Tropical Health Matters

Guest blog from Omede Ogu, National Malaria Control Program, Abuja

Nigeria’s LLIN Universal Campaign started in May 2009, and at the moment 15 states have been covered with approximately 24 million LLINs distributed so far. There are 39 million LLINs more to go.

The target is 100% coverage of all the households in the 36 states plus the Federal Capital Territory, targeting 80% utilization. Effort to cover the remaining states is on.

The most challenging aspect for the remainig states is resource mobilization for the operational cost to the tune of over 3 billion Naira (~$20,000,000). Opportunities for support exist however through the States, the Local Government Authorities, The MGD Office and engagement of the private sector, along with resources from other RBM Partners.*

We are expectant and confident that come December 2010 all the households will be covered. This is not only doable but a must. We call for further support for this noble cause using the network of people who read this blog.

Thank you.

*e.g. Unicef, WHO, DfID, USAID, Global Fund, World Bank Booster …

ps – support is also needed to ensure that people hang up and sleep under their nets.

Endemic countries are working hard to reach universal coverage (UC) by 31 December 2010.  With many countries relying on the small number of LLIN manufacturers, there is a big challenge and much competition among countries to get this done. Burkina Faso is a case in point.

For understanding of the situation the country ‘road map’ toward UC in 2010 presents the following information:

• 8,487,000 needed for 2010
• 1,581,000 currently in use
• 7,466,134 expected from Global Fund
• 1,020,866 gap

The actual dates for the mass distribution have been steadily pushed back as Global Fund supplied nets have not arrived and challenges remain to find a donor to fill the gap.

This has not stopped the National Malaria Control Program from getting the process rolling. A national launch was held on 12 July at Nanoro, about 85 km from Ouagadougou. It was expected thereafter that from region to district to health facility level effort would be made to count houses and residents in order to get a good estimate of where nets need to go. It seems that without nets physically present, district level preparations are on hold.

An interesting prospect in the wider net picture is the widespread availability non-treated nets for sale along the roadside. This implies that there must be some level of demand, for which people are willing to pay.

Two questions arise. First, will mass campaigns drive local entrepreneurs out of business? Secondly, if the local businesses persist, what role can they play in keeping up with gaps in net supplies.  Though not as technologically advanced as LLINs, these commercial nets might fill a gap if supplies of longer lasting insecticide packets were also sold.

As the end of December approaches, we come to suspect that UC may occur in waves over the next two years as supplies become available. In the meantime there needs to be research into the local net markets to learn about what is driving demand, the extent of this demand and the potential for the private sector to fill gaps now and as we need to keep up supplies into the future.

The recent meeting of the African Leaders Malaria Alliance (Alma) as part of the African Union summit reconfirmed commitment to achieving universal coverage with long lasting insecticide-treated nets by the end of 2011. The President of Tanzania and Chairman of Alma, writing in The Guardian, explains that, “Successes in malaria control have been substantial. Mosquito-net coverage in 20 African countries is at least five times higher today than in 2000, leading to significantly fewer cases of disease and death.”

While some places like Zanzibar in Tanzania and Rwanda have made serious incursions in malaria morbidity and mortality by concerted efforts at LLIN and malaria medicine distribution, others are facing challenges to meeting the 31 December 2010 goal. Nigeria has completed its mass distribution in only about one-third of its states, and Burkina Faso is still awaiting shipments of the LLINs.

Even when the nets arrive and are distributed, we still need to be vigilant.  Aside from hanging up the nets and sleeping under them in one’s normal place of residence, we also need to be concerned about population movement.

Researchers from the University of Michigan found that, “The greatest risk factor for a child living in an urban area in Kenya was whether the child spent at least one night a month in a rural area. Those children were nine times more likely to contract malaria.”

Movement between rural and urban areas in Africa is quite normal as extended family members are divided between the two areas. Although urban areas are often more hostile to anopheles mosquito breeding and have variable malaria micro-environments, urban residents definitely get exposed to malaria-bearing mosquitoes when they return ‘home’ to the rural village for ceremonies and holidays. It is not uncommon to send children to stay with village grandparents during school breaks and vacations.

