Tropical Health Matters

We have seen photos of challenging uses of long lasting insecticide treated nets (LLINs) from across malaria endemic countries.  Some donors may become indignant that their valuable, life-saving commodities are not being used as intended, or shall we say ‘misused’.

We must remember that use is in the eyes of the beholder.  We had similar challenges when distributing monofilament nylon water filters to prevent guinea worm. Many in the villages thought these were ideal for straining cassava starch.  Innovations designed in one culture may not fit congruently into the life of another.

The various uses of LLINs reflect real perceived needs of the populations – a place to dry fish, a way to protect vegetables from pests, a beautiful wedding veil. So where does the problem lie. The attached photos by Esther Lu taken in the Karamajong NE District of Uganda add to our ‘net creativity’ portfolio.

We have seen over and over again that mass LLIN distribution campaigns are barely able to mobilize the resources to carry out the distribution, including getting enough nets to the right places at the right times. Not surprisingly few resources have been devoted to follow up and community-based health education by trusted community members.

So is misuse of nets a problem of recipients’ behavior or a problem of financing and planning by program managers?

During a recent community mobilization and supervisory visit to Abat community Onna Local Government Area (LGA) in Akwa Ibom State, Nigeria, colleagues saw nets from last year’s mass distribution being used to protect vegetable gardens.  Bright Orji commented that, “When we spoke with community about the mis-use, they claimed that those were torn nets. We did not believe them, and also told them that torn nets could be amended.”

The team took four pictures of different nets in several places, Orji said that, “Mis-use is on the rise, and we need to counter this urgently.” Before they had nets community members used a small shade built of palm fronds to protect the plants, but apparently the nets are seen as a better deal as they also keep off some animals and insects. Ironically if community members think nets will keep off insects are fooling themselves as sun exposure will destroy the pesticide.

The team had heard complaints about nets before – sleeping under a net is too hot; nets are difficult to hang. Because of such complaints, Orji noted, “In our focal communities we are teaching community health workers to hang nets using net hangers provided by the State Ministry of Health (SMOH).”

We wondered whether people are using the nets that adults would have used, or are they taking away from children and pregnant women? Orji explained that, “Most households in our LGAs have more than two. Some nets had been given to pregnant women before the State placed two nets per household. So, men can take new ones from State to use while women continue to use the ones obtained from us or vice visa.”

Orji added that, “It is very important for a formative research to investigate net use, reasons for non use and mis-use. We will develop a proposal to the SMOH for this.”

Apparently the local health authorities were unaware of this problem until Orji “shared the photos at one of our partners’ meetings.” An SMOH staff member on the mobilization/supervision team told Orji that, “We only do monitoring when an NGO invites us, or go out whenever the National Malaria Control Program visits.”

This net mis-use highlighted some of the gender dynamics in the community. In terms of growing these vegetables, and farming in general, it is women’s responsibility. Orji explained that, “One of the villlage chiefs informed us that women are the ones farming all their lands. In Onna the tradition is that men stay at home to drink while women go to farm.”

Therefore the women most likely put up the nets over the vegetables.  Orji somewhat joking added that, “Perhaps when the man got drunk, the woman decided to punish him by exposing him to mosquitos through the removal of his net.”

What we have learned from this experience is two-fold. Follow-up education and assistance is needed to ensure that nets given out freely are actually used for the intended purpose. Secondly, this effort will be aided by formative research on how people perceive and value the nets. Otherwise all we will achieve is universal coverage of vegetable gardens! We should also find the agriculture extension agents in the area to help the people find better ways to protect their gardens from pests, otherwise nets will remain an attractive option.

Uganda’s 2010 Roll Back Malaria Roadmap seemed reassuring.  Apparently 2.7m nets were already in place by late 2009, and supposedly a supply of another 18m long lasting nets (or at least the funding) was ready for achieving universal coverage by December 2010.

