Impact of a malaria bed-net distribution campaign in Togo: Lessons learned regarding distribution criteria

In December 2004, Togo carried out a National Integrated Health Campaign, in which all households were eligible to receive free insecticide treated bednets (ITN) for every child between the ages of 9 and 59 months throughout the country. In 2008, the Centers for Disease Control and Prevention conducted a nationwide survey designed to measure, among other things, the impact of the ITN campaign on mortality levels among young children. An analysis was carried out to compare mortality changes according to whether or not households received ITNs for their young children and according to whether or not households were eligible to receive ITNs (i.e., whether there were 9-59 month-old children in the household at the time of the distribution). Surprisingly, it was found that, since the campaign, early mortality decreased sharply in households that were not eligible to receive ITNs and increased in households that were eligible, giving the appearance that ITN use was counterproductive. Further analysis, however, revealed that this occurred because the distribution criteria excluded many of the highest risk households from net distribution, since the absence of children in those households was often a result of mortality among young children before the distribution occurred. Meanwhile, the lower risk households received nets because they all contained children who had survived. An important lesson to be learned from this analysis is that campaigns to distribute ITNs (and other potentially life-saving interventions) should take into account factors such as previous mortality in order to improve their impact.