These children would not have acquired any malaria immunity in the city. Travel history is an important part of investigations when these children are back in the city and become sick.

The question arises – are there enough LLINs in the villages to accommodate these temporary visitors and protect them from malaria?

Guinea worm elimination efforts faced similar problems – people may have a well or a cloth filter at their main residence in the village but not at their farm hamlet/settlement. Were they to expected to carry their filters back and forth, possibly leaving from family members exposed to infested water supplies at one location or another, or be given at least two filters – one for each residence? Likewise, can we expect people to carry their nets around?

These may seem like insignificant questions when countries are still grappling with just getting and distributing enough LLINs to achieve universal coverage in the next 153 days, but ultimately for elimination to succeed, every case counts, and every preventive effort must be made.

My colleague Bright Orji in Nigeria sent these pictures of creative net uses after the recent mass LLIN distribution. Malaria program managers are worried that people may not hang up the nets after receiving them. These are hung – but not in the right place. The first picture shows how nets cover a farmer’s nursery for young plants.

The next two pictures show a LLIN pen for goats.

The next net pictures shows World Cup fever in Nigeria but will not prevent malaria fever.

Finally, a village ‘super market’ is protected by LLINs

Nigeria DHS 2008 results as well as recent net campaign follow-up survey results have shown that even when households have nets, people do not sleep under them. Now we know why. Our health education/behavior change activities must improve if ownership can become net use.

Is the malaria house in order? NGOs worry about donor funding ceilings that affect their own funding floors, agencies distributing nets need to unlock store room doors and net recipients look at their ceilings and wonder how to hang their nets. This is some of the news that threatens success of efforts to achieve universal coverage.

One man’s ceiling is another man’s floor – so the saying goes. One would hope that support from the Global Fund, The World Bank, US Government and DfID, among others, would be a sturdy floor or foundation on which governments in endemic countries could build a strong malaria control program.

It becomes evident reading an article posted at World Sentinel that if donors to the Global Fund actually succeed in setting funding ceilings, the financial floor to control malaria in endemic countries will become less stable. Specifically, “NGOs are outraged at developments of the current Board meeting of the Global Fund Board to Fight AIDS, Tuberculosis and Malaria, taking place in Geneva, Switzerland. Many donor governments are promoting the establishment of a ceiling on the next round of disease fight grants to developing countries.”

This ceiling would stifle innovation, dampen country ambitions and cost lives according to the Global AIDS Alliance. We have discussed concerns that not all endemic governments are making a serious financial commitment to malaria control, and if the donors’ ceiling drops and their own floor falls, who will make up the funding gap?

An equally frightening part of the ‘malaria house’ becomes evident “even as donations roll in and millions of bed nets pile up (behind the doors of) warehouses across Africa, aid agencies and non-governmental organizations are quietly grappling with a problem.” But even when these nets are released, they may not be used.

“Data suggest that, at least in some places, nearly half of Africans who have access to the nets refuse to sleep under them,” according to the Los Angeles Times. Why are nets not hanging from all ceilings?

The LA Times article gives some reasons why villagers won’t hang nets in their houses: perceived poor ventilation when sleeping under nets, not being sure how to hang them over sleeping mats, and not viewing malaria as a serious enough threat to warrant the inconveniences of hanging and using one. Clearly education on net use has not often gone together with getting the distribution numbers higher. As Sonia Shah says, nets may be “‘gifts’ that many neither want nor use.”

Maybe if we convince donors and governments that nets and other malaria commodities are being used, they will remove their funding ceilings and give us a chance to eliminate malaria from all houses in endemic countries.

The push is in high gear to ensure Universal Coverage of malaria interventions, especially long lasting insecticide-treated nets, by the end of 2010. Nigeria may have the biggest task – aiming to distribute over 60 million LLINs, but all endemic countries are facing the challenge.

