</p><p>Use of ITNs among pregnant women is well below national and international targets; a recent meta-analysis of national survey data in 37 countries for the years 2009–2011 estimated the median use of an ITN the previous night among pregnant women was 35.3% (range 5.2%–75.5%) <xref rid="pmed.1001717-vanEijk1" ref-type="bibr">[7]</xref>. ITN use was higher in areas with both a high disbursement of funds for malaria control and a lower per-head gross domestic product. Younger or adolescent, unmarried, and less educated women are significantly less likely to use ITNs, which may be related to lower affordability and in-household access among these women <xref rid="pmed.1001717-Hill1" ref-type="bibr">[8]</xref>.</p><sec id="s3"><title>Public Health Rationale for Net Distribution to Pregnant Women</title><p>LLINs are a powerful public health tool and, when used by pregnant women, contribute to improving maternal, neonatal, and infant health, with long-lasting benefits to the developing child. Worldwide, an estimated 125 million pregnancies are at risk from malaria each year <xref rid="pmed.1001717-Dellicour1" ref-type="bibr">[9]</xref>. Pregnant women are 1.5 times more susceptible to malaria infection than non-pregnant women <xref rid="pmed.1001717-Taylor1" ref-type="bibr">[10]</xref> and malaria infection can have devastating consequences on maternal, newborn, infant, and child health. In Africa, 10,000 women <xref rid="pmed.1001717-Guyatt1" ref-type="bibr">[11]</xref>,<xref rid="pmed.1001717-Menendez1" ref-type="bibr">[12]</xref> and between 75,000 and 200,000 infants <xref rid="pmed.1001717-Steketee1" ref-type="bibr">[13]</xref>,<xref rid="pmed.1001717-Murphy1" ref-type="bibr">[14]</xref> are estimated to die annually as a result of malaria infection during pregnancy, and approximately 11% (100,000) of neonatal deaths are due to low birth weight (LBW) resulting from <italic>Plasmodium falciparum</italic> infections in pregnancy <xref rid="pmed.1001717-Desai1" ref-type="bibr">[15]</xref>. In the absence of malaria control in pregnancy, it is estimated that 11.4 million (95% credible interval [CrI], 10.7–12.1) pregnancies would have experienced <italic>P. falciparum</italic> placental infection at some stage of pregnancy, accounting for 41% of the estimated 27.6 million live births in sub-Saharan Africa in 2010 <xref rid="pmed.1001717-Walker1" ref-type="bibr">[16]</xref>. Combined with estimates of the relationship between placental infection and the risk of LBW, 900,000 (95% CrI, 530,000–1,240,000) LBW deliveries per year were estimated to be caused by placental malaria. The end of the first trimester is a key period during which 65% (95% CrI, 61%–70%) of the potentially infected pregnancies first experience infection, and primigravidae experience a high proportion 39% (95% CrI, 33%–46%) of the total potential malaria-attributable LBW burden.</p><p>LLINs have been proven in clinical trials and in field programs to substantially reduce the adverse consequences of malaria in pregnancy, reducing maternal anaemia, severe anaemia, peripheral and placental malaria, and low birth weight <xref rid="pmed.1001717-Menendez2" ref-type="bibr">[17]</xref>–<xref rid="pmed.1001717-terKuile1" ref-type="bibr">[19]</xref>, and LLINs are highly cost effective <xref rid="pmed.1001717-Worrall1" ref-type="bibr">[20]</xref>. As a consequence, LLINs, along with intermittent preventive treatment in pregnancy (IPTp) <xref rid="pmed.1001717-Menendez2" ref-type="bibr">[17]</xref>,<xref rid="pmed.1001717-Kayentao1" ref-type="bibr">[21]</xref>,<xref rid="pmed.1001717-terKuile2" ref-type="bibr">[22]</xref>, together with effective case management of malaria, are recommended by WHO in malaria endemic settings in Africa. At 2012 coverage levels across 32 countries in sub-Saharan Africa, LLIN or IPTp use among women in their first or second pregnancies was significantly associated with a decreased risk of neonatal mortality (incidence rate ratio 0·82; 95% confidence interval (CI), 0·698–0·96) and reduced odds of low birth weight (adjusted odds ratio 0·79; 95% CI 0·73–0·86), compared with newborn babies of mothers with no protection, after controlling for potential confounding factors <xref rid="pmed.1001717-Eisele1" ref-type="bibr">[23]</xref>.