Category Archives: ITNs

Winning the fight against malaria in Huambo Province, Angola

Colleagues[1] from the Ministry of Health, Huambo, Angola and Jhpiego are presenting a poster at the 64th ASTMH Annual Meeting in Philadelphia at noon on Tuesday 27th October 2015. Please stop by Poster LB-5246 and discuss the results as presented in the Abstract below.

Angola malaria mapHuambo is on of Angola’s 18 provinces, with close to 2 million inhabitants. Traditionally malaria has accounted for a large portion of clinic consultations, hospitalizations, and child and maternal mortality. Angola has three epidemiological strata: hyper-endemic area (north), meso-endemic stable area (central area), where Huambo is located, and meso-endemic unstable area (south).

The main malaria vector is Anopheles gambiae (ss, melas and arabiensis) and Anopheles funestus. Parasitological studies show 85% of cases are P falciparum and 15% are P vivax.

The Huambo Provincial Health Directorate has been working with stakeholders including national and international NGOs, traditional leaders, churches, religious leaders, police, army and media to fight malaria. This collaboration is showing results.

Huambo ProgressCases have dropped steadily from 620,300 in 2008 to 68,547 in 2014. Likewise deaths have declined from 1,559 to 17 in the same period. During this period there has been an increase in training and supervision of health professionals to improve their malaria prevention, diagnosis and treatment skills.

Rapid diagnostic tests have been deployed to all health units. Work with community organizations has resulted in health fairs (Uhayele Vimbo) in more remote locations. Over the most recent 5-year period the number of antenatal care clients receiving two doses of IPTp with SP has increased from 10,938 to 68,183 or from 30% to 54%.

Finally 330,000 ITNs were distributed between 2010 and 2014. The Province and its organizational and community partners are committed to sustaining these achievements in order to further reduce malaria morbidity and mortality.

[1] João Carlos F. Juliana, Jhony Juarez, Clementino Sacanombo, William R. Brieger


Jhpiego Malaria Activities Featured in Posters at ASTMH Annual Meeting

AM15bannerToday marks the start of the 64th annual meeting of the American Society of Tropical Medicine and Hygiene from 25-29 October 2015 in Philadelphia. Please stop by the poster sessions Monday, Tuesday and Wednesday to see a sampling of Jhpiego’s malaria programs. We are featuring Angola, Nigeria, Burkina Faso, Tanzania, Kenya and Rwanda. You can also discuss with Jhpiego staff at Booth #100 in the Exhibition Hall.

Poster Session A Monday 26 October 2015JHPIEGO Logo 2007

  • LB-5094 – Readiness for Malaria Elimination: Using HMIS data to Map Malaria Test Positivity in Huambo Province, Angola – João Carlos F. Juliana1, William R. Brieger2, Jhony Juarez3, Connie Lee3, Clementino Sacanombo1 – 1Ministry of Health, Huambo, Angola, 2The Johns Hopkins University, Baltimore, MD, United States, 3Jhpiego, The Johns Hopkins University, Baltimore, MD, United States.
  • 385 – Health Systems Strengthening: Improving quality of services for prevention of malaria in pregnancy through the Standards-Based Management and Reward approach in Kenya – Augustine M. Ngindu1, Gathari Ndirangu2, Sanyu N. Kigondu2, Isaac M. Malonza3 – 1USAID-MCSP, Kisumu, Kenya, 2USAID-MCSP, Nairobi, Kenya, 3Jhpiego Kenya, Nairobi, Kenya