The RBM partnership assisted countries conduct a gap analysis last year – known as the road map – in order to identify any funding and/or supply shortfalls. Through this we can see that concerted effort by partners is needed so that universal coverage can become a reality. Examples of the gaps facing universal coverage follow:

• Mozambique – 4.5 million nets
• Botswana – 0.35 million nets
• Angola – 3.4 million nets
• Kenya – 12 million nets
• Burkina Faso – 1 million nets

Let us assume that partners will pull together and nets will be found.  Will the aim of universal coverage thereby be achieved by 2015? One issue that may have been neglected is how long lasting are ling lasting nets?

In Ghana a study collected 255 LLINs 38 months after distribution.  Some key findings were

• An average of 40 holes of varying sizes per net
• Half had seam failure
• Only 15% retained full insecticide strength

Likewise, LLIN maintenance behavior was observed in Laos after 2–3 years of use, and “About 40% of the observed nets had holes/were torn.” Two years after LLINs were distributed as part of an immunization campaign in Togo, 200 nets were analyzed. Apparently 9% were not being used and one-third had unacceptable concentration levels of deltamethrin.

Finally in Uganda washing of LLINs did not appear excessive as in some reports, and so loss of insecticide was possibly attributed to “time which has to be seen as a proxy variable for regular use or handling of the net or exposure to environmental factors.”

The implication is that even if we fill the gaps and achieve universal coverage by December 31, 2010, will we be able to achieve the aims of reduced morbidity and mortality by 2015?  The challenge is more than catch up and keep up. We may in fact need millions and millions of replacement LLINs by 2013.

Bauchi is the next Nigerian state to experience the drive to universal coverage with over 60 million long-lasting insecticide-treated nets expected to be in place nationally by the end of 2010. Nearly 2 million nets are targeted for Bauchi alone.

According to a representative of the National Malaria Control Program, “preliminary report showed that over 15 million LLIN were distributed to beneficiaries between May and December, 2009 in nine states,” out of the 36 total (plus Abuja). This figure is down from the projected 12 states and 22 million nets slated for 2009. Thus, there is even greater logistical and management pressure to reach the remaining 75% of states/people by the end of 2010.

Nigeria is not the only country trying to catch up with net distribution to meet 2010 targets.  Burkina Faso is hoping to cover all households in a campaign in July. In addition, in December the UN Special Envoy’s office explained that Kenya “is facing a “critical” shortage of funding for 11 million nets that must be addressed.”

Sometimes efforts are delayed, as they have been in Burkina Faso and Akwa Ibom State Nigeria, when expected donor support and net supplies are not available when and as expected. The slower than anticipated progress in Nigeria occurs despite the fact that “World Bank, DfID, USAID, and UNICEF … the Global Fund and many other funding agencies, NGOs, and the private sector” have joined together in the effort.

A team of researchers from Burkina Faso and Germany has warned that, “Lack of coordination between donors and international health agencies is leading to the needless deaths of too many African children from malaria.” Even with donor support and coordination, one cannot afford to repeat a massive campaign twice, and so malaria program staff wait until they get the nets they need to reach everyone.

While adequate numbers of nets will likely be in place by 31 December 2010, the battle will not be over. The UN Special Envoy “emphasized that global efforts should focus not only on solving the malaria problem in the short term, but also on sustaining prevention and treatment so that it won’t once again spiral out of control.” He explained that even when we succeed in distributing the needed nets, we must remain on top of the efforts – the achievement will only occur when people actually sleep under the nets regularly.

Researchers from Burkina Faso give us pause to reflect when they reported on “Decreased motivation in the use of insecticide-treated nets in a malaria endemic area in Burkina Faso.”  Continued outreach efforts to encourage people to sleep under their nets every night for years to come may prove more challenging that distributing millions of nets by the end of 2010.