</p></sec><sec id="s4"><title>Routine Distribution through Antenatal Care Clinics—An Important “Keep Up” Strategy</title><p>The delivery of free or subsidized LLINs (or vouchers) to pregnant women through ANC services is a key strategy for controlling malaria and increases coverage and use by both pregnant women <xref rid="pmed.1001717-Pettifor1" ref-type="bibr">[24]</xref>–<xref rid="pmed.1001717-Hanson1" ref-type="bibr">[27]</xref> and their infants <xref rid="pmed.1001717-Pettifor1" ref-type="bibr">[24]</xref>,<xref rid="pmed.1001717-Guyatt2" ref-type="bibr">[25]</xref>. As infants in most malaria-endemic settings sleep with their mother during the first year of life (or longer), the protective effect of an LLIN delivered to a pregnant woman is therefore extended through the infant's first year of life.</p><p>Routine ANC services constitute an important delivery channel that ensures pregnant women who attend ANC at least once (77% in sub-Saharan Africa) <xref rid="pmed.1001717-UNICEF1" ref-type="bibr">[28]</xref> are covered with an LLIN from their first ANC visit and in subsequent pregnancies and plays an important role in maintaining population-level coverage between campaigns, particularly for women who become pregnant between campaigns and for infants born outside of campaign years <xref rid="pmed.1001717-Kulkarni1" ref-type="bibr">[29]</xref>,<xref rid="pmed.1001717-Grabowsky1" ref-type="bibr">[30]</xref>. Whilst mass campaigns can rapidly scale up coverage, by as much as 30%–80% <xref rid="pmed.1001717-Kilian1" ref-type="bibr">[31]</xref>, universal coverage will not be maintained without the continuous distribution of LLINs, and ANC routine services have proven effective for reaching pregnant women <xref rid="pmed.1001717-UNICEF1" ref-type="bibr">[28]</xref>,<xref rid="pmed.1001717-West1" ref-type="bibr">[32]</xref>–<xref rid="pmed.1001717-Hightower1" ref-type="bibr">[35]</xref>.</p><p>In addition, campaign delivery of LLINs to households with pregnant women <xref rid="pmed.1001717-Okeibunor1" ref-type="bibr">[36]</xref>, households with children under 5 years of age <xref rid="pmed.1001717-Khatib1" ref-type="bibr">[37]</xref>, or households with low socioeconomic status <xref rid="pmed.1001717-Ahmed1" ref-type="bibr">[38]</xref> has shown limited impact on increasing coverage among pregnant women <xref rid="pmed.1001717-Hill1" ref-type="bibr">[8]</xref>, supporting the need for routine ANC services. Notwithstanding important limitations of modelling studies, which in the absence of evidence use some assumptions (costs, efficiencies of scale, data from a limited number of countries, etc.), modelling has demonstrated that a combination of an ANC- and school-based distribution would sustain the high coverage achieved in recent years by the mass campaigns <xref rid="pmed.1001717-Koenker1" ref-type="bibr">[39]</xref>. Modelling also predicts that supplementing mass distribution campaigns with ANC delivery could achieve a 1.4 times greater reduction in child mortality than mass distribution alone, as children born between campaign years would be covered during the most vulnerable time <xref rid="pmed.1001717-Okell1" ref-type="bibr">[40]</xref>. Delivery of LLINs through ANC to pregnant women is an effective, sustainable strategy for continuous distribution <xref rid="pmed.1001717-Sexton1" ref-type="bibr">[41]</xref>; greater effort is needed to encourage women to initiate ANC attendance early in the first trimester, and promoting the availability of a free ITN at early ANC booking may encourage women to initiate ANC earlier <xref rid="pmed.1001717-Sexton1" ref-type="bibr">[41]</xref>.