Category Archives: ITNs

Challenges and Recommendations in Distribution of LLINs in Urban Contexts

by Brooke Farrenkopf

With the malaria team made up of public health nurses and an infectious disease specialist in Kumasi

I participated in a study on urban distribution of long lasting insecticide treated bednets (LLINs) as part of the USAID/PMI VectorWorks Project of the Johns Hopkins University Center for Communication Programs aided by a JHU Global Health Field Placement Scholarship. I conducted qualitative interviews to support a programmatic study on the challenges associated with mass distributions in urban contexts and helped develop report recommendations for developing the guidelines for future campaigns in urban areas. I am sharing my findings here.

As noted VectorWorks is funded by the US President’s Malaria Initiative and works to improve access to long-lasting insecticide treated nets (LLINs) in 12 countries in Asia and Africa. VectorWorks Ghana, through collaboration with the National Malaria Control Program (NMCP) and partners, supports the following distribution campaigns:

  • School-based distribution, occurring every May for grades 2 and 6
  • Continuous facility-based distribution at ANC and EPI visits
  • Point mass distribution campaigns, occurring every 3 years

In Kumasi, Takoradi, and Tamale, a point mass distribution campaign had already occurred. The campaign in Accra occurred while I was in Ghana, and I was able to visit the distribution sites and the health facilities where a portion of the LLINs were stored. Here, I was able to see some of the logistical challenges associated with the urban context.

I was also able to see the solutions put in place by the local malaria teams. One solution to improve program delivery was the development of a coupon coding system. As each community member attended the distribution site to receive a LLIN, Ghana Health Service (GHS) staff had to match their registration coupon with the coded coupon in the book. The coding system organized the coupons and identified members who had not attended distribution.

Mass distribution campaigns are the most effective method to rapidly increase long-lasting insecticidal net (LLIN) coverage.  Mass distribution in urban areas with characteristically large and heterogeneous populations of high population density comes with higher costs and difficult logistics. Many inhabitants are not indigenous to the area and are of varied religious, occupational, and socioeconomic backgrounds. Urban areas commonly have large mobile working class populations that are difficult to access. These characteristics are unique to urban areas and introduces the need for improved guidelines in urban areas.

VectorWorks Ghana Team

To date, the National malaria Control Program (NMCP) guidelines for point mass distribution in Ghana have made no distinction between urban and rural areas and have therefore not addressed these differences. This study intended to provide information to refine these guidelines.

Most interviews were conducted in hospitals and health facilities where the members of the malaria teams were located. The interviews were conducted in-person in the four largest metropolitan areas in Ghana: Kumasi, Greater Accra, Takoradi, and Tamale. I helped develop and follow a question guide that covered each phase of the distribution focusing on the challenges, solutions, and recommendations associated with each phase of distribution.

Most common challenges with implementation in urban communities:

  • Reaching community members during registration
  • Completing registration within the period of days provided and the volunteers allocated, because the population was too dense to reach all of the households and many community members were not at home during registration
  • Beneficiary dissatisfaction with universal health coverage definition of sufficient LLIN coverage {one net per two people in each household}

Most common recommendations for future distributions:

  • Greater inclusion of sub-metro teams in development of the micro plan
  • Increase the resources to recruit and remunerate more volunteers and supervisors to enable more distribution sites, help control crowds, and allow fewer days for each phase
  • Intensify social mobilization and allow sub-metros to help develop this plan to utilize local resources, especially to improve understanding of universal health coverage definition of one net per two people and to inform about logistics
  • Increase the number of registration days
  • Conduct a utilization study to understand coverage of LLIN use and barriers to  consistent use.

I was able to speak with public health nurses, malaria experts, and district health directors, and hear their insight on how to improve future campaigns. My favorite anecdotes included examples of how teams developed innovative solutions to improve campaign efficiency or strategically access hard to reach populations.

The observations and recommendations by the respondents themselves should guide future LLIN campaigns in urban settings in Ghana.

