Prioritizing the scale-up of interventions for malaria control and elimination

Peter Winskill,Patrick G Walker,Azra C Ghani,Richard E Cibulskis

doi:10.1186/s12936-019-2755-5

Abstract

BackgroundA core set of intervention and treatment options are recommended by the World Health Organization for use against falciparum malaria. These are treatment, long-lasting insecticide-treated bed nets, indoor residual spraying, and chemoprevention options. Both domestic and foreign aid funding for these tools is limited. When faced with budget restrictions, the introduction and scale-up of intervention and treatment options must be prioritized.MethodsEstimates of the cost and impact of different interventions were combined with a mathematical model of malaria transmission to estimate the most cost-effective prioritization of interventions. The incremental cost effectiveness ratio was used to select between scaling coverage of current interventions or the introduction of an additional intervention tool.ResultsPrevention, in the form of vector control, is highly cost effective and scale-up is prioritized in all scenarios. Prevention reduces malaria burden and therefore allows treatment to be implemented in a more cost-effective manner by reducing the strain on the health system. The chemoprevention measures (seasonal malaria chemoprevention and intermittent preventive treatment in infants) are additional tools that, provided sufficient funding, are implemented alongside treatment scale-up. Future tools, such as RTS,S vaccine, have impact in areas of higher transmission but were introduced later than core interventions.ConclusionsIn a programme that is budget restricted, it is essential that investment in available tools be effectively prioritized to maximize impact for a given investment. The cornerstones of malaria control: vector control and treatment, remain vital, but questions of when to scale and when to introduce other interventions must be rigorously assessed. This quantitative analysis considers the scale-up or core interventions to inform decision making in this area.

Highlights

A core set of intervention and treatment options are recommended by the World Health Organization for use against falciparum malaria
Vector control is implemented in all malaria-endemic countries, with the specific intervention mix between long-lasting insecticide-treated bed nets (LLINs), indoor residual spraying (IRS) and other methods influenced by the distribution, relative abundance and behaviour of different vector species, as well as other context-specific factors such as the historical use of a particular form of vector control
LLINs are estimated to be the most cost-effective intervention and are scaled first in the majority of simulation runs (Fig. 1, Additional file 2: Figure S1). In both medium and high transmission settings, achieving high levels of LLIN coverage prior to scaling-up treatment is estimated to be the most efficient. This is because LLIN coverage works synergistically with treatment coverage scale-up by reducing disease burden and the number of treatments that are required (Fig. 2)

Summary

Introduction

A core set of intervention and treatment options are recommended by the World Health Organization for use against falciparum malaria These are treatment, long-lasting insecticide-treated bed nets, indoor residual spraying, and chemoprevention options. The World Health Organization (WHO) Global Technical Strategy for Malaria 2016–2030 (WHO-GTS) sets the goal of universal access to malaria prevention, treatment and diagnosis [1] This includes a core package of recommended interventions for reducing malaria-related morbidity and mortality: diagnosis and treatment of clinical and severe malaria, vector control with long-lasting insecticide-treated bed nets (LLINs) or indoor residual spraying (IRS) and chemoprevention for high-risk groups (infants, children in areas of seasonal transmission, pregnant women). The WHO recommends universal coverage of the population at risk with either LLINs or IRS [1] and whilst a combination of the two is deployed in some areas (primarily for insecticide resistance management), WHO recommends attaining high coverage of a single method before a second form is deployed

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