</p><p>In short, the distribution of LLINs through routine services, ANC services included, is an important strategy and will require a sustained commitment to health systems strengthening; and neglecting this strategy will impede a country's ability to maintain universal coverage over the longer term. Delivery of LLINs through ANC has been observed to increase pregnant women's attendance at ANC clinics <xref rid="pmed.1001717-Beiersmann1" ref-type="bibr">[42]</xref>, which is an important platform through which women receive other essential antenatal care services, such as prevention of mother to child transmission of HIV (PMTCT); management of anaemia, syphilis, and other conditions; birth planning; etc. In addition, ANC clinics provide an opportunity to educate, inform, and encourage women to use ITNs.</p></sec><sec id="s5"><title>Recent Policy and Funding for LLINs among Key Donors and Partners</title><p>The policy shift towards universal coverage reflects huge progress in malaria control and is a laudable goal that has injected enthusiasm into the global malaria community and has attracted calls for elimination. Notwithstanding, funding for malaria control peaked at $US2 billion in 2011 <xref rid="pmed.1001717-Paintain1" ref-type="bibr">[43]</xref> and has begun to decline, ushering in an era of limited resources. Amidst the push to achieve universal coverage and dwindling resources, there is the potential danger whereby “keep-up” strategies lose resources and funding to its more attractive “catch-up” counterpart.</p><p>Despite recent encouraging statistics on funding for continuous delivery systems, including ANC, increasing from 22% in 2008–2010 of all funding commitments to 42% for the 2012–2016 funding interval <xref rid="pmed.1001717-Paintain2" ref-type="bibr">[44]</xref>, the funding gap has meant that the routine systems are the first to be left unfunded. One estimate for 2013–2016 suggests current funding commitments meet just over half of countries' needs, leaving a funding gap of approximately 374 million LLINs <xref rid="pmed.1001717-Paintain1" ref-type="bibr">[43]</xref>, and in a funding review of the Global Fund to fight AIDS, Tuberculosis, and Malaria and other major donors the authors report that 70% of as-yet-unfunded LLINs are for continuous delivery systems <xref rid="pmed.1001717-Paintain2" ref-type="bibr">[44]</xref>. The majority of LLINs delivered from 2010–2012 in sub-Saharan Africa were through mass campaigns as countries sought to reach the 80% coverage target <xref rid="pmed.1001717-World5" ref-type="bibr">[6]</xref>,<xref rid="pmed.1001717-Paintain1" ref-type="bibr">[43]</xref>. Some of the LLINs used in these campaigns were re-allocated by national planners from routine ANC delivery to fill gaps in campaigns, as reported in Angola (2013), Cote d'Ivoire (2008), Cameroon (2011), Democratic Republic of Congo (2012, 2013), Kenya (2011), Malawi (2011), Nigeria (2014), Togo (2011), and Uganda (2012, 2014) (Matthew Lynch, Johns Hopkins University, personal communication, June 2014).</p><p>These trends prompted a policy recommendation from the WHO Vector Control Technical Expert Group to the Malaria Policy Advisory Committee (MPAC) noting that, although universal coverage was still the priority, LLINs distributed through routine channels such as ANC and EPI should continue regardless of mass campaign timing, and that nets for routine distribution should not be diverted to campaigns. This recommendation has been approved by MPAC <xref rid="pmed.1001717-WHO1" ref-type="bibr">[45]</xref> and a policy recommendation published <xref rid="pmed.1001717-World4" ref-type="bibr">[5]</xref>.</p></sec><sec id="s6"><title>Recommendations</title><p>The shortfall in funding for malaria, generally, and for LLINs, in particular, calls for endemic country programs, malaria donors, implementing agencies, and partners to adopt the most cost-effective strategies to deliver this life-saving intervention. The challenge will be to ensure that population-wide coverage does not fall while maintaining highest priority for pregnant women and children. The arguments for maintaining the ANC distribution mechanism are strong. This mechanism reaches the highest risk population of mothers and their newborns, takes advantage of the fact that most pregnant women visit ANC clinics, is the only antenatal malaria prevention intervention that provides protection in the first trimester of pregnancy, and adds an important benefit to the focused ANC delivery system as it serves to encourage ANC attendance.