References

  • VectorWorks (2017) Johns Hopkins center for Communication Programs. http://ccp.jhu.edu/projects/malaria-vector-control/
  • de Beyl CZ, Koenker H, Acosta A, Onyefunafoa EO, Adegbe E, McCartney-Melstad A, Killian A (2016) Multi-country comparison of delivery strategues for mass campaigns to achieve universal coverage with insecticide-treated nets: what works best? Malaria Journal, 15(1): 1.
  • Stakeholder Review of Experiences in urban Long-Lasting Insecticidal Net (LLIN) campaign distributions (2012). Malaria Consortium Africa.

The Business Case for Malaria Prevention: Employer Perceptions of Workplace LLIN Distribution in Southern Ghana

Kate Klein as part of her Master of Science in Public Health program in Social and Behavioral Interventions at the Johns Hopkins Bloomberg School of Public Health undertook a study of the potential for private sector involvement in malaria prevention in Ghana. She shares a summary of her work here. During her practicum in Ghana she was hosted by JHU’s Center for Communications Programs and its USAID supported VectorWorks Program. Her practicum she was also supported by the JHU Center for Global Health, and she presented her findings in a poster at the CGH’s Global Health Day on 30th March 2017. Her essay readers/advisers were Dr. Elli Leontsini (Department of International Health) and Kathryn Bertram (Center for Communication Programs).

Malaria is endemic in all parts of Ghana and significantly burdens families, communities, and economies. Malaria remains a leading cause of morbidity and mortality in Ghana; it accounts for eight percent of deaths in the country (The Global Fund, Ghana). It was also responsible for about 38% of outpatient visits, 27.3% of admissions in health facilities, and 48.5% of under-five deaths in 2015 (Nonvignon et al., 2016). In Ghana, the estimated cost of malaria to businesses in 2014 alone was estimated to be US$6.58 million, and 90% of these were direct costs (Nonvignon et al., 2016). Malaria leads to reduced productivity due to increased worker absenteeism and increased health care spending, which negatively impact business returns and tax revenue to the state (Nabyonga et al., 2011).

Although long-lasting insecticidal treated nets (LLINs) are a well-documented strategy to prevent disease in developing countries, most governments, including Ghana, lack the resources needed to comprehensively control malaria. The Global Fund (GF), USAID/President’s Malaria Initiative (PMI Ghana), and the United Kingdom Department for International Development (DfID Ghana) are the main donors for the national malaria control strategy and have worked primarily with the public sector (World Malaria Report, 2015). As government funding remains unable to close the funding gap for malaria, there is an increasing need to revitalize the private sector in sales and distribution of this life-saving technology.

A “Journey mapping” exercise to consider the process of employers buying and distributing nets to employees, created during a PSMP advocacy workshop in December 2016

Ghana is looking to the private sector to encourage a departure from previous dependence on donor-funded free bed nets. The Private Sector Malaria Prevention (PSMP at JHU) project is being implemented in Southern Ghana to increase commercial sector distribution of LLINs. Three case studies served as a situation analysis and exemplified the potential for the PSMP: a rubber producing company, a mining company and a brewery.

All three had experience in malaria control and prevention but only one had specific experience with LLINs (which dovetailed well with its own corporate strengths in logistics management as exemplified by other bottling companies in Africa). Another supported the idea of adding LLINs to its existing indoor residual spraying and community health education efforts, but needed to consider how to develop the flexibility to engage in multiple malaria interventions.

The third had had the right climate and leadership to be able to partner with PSMP, but recently underwent a takeover by a large multinational brewing company and the resulting period of transition could potentially complicate their participation in LLIN distribution efforts from a budgetary standpoint. Generally these companies had the understanding of the potential benefits to the company of situating malaria control within their structure, and thus being early candidates for adoption of the PSMP.

While the three case study companies recognized the business case for malaria, this was not a unanimous opinion among other five companies interviewed. Their concerns ranged from a preference toward treatment interventions to concerns expressed by employees about the difficulty of achieving high levels of net usage due to an array of complaints surrounding sleeping under LLINs. Some of these others had financial constraints.

Through case studies and interviews PSMP was able to identify various challenges moving forward as well as areas where further clarity must be sought. PSMP learned that several companies are pouring their resources into strong treatment and case management programs, and one challenge will be determining how to push for preventative action, such as LLIN distribution, when treatment mechanisms are so established and bias exists.

