This 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

In 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:

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