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

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

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

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

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

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

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

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

Reduction in prevalence and anemia AMP BCC Workshop Bamako September 2010

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

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

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

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

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

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

ITNs distributed in Sub-Saharan Africa 2004-2010 (2nd Quarter) 331 million nets distributed 2004- 2010 218 million useful nets (distributed 2008-2010) 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

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

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

Phenotypic pyrethroid resistance Thanks to Vincent Corbel AMP BCC Workshop Bamako September 2010

Corporate Sector http://www.gbcimpact.org/ AMP BCC Workshop Bamako September 2010

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

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