Assessment of Uganda’s Roadmap progress credited the country with achieving procurement of these nets. It seems odd therefore that the 2011 Roadmap indicates that 6.4m nets are in place and 10.4m need to be distributed in 2011. What’s going on?

A new study by Carla Proietti and colleagues provides some answers. Not only do they document continued high transmission in the northern part of Uganda (polymerase chain reaction rate of 72% in children below five year of age), a situation that threatens control efforts by neighbors, but they also identify plausible reasons for the lag.

The researchers politely suggest that, “The failure to reduce the burden of malaria could reflect sub-optimal implementation of malaria control measures.” They also explained that, “Malaria control efforts in Apac (sub-county) were not reliably monitored in the last decade and affected by political unrest in preceding years.”

Stockouts of anti-malarial ACTs was also listed as a problem. It should be recalled a few years ago that, “The Global Fund has decided to suspend its five grants to Uganda because there is evidence of serious mismanagement by the Project Management Unit (PMU) for Global Fund grants in Uganda.” Although the programs have resumed, satisfactory settlement of the problem was not achieved.

In light of this study Childsurvival.net warns us not to let successes in recent years blind us to reality. “Those who believe that Africa is within shooting distance of malaria elimination may wish to reconsider their position after reading this article (Proietti et al.). One should qualify this Ugandan article in several ways: 1) Local insurgency in the area under consideration, 2) Hiccoughs with the GF over misappropriation of resources, 3) Autocratic gerontocracy at the national level. Unfortunately, these three factors are not peculiar to Uganda.”

As mentioned yesterday, Roadmaps are a good tool to help us plan for malaria control and elimination – but we must stay on the road for them to work.

We are unlikely to eliminate mosquitoes, according to Tanya Russell and colleagues, but she notes that this should not stop us from implementing all available interventions. Specifically their study of malaria vectors in Tanzania found that the at reduced densities of mosquito populations, they try to reproduce more, meaning we may never get below 10% mosquito elimination.

Instead, a member of the National Malaria Control Program in Tanzania says our goal “should be to reduce, and eventually halt, transmission of the parasite, rather than eliminating the vector.” If we can achieve no more than 90% elimination of mosquitoes, what is a realistic coverage figure for malaria interventions?

Applications of net and case management strategies in Rwanda and Ethiopia have definitely shown that major drops in malaria incidence are possible.  But the RBM targets of 80% coverage (85% for the US President’s Malaria Initiative) are elusive.  Demographic and malaria surveys from Senegal, Liberia and Nigeria show that even in homes that own nets, net use among people at most risk, does not reach this target.

Are we really sure that 80% is the right target?

Fred Binka was one of the first to demonstrate that people living in homes without nets can be protected by their neighbors’ nets, which kill mosquitoes in the community. ITNs “provided very good personal protection to children using them, and also protected nonusers in nearby compounds. Among nonusers, the mortality risk increased by 6.7% with each additional shift of 100 m away from the nearest compound” with nets. This led the researchers to speculate on the need to study whether the “mass effect from a small number of highly dispersed nets would provide equivalent protection to complete coverage.”

A few years later William Hawley and co-researchers reported that, “protective effect of ITNs on compounds lacking ITNs located within 300 meters of compounds with ITNs for child mortality, moderate anemia, high-density parasitemia, and hemoglobin levels.”

As part of the move toward universal coverage, Killeen and colleagues examined the importance of considering all household members, not just the ‘vulnerable.’ The group condluded that …

Using field-parameterized malaria transmission models, we show that high (80% use) but exclusively targeted coverage of young children and pregnant women (20% of the population) will deliver limited protection and equity for these vulnerable groups. In contrast, relatively modest coverage (35%–65% use, with this threshold depending on ecological scenario and net quality) of all adults and children, rather than just vulnerable groups, can achieve equitable community-wide benefits equivalent to or greater than personal protection.