Poster Session B Tuesday 27 October 2015

  • 969 – Improving provision of malaria services through provider training in Burkina Faso – Ousman Badolo1, Stanislas Nebie1, Moumouni Bonkoungou1, Mathurin Dodo1, Thierry Ouedraogo1, Rachel Waxman1, William R. Brieger2 – 1Jhpiego, Baltimore, MD, United States, 2Johns Hopkins University, Baltimore, MD, United States
  • 680 – Institutionalization of Quality of Care in Health Facilities Improves Management of Malaria in Pregnancy in Tanzania – Jasmine W. Chadewa, Rita Mutayoba – Jhpiego, Dar es Salaam, Tanzania, United Republic of Tanzania
  • LB-5224 – Health systems strengthening – Advocacy facilitates availability of sulfadoxine pyrimethamine for prevention of malaria in pregnancy in Kenya – Augustine M. Ngindu1, Gathari G. Ndirangu2, Wekesa Kubasu3, Isaac M. Malonza4 – 1USAID-MCSP, Kisumu, Kenya, 2USAID-MCSP, Nairobi, Kenya, 3MOH, Bungoma, Kenya, 4Jhpiego,, Nairobi, Kenya Poster
  • LB-5246 – Winning the fight against malaria in Huambo Province, Angola – João Carlos F. Juliana1, Jhony Juarez2, Clementino Sacanombo1, William R. Brieger3 – 1Ministry of Health, Huambo, Angola, 2Jhpiego, The Johns Hopkins University, Baltimore, MD, United States, 3The Johns Hopkins University, Baltimore, MD, United States

Symposium #83 Organized by Jhpiego, RBM Malaria in Pregnancy Working Group – Prioritizing Malaria in Pregnancy as Malaria Transmission Declines – Tuesday, October 27, 2015 1:45 – 3:30 PM

Poster Session C Wednesday 28 October 2015

  • 1655 – Intermittent Preventive Treatment in Pregnancy: Increasing the Doses in Burkina Faso – Ousman Badolo1, Stanislas P. Nebie1, Mathurin Dodo1, Thierry Ouedraogo1, Rachel Waxman1, William R. Brieger2 – 1Jhpiego, Baltimore, MD, United States, 2Johns Hopkins University, Baltimore, MD, United States
  • 1330 – Use of community health volunteers to increase coverage for integrated community case management in Bondo, Kenya – Savitha Subramanian1, Mark Kabue2, Dyness Kasungami1,   Makeba Shiroya-Wadambwa3, Dan James Otieno4, Charles Waka3 – 1John Snow, Inc., Rosslyn, VA, United States, 2Jhpiego, Baltimore, MD, United States, 3Jhpiego, Nairobi, Kenya, 4John Snow, Inc., Nairobi, Kenya
  • 1657 – LLIN distribution campaign processes: Lessons learned and challenges from Akwa Ibom State, Nigeria – John Orok1, Bright Orji2, Enobong Ndekhedehe2, William R. Brieger3 – 1Ministry of Health, Akwa Ibom State, Uyo, Nigeria, 2Jhpiego, Baltimore, MD, United States, 3Johns Hopkins University, Baltimore, MD, United States
  • 1656 – Use of Long Lasting Insecticide-Treated Bednets in Akwa Ibom State Nigeria after a Major Distribution Campaign – Enobong U. Ndekhedehe1, John Orok2, Bright C. Orji1, William R. Brieger3 – 1Jhpiego, Baltimore, MD, United States, 2Ministry of Health, Akwa Ibom State, Nigeria, Uyo, Nigeria, 3Johns Hopkins University, Baltimore, MD, United States

Individual and Household Level Risk Factors Associated with Malaria in Mutasa District, Zimbabwe: a Serial Cross-Sectional Study

Mufaro Kanyangarara and her PhD thesis adviser, Luke Mullany of the Johns Hopkins Bloomberg School of Public Health Department of International Health, have been looking into the challenges of controlling and eventually eliminating malaria in a multi-country context in southern Africa. We are sharing abstracts from her pioneering work including the following which explores risk factors on the Zimbabwe-Mozambique order.

Background: Malaria constitutes a major public health problem in Zimbabwe, particularly in theMAP 2000 and 2015 S Africa north and east bordering Zambia and Mozambique. In Manicaland Province in eastern Zimbabwe, malaria transmission is seasonal and unstable. As a result of intensive scale up of malaria interventions, malaria control was successful in Manicaland Province. However, over the past decade, Manicaland Province has reported increased malaria transmission, and the resurgence of malaria in this region has been attributed to limited funding, drug resistance and insecticide resistance. One of the worst affected districts is Mutasa District. The aim of the study was to identify malaria risk factors at the individual and household levels to better understand what is driving factors associated with malaria and consequently enhance malaria control in eastern Zimbabwe.

