|Medical Assistance to Self-settled Refugees (Institut Tropical - Tropical Institute, Antwerp, Belgium, 1998)|
|5. Control of epidemics|
|Costs and effects of controlling epidemics in the Forest Region|
The cost-effectiveness of epidemic control measures against cholera, measles and meningococcal meningitis in the Forest Region is summarised in Figure 34.
All activities were very cost-effective, except meningococcal meningitis vaccination. Indeed, rehydrating a cholera patient is one of the most effective medical interventions existing. Also measles vaccination and measles case management are very cost-effective health care interventions in developing countries.117 A recent study in Nigeria found that meningococcal meningitis vaccination was considerably less cost-effective than case management,116 but this critically depends on attack rates and timing of vaccination.
One should treat these data with caution, and this for several reasons. First, different sources for cost estimates had to be used, and their reliability varied. For instance, cost of meningococcal meningitis mass vaccination was better documented than cost of measles vaccination. Second, the cost was estimated as a marginal cost to the routinely functioning health system. Activities mainly developed within the existing facilities, such as case management, tend to have a lower marginal cost than activities for which an additional programme was organised, such as the 'rehydration-and-chlorination' cholera control strategy or meningococcal meningitis vaccination. However, this method of cost estimation was the best possible with the data available, and is widely used.104,105 Lastly, the assumptions used for reduction in attack rates and CFRs are imprecise. Reported or estimated attack rates and CFRs are already imprecise ('intervention' situation), but attack rates and CFRs in the absence of any health care ('natural' situation), or in the absence of additional epidemic control measures ('routine' situation) are even more difficult to estimate. To what extent data from the literature can be used in Guinea is doubtful. Predicting 'what would have happened if... ' is often highly speculative.
The cost-effectiveness of epidemic control as part of routine health services was very favourable. But for measles, the coverage reached was low. During cholera and meningococcal meningitis epidemics in Guinea, efforts were made to improve case management, and care was made free of charge. The data available from Guinea do not allow for calculating the cost-effectiveness of such measures to encourage the use of routine health services, but it may well be that they were very cost-effective.
The role existing health services can and should play in control of epidemics is an important issue. In sub-Saharan Africa, health services often lack the means and experience to tackle epidemics adequately.* They may run out of stock of the necessary drugs, and may have difficulties coping with the increased workload. In Guinea, existing health services could play a useful role during epidemics, but they had to be strengthened to do so. The decrease in measles vaccination coverage during the temporary abolition of the mobile teams illustrated that even if they receive additional means health services cannot always easily carry out additional activities.
[* It is not uncommon to hear reports of health services continuing 'business as usual' while an epidemic of cholera or meningococcal meningitis is ravaging the district.]
Control of epidemics through existing health facilities undoubtedly helped to reduce costs thanks to the availability of many trained manpower, and the existence of a relatively dense network of health facilities. Moreover, when the basic health services offer an appropriate response to epidemics, they intervene in a very vulnerable situation, when the population is worried and panic sometimes reigns. The credibility gained by a useful intervention in such circumstances can increase the prestige of the health service, and may subsequently improve coverage and utilisation of routine activities. Disease surveillance and capacity building for epidemics control should not only be an integral part of a refugee-assistance programme, but of any health service in sub-Saharan Africa. Such capacity may considerably increase the efficiency and acceptability of the health services overall.