Barat has called for ‘data driven decision making‘ in the effort to eliminate malaria. Using data in models as done by Killeen is a further important step. The onchocerciasis control community has been working with such models for over 15 years now. New data are fed into the Onchosim model based on program progress such that it is possible to forecast that onchocerciasis could be eliminated from areas with high initial prevalence if 65% coverage of ivermectin treatment were maintained for at least 25 years.

Unlike onchocerciasis control, malaria elimination rests on multiple interventions.  This makes modeling much more urgent, as outlined by malERA’s research agenda for eradication. Since universal coverage unfortunately does not mean universal usage, we need to seek valid data and models to help us plan for distribution of malaria interventions more strategically in ways that are affordable and can be maintained and at the same time can achieve maximum reductions in morbidity and mortality.

Malaria elimination efforts move along a pathway outlined by the Roll Back Malaria Partnership that begins with limited control, moves on to scaling up and then aims as sustaining the scaled up interventions so that incidence drops and we can enter the pre-elimination phase.  The scale up efforts that have been most intense in the past three-year effort to reach universal coverage (UC) have been known by the acronyn SUFI – scale up for intervention.

SUFI and UC are also viewed against the backdrop of RBM targets set in 2000 to achieve 60% coverage by 2005 and 80% by 2010.  The implication is that we may claim success with 20% of the population still not reached, which appears to counter the aims of UC.  Therefore a bigger question is whether we are simultaneously achieving SUFE – scale up for equity.

From the standpoint of malaria control equity should focus on whether those people who are most vulnerable to infection have access to interventions.  Vulnerability or risk has been viewed from two perspectives: 1) people who are more likely to experience infection because of their immune status such as children below 5 years of age and pregnant women and 2) people living in poverty whose financial and housing situation expose them more to infection and whose incomes are more at risk when they suffer from malaria.

Presented here are snapshots from health surveys in Nigeria, Liberia and Senegal that compare household net ownership with wealth quintile (Demographic and Health Survey, Malaria Indicator Survey). These countries have achieved differing levels of coverage and access to low income groups that help us question how equity relates to malaria control.

Nigeria is characterized by low overall coverage. During recent discussions at a retreate among maternal and child health professionals, colleagues raised the question of whether we can consider equity when coverage is very low. Nigeria prior to the mass net distribution efforts of 2009-11 provides some interesting information for the discussion. Although households in the lower wealth quintiles are slightly more likely to have any kind of bednet, the ownership of an insecticide treated net (ITN) is much greater in the wealthier homes. This may not be unrelated to the fact that ITNs in the early phases of control were often sold or subsidized, limiting their access to people with better income.

Liberia and Senegal with moderate and higher levels of coverage display the same overall trend as Nigeria with poorer household more likely to have some kind of bednet, but when it comes to ITNs, the poorer ones also have some advantage.  At the time of their surveys, both Senegal and Liberia had been doing some mass net distributions, and the benefit to the lower income people in their countries seems apparent.  It should be noted that higher income people may not need nets as a main protecteive measure if they live in better constructed homes that usually have window and door screening, an expensive intervention on its own.

One might conclude that Universal Coverage does have a strong equity or SUFE component.  We also need to investigate whether other interventions like prompt case management and intermittent preventive treatment are also reaching the people in most need.

Use of long lasting insecticide-treated nets has an impact on malaria transmission, but the key to achieving an effect is ensuring that people both own and use the net.  A study from southern Benin has taken this process to the next level. Georgia Damien and colleagues found that, “only correct use of LLINs conferred 26% individual protection against only infection.”

The authors distinguished the use of LLINs – whether children were sleeping under it during the control – from the correct use – whether the LLINs were correctly hung and tucked and were not torn.
As reported by other sources, possession of a LLIN, in this case over 90% of households in a southern Benin community, did not guarantee use, which varied on average from 73% in the rainy to 67% in the dry seasons.  Correct use likewise varied from 68% to 42% by season.

Although the Benin study implies that the protective effect of nets may result only from ‘correct use’, earlier work in Ghana showed that some protection was possible even if a household did not have LLINs.

