Nets, Mobility and Universal Coverage

alma-countdown.jpgThe 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?

filter-use-at-home-2.jpgGuinea 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.

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