Multilateral Initiative on Malaria 2018

April 2018 was a significant and exciting month for malaria, rich with new commitments and milestones reached in the fight to end malaria once and for all. It stated with many partners and stakeholders convening in Dakar, Senegal, for the Multilateral Initiative on Malaria (MIM) conference. MIM, founded in 1997, is an alliance of individuals and organizations that work to strengthen and discover tools for malaria control in Africa through collaborative research and training. PMI VectorLink staff attended and gave presentations on a number of indoor residual spraying (IRS) topics from environmental compliance to data collection and mapping.

Peter Chandonait presented on Environmental Compliance Concerns and Solutions that Arise from Malaria Control via IRS.

Ashley Thomas presented on Technology and Vector Control: How Real-time Data, Mobile tools, and Mapping can Improve Operations and Results.

Allan Were and Dereje Dengela presented on Capacity Building for IRS in Africa.

Ashley Thomas and Dereje Dengela presented on The Impact of IRS on Measures of Malaria Transmission and Incidence.

 

To view the presentations in depth, head over to the Vector Learning Xchange to download and view at your leisure.

World Malaria Day 2018

This year, the PMI VectorLink Project celebrates World Malaria Day by recognizing the many spray operators who defend their communities from the threat of malaria. Since 2006 the President’s Malaria Initiative has protected millions of people in sub-Saharan Africa from malaria through Indoor Residual Spraying (IRS). Our spray operators go household to household to spray insecticide on walls and ceilings – targeting mosquitoes that carry the malaria parasite. The PMI VectorLink Project helps build the capacity of communities to deploy vector control tools like IRS, but without the commitment of our health workers and spray operators, the fight against malaria would be hard lost. We would like to recognize and thank the thousands of malaria fighters who suit up and spray to end malaria.

One such malaria fighter is very special to us. Meet Nidio Macie, a former IRS spray operator who rose in rank to become a district coordinator in Mozambique’s Milange District in Zambezia Province. As a young boy, Nidio dreamed of being a soldier in the military. He wanted to save lives and protect his country from threat. Each morning he would stand in awe as he watched his aunt gear up and head out to the field with her fellow spray operators to ward off the mosquitoes that had been ravaging his community with death and disease.

“Whenever I saw the spray operators, I used to follow them out to their work bases and watch them mix insecticide and load it into their spray pumps. I loved seeing them suited up in their protective overalls – they looked like soldiers to me.”

Watching the spray operators in action motivated Nidio to join the PMI VectorLink Project to fight against malaria. In 2017, PMI protected 1.7 million people in Mozambique from this deadly disease with IRS thanks to malaria fighters like Nidio.

To this day, Nidio’s childhood memories motivates him to serve and protect his community. “There is a motto we use here,” he says, “KILL MOSQUITO, SAVE THE PEOPLE! I go out and I save lives.”

PMI Prevails in Protection

Despite Political Unrest in Kenya, PMI AIRS Provides Protection Against Malaria

Pregnant women and children under five are at high risk of contracting malaria in areas where the disease is endemic. The PMI AIRS Project in Kenya carried out indoor residual spraying in the country’s Lake Victoria region, providing 2.2 million people protection against malaria.

Approximately three-quarters of Kenya’s population is at risk of contracting malaria. In 2017, the U.S. President’s Malaria Initiative (PMI) conducted a successful indoor residual spraying (IRS) campaign in Kenya’s Lake Victoria Region, protecting more than 900,000 people from malaria. The lake region accounts for the country’s highest malaria burden. Based on the success of the 2017 campaign, the PMI Africa Indoor Residual Spraying (AIRS) Project was eager to carry out the 2018 IRS campaign, which aimed to more than double the number of structures sprayed from approximately 212,000 in 2017 to more than 488,000 in 2018.

However, when Kenya’s Supreme Court annulled the country’s presidential election in August 2017, political unrest and violence broke out throughout the country, particularly in the lake region. The lake region is the homeland of Kenya’s opposition leader, center of Kenya’s opposition political party, and traditional home of the Luo minority ethnic community. Roads were frequently impassable because of barricades, tear gas and roadside checkpoints; and businesses and government offices were closed for weeks with key local partners and stakeholders unavailable.

Headquartered in the lakeside city of Kisumu, the project was faced with the challenge of continuing its activities, including IRS, entomological monitoring and health facility surveillance, while ensuring the safety of its project staff. Project staff are from diverse ethnic backgrounds and would need to risk their personal safety to access spray areas, continue pre-IRS planning activities, or collect entomological data to inform vector control.

These challenges could have easily provided reason to cancel the 2018 IRS campaign and delay IRS expansion for future years, however, the PMI AIRS Project and its staff refused to accept the delay, determined to protect people this year. Among the 2.2 million people targeted to receive IRS in 2018, roughly 15% are children under age five and 2% are pregnant women: populations of people with the highest malaria mortality rates and living with the greatest risk of the malaria disease burden.

