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.

Rwanda has been commended for progress made toward eliminating malaria. Just to the south, Burundi appears to be experiencing an upsurge of the disease. Can it be contained?

MSF reports that, “Burundi has been grappling with a serious increase of malaria patients since the start of the year. The MSF teams have been cooperating with Burundi authorities to fight the spread of the disease by treating patients and distributing mosquito nets to prevent new infections.”

Fortunately the Canadian Red Cross has been working in Burundi distributing bednets, but donor support for malaria control in Burundi has not kept up with that of Rwanda.
Rwanda with a population of 9.2 million, has benefited much more from international donor support. Rwanda is in its fifth year of funding from the US President’s Malaria Initiative  and has received Global Fund malaria grants three times of which $109.5 million has been disbursed and another $100 million is in the pipeline.
Burundi with a population of 7.8 million, has just begun to receive attention from USAID’s malaria efforts. Of a current $53 million Global Fund Malaria grant, Burundi has received $17 million. A new Round 9 grant for $60 million has yet to be signed.

Burundi’s Road Map to 2010 shows a gap of 2.5 million long lasting insecticide-treated nets, and nearly half a million doses of artemisinin-based combination therapy drugs. Rwanda has no gap in these commodities.

When moving toward malaria elimination, we need to plan on a regional basis, not just country by country. Neither infected mosquitoes more humans bearing malaria parasites respect borders. Countries may need to be their brother’s keeper in order to protect the gains they have made.

Fortunately the Southern African Development Community‘s malaria elimination strategy enshrines this philosophy of mutual help among neighbors.  Other regions should follow suit.

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.