Fink amfm meeting fink1 0

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Fever, Parasitemia and Access to Subsidized ACTs – Evidence from Uganda’s Eastern Province

Jessica Cohen Bill Dickens Günther Fink AFFORDABLE MEDICINES FACILITY-MALARIA REVIEW AND THE FINANCING OF FEBRILE ILLNESS MANAGEMENT September 17-18 2012 The National Academies, Washington, DC 20037

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Uganda

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RDT Study Districts

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92 Study Villages: May 2011 to April 2012

•2500 Households •15,000 Individuals > 30,000 Illness reports

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Endemicity • At the end of the trial, free testing was offered to all household members • About 66% of members were present and consented to testing, for a total of 9887 tests (96% consented) • About 50% of children and 30% of adults (all without acute health problems) were found to test positive highly endemic area

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Most Common Morbidity Symptoms Percentage of respondents reporting symptom

100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0%

Mean: 1.1 cases per household and month

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Where Do Fever Patients Seek Treatment?

Unknown 20%

Clinic 11%

Other 3% Hospital 5% Drug shop 39%

Health Center 22% Note: 23% of fevers don’t seek treatment at all.

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Most Common Drug Treatment Fraction of fever patients getting‌

0.7 59.0%

0.6 0.5 0.4 0.3

33.8%

35.5%

ACT

Other antimalarial

27.7%

0.2 0.1 0 Antibiotic

Painkiller

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Other Antimalarials Other 1%

Artenam 7% Chloroquine 9% SP/Fansidar 6%

Quinine 77%

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Change in Treatment over Time Fraction of fevers seeking treatment getting treated with Coartem and Quinine

0.4

0.35

0.3

0.25 Fraction of fevers treated with quinine Fraction of fevers treated with Coartem

0.2

0.15 1

2

3

4

5 6 FB Round

7

8

9

10

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Timing of the AMFm 30 Cumulative AMFm ACTs Arriving in Public Facilities

Million Doses of AMFm ACTs

25

20

15

10

5

0

Cumulative AMFm ACTs Arriving in Private Facilities

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ACT Distribution in Retail Sector: How Many Shops Stock ACTs? 1

Fraction of Licensed Drug Shops Stocking Coartem

85.1% 0.9 0.8 0.7 0.6 0.5 0.4

32.5%

0.3 0.2 0.1 0

Baseline

Endline

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ACT Pricing in the Retail Sector 3500

Mean reported price in USH

3000

2500

2000

1500

Mean Price for Coartem

1000

95% CI 95% CI 500

0 June

July

August

September

October

November December

January

February

March

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Malaria Testing (28% overall) 0.7

Fraction of fever patients getting tested at..

63.1% 0.6 50.5%

51.5%

Clinic

Health Center

0.5

0.4

0.3

0.2

0.1

8.9%

0 Drug shop

Hospital

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Self-reported Test Results (N=23,849) 0.7 Not tested

Fraction of patients getting‌

0.6

Report to have tested positive Report to have tested negative

0.5

0.4

0.3

0.2

0.1

0 Antibiotic

Painkiller

ACT

Other antimalarial

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Treatment of Confirmed Malaria Tests (N=1800) 0.7

0.6

Fraction of patients getting‌

Positive Negative 0.5

0.4

0.3

0.2

0.1

0 Antibiotic

Painkiller

ACT

Other antimalarial

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Trends in ACT Treatment by Age Group Fraction of fever patients getting an ACT

0.50 0.45 0.40 0.35 0.30 0.25 0.20 0.15 0.10 0.05 0.00

Ages 0-4

Ages 5-19

Ages 20+

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Trends in ACT Treatment by Wealth Quintile (All) Fraction of fever patients getting an ACT

0.50 0.45 0.40 0.35 0.30 0.25 0.20 0.15

Poorest

0.10

Asset Quintile 3

0.05 0.00

Richest

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Trends in ACT Treatment by Wealth Quintile (Untested)

Fraction of fever patients getting an ACT

0.45 0.40 0.35 0.30 0.25 0.20

0.15

Poorest 0.10 0.05 0.00

Asset Quintile 3 Richest

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Trends in ACT Treatment by Wealth Quintile (Tested Positive) Fraction of fever patients getting an ACT

0.70

59.1% 0.5909091

0.60

0.50

0.40

0.30

0.20

Poorest Asset Quintile 3

0.10

0.00

Richest

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Trends in ACT Treatment by Wealth Quintile (Tested Negative) Fraction of fever patients getting an ACT

0.70

0.60

0.50

Poorest Asset Quintile 3 Richest

0.40

0.30

0.20

0.10

0.00

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Main Findings • The percentage of fever patients getting an ACT has increased from about 30% in June 2011 to 40% in April 2012 (and the quinine share has fallen by about the same amount) • Increases in ACT access are particularly large for low SES households • Testing affects but no necessarily determines treatment choice: – about 50% don’t get an ACT even when tested positive – about 25% get an ACT even when the test result is negative

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Backup Slides

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Positivity by Age Group 0.8

0.7

Overall, 49% of asymptomatic patients tested positive

Fraction of RDTs positive

0.6

0.5

0.4

0.3

0.2

0.1

0 0-4

5-9

10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 Age Group

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Parasitemia by Sex 80%

70%

Percentage of positive RDTs

60%

50%

40%

30%

20%

Male

Female

10%

0%

0-4

5-9

10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64

Age group

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Malaria Seasonality 75%

Percentage of administered Slides Positive

70%

65%

60%

55%

50%

45%

40% Note: 95% confidence intervals need to be adjusted for spatial clustering

35% July

August

September

October

November December

January

February

March