To successfully increase IRS coverage, the project built 40 new operational sites across the region, purchased 113,990 bottles of insecticide plus other IRS commodities, and recruited and trained an additional 3,888 people to deliver IRS. These sites were in addition to the 28 operational sites and 3,067 people who were trained and worked in 2017. During the prolonged political unrest, expansion of coverage was particularly challenging.

On March 24, 2018, the project accomplished its goals in just six weeks, protecting more than 2.2 million people from malaria in the region burdened with the highest incidences of the illness.

PMI VectorLink Published in the Malaria Journal

The PMI VectorLink Project’s study “Nationwide insecticide resistance status and biting behaviour of malaria vector species in the Democratic Republic of Congo” was published in the peer-reviewed journal Malaria Journal on March 26, 2018. The study found that widespread resistance to permethrin in the Democratic Republic of the Congo is concerning and alternative insecticides should be evaluated to ensure the efficacy of vector control programs.

Globally, the Democratic Republic of Congo (DRC) accounted for 9% of malaria cases and 10% of malaria deaths in 2015. As part of control efforts, more than 40 million long-lasting insecticidal nets (LLINs) were distributed between 2008 and 2013, resulting in 70% of households owning one or more LLINs in 2014. To optimize vector control efforts, it is critical to monitor vector behaviour and insecticide resistance trends. Entomological data was collected from eight sentinel sites throughout DRC between 2013 and 2016 in Kingasani, Mikalayi, Lodja, Kabondo, Katana, Kapolowe, Tshikaji and Kalemie. Mosquito species present, relative densities and biting times were monitored using human landing catches (HLC) conducted in eight houses, three times per year. HLC was conducted monthly in Lodja and Kapolowe during 2016 to assess seasonal dynamics. Laboratory data included resistance mechanism frequency and sporozoite rates. Insecticide susceptibility testing was conducted with commonly used insecticides including deltamethrin and permethrin. Synergist bioassays were conducted with PBO to determine the role of oxidases in permethrin resistance.

In Lodja, monthly Anopheles gambiae s.l. biting rates were consistently high at > 10 bites/person/night indoors and outdoors. In Kapolowe, An. gambiae s.l. dominated during the rainy season, and Anopheles funestus s.l. during the dry season. In all sites, An. gambiae and An. funestus biting occurred mostly late at night. In Kapolowe, significant biting of both species started around 19:00, typically before householders use nets. Sporozoite rates were high, with a mean of 4.3% (95% CI 3.4–5.2) for An. gambiae and 3.3% (95% CI 1.3–5.3) for An. funestus. Anopheles gambiae were resistant to permethrin in six out of seven sites in 2016. In three sites, susceptibility to deltamethrin was observed despite high frequency permethrin resistance, indicating the presence of pyrethroid-specific resistance mechanisms. Pre-exposure to PBO increased absolute permethrin-associated mortality by 24%, indicating that resistance was partly due to metabolic mechanisms. The kdr-1014F mutation in An. gambiae was present at high frequency (> 70%) in three sites (Kabondo, Kingasani and Tshikaji), and lower frequency (< 20%) in two sites (Lodja and Kapolowe).

 

 

PMI Pilots New WHO-Recommended Insecticide

First New WHO-Recommended Insecticide in 40 Years Piloted
in Tanzania

An IRS spray operator prepares the Sumishield® insecticide for spraying. Photo by: Nduka Iwuchukwu

The U.S. President’s Malaria Initiative protects millions of people from malaria each year through indoor residual spraying (IRS), which kills the mosquitoes that transmit malaria by spraying insecticide on the walls, ceilings and other indoor resting places of those mosquitoes. Mosquitoes’ resistance to insecticides used in IRS is growing, however, threatening the impact of malaria control strategies and the spread of the disease. Of the four classes of insecticides recommended by the World Health Organization (WHO) for use in public health programs, mosquitoes in many areas are increasingly resistant to all but one. As a result, the cost of IRS has risen due to the reliance on more expensive insecticides to ensure efficacy of IRS, and insecticide resistance management strategies are difficult to implement given the lack of available options.

Recently, WHO recommended the use of Sumishield® from a new class of insecticides for IRS. The insecticide, developed by Sumitomo Chemical in Japan, is the first new insecticide recommended for use in public health in 40 years.

In February and March 2018, the PMI VectorLink Project piloted the insecticide in Tanzania to assess both community acceptance and any operational issues. The project will monitor the entomological and epidemiological impact of the new insecticide.

The pilot was conducted in Tanzania’s Mara Region in Musoma Rural district. The project sprayed 43,880 structures with the insecticide, protecting 175,116 people from malaria. The pilot was part of a larger IRS campaign in the country, which protected more than 2.6 million people.

Malaria stakeholders are optimistic about the prospect of another insecticide that can be used to help overcome resistance. Ernest Gamba, the National Malaria Control Program’s Malaria Focal Person for Musoma Rural District, said, “We are very thankful our district was chosen to be a pilot district for Sumishield® so that the rest of Tanzania can learn from the experience we acquired by being the first to use this new product.”