Methods: Between October 2012 and September 2014, individual demographic data and household characteristics were collected from cross-sectional surveys of 1,116 individuals residing in 316 households in Mutasa District. Factors characterizing the surrounding environment were obtained from remote sensing data. Factors associated with malaria (measured by rapid diagnostic test [RDT]) were identified through univariate and multivariate multilevel logistic regression models.

Results: A total of 74 (6.4%) participants were RDT positive. Parasite prevalence differed by season (10.4% rainy and 2.9% dry, OR 4.52, 95% CI 2.11-9.69). Sleeping under a bednet showed a protective effect against malaria (OR 0.54, 95% CI 0.29-1.00) despite pyrethroid resistance. The household level risk factors protective against malaria were household density (OR 0.89, 95% CI 0.87-0.97) and increasing distance from the border with Mozambique (OR 0.86, 95% CI 0.76-0.97). Increased malaria risk was associated with recent indoor residual spraying (OR 2.30, 95% CI 1.16-4.56).

Conclusions: Malaria risk was concentrated in areas located at a lower household density and in closer proximity to the Mozambique border. Malaria control in these “high risk” areas may need to be enhanced. These findings underscore the need for strong cross-border malaria control initiatives to complement country specific interventions.

Malaria Status in the 2014-15 Rwanda Demographic and Health Survey

Rwanda is experiencing low and very low levels of malaria test positivity rates, thought there are a few districts near the borders with Uganda, Tanzania and Burundi that have relatively higher transmission. Overall the country is strategizing how to move toward the pre-elimination phase on the pathway to malaria elimination. This is defined as a test positivity rate of less than 5% during the high transmission season.

DHS 2010 Malaria Prevalence in Children 6-59 MonthsIt is important to distinguish between test positivity rate and prevalence rate. The most recent survey report that gives prevalence is the DHS 2010 with a rate of 1.4% in children below 5 years of age and 0.7% among women of reproductive age. During 2010 the health management information system shows that among those tested (microscopy or RDT) for malaria, 24% were positive. The population for test positivity reports is a much smaller group that is already suspected of having malaria. That said, 24% or the 2013 rate of 29% is still far from the 5% cut-off for pre-elimination status.

Rwanda still maintains a policy of universal coverage with insecticide treated nets (ITNs). Rwanda also has a policy that every pregnant woman should receive an ITN during her first antenatal care visit. Ideally in order to reach pre-elimination status, a country needs to sustain high coverage of malaria prevention and treatment interventions at an 80% level for several years.

The newly released preliminary results of the 2014-15 DHS provide an opportunity to examine achievements. The 2014-15 DHS found that 81% of households had at least one ITN, while 43% had achieved the universal coverage target of one ITN per two household members. These numbers remain basically unchanged from the 2013 Malaria Information Survey (83% and 43%), while the 2010 DHS found 82% of households had a net, but did not report on the indicator of one net per two people. In short, it appears that coverage levels have been maintained at a certain level.

DSCN7129a pregnant women get ITNs when register for ANC RwandaDHS 2014-15 shows that 99% of pregnant women in Rwanda received antenatal care from a skilled provider. That means that basically all pregnant women should have received an ITN. 73% of pregnant women had slept under an ITN the night before they were surveyed, while 88% of all women of reproductive age slept under a net. 68% of children below the age of five years slept under an ITN the night before their household was surveyed, while 80% who lived in households that owned an ITN did so.

Indoor Residual Spraying (IRS) is focused on certain high transmission/burden districts. The preliminary 2014-15 DHS does not report on this and the 2013 MIS reports broadly by region, hence one sees coverage reports for IRS in the east (22%) and south (16%), where there is greater malaria burden, but this cannot be linked to specific districts that may have been targeted.