For those companies who are making tremendous strides in malaria prevention, bringing recognition to these successes through advocacy will be necessary for encouraging future participation and convincing other similar employers of the benefits of starting their own LLIN distribution programs. Finally, PSMP needs to prioritize clarifying viewpoints on LLIN efficacy and use, with a focus on understanding why employers may hold unfavorable views and what it would take to overturn them.

In the future it will be necessary to move beyond the occupational considerations specific to mining and agro-industrial operations and consider how the work has changed the environment into a malaria habitat and the non-traditional work hours that may create more significant Anopheles mosquito exposures. PSMP should gather specific information on lifestyle, housing, and work environments during future visits with employers so that companies that have the most to gain through LLIN distribution are identified and targeted.

Myanmar – update on malaria indicators

Myanmar is one of the countries at the epicenter of the developing resistance of malaria parasites to artemisinin based drugs. This means there is a strong need for prompt, appropriate and thorough diagnosis and treatment of febrile illnesses and malaria as well as the regular use of effective malaria preventive technologies. The 2015-16 Demographic and Health Survey for the country is thus a timely source of information to improve malaria interventions. Highlights from the DHS follow.

The first major concern is both lack of insecticide treated nets as well as low use of those available as the pie chart from the DHS makes clear. Ironically 97% of households have some kind of net, but 73% do not have an insecticide treated one. Although the Global Fund has supported distribution of 4.3 million ITNs in the country, there are over 56 million people living there. The US President’s Malaria Initiative has procured nearly 900,000 ITNs for the country. Although low across all economic strata, the lowest wealth quintile have the highest ITN possession (35%).

The 2013 concept note submitted by Myanmar to Global Fund under the new funding mechanism identifies many of the challenges: “Factors that may cause inequity to services for treatment and prevention: There are several population groups, which are poorly served by the health system and malaria services such as those living in remote border areas, migrant populations, forest workers and miners where malaria transmission is intense. Many of them are internal and external migrants who usually have limited access to malaria prevention and control. Major factors include distance from health facilities and poor awareness of malaria and its prevention.”

Key strategies in the Global Fund Concept Note do address quality malaria diagnostics and appropriate treatment. Unfortunately DHS results do not yet show the impact of improved diagnosis and treatment. “Overall, 16% of children under age 5 had a fever in the 2 weeks before the survey. Advice or treatment was sought for 65% of these children with recent fever, and 3% had blood taken from a finger or heel, presumably for diagnostic testing.” A variety of public and private sources were used to seek fever treatment, but “Only 1% of children received antimalarial drugs for treatment of fever in the 2 weeks preceding the survey.”

In addition to formal donors, there are coalitions and consortia who provide encouragement, technical assistance, advocacy and capacity building for eliminating malaria in the Asia-Pacific region. While the country needs to take stronger leadership in malaria elimination, all groups need to come together and strengthen the malaria interventions in Myanmar as these have implications for eliminating the disease in the region as a whole.

Malaria in Pregnancy Progress in Nigeria – the 2015 Malaria Indicator Survey

With an eye toward the future Nigeria’s National Malaria Control Program also refers to itself as the National Malaria Elimination Program (NMEP). Given that Nigeria has the highest burden of malaria in Africa, along with around one-quarter of sub-Saharan Africa’s population, the elimination goal will take a lot of work.

Recently the 2015 Malaria Information Survey (MIS) for Nigeria was released and gives a perspective on how far we have some and how far we need to go. We will focus on malaria in pregnancy (MIP) interventions today.

Intermittent Preventive Treatment for pregnant women (IPTp) using sulfadoxine-pyrimethamine (SP) remains the key MIP intervention due to the high and stable malaria transmission that still persists. There is always a challenge in delivering health interventions that require multiple contacts, and IPTp is not exception. The difficulty in achieving two doses when that was policy was clear. Now that WHO recommends monthly dosing from the second trimester forward (giving the possibility of 3, 4 or more doses), the service delivery challenge is heightened.

