Category Archives: ITNs

Community Directed Interventions to Enhance PHC and MCH

William Brieger of the Department of International Health, JHU Bloomberg School of Public Health, delivered the keynote address to the Community Based Primary Health Care Working Group at the 2015 American Public Health Association in Chicago. The focus was on Community Directed Interventions (CDI) as a way to enhance implementation of primary health care and maternal and child health. Some excerpt from the talk follow.

Ivermectin coverageThe origins of the CDI Approach are based in Onchocerciasis Control and the implementation research done by the Tropical Disease Research (TDR) Program of WHO and collaborating agencies to help establish the foundational guidance of the African Program for Onchocerciasis Control in 1995. Since then we have seen an expansion of CDI into other health issues

We should start discussion with an understanding of ‘community’ which Rifkin et al. (1988) defined as a group of people living in the same defined area sharing basic values, organization, and interests. White (1982) proposed that community is an informally organized social entity which is characterized by a sense of identity. Manderson et al. (1992) in their work for TDR defined community as a population which is geographically focused but which also exists as a discrete social entity, with a local collective identity and corporate purpose.

Communities are people sharing values and institutions. Community is based on locality (geographic), interdependent social groups, interpersonal relationships expressed through social networks and built on s culture that includes values, norms, and attachments to the community as a whole as well as to its parts. Prior to developing any community intervention we must understand the boundaries, composition and structure of a community from the perspectives of its own members, as their local knowledge and participation are central to success.

community systemsCommunity Systems Strengthening has been taken up by the Global Fund in order to enhance coverage of various health interventions such as HIV drugs and bednets to prevent malaria. Community systems are community?led structures and mechanisms used by communities through which community members and community based organizations and groups interact, coordinate and deliver their responses to the challenges and needs affecting their communities. Many community systems are small?scale and/or informal. Others are more extensive – they may be networked between several organizations and involve various sub?systems. For example, a large care and support system may have distinct sub?systems for comprehensive home?based care, providing nutritional support, counselling, advocacy, legal support, and referrals for access to services and follow?up.

Efficacy, Social Control and Cohesion are important characteristics of communities that enable them to take on project and solve problems. Collective Efficacy is a perceived ability to work together. Social control provides evidence that communities are able to enforce their norms. Cohesion describes social interaction that brings people together. A strong sense of identity and a sense of belonging describe communities that can get things done. These characteristics lead to community competency to collaborate effectively in identifying the problems/needs of the community, achieve a working consensus on goals and priorities, agree on ways and means to implement the agreed-upon goals, and collaborate effectively in the required actions.

Communities chooseIt is important to distinguish between Community Based Intervention (CBI) and Community Directed Intervention. CBI takes place in the community but a Health/Development agency exercises authority over decisions on project design and implementation. Project activities (e.g., service delivery dates and procedures) are designed by the agency. Activities simply happen in the community.

With CDI the community exercises authority over decisions and decides on acceptable method to implement projects. This ensures sensitivity to local decision-making structures and social life. Activities happen both in and by the community; the community is in control.

CDI was pioneered for Onchocerciasis (River Blindness) Control as community directed treatment with ivermectin (CDTI). When communities are in charge, coverage is better than when ivermectin distribution is centrally organized by a health agency. The original 1995 CDI field testing showed better ivermectin coverage when the community was in charge of distribution. Since the beginning of CDTI, over 200,000 villages in 18 African countries have been distributing ivermectin annually through their own efforts. Lessons learned over the years are that CDI works best when 1) the smallest level of an organized community is the basis of action (e.g. a hamlet, a clan/kin group) and 2) communities are encouraged to choose as many CDDs as they think they need to get the job done. This means that the community is in charge, not individual volunteers who can be replaced anytime the community finds the need.

With CDI for onchocerciasis or any other health program, Communities plan and chose how to deliver services. This may be house-to-house, central place distribution or a combination. Health workers provide training and supervision to volunteer village health workers called community directed distributors (CDDs).

CDI study 2008TDR observed that CDI naturally expanded to include other services wanted by the community such as immunization, community development, water and sanitation, agriculture and forestry, HIV-AIDS, family planning, guinea worm, Vitamin A. TDR and APOC then decided that CDI with other service components should be systematically tested. The project sites added in a systematic manner other interventions to existing CDTI programs including home management of malaria, ITN distribution & promotion, TB DOTS, Vitamin A in addition to continued ivermectin distribution. These services varied in complexity and communities responded by dividing the work among several different volunteers.

Appropriate malaria treatment CDI studyCoverage of interventions like malaria case management, ITN promotion and Vitamin A distribution was higher in the intervention areas compared to the delivery of these services through the routine health system. TB DOTS presented the only challenge because of the social stigma associated with the disease. The study concluded that CDI can effectively incorporate high impact, evidence based interventions while at the same time maintaining and increasing ivermectin coverage. Since CDI does not rely on one volunteer but whole community effort, the problem of overburdening on community health worker did not arise. Other incterventions ould benefit from CDI such as Misoprostol, Intermittent Preventive Treatment, Deworming, Oral Rehydration solution, Zinc, Cotrimoxazole, Amoxicillin, Soap for handwashing and WaterGuard treatment kits.