Rwanda also has a policy that all suspected malaria cases should be tested, whether with microscopy in health centers or rapid diagnostic tests by village health workers. It is only those persons testing positive for malaria who are supposed to be given malaria medicine.

DHS shows that 1439 children below five years of age (or 19% of the total) had fever in the two weeks prior to the survey. Of these 36% reported having a blood test performed, and 11% of those with fever received the approved artemisinin-based combination (ACT) therapy drug. The report does not indicate the actual testDSCN7282 results of those receiving ACT.

As Rwanda strategized toward reaching malaria pre-elimination status it can consider ways of enhancing ITN use, not only among vulnerable groups like small children and pregnant women, but all members of the household. As prevalence drops, so does acquired immunity, putting adults at greater risk.

The universal coverage target of at least 1 net for every two people in a household must be maintained, especially since it is nearing three years since the last universal coverage distribution campaign. Either another campaign will be needed or efforts to strengthen delivery of nets to families through routine health services.

In addition prompt and appropriate treatment based on diagnostics can be strengthened. One would have expected more children with fever to have been tested for malaria that the DHS reports.

Internal and external support is needed. Rwanda has been on the verge of reaching malaria pre-elimination status several times in the past decade. Even though malaria is no longer the top cause of death, we should not reduce our efforts to create a malaria-free Rwanda.

Invest in Using Preventive Services: an Update from the 2014-15 Uganda Malaria Information Survey

MIS Uganda 2014-15The Demographic and Health Survey people have just released the preliminary MIS results for Uganda. From the viewpoint to the Millennium Development Goals (MDGs), there are cautiously positive signs.

Insecticide treated bednet ownership by households has reached 90%. Equity appears to have been achieved with the households in the lowest, second and third wealth quintiles registering 92%, 94% and 93% ownership. The highest and next highest quintiles had 85% and 88% ownership respectively. Those in the higher wealth quintiles often have better quality housing that of itself offers preventive benefits.

An interesting number is that over 86% of households obtained their nets through campaigns. It appears that the catch up phase of net distribution is repeating itself and the more sustainable keep up phase where nets are provided through routine services has not taken effect.

Household ownership of at least one net translates into use by only 69% of residents generally, and still only 74% in homes that actually own a net. Net use by ‘vulnerable groups’ was a bit better: 74% for children below five years of age and 75& for pregnant women. Thus we can see that household ownership does not guarantee that we meet the 2010 target of 80% coverage/use.

We have moved from recommending two doses of sulfadoxine-pyrimethamine as intermittent preventive treatment for malaria in pregnancy to three or more. The MIS does not report on increased doses but even for two contacts, only 25% of recently pregnant women in Uganda were covered.

The results show that malaria prevention is still an elusive goal. Thirty per cent of children given malaria rapid diagnostic tests during the survey had malaria parasite antigens. We must invest more in ensuring that preventive interventions are routinely available and are actually used before our attention is diverted from the MDGs to the SDGs.

RBM Consensus: Continuous Distribution of Long-Lasting Insecticidal Nets in Africa through Antenatal and Immunization Services

LLIN Statement HeadingThis statement is issued by the Roll Back Malaria (RBM) Partnership Working Groups on Malaria in Pregnancy and Vector Control, together with the Alliance for Malaria Prevention. Our aim is to appeal for more complete implementation of the WHO Recommendations for Achieving Universal Coverage With Long-Lasting Insecticidal Nets in Malaria Control (released September 2013, revised March 2014) [1]. In particular we wish to draw attention to this recommendation regarding long-lasting insecticidal nets (LLINs): “Continuous distribution channels should be functional before, during, and after the mass distribution campaigns to avoid any gaps in universal access to LLINs”.


DSCN7129a pregnant women get ITNs when register for ANC RwandaIn most settings, pregnant women, infants and children under 5 years of age are at considerably higher risk of contracting malaria and developing severe disease than the general population. In sub- Saharan Africa, up to 90 percent of deaths due to malaria occur in infants and children under age 5. LLINs together with effective case management and intermittent preventive treatment in pregnancy (IPTp) are essential interventions for these vulnerable populations.