We can see in the attached graph from the MIS report that while there is progress, it remains well below the 2010 Roll back malaria Target of 80%. Part of the problem resides in the fact that the 2013 DHS showed only 61% of pregnant women attended even one antenatal care visit while 51% attended four or more.

The second lesson of the graph is missed opportunities. There is a gap between IPTp1 coverage of 37% and at least one ANC visit of 61%. Granted, 18% of women made their first visit in the first trimester when SP is not given, but not all of those stopped ANC then. The next evidence of missed opportunities is the gap between IPTp1 and IPTp2, almost a quarter of women who started IPTp did not get a second dose. We cannot say that the women’s own attendance gaps account for all the missed opportunities; some are likely due to health systems weaknesses such as stock-outs and health staff attention.

Key demographic factors are linked to receiving two or more IPTp doses. Only 30% or rural women received two or more compared to 50% of urban. There was a steady progression from 21% of the poorest women to 55% of those in the highest wealth quintile. A second chart also shows variation by section of the country. These access gaps are why we have advocated for supplementary distribution of IPTp through trained community health workers.

Use of insecticide treated bed nets by pregnant women shows a similar increase over time. The dip in 2013 probably related to fact that mass campaigns had occurred between 2009 and 2011 and thus by the time of the survey some nets had become damaged and abandoned. A major challenge in achieving net coverage is NOT relying on periodic distribution campaigns only, but ensuring regular and reliable supplies during routine services such as antenatal care. This again is a health systems problem that must be solved.

Net access is not only a health systems issue, bit may be factor of internal household dynamics. Even when the household possesses nets, only 63% of pregnant women therein slept under one the night before the survey. Community education needs strengthening – more than just telling people what to do but involving them is solving the problems of net use.

So as mentioned earlier, progress is being made, but more effort is needed. We are especially concerned because of the precariousness of global financial support for disease control. Nigeria needs to strategize how it can meet its own needs in protecting pregnant women and their unborn children from malaria, disability and death.

Malaria Excerpts from WHO’s New Antenatal Care Recommendations

new-who-anc-recommendations-2016Many years ago WHO formulated guidance for encouraging 4 Focused Antenatal Care (FANC) that addressed the reality that 1) ANC attendance schedules were not standardized, 2) service package elements were not clearly laid out, and 3) women found it difficult to attend ANC as many times as some countries recommended. The New York Times reported that WHO now recommends 8 ANC visits in large part because greater action is needed in light of the fact that …

“About 300,000 women die in pregnancy or childbirth each year, the agency said, and more than six million babies die in the womb, during birth or within their first month. Many of those deaths can by prevented through simple interventions.”

The new recommendations number 49 and strongly consider the roles of all health workers from auxiliaries to doctors – stressing task shifting to ensure that women have access to life saving services.  Below are extracted some of the aspects that relate to malaria.

  • In areas with endemic infections that may cause anaemia through blood loss, increased red cell destruction or decreased red cell production, such as malaria and hookworm, measures to prevent, diagnose and treat these infections should be implemented.
  • Malaria prevention: intermittent preventive treatment in pregnancy (IPTp): In malaria-endemic areas in Africa, intermittent preventive treatment with sulfadoxine-pyrimethamine (IPTp-SP) is recommended for all pregnant women. Dosing should start in the second trimester, and doses should be given at least one month apart, with the objective of ensuring that at least three doses are received.

The above recommendation has been, “Integrated from the WHO publication Guidelines for the treatment of malaria (2015), which also states: ‘WHO recommends that, in areas of moderate-to-high malaria transmission of Africa, IPTp-SP be given to all pregnant women at each scheduled ANC visit, starting as early as possible in the second trimester, provided that the doses of SP are given at least 1 month apart. WHO recommends a package of
interventions for preventing malaria during pregnancy, which includes promotion and use of insecticide-treated nets, as well as IPTp-SP’. To ensure that pregnant women in endemic areas start IPTp-SP as early as possible in the second trimester, policy-makers should ensure health system contact with women at 13 weeks of gestation.”

  • anc-attendance-4-countriesTask shifting components of antenatal care delivery: Task shifting the distribution of  recommended nutritional supplements and intermittent preventive treatment in  pregnancy (IPTp) for malaria prevention to a broad range of cadres, including auxiliary
    nurses, nurses, midwives and doctors is recommended.