MIPJhpiego an NGO affiliate of the Johns Hopkins University used CDI to deliver malaria in pregnancy (MIP) prevention services in Nigeria including Intermittent Preventive Treatment and Insecticide Treated Nets. Contrary to fears that CDI would detract from antenatal care attendance, the work of CDDs actually ensured that ANC attendance increased over time. Through CDI IPTp coverage increased compared to control communities and more pregnant women slept under ITNs regularly.

Community-Clinic modelJhpiego next expanded CDI for MIP into integrated Community Case Management (iCCM), thus taking community case management beyond community based care. Giving communities responsibility for organizing and managing their services using the CDI approach meant greater access to services whenever people need them. Using the CDI approach to iCCM CDDs reached 7,504 clients who presented signs and symptoms of malaria. CDDs successfully conducted malaria diagnosis using the rapid diagnostic test (RDT) kits. Overall, 47.8% tested positive while 52.2% tested negative. CDDs adhered to guidelines and all the 3,587 clients with positive RDT results received appropriate anti-malarial medicines. As appropriate 21.0% were treated for diarrhoea, 11.0% for pneumonia (of whom 68.0% were referred to the health facility)

CDDsA Supervisory Checklist and Performance Standards were developed and used for Assessing CDD performance. The results were discussed at monthly CDD meetings at their nearest health facilities. This led to further improvements in History taking, Examination, Conducting RDTs for Malaria and Illness Management.

TDR has done further scoping to learn if CDI would be acceptable by health workers and community members in Urban, Nomadic and Underserved Rural Communities. CDI was favorable received. In conclusion we have learned over the years that CDI can involve women, families and communities in meeting their own health needs.

Use of Long Lasting Insecticide-Treated Bednets in Akwa Ibom State Nigeria after a Major Distribution Campaign

hang net Picture1Colleagues[1] from Jhpiego Nigeria and the Akwa Ibom State Ministry of Health are presenting a poster at the American Society of Tropical Medicine 64th Annual Meeting Wednesday 28 October 2015. Visit Poster 1656. In the meantime review some of the net use factors below.

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 conducted a mass net distribution in 2010 during which 1.8 million LLINs in the 31 local government areas (LGAs/Districts).

An estimated 2.7 million nets were acquired with Global Fund support for replacement distribution in November and December 2014. To learn about the outcome of the exercise, the Ministry 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 to gather follow-up information on number of households that acquired nets, hung nets, slept under nets, their reasons for not using nets and sources of information about nets.

Net use by HHInterviewers from each LGA were trained to use the checklist and recognize appropriate net hanging and use. Twelve interviewers were assigned to each Ward of each LGA.

A total of 2,696,476 net cards were issued to households based on two nets per household, and 2,626,966 nets (97.4%) were redeemed. Retention rate in 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%).

source of informationMain 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. Hence there is need to use LLINs throughout the year. In contrast between 2013 DHS (14.1% residents slept under LLIN) and current results is stark and implies that net use may likely decline as nets age.

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.

[1] Enobong U. Ndekhedehe, John Orok, Bright C. Orji, William R. Brieger

 

LLIN distribution campaign processes: Lessons learned and challenges from Akwa Ibom State, Nigeria

using net Picture1Colleagues[1] from Jhpiego Nigeria and the Akwa Ibom State Ministry of Health are presenting a poster at the American Society of Tropical Medicine 64th Annual Meeting Wednesday 28 October 2015. Visit Poster 1657. In the meantime review the abstract below.

Long Lasting Insecticide-Treated Nets (LLINs) protect users from malaria only if they reach the home. A smoothly functioning distribution is essential to ensure nets reach their end users. Routine distribution at clinics helps to HH comp Picture1maintain supplies, but mass campaigns are also needed to replace nets on a wide scale.

The recent LLIN mass campaign in Akwa Ibom State Nigeria offers lessons and challenges on this process. A State support team was set-up and estimated the total nets needed on one net to 2 people. A total of 21,167 different cadres of personnel were recruited from supervisory to outreach jobs. One-day training was conducted in batches in each of the 31 Local Government Areas (LGAs). To begin household mobilizers issued net cards and registered household members Town announcers helped in demand creation.

Volunteer educates Picture1A private firm was hired bring 2,715,160 nets to 1,242 delivery points. A reporting tool tracked and monitored the distribution process. Reports flowed from the distribution points to the Ward supervisor, the LGA team leader and on to the state technical support team. The State team met at the end of each day to review activities and address challenges and re-strategize. The distribution lasted from 18-22 December, 2104.

Overall, thirty-five thousand households were mobilized, and no settlement was reported omitted. 2,715,160 nets were distributed, and 88,049 nets remained in the LGAs, while 23,080 were left in the central store for mob-up. Unfortunately 145 50-net bales were missing. Mobilization led to active involvement of the faith-based leaders, traditional rulers and members of the national youth service corps scheme.

not use net Picture1Despite advocacy, state political officials focused more on upcoming elections that the net distribution. Although demand was created and short term need was met, more attention is needed to longer term use and supplies for routine services.

The remaining supplies unfortunately were affected by security lapses and lost nets and may not serve the needs of complimentary routine distribution. The State needs to assess the long term costs and sustainability of such massive efforts in terms of meeting its malaria control needs.

[1] – John Orok, Bright Orji, Enobong Ndekhedehe, William R. Brieger

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”.

Rationale

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.

Challenge

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.

Action

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].

Reference

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: http://www.who.int/malaria/publications/atoz/who_recommendation_coverage_llin/en/

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..