Antenatal care (ANC) and childhood vaccination clinics (i.e. those implementing the Expanded Program on Immunization, or EPI) offer effective channels for continuous distribution of LLINs since these provide a venue for structured visits targeting pregnant women, infants and young children. The use of ANC and EPI clinics for this purpose is further supported by the following considerations:

  • In most countries a large proportion of pregnant women attend ANC at least
  • EPI is one of the most equitable programs in child health, with high coverage globally.
  • Availability of LLINs in ANC and EPI sessions provides an incentive to attend and thus improves coverage of ANC and
  • Visits to ANC and immunization sessions are key opportunities for counseling pregnant women and mothers to promote the use of LLINs by pregnant women, infants and young

Other LLIN distribution channels may also offer good opportunities for achieving and maintaining universal coverage in addition to mass campaigns [1]. Each national malaria control program should develop its own LLIN distribution strategy that includes both mass distribution and continuous distribution channels, based on an analysis of the context of its local opportunities and constraints, and then document this in the national strategic plan. Program planning and implementation of continuous LLIN distribution should be conducted under the leadership of the national malaria control program, in conjunction with maternal health and EPI programs, as appropriate. Program implementers have an opportunity to reinforce counseling on the use of LLINs at ANC and immunization services.


Some countries are faced with the challenge of insufficient LLIN stocks. Reports from several countries indicate that LLINs have been reallocated from ANC/EPI services to mass campaigns, as a means of compensating for shortfalls in stocks. However, we are concerned about this practice in the absence of an analysis of the impact on LLIN coverage of vulnerable groups. All possible efforts must be made to achieve or maintain universal coverage and, in the absence of sufficient LLINs, to avoid compromising coverage of vulnerable groups. Recognizing that intermittent mass campaigns are essential to maintaining high levels of coverage, and acknowledging that there may be disruption of routine systems during mass campaigns, every effort should be made to minimize these disruptions. The potential reallocation of LLINs from routine distribution channels to mass campaigns must be informed by local data indicating that this will not compromise protection of vulnerable groups such as pregnant women, infants and children under 5 years of age.


The RBM Working Groups and the Alliance for Malaria Prevention therefore strongly urge national program managers responsible for malaria control, ANC and immunization services, and all health professionals concerned with these services, to heed and rapidly implement the WHO recommendations, which indicate that in addition to mass campaigns, a high priority should also be given to continuous distribution of LLINs during and after mass campaigns – such as through ANC, EPI services, and mother and child health weeks/months campaigns, as appropriate to the local context [1].


1.   WHO recommendations for achieving universal coverage with long-lasting insecticidal nets in malaria control. Geneva: World Health Organization, Global Malaria Programme; 2013 (revised March 2014). Available from:

This statement was developed among the following Partners:

LLIN partners

Monitoring Net Use: Ensuring a Major Investment Pays Off

wmd2015logoJohn Orok, the Director of Akwa Ibom State’s Malaria Control Program in Nigeria, and colleagues have shared with us the follow-up survey results following a mass LLIN distribution campaign in his state in late 2014. Unless we monitor our investments in nets, we will not “Defeat Malaria.”

While long lasting insecticide-treated nets (LLINs) have made a major dent in the incidence of malaria in Africa, LLINs need to be replaced at intervals. Akwa Ibom State Ministry of Health (SMOH) conducted a mass net distribution in 2010 during which 1.8 million LLINs were handed out in the 31 Beneficiary hang her Net 2015local government areas (LGAs/Districts). An estimated 2.7 million nets were acquired with Global Fund support for replacement distribution in November and December 2014. In an effort to learn about the outcome of the exercise, the SMOH organized a follow-up household survey in all LGAs in January 2015.