With the big push to achieve universal coverage of long lasting insecticide-treated nets (LLINs) by the end of 2010, most countries are relying on procurement from a few big companies, most not located in endemic regions. As the Roll Back Malaria Partnership explains:

Rapidly scaling up to universal coverage for populations at risk is critical to achieve the targets of 50% mortality and morbidity reduction by 2010 and a 75% reduction in morbidity and near zero mortality by 2015. The principle of scale-up has been promoted since 2005 by the RBM Partnership. This commitment has been reaffirmed by the UN Secretary-General’s call on World Malaria Day in April 2008 to “put a stop to malaria deaths by ensuring universal coverage by the end of 2010” through the use of vector control and case management tools and strengthening of community-level efforts.

Because most country coverage figures show a major gap in net ownership AND use, the term ‘catch up‘ has been used to describe this massive scale up. For example, the recently released 2008 Nigeria Demographic and Health Survey shows

• 17% of households have any kind of bed net, treated or not
• 12% of children under 5 years of age slept under any net
• 11% of these children slept under an ITN
• 12% of pregnant women also slept under any net

Kenya’s newly launched national malaria strategy documents that in 2007 40% of pregnant women slept under an ITN, as did 50% of children under 5 year old.

These figures are well below the 2010 RBM coverage target of 80%. As the UN concedes, “Nigeria and Kenya (are) two nations which together account for one third of the estimated 1 million deaths worldwide from the deadly disease.” While Nigeria alone is in the process of distributing more than 60 million LLINs by the end of 2010, this feat aby itself will not guarantee achieving the MDGs.  As RBM explains …

Even if parasite prevalence falls to low levels, malaria control will not eliminate the mosquito vector, the parasite, or the favorable environmental conditions for transmission in many locations. To keep malaria at bay, countries need to maintain high levels of coverage even in the absence of a large number of cases. Relaxation of control—whether because of the decline in political will, decrease in funding, or some other reason—could lead to resurgence in transmission and to epidemics.

The maintenance phase of intervention is known also as ‘keep up.’ This means replacing LLINs that are damaged or lose their insecticide strength or to provide nets to new members of a population.

RBM has estimated a 4-5 year life-span for LLINs. As Stephen Smith from CDC reminds us, “Long-lasting nets don’t last forever.”  Smith cites data from Laos and Ghana that show in field conditions nets may be effective for only 1-3 years. This in part stems from the fact that manufacturers do not guarantee the strength of the insecticide beyond 20 washings. Behavior change to prevent frequent washings has not been easy. Nets are also damaged with holes and tears, and while this does not affect the insecticide potency, it may expose the sleeping person to mosquito bites.

So where are the continuous net supplies coming from to keep up? The New Times of Kigali provides one answer. “Rwanda’s manufacturing giant, Utexrwa has entered into a partnership with German chemical and pharmaceutical giant, Bayer to produce over 70, 000 anti-malaria bed nets.”

This brings another partner to the continent to join A to Z Textile Mills in Tanzania who through and agreement with Sumitomo Chemical have been producing long lasting nets since about 2003.  Local production has so far not been able to meet the bulk of the scale up needs for malaria control.

Hopefully local production will be positioned to address the keep up/maintenance needs for nets. This will require coordination between manufacturers, national malaria control programs and the private commercial sector to guarantee a market for nets.  This also assumes that WHO’s pesticide evaluation processes is scaled.

Local production is often made synonymous with capacity building. Without a realistic business plan and collaboration among malaria partners, local production may become a disappointment.

A consensus has evolved that as malaria interventions become more widespread and successful, the need for Artemisinin-based Combination Therapy (ACT) medicines will decrease in endemic countries.  As a case in point, The RBM Needs Assessment produced by Burkina Faso in 2008 and used as a base for planning the Round 8 GFATM proposal projected a decline in the number of P. falciparum malaria cases and hence, a decrease in the need for ACT supplies.

While the attached chart shows a projected decrease in malaria cases starting in 2009, there is little evidence that LLIN distribution and use are adequate enough at present to produce such a drop.  Burkina Faso’s RBM Road Map shows that the most recent coverage is LLINs is 24% for children below 5 years of age and 28% for pregnant women.