</p><p>Going forward, national malaria programmes and donors alike will have to make difficult decisions to balance costs with the benefits and impact of investments in LLINs. WHO's MPAC has recommended that routine LLIN distribution (through ANC and the EPI) continue “before, during, and after” campaigns, and that recommendation needs to be adopted by Ministries of Health and donors <xref rid="pmed.1001717-World4" ref-type="bibr">[5]</xref>,<xref rid="pmed.1001717-WHO1" ref-type="bibr">[45]</xref>. For routine distribution to continue, unaffected by campaigns, donors need to make their funding commitments for LLIN procurement for both routine and campaign delivery explicit and well in advance (2 years minimum), to allow governments to plan ahead for both catch-up and keep-up. Governments will need to track both stock of LLINs and their coverage and ensure that there are sufficient commodities for delivery through both routine and campaign strategies, requiring quality data on ANC delivery of LLINs, both through strengthened Health Management Information System reporting of LLIN distribution and through national surveys. Where choices must be made, high-risk groups (pregnant women and children under 5 years of age) should be prioritized for the same reason these groups were targeted under the pre-universal coverage WHO strategy. Receiving a net as an integral part of antenatal care sends a powerful message to a pregnant woman that this tool is important to protect herself and her child. Ministries of Health need to maximise ANC opportunities, for example, to use LLINs delivery at ANC clinics to promote earlier and increased demand for ANC, and vice versa.</p></sec></body><back><ack><p>We are grateful to the President's Malaria Initiative's Malaria in Pregnancy working group for their input and direction on this topic and for their comments.</p></ack><fn-group><fn fn-type="other"><p><bold>Provenance:</bold> Not commissioned; externally peer reviewed</p></fn></fn-group><ref-list><title>References</title><ref id="pmed.1001717-World1"><label>1</label><mixed-citation publication-type="other">World Health Organization (1993) Implementation of the global malaria control strategy: report of a WHO study group on the implementation of the global plan of action for malaria control 1993–2000 [meeting held in Geneva from 8 to 12 February 1993]. WHO Study Group on the Implementation of the Global Plan of Action for Malaria Control. 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Accessed 13 July 2014.</mixed-citation></ref><ref id="pmed.1001717-WHO1"><label>45</label><mixed-citation publication-type="journal"><collab>WHO Malaria Policy Advisory Committee and Secretariat</collab> (<year>2013</year>) <article-title>Malaria Policy Advisory Committee to the WHO: conclusions and recommendations of September 2013 meeting</article-title>. <source>Malar J</source><volume>12</volume>: <fpage>456</fpage>.<pub-id pub-id-type="pmid">24359206</pub-id></mixed-citation></ref></ref-list><glossary><title>Abbreviations</title><def-list><def-item><term>ANC</term><def><p>antenatal care</p></def></def-item><def-item><term>CI</term><def><p>confidence interval</p></def></def-item><def-item><term>CrI</term><def><p>credible interval</p></def></def-item><def-item><term>EPI</term><def><p>expanded programme on immunisation</p></def></def-item><def-item><term>IPTp</term><def><p>intermittent preventive treatment in pregnancy</p></def></def-item><def-item><term>ITN</term><def><p>insecticide treated net</p></def></def-item><def-item><term>LBW</term><def><p>low birth weight</p></def></def-item><def-item><term>LLIN</term><def><p>long-lasting insecticide treated net</p></def></def-item><def-item><term>MPAC</term><def><p>Malaria Policy Advisory Committee</p></def></def-item><def-item><term>PMTCT</term><def><p>prevention of mother to child transmission of HIV</p></def></def-item><def-item><term>RBM</term><def><p>Roll Back Malaria</p></def></def-item></def-list></glossary></back></pmc></record>Pour manipuler ce document sous Unix (Dilib)
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