1. Malaria Technical Update – ITNs
Sixte Zigirumugabe
President’s Malaria Initiative
With thanks to Michael Mcdonald-PMI, Jo Lines WHO-GMP,
Ibrahim Soce Fall-WHO Afro
The Alliance for Malaria Prevention
Behavior Change Communication Workshop
for Long-Lasting Insecticide-Treated Net (LLIN) Scale Up to Universal Coverage and Use
Bamako, Mali 21 – 24 September, 2010 1

2. Why ITNs? Most available tool for malaria prevention
Most easy to use component of IVM
Proven reduction of malaria related morbidity and mortality among the most vulnerable target groups.
AMP
BCC Workshop
Bamako September 2010

3. Conditions for ITNs desired impact
Large Coverage
Adherence: appropriate usage
Insecticide-treatment (LLINs nowadays)
Well designed and implemented BCC
AMP
BCC Workshop
Bamako September 2010

4. Some ITN Use documented facts
Individual protective effect
Reduction in malaria vector population
Reduction in all-cause mortality in infants
Reduction in health facility visits by sick children
Reduction in maternal &placental malaria
Reduction in maternal anemia and LBW
Community/ Mass effect
AMP
BCC Workshop
Bamako September 2010

5. Trends in the use of ITNs 2000-2005 Source: DHS, MICS and MIS 2000-2007
AMP
BCC Workshop
Bamako September 2010

6. Malaria Cases and Deaths in Selected Countries (2001-2006)
AMP
BCC Workshop
Bamako September 2010

7. Increases in ITN Ownership DHS 2005-2008
AMP
BCC Workshop
Bamako September 2010

8. DHS Declines in Under-5 Mortality
AMP
BCC Workshop
Bamako September 2010

9. Reduction in prevalence and anemia
AMP
BCC Workshop
Bamako September 2010

10. ITNs and Pregnancy Pregnant Women in ITN Village: During Pregnancy:
< parasitemia 27%
< anemia 16%
At Delivery:
< placental malaria 20%
< preterm delivery 40%
Higher mean birth
weight 68.8 g
(Ter Kuile, et al. 1999; W. Kenya)
Likewise ITN for pregnant women have a significant beneficial impact. In this study from Kisumu Kenya….
AMP
BCC Workshop
Bamako September 2010

11. LLIN strategies for Universal Coverage –
World Health Organization
25 March, 2017
LLIN strategies for Universal Coverage –
All age-groups - targeting to vulnerable groups only if necessary
Socio-economic equity AND geographic equity
draft indicators & how the mass effect works
Campaigns every 3 years – Yes but not alone!
Current LLIN strategies assume that all LLINs exactly 3 years. Periodic campaigns alone give full and full-time coverage of the target population – but the data says this assumption is false!
Must have Keep-Up too - give equal priority to routine systems – ANC + EPI ?
Re-treatment of local nets during campaigns
Joe Lines WHO GMP
ANC coverage % times # Pregnant women times ITN durability yrs
AMP
BCC Workshop
Bamako September 2010 11

12. Modelling shows how continuous routine distribution through EPI can complement fixed-interval campaigns (Deaths Averted) Joe Lines WHO GMP ?
AMP
BCC Workshop
Bamako September 2010

13. LLIN Durability Need constant flow of location-specific data.
Multi-country studies show unexpectedly large variation in effective life between locations – even more variation between locations than between brands
Evidence that the relative lifespan of different brands is not constant but varies in different contexts
So a global “top five” ranking is not realistic
Draft standard durability monitoring methods (by CDC and MC experts) now being circulated. Should user preference also be included?
Need constant flow of location-specific data.
It is anticipated that this monitoring will be recommended as "good practice" in all large-scale procurements/deployments, for all implementation agencies, and all donors, especially GFATM.
How to feed this data back to inform product choice in GF procurement?
WHO will set standards and criteria for its independence and quality – this is the key condition for procurement
Need for technical support from VCWG to roll-out these monitoring methods
Joe Lines WHO GMP
AMP
BCC Workshop
Bamako September 2010

14. LLIN Durability & Universal Coverage
Responding to a mixture of nets – range of conditions, include untreated nets
- operational research needed, procurement SOPs, Logistics SOPs, Village- and Household-level SOPs
Indices of Universal Coverage
Procure 1 net for 1.8 people at population level in order to achieve 1 for 2 at HH level.
M&E questions – how to enumerate uncovered sleeping places?
Nets per person ratio at programme, village and HH levels
Joe Lines WHO GMP
AMP
BCC Workshop
Bamako September 2010

15. LLIN Durability & Universal Coverage…. Cont.
Do we need to remove old nets?
2 reasons suggested ... Blocking new nets and environmental pollution. But Evidence?
Research project - assess need to dispose and methods ( meanwhile DON”T burn )
Old nets are best re-used within the community – e.g., under the bed, as eave-curtains, or to protect seedlings / cabbages
Joe Lines WHO GMP
AMP
BCC Workshop
Bamako September 2010

16. ITNs distributed in Sub-Saharan Africa 2004-2010 (2nd Quarter)
331 million nets distributed
218 million useful nets
(distributed )
19-20 million nets distributed/month
By end of 2010 enough nets to cover needs….
But what about use?
(Net Mapping Project)
AMP
BCC Workshop
Bamako September 2010

17. Integrated Vector Management: Five Key Elements
A rational decision-making process for optimal use of resources for vector control
Cross sector collaboration
Integrated approach
Advocacy, social mobilization and legislation
Evidence-based decision-making
Capacity-building
AMP
BCC Workshop
Bamako September 2010

18. Insecticide Resistance Sources of Selection
Agriculture
Vector Control
Pollutants in larval habitats
Domestic
Resistance Management
The spread of knockdown rate has NOT been followed by immediate and obvious control failure.
Ideally rotate to non-pyrethroid for IRS
Need to build capacity and fill data gaps
Support IVM
AMP
BCC Workshop
Bamako September 2010

19. Phenotypic pyrethroid resistance
Thanks to Vincent Corbel
AMP
BCC Workshop
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20. Corporate Sector http://www.gbcimpact.org/
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BCC Workshop
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21. Achieving Impact at Scale through partnership
Private, Commercial
Public
Clinical Services
Policy
Standards/Norms
Regulatory
Training
M&E
Consumer Information
Clinical Services
Drug Sellers
Marketing
ITNs
RBM
Distribution
Equity & Vulnerable Groups
Distribution
Sustainability
Clinical Services;
Prevention and Environmental Health activities;
Household and Community Demand Creation
Other Health/community Development Services
CBOs, NGOs
AMP
BCC Workshop
Bamako September 2010

22. Summary : Environmental Health Livelihood Education Malaria HIV/AIDS
Agriculture
Communications
Economic Development
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BCC Workshop
Bamako September 2010 22