Furthermore, the major distribution campaign to achieve universal coverage of LLINs in Burkina Faso is not slated to take off until July 2010 at the earliest.

Specifically, the Global Fund reports that, “The Global Fund has shown that where distribution of insecticide-treated bed nets (ITNs), spraying and treatment are scaled up to national population coverage, malaria cases and child mortality can be reduced by up to 50 percent.” It appears that in the countries cited, less than 80% coverage was able to achieve up to 50% reduction in cases over a couple years.

The major challenge though is how to ensure coverage/use after a big campaign, since actual use if often much less than proportions of households possessing nets. Then too, there is the challenge of promoting continued use. Lea Pare Toe and colleagues recently reported research findings on decreased motivation to use ITNs in Burkina Faso. Factors included –

• Acceptance was moderated by the fact that mosquitoes not seen as only cause of malaria
• Use of ITNs adversely affected by functional organization of the houses: e.g. if also cook in sleeping areas, see nets as fire hazard
• Bednets not used when perceived benefits of reduction in mosquito nuisance and of malaria were considered not to be worth the inconvenience of daily use

Universal coverage is not a one-time event. It must be maintained for many years. There must be continuous supplies of nets for new people and to replace old nets.  If after 3-4 years coverage falls, severe cases and mortality will rise as populations would have lost immunity.

And finally, any reduction in ACT need and use depends on use and acceptance of RDTs.  As the chart above shows, we will have no shortage of fever illness episodes even as malaria reduces.  Unless we couple diagnosis AND treatment, ACTs will be wasted and shortages will arise, especially if we reduce our orders of ACTs before we are sure that universal net coverage effects have really begun.

Ten years have passed since USAID’s NetMark Project started, and observances of program closure were held in Washington earlier this week. The project evolved over time, but a constant theme was strengthening private sector partners – manufacturers, retailers and even advertisers – to make a sustainable contribution to international malaria targets for insecticide treated net (ITN) ownership in Africa.

In its earliest incarnation in Nigeria NetMark worked primarily to build the capacity of endemic country based textile and pharmaceutical companies to make and bundle bed nets and packets of insecticide that would be used by the purchaser to soak the nets.  These nets/insecticide bundles began appearing in shops, and were also available through subsidized voucher schemes in some areas.

NetMark even identified local net stitchers to ensure an ever more grassroots approach to net production and distribution. One example was a local NGO that hired poor women to make nets and generate an income. In Nigeria government and donor agencies initially jumped on the idea of locally produced nets, making sizable orders for their control programs.

Then Long Lasting Insecticide-treated Nets (LLINs) appeared on the scene and business nearly dried up for the local companies whose ITNs had to be treated every six months.

Since the advent of LLINs NetMark has partnered with the international manufacturers and endemic country wholesalers to maintain a private sector role in net distribution.  They still hope that LLIN technology will start up soon in Nigeria, thus marking a return to their original goal of boosting local production.

Nigeria, like most countries that are running up to the 2010 RMB goals of universal net coverage, has started massive distribution campaigns of free nets to achieve a two net per household coverage.  Unfortunately, local LLIN production is not currently in the picture, but there is always the ‘keep-up’ side of net programs – quickly and locally available net supplies will be needed to maintain stocks for purchase by interested people and for governments and donors to buy and give newly pregnant women.

An award winning video on the NetMark experience can be viewed on their website.  The documentary stresses sustainability. Medical News Today quotes Juan Manuel Urrutia, AED’s Johannesburg-based deputy director of NetMark as saying,”We worked ourselves out of a job. They don’t need us anymore, and I’m proud of that.” That would be sustainability.

In fact we still need to watch what happens. Will there be a private market in Nigeria after 60 million free nets have been distributed? Will donors and government agencies actually buy locally manufactured LLINs (once they become available) to maintain the keep-up coverage activities at maternal and child health clinics? Will households decide to buy additional nets to supplement their two free nets? Concerted effort by national malaria partners will be needed to provide positive answers to these questions.