Readers should download the full set of recommendations for more details on the above. We do offer a challenge. Since the 4-visit FANC processes, that was adopted in part because of the difficulty in getting pregnant women to attend ANC many times, is still not fully achieved (see graph), we must now strengthen community involvement, mobilization and education to double that target to 8 visits. Efforts must focus on women, men, elders and even youth. Health workers also need education and motivation to adopt a client-friendly attitude to make this new schedule work.

Malaria, Lymphatic Filariasis and Insecticide-treated Nets

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Throughout Africa one of the main vectors that carry Lymphatic Filariasis (LF) is the Anopheles mosquito, which also carries the malaria parasite. The Carter Center has been promoting use of insecticide treated nets (ITNs) for many years as part of its LF control efforts, but others may not have gotten the message.

The global community is targeting LF for elimination in 2020. The primary strategy is mass drug administration annually with ivermectin and albendazole. The plan is that up to seven annual rounds of drug distribution in endemic communities where 90% of population coverage is achieved is necessary to stop LF transmission. The Carter Center explains that distribution of long-lasting insecticidal bed nets (LLINs) protects pregnant women and children who cannot take drug treatment.

The LF strategy often builds on and integrates with onchocerciasis control efforts where these diseases overlap. The community directed treatment with ivermectin (CDTI) model pioneered by the African Program for Onchocerciasis Control  (APOC), wherein communities or villages plan together the distribution process including selecting their own community directed distributors (CDDs). This model has also been used to distribute ITNs.

20160818_100110-1A second component of the LF strategy is morbidity management which focuses on enhanced personal hygiene or cleaning of the parts of the body that experience lymphedema. Another aspect uses surgery to address some of the worst effects, hydrocele.  While this component does not ‘control’ LF, it is a necessary effort to reduce suffering and the negative stigma from the disease.

To judge whether transmission has stopped and elimination has been achieved Transmission Assessment Surveys (TAS) are conducted with rapid diagnostic tests on young children after at least 5 years of MDA in a community.  Specifically WHO recommends an implementation unit must have completed five effective rounds of annual MDA defined as achieving rates of drug coverage exceeding 65% in the total population.

For example the Carter Center in Support of the Nigerian Federal Ministry of Health worked in Plateau and Nasarawa States through community health education, delivery of long lasting insecticide-treated nets (LLINs) and 33 million drug treatments for lymphatic filariasis and river blindness between 2000 and 2011. “In 2012, it was confirmed (through TAS) that lymphatic filariasis transmission had stopped. Post-treatment surveillance is currently underway to assure that the parasite is not reintroduced into the area.”

Another component of the assessment process is yet to be fully realized. That is the testing of mosquitoes for the presence of microfilariae. This indirectly implies an important role in preventing human-vector contact as would be achieved through the use of ITNs as well as indoor residual spray (IRS).

Vector control can benefit more than one disease. Integrated vector management is seen as a key tool to prevent reintroduction of LF in areas where anopheles mosquitoes carry the disease and where ITN campaigns are successful.

Ultimately the key to benefiting from the disease control synergies provided by insecticide-treated nets is an understanding what if any effect nets have on transmission. This poses a challenge in terms of separating it from the effect of MDAs as well as the fact that MDAs are time-limited. As MDAs are still underway in many places it is incumbent on program managers to monitor and evaluate the impact of all activities, treatment and vector control, over the next decade to determine the success of eliminating LF and hopefully malaria, too.

Tanzania – Malaria Indicators Low, Still Need Work

Success in the war against malaria is not guaranteed. Two articles to that effect have appeared The Citizen of Dar es Salaam following presentation of findings from the most recent (2015-16) Tanzania Demographic and Health Survey (DHS)/Malaria Indicator Survey (MIS).

Slide2On Tuesday (21 June 2016) the news story noted the increase in malaria prevalence among children below the age of 5 years, which was attributed to “the decline in the use of mosquito nets and low distribution of nets to households.” Then in a Wednesday (22 June 2016) Editorial, the paper noted that this “backtracking” is a “worrisome situation, for malaria is a problem that puts such a heavy burden on the government and the country’s economy.”