The state formed a technical working group which developed a checklist and interview guide for to gather follow-up information on the number of households that acquired nets, hung the nets, slept under the nets, their reasons for not using nets and sources of information about nets. Interviewers were recruited for each LGA and trained to use the checklist and recognize appropriate net hanging and use. Twelve interviewers were assigned to each Ward of each LGA.

Who Sleeps Under LLINs in Akwa Ibom StateA total of 2,696,476 net cards were issued to households based on approximately two nets per household, and 2,626,966 nets (97.4%) were redeemed. Retention rate in the sampled households was 97.1%, while hanging rate of those retained was 71.8%%. Overall 69.6% household members reported that they slept under a net the previous night. A greater proportion of pregnant women (92.1%) reported using nets compared to children below 5 years of age (82.3%) and other household members (63.3%). Main reasons for not using nets included feeling hot (44.5%), inability to hang the net (19.7%) and concern about the chemical used to treat the net (11.4%).

Akwa Ibom is located in Nigeria’s highest malaria transmission zone, and hence there is need to use LLINs throughout the year. The contrast with 2013 DHS, where only 14.1% of residents overall slept under an LLIN, results is stark and implies that net use may likely decline as nets age beyond an ideal replacement schedule of every 2-3 years. Even 1-2 months out from a campaign there are people who are not hanging and using nets. Continuous systems for community level education and reinforcement and health system-based routine distribution for periods between campaigns are needed to ensure this major investment in controlling malaria pays off..

Highlights from Malawi’s 2014 Malaria Information Survey

Two major forms of malaria data collection help inform national malaria control programs and their supporters about progress and help focus continued resources and interventions. Routine national health information tells us about program implementation on a regular basis. National surveys give us a point-in-time picture of coverage.  For the latter, Malawi has been fortunate in recent times to have conducted Malaria Information Surveys every two years.

Pf_mean_2010_MWIMalawi continues to have endemic malaria as documented by the MAP project in the attached graphic. While some of its neighbors in southern Africa are moving toward elimination, Malawi still experiences prevalence (as measured by rapid diagnostic test) in children below five years of age of 43%, 28% and 33% in 2010, 2012 and 2014 respectively.

In the chart below we can see that malaria preventive measures have varied in coverage over the three survey periods and may be said to be on a very slightly upward trend.  The Roll Back Malaria target of 80% coverage by 2010 and the US President’s Malaria Initiative target of 85% are still illusive.

In fact, simply having an ITN in the home is no guarantee that people will use it. Overall in 2014 72% of people living in a house with a net slept under one the night before the survey. The rate of use was better for children below five years of age (87%) and pregnant women (85%), but a gap remains.

Malawi MIS 2014 HighlightsOverall coverage for two doses of sulphadoxine-pyrimethamine (SP) for intermittent preventive treatment in pregnancy (IPTp) remains low. Now that WHO is recommending IPTp with SP during each antenatal care visit after 13 weeks, we are aiming for 3, 4 or more doses. In 2014 89% pregnant women in Malawi received one dose, 63% received two and 12% received three.

Malaria treatment for febrile children was the indicator with the best performance (not counting the fact that treatment was not always preceded by a diagnostic test).  Most (93%) of children took an artemisinin-based combination therapy (ACT) drug, and 74% took it within a day of fever onset.

The 2014 MIS provides more detailed breakdown by region and socio-economic group, which should be helpful for planning.  The major take home message though is that five years after the RBM target dates, many countries, Malawi included, have not been able to scale up and sustain the high intervention coverage needed to bring down mortality and guide us on the pathway to malaria elimination.

As the 2015 Millennium Development Goals are being replaced with a broader development agenda, we hope that malaria will not become a neglected tropical disease again. Actually using data from the MIS to take timely decisions by national programs and donors is essential to keep us on the path.