Binka and co-researchers reported that, “The death rate among unprotected individuals increased with distance from the nearest compounds with bed nets. This suggests that (insecticide-treated nets) are protecting other individuals without bed nets who sleep close to protected compounds.”

Much of our hope for achieving morbidity and mortality goals rests on what could be called this community protective effect of nets, since it is difficult, considering the nature of human behavior, to expect everyone to use a net, let alone use it correctly.

We now know our goal for universal net coverage will not be met until well into 2011. The challenge as can be seen in the photos is not just distribution, but effective community health education to ensure that nets are valued and used correctly.

Whether overnight stays in farming huts poses a risk of malaria infection is a question being asked by researchers in Laos. Daisuke Nonaka and colleagues determined that “staying overnight in farming huts was not associated with an increased risk of malaria infection in the setting where ITNs were widely used in farming huts.”

Net use was greater in the rainy reason than dry in both farm huts (95% vs 66%) and main residences (82% vs 86%), and there were fewer nets on average in huts in the dry (1.1) and rainy seasons (2.3). The average number in main residences decreased from 3.1 in the dry to 2.1 in the rainy seasons.  This implies some movement of both people and nets between residences and seasons.

Another interesting finding was that there was higher prevalence of malaria when 5 or more people shared a net. Though the findings do not specify whether these sharing practices vary by residence or season, one might suspect a bit more crowding in the farm huts, and this should be explored.

Ensuring adequate number of ITNs to achieve universal coverage when people have one residence is a big challenge. In fact most procurement estimates are based on population, not residences.  Are there enough nets to cover all sleeping spaces, even if this means extra nets for a family?

Researchers in Tanzania when net supplies were not as large as today found that, “The household’s location at the time of interview (whether at their farm or village homes) was associated with parasitemia, and those residing at their farms were more likely to be parasitemic than those at their village houses, all other things held constant.”

Likewise, we found that mobility between farm and town settlements affected availability and use of cloth filters to prevent guinea worm.  Absence from the farm settlement at the time of ivermectin distribution is an important factor that affects coverage in onchocerciasis prevention efforts.

Unlike bednets, cloth filters for guinea worm can be more easily carried from one residence to another, and ivermectin pills can be kept easily until a mobile villager comes back.  Bednets by themselves pose challenges of hanging in even one residence, but ultimately we need to address the challenge of matching bednet supplies with the fact that rural people can have more than one residence in order to eliminate the disease.

Widespread efforts to scale up insecticide treated net ownership to meet 2010 Universal Coverage targets are underway in most endemic countries of Africa.  The majority have been using their Global Fund grants to make this leap, supplemented by contributions of other partners.

What happens when a country does not have Global Fund resources at this time? Current efforts in Sierra Leone to reach its nearly 6 million citizens provide a lesson on how to cope.

The AFP has reported on a “20-million-dollar campaign to distribute mosquito nets has been funded by the World Bank, the British Department for International Development (DFID), the Federation of the International Red Cross, the United Methodist Church and other health partners.” These partners are “attempting to get insecticide-treated mosquito nets into each household in the country and to ensure their proper use,” using a house-to-house campaign, which is challenged by poor road conditions.

VOA quotes Lianne Kuppens of Unicef in Sierra Leone who said, “”We have roughly 6 million people and we have 3.2 million bed nets already in the country as we speak. So it’s the first time ever that we are going for universal coverage of bed nets.”

Kuppens also noted that ITN use by children below 5 years of age was below 25%, a problem exacerbated by net mis-use – “nets often find their way into the marketplace or are used as fishing nets or shower scrubs. Vegetable growers use mosquito nets to protect cabbages and carrots from harmful bugs.”

VOA also reports that the campaign has a strong “hang up” component that is using “Street theatre, community radio and religious leaders (to) help convince people that hanging their nets over their beds is better in the long run than selling them or catching fish with them.”