Slide1A look at the preliminary DHS does confirm the concerns about insecticide treated nets (ITNs).  After nearly 10 years of progress, reported ITN availability in households declined. This was reflected in a drop in reported use by children below 5 years of age as well as pregnant women. It should be noted that targets set in 2000 in the Roll Back Malaria Abuja Declaration had been 80% by the year 2010, and those had almost been achieved in 2012, but the fall to around 50% in 2015-16 is discouraging.

Another preventive measure has also faced difficulty. Pregnant women should receive doses of Sulfadoxine-pyrimethamine (SP) as part intermittent preventive treatment (IPT) during antenatal care (ANC).  Until 2012 the recommendation was two contacts, but the World Health Organization has raised this to three or more depending on the number of times a woman attends ANC. So far IPT has not reached 40% or half of the Abuja target.

Slide3This low IPT coverage is ironic since most women attend ANC at least once in Tanzania. At present only 68% of women who had been pregnant received the first dose of IPT even though 98% registered for ANC. Granted that some may have registered in their first trimester when they would not yet be eligible for IPT, but the gap is quite large and signals missed opportunities, which are often caused by stock-outs. Even though the proportion of women attending up to ANC visits could be better, these attendances should produce better delivery of the 3rd IPT dose.

Slide4Malaria can also be controlled through prompt and appropriate treatment. While testing and treatment of children with appropriate artemisinin-based combination therapy (ACT) has increased, this are is still problematic. In particular, while WHO recommends that all cases of fever should be tested, less than a third received a test (rapid diagnostic test – RDT or microscopy). Testing helps distinguish malaria from other fevers, and ACTs should not be given unless malaria is confirmed. We can see that more ACTs are provided than the number who were tested, so treatment based solely on signs and symptoms is still the norm. Again there is need to explore the availability of both RDTs and ACTs as factors that have made these targets difficult to achieve.

Tanzania continues to receive support from the Global Fund and the US President’s Malaria Initiative, among other partners. It is incumbent on all partners, global and national, to use these results as a wake up call to to plan for better delivery of malaria services and thus a reduction of both the economic and health burden of malaria in Tanzania.

 

Kenya – the long road to controlling malaria in pregnancy

Augustine Ngindu, the Technical Advisor for Malaria in Kenya’s Maternal and Child Survival Program (USAID, Jhpiego) shares with us the steps and processes in building a national response to controlling malaria in pregnancy (MIP) in Kenya.

Recently Stephanie Dellicour and colleagues wrote about the challenges in the delivery of interventions to prevent malaria in pregnancy in Kenya in Malaria Journal. They examined MIP services in Nyanza Province of western Kenya between February and May 2010. At that time they found that, “… delivery of  IPTp (intermittent preventive treatment in pregnancy) and ITNs (insecticide treated nets) through ANC (antenatal care) was ineffective and more so for higher-level facilities. This illustrates missed opportunities and provider level bottlenecks to the scale up and use of interventions to control malaria in pregnancy delivered through ANC.”

Kenya National malaria StretegySince that time the National Malaria Control Program (NMCP) has made efforts to address these problems by building on the national malaria strategy (NMS) 2009-2017 that recommend provision of IPTp only in high malaria transmission areas based on strong epidemiological evidence.  In 2010 NMCP revised the national guidelines on diagnosis, treatment and prevention of malaria in line with the NMS 2009-2017. Then in 2011 NMCP in collaboration with Jhpiego developed simplified MIP guidelines on provision of IPTp in line with the national guidelines (each pregnant woman to receive at least 2 IPTp doses starting from 16 weeks of pregnancy at 4 weeks interval). Also in 2011 Maternal and Child  health care workers in all 14 high malaria transmission areas were trained on provision of MIP using the simplified guidelines.

Trends in IPTp in Malaria Endemic Areas fromIn 2012 health facility in-charges in the same high transmission areas were trained on MIP quality performance improvement. Then in 2013 promotion of early start of  IPTp in the second trimester through sensitization of pregnant women was started in two out of the 14 malaria endemic counties. This resulted in increased IPTp2 coverage from 25% as reported in the kenya Malaria Indicator Survey) (KMIS 2010) to 63% (US-CDC survey 2013).