“Zero Malaria! Count Me In!”: Senegal’s national commitment to the Last Mile to Malaria Elimination

Yacine Djibo, Founder & President of Speak Up Africa is helping focus International Women’s Day (March 8th) on efforts to protect women from malaria in Senegal. She is highlighting the commitments of 8 strong and beautiful women, in Senegal, that are dedicated to eliminating malaria in their country. These commitments are part of an inclusive mass communication campaign that aims to launch a national movement in favor of malaria elimination in Senegal: the “Zero Malaria! Count Me In” campaign

ZeroPaluInternational Women’s Day, represents an opportunity to celebrate the achievements of women all around the world. This year’s theme is “Empowering Women – Empowering Humanity: Picture it” envisions a world where each woman and girl can exercise her choices, such as participating in politics, getting an education or fighting malaria. Below is the fifth feature on women fighting malaria.

Mrs. Oulèye Bèye, Head of the Prevention & Partnership Department at the National Malaria Control Program (NMCP), likes to remind us the national claim stating that “Technicians cure malaria but communities fight it”. It is a simple, yet powerful statement that summarizes the very purpose of all our endeavors. Efforts to reach remote populations and positively change communities’ behaviors are a constant battle for the NMCP.

3. Ouleye Beye ENG

Mrs. Oulèye Bèye, National Malaria Control Program, Senegal

The scale up of proven interventions recommended by the World Health Organization, have been essential in achieving this drastic decrease in malaria mortality rates over the years. These strategies include ensuring the availability of Artemisinin-based combination therapy (ACT) in health facilities, the mass distribution of free mosquito nets and the introduction of rapid diagnostic tests.

To be effective, all of them require significant and unconditional uptake by beneficiaries. Needless to say that the successes achieved through effective and safe malaria control campaigns, a strong national leadership and a dynamic set of partners are all at risk, if we fail to realize that populations must no longer be considered as plain beneficiaries but as stakeholders of utmost importance.

iwd_squareBy leading the effort around the “Zero Malaria! Count Me In” campaign at the national level, Ouleye strives to create a popular movement and actively engage each and every Senegalese citizen in the fight for a malaria-free Senegal. Sensitization and awareness raising must be the first step of any malaria elimination intervention if we want to achieve positive results in the long run.


Headquartered in Dakar, Senegal, Speak Up Africa is a creative health communications and advocacy organization dedicated to catalyzing African leadership, enabling policy change, securing resources and inspiring individual action for the most pressing issue affecting Africa’s future: child health.

Insecticide treated nets, a fishy subject

Not long ago I had written a blog posting suggesting that widespread misuse of ITNs/LLINs was probably not a major problem. To date the main official published information on the topic came from a community near Lake Victoria that had received an DSCN0189abundance of nets through uncoordinated donor activity and the excess was being used to dry fish on the shore.

True, newspaper articles over the years have featured Ministry of Health officials in numerous countries berating their citizens not to use nets for fishing, agriculture and other non-disease control needs, but evidence had not been forthcoming in the numerous national demographic, health and malaria surveys over the years. There is also the acknowledged possibility that old nets are being repurposed since there are inadequate disposal mechanisms available.

Such concerns are not idle. We also documented misuse of LLINs in Akwa Ibom State with photographs LLINs for goal post 3of nets used to make football goals, protect seedlings in a nursery, cover small kiosks selling food items and penning animals. This occurred in areas where there was inadequate partnership, planning and follow-up with the community by health officials.

Now the New York Times has stirred up the controversy again with strong visual evidence of a fishing communities in Zambia and Tanzania using ITNs for not only fishing, but also making chicken pens, ropes, footballs and football goals. People in that community explain their economic needs which are huge in this poor area of the world, and present the hard choice between augmenting their livelihoods and sleeping under an ITN. The environmental impact of the insecticides when nets are misused was also highlighted. The immediate thought is that malaria control efforts must be integrated into health and development efforts in a country.

The US President’s Malaria Initiative has issued a statement of concern. PMI recognizes that misuse of nets can depend on the particular environment (e.g. near water), but also recognizes the need, as mentioned above, of collaborating with the community to get things right in the first place. These problems will persist until national malaria control programs focus less on the total numbers of nets distributed and more on the actual factors that influence net use.