But back to the Global Fund …

Sierra Leone’s experience with the Global Fund (GF) may certainly be influenced by its status as a post-conflict country.  The Principal Recipient of the current Round 7 Grant, the Ministry of Health, has, according to GF progress reports, experienced some management challenges.

The Round 7 grant has been running for 2 years and just recently received a “conditional Go” for Phase 2 funding.  ITNs were a small piece of this grant that aimed more at improving malaria treatment.  By 30th April 2010 the grant had distributed only 277,093 of a targeted 312,498 nets for young children and pregnant women.

While the GF does not attempt to strengthen health systems directly, it certainly makes it possible for countries to use grants for their own health system strengthening efforts. More countries should take advantage of this potential. In the meantime, partners should continue to pull together as is the case in Sierra Leone to ensure Universal Coverage.

The Center for Global Development developed a Millennium Development Goal trends report to coincide with the MDG Summit this week. The Report explains that …

The MDG Progress Index includes only 8 of the 60 progress indicators tracked and reported by the United Nations (see appendix I for complete list). We selected these 8 core indicators due to their (1) accuracy in capturing the original Millennium Declaration goals; (2) data availability; and (3) usage in the development literature.

The authors “… excluded … five malaria indicators because of the lack of available data – especially for baseline years.” Ideally the baselines should have been around 1990.  It was not until around the time that the Roll Back Malaria Partnership was formed that there was agreement on malaria indicators to be tracked and their actual measurement was done.

One of the excluded indicators was, “Proportion of children under 5 sleeping under insecticide-treated bednets.” Out of interest we examined DHS reports from three countries where ITN use was reported – Ghana, Nigeria and Zambia – as seen in the charts below with 2002/03 and 2008 information available.

These three countries present very different pictures, but none were approaching the 2010 RBM target of 80% coverage during their 2008 surveys.  Nigeria with the highest burden in sub-Saharan Africa was the farthest and had made the least progress. Zambia is said to be among the best performing countries and yet it was just a little over halfway to the 2010 target in 2008.

Maybe the move toward Universal Coverage will produce some major jumps in these indicators. But already some countries like Ghana have had to re-evaluate the feasibility of the 31 December 2010 Universal Coverage target due to net procurement challenges. Ghana now is aiming for 2011 to ensure there is at least one LLIN for every two people.

We may not have perfect data to track all MDG indicators, but we should use what is available to aid the planning and decision making to reach targets and sustain them.

Guest Blog by Tony Anammah, DELIVER PROJECT, Nigeria

The Universal LLIN campaigns in Sokoto, Kebbi, Kaduna and Adamawa States had one thing in common – the LLINs were provided alongside other interventions like immunization (especially polio), nutrition screening, vitamin A supplementation, deworming and provision of ante natal care services.

A quick assessment of what transpired during the Child Health Week in these states showed that there was some level of success in integrating the interventions in the above metioned states. This success was in terms of the fact that communities were more willing to accept polio immunization because of the  ‘mosquito’ nets. The Immunization Plus Days (IPDs) actually provided a good structure for the delivery of these nets to households and the structure designed for the distribution of the nets (if it had been stand alone campaigns) was modified to incorporate all the interventions.

The challenge was not if the communities will accept the nets or ensuring that the nets gets to all the communities. The major challenge is if the households will actually use the nets. This needs to be closely monitored and followed up. There was an end process monitoring after the campaigns but it will be interesting to know how well the households are using their nets some months later.

Even though there were some successes, there were a number of challenges. One of such challenge was that the time to plan for such an elaborate campaign to integrate all the interventions was evidently too short and there were clashes in programmes delivery strategies. There were some level of cooperation between the programme managers but at the same time, each manager was equally keen on delivering on their individual programme obejectives.

On the average, it can be said that there was some level of success but  it will be wonderful to see if this kind of attempt to integrate interventions can be sustained and lessons learnt incorporated into strategies. But most importantly, it must be ascertained if integrating these interventions has actually been beneficial to the fight to reduce mortality due to malaria.