From 2014 to date the practice of sensitizing pregnant women using community health workers/volunteers has been replicated in other counties. IPTp2 coverage has increased from known 25% (KMIS 2010) to 56% (KMIS 2015) in the malaria endemic counties. Likewise use of ITNs by pregnant women increased from 50% in 2010 to 79% in 2015.

Although IPTp coverage is still below national target, the lost opportunities are being addressed. Kenya is still confronting multiple challenges including SP stock-out and devolution of health services to county governments but is set on making progress and saving mothers’ lives.

Manufacturing Mosquito Nets ‘At Home’

The technology of insecticide treated nets (ITNs) to prevent malaria has been around for over three decades. ITNs have evolved from a process of semi-annual soaking and impregnating nets with a safe insecticide at the household or community level to long lasting insecticide-treated nets (LLINs) where the insecticide is integrated into the nets during the manufacturing process. The challenge has always been guaranteeing enough currently treated nets to cover the population and impede malaria transmission.

IMAG0170Recently Rwanda announced its intentions to establish LLIN manufacturing in-country. The Ministry of Trade and Industry has begun screening of bidders. The government’s main rationale for this move is projected the need for a large and continuous supply of LLINs in the country through 2020, “making it a prudent to set up a production plant in the country.” When this information was shared with our malaria/tropical health update mailing list a number of readers expressed interest and hope that their own governments would follow suit. This post provides some background for readers to consider.

The idea of locally made mosquito nets is not new. MacCormack and Snow documented that, “95% of people were already sleeping under locally-made DSCN5582nets,” in The Gambia in the 1980s. Likewise in Burkina Faso it was common to find nets made from imported materials or local cotton that were sewn by local tailors.

The idea of drawing on the combination of local or regional textile and chemical industries to produce an ITN kit containing both net and approved insecticide for home/community soaking was tested in several countries by the USAID sponsored NetMark project between 1999–2009. Although the project made ITNs available at reduced prices and resulted in gains in  awareness, ownership, and use of nets, “none of the countries reached the ambitious Abuja targets.”

NARCHOct03 012Even at reduced prices the ITNs made available through this commercial sector approach were still more expensive than most families could afford. In addition partway through the project the emphasis shifted from local products to imported LLiNs leaving a leaving a very bitter taste, particularly in Nigeria with its large industrial sector, in mouths of the textile and chemical partners who during malaria partners meetings at the time expressed a sense of betrayal.

A-Z Olyset Commercial BagTalk arose in Nigeria about the potential for starting LLIN production in the country, but no one stepped forward with funding or technical assistance. In the meantime, on the other side of the continent, A to Z Textiles of Tanzania entered into a partnership and by 2003 LLINs were being produced in Arusha.  Sumitomo Chemical provided a royalty-free technology license to the company for its Olyset LLINs. “By 2010, Olyset Net production capacity (at A to Z) reached 30 million LLINs per year, creating 8,000 jobs; more than half of the global Olyset Net output and an outstanding contribution to the local economy.”

Over the years A to Z Textiles were hard pressed, just like the few other LLIN manufacturers, to meet global demand. Over the period, the focus changed from protecting young children and pregnant women to universal coverage of the population. Also research and actual use found that the lifespan of an LLIN was not the 5 years as initially projected, but more like two. These factors meant that supply could rarely meet demand for regular replacement nets. No wonder Rwanda wants its own LLIN factory!

ITNs Use TanzaniaIn addition to supply issues, does local availability of LLINs make a difference in fighting malaria? Regular studies by the Demographic and Health Survey group of USAID in Tanzania found that ITN use increased over time by children below five years of age. The most recent survey still shows that the 2010 Abuja target of 80% was not met (let alone a target of universal coverage), but the findings hint at the importance of having locally available LLINs.

Let’s wish Rwanda success in establishing its LLIN manufacturing capacity. For colleagues in Nigeria and elsewhere who have expressed interest in this issue, your advocacy work is just beginning.

 

An Ideation Model: Attitudes, Beliefs and Practices Relevant to Malaria Prevention and Treatment in Madagascar and Liberia

Stella Babalola, Nan Lewicky, Grace Awantang, Michael Toso, Hannah Koenker, Arsene Ratsimbasoa, Monique Vololona of the Johns Hopkins Center for Communication Programs and the Division for Malaria Control, Madagascar Presented findings on how local perceptions help predict uptake of malaria interventions at the 143rd American Public Health Association Annual Meeting, October 31 – November 4, 2015, in Chicago. Their presentation on Liberia and Madagascar is summarized below.

While Liberia has an average malaria parasitemia prevalence of 28%, malaria is considerable less common in Madagascar and varies by region and altitude. This difference provides an interesting opportunity to observe similarities and contrasts in community perceptions of the disease.

Slide6Theoretical basis of the research is based on the Ideation model which has been described as follows and as seen in the attached figures:

  • “New ways of thinking and the diffusion of those ways of thinking by means of exposure to mass media and social interactions in local, culturally homogeneous communities” – Kincaid, 2000
  • “views and ideas that people hold individually” – van de Kaa 1996

Slide7The ideation model has successfully predicted current use of a contraceptive method as well as accessing childhood immunization. The team took up the challenge to learn whether this model would be applicable to malaria interventions.

Malaria-related ideation was proposed to consist of: Malaria knowledge (cause, symptom, prevention); Perceived susceptibility to malaria; Perceived severity of malaria; Perceived self-efficacy to prevent malaria; and Social interactions about malaria. These may lead to uptake of malaria interventions.

Slide10Items for measuring bed net ideation could include – knowing where to procure a bed net, Willingness to pay for bed net, Having a positive attitudes towards bed net (derived from ten attitudinal statements), Perceived response-efficacy of bed nets, Perceived self-efficacy for procuring and using bed nets, Participation in household decisions about bed nets, Descriptive norm about bed net use and Social interactions about bed net use.

Percent of female caregivers that slept under an ITN on the night before survey increased by level (score) of bed net ideation as seen in the graph. Results (odds ratio) of logistic regression of sleeping under an ITN on bed net ideation and other covariates showed a similar trend.

Slide15Intermittent Preventive Treatment of Malaria in Pregnancy ideation measures included the following:

  • Knows name of the drug for malaria prevention during pregnancy
  • Knows the timing of first dose of IPTp
  • Has positive attitudes towards ANC and IPTp (derived from four attitudinal statements)
  • Perceived response-efficacy of IPTp
  • Woman participates in decisions about own health
  • Social interactions about malaria and pregnancy
  • Descriptive norm about ANC visits

Slide21The percent of women who took at least two doses of IPTp during their most recent pregnancy also increased by level of IPTp ideation Likewise the results (odds ratio) of logistic regression of obtaining at least two doses of IPTp on IPTp ideation and other covariates were highest among those with highest levels of ideation.

Items for measuring case management ideation included –

  • Perceived response efficacy of malaria diagnostic test
  • Perceived self-efficacy for detecting uncomplicated malaria
  • Perceived self-efficacy for detecting severe malaria
  • Descriptive norm about prompt treatment of malaria in children
  • Social interactions about malaria treatment
  • Participation in household decisions about child health
  • Positive attitudes towards appropriate malaria treatment

Slide27Again the percent of children sick with fever in past two weeks who received prompt ACT treatment by caregiver’s increased with increasing level of treatment ideation. As before the results (odds ratio) of logistic regression of prompt ACT treatment on caregiver’s treatment ideation and other covariates shows highest levels of ideation were associated with greated treatment seeking.

The team concluded that the same ideation model with demonstrated validity for family planning, child immunization, WASH and other health behaviors is relevant for malaria prevention and treatment. Strategically designed messages and interventions addressing ideational variables can help foster adoption of health-protective malaria prevention and treatment behaviors.

The authors acknowledge The US President’s Malaria Initiative (PMI) for technical guidance on the implementation of the surveys and The Ministry of Health and Social Welfare in Liberia and the Ministry of Health in Madagascar for their collaboration on the surveys.