Building Capacity for Surveillance

University students on a work experience program in front of the newly built entomology research complex at Nasarawa State University, Keffi. Photo by: Okeke Ifeanyi Joseph

According to the 2017 World Malaria Report, Nigeria accounts for 27 percent of all malaria cases across the globe – the highest of any other country. Effective malaria control programs require strong entomological research institutes and entomologists to allow for effective, data-driven decision making for vector control. Since 2008, the U.S. President’s Malaria Initiative (PMI) has worked in partnership with the Government of Nigeria to strengthen the country’s capacity in entomological research. In 2017, PMI launched the PMI VectorLink Project, which continues to support Nigeria at the national and state level, carrying out vector surveillance activities in seven PMI-supported Nigerian states.

Through the PMI-funded Africa Indoor Residual Project, a predecessor to the PMI VectorLink Project, PMI collaborated with the Nasarawa State University, Keffi, in 2013, to establish the first insectary in North Central Nigeria. The PMI-funded insectary provided a supply of susceptible colonies of Anopheles gambiae s.s. (Kisumu strain), the mosquito most commonly found to carry malaria. The colonies were used to carry out wall bioassays for entomological monitoring during indoor residual spraying (IRS) in Nasarawa State as well as for other entomological research in the country. Up until 2017, the insectary supported entomological surveillance activities at the Nasarawa State sentinel site and provided students with hands-on experience and support with their postgraduate research. The university introduced a postgraduate program in Applied Entomology and Parasitology in the Department of Zoology to help build a cadre of qualified entomologists.

“The collaboration between the Nasarawa State University and the PMI VectorLink Project has led to the strengthening in capacity of our students to conveniently engage in meaningful research, in addition to exposing them to international research standards and methods,” said Dr. Ombugada Ruth Jamila, Head of Department, Zoology at Nasarawa State University, Keffi. “We will continue to appreciate the commitment of the PMI VectorLink Project in promoting academic development and malaria vector control in Nigeria.”

In 2018, the university completed construction of a fully-equipped laboratory complex dedicated to entomological research and to the training of students in the field of medical entomology. The complex includes a general laboratory, a taxonomy/resistance studies unit, a molecular research lab, an insectary, a data repository, presentation rooms, lecture halls, and office spaces. In addition to supporting the university in entomological research and capacity building, the laboratory will also support the PMI VectorLink Project in putting vector control as a key approach to prevent and eliminate malaria in Nigeria.

Music for Malaria Prevention

In Northern Uganda’s Amolatar District, four young adults are dancing and singing to change the way their community views indoor residual spraying (IRS) and, in turn, improving the overall health of their communities.

Anthony Okello, 26 years old, joined the PMI-funded Uganda IRS Project in 2014 as a storekeeper. As a father of two and a village health team member, Okello understood the impact IRS had on malaria transmission. “I was responsible for sending in blood samples for malaria detection,” he said. “Before IRS, seven out ten cases would be detected as malaria. After IRS, there were only about two or three.” Okello also noted that his children rarely get sick now as they did before spraying was introduced to his home.

Despite the benefits of IRS, Okello noticed that many people in his community had refused to allow their homes to be sprayed. In 2015, a year after working with the project, he decided to write a song about IRS to encourage his community to embrace IRS. “Some community members did not understand the importance of IRS. I thought, if I write this song, they can pick up messages from it.”

A former choir member and church leader, Okello had always dreamed of becoming a singer but could never afford to produce music. With the income he earned from his job as an IRS storekeeper, Okello spent 700,000 shillings of his own money to produce the song. He then asked his fellow spray operators to join him in spreading the message at local markets. Okello distributed the song to all 27 storekeepers in Amolatar District. The song is being played at trading centers in the evenings and on market days to help educate the community about malaria and IRS. In addition to IRS messages, the song also includes other malaria prevention and treatment measures, including sleeping under an insecticide-treated net and health care visits for antenatal care for pregnant women and those experiencing fevers and other malaria symptoms. Okello said that in 2015, 20-30 houses were not sprayed. In 2017, that number has dropped to two. High IRS coverage is essential to ensuring efficacy. The U.S. President’s Malaria Initiative has set a target of 85% IRS coverage in communities to kill the mosquitoes that transmit malaria and ensure protection for the community. “The music helped us a lot to mobilize people for the spray activities,” he said. “Many people had listened to the music and learned how important IRS is in controlling malaria.”

“IRS has made me famous in the community. It’s made me a musician,” Okello said. “Before people didn’t think I could advise others like youth and now they always visit me and ask my advice and ask me questions.”

The income also has helped Okello support his family. “I’m an orphan, and many of the elders in my family have died. I was able to take in my niece who is an orphan and pay for her school. My plan is to become a great musician so I can protect my family. And if that doesn’t work out, I’ll keep chickens.”

Annet Amuge, 17, joined the music group not long after becoming a spray operator for the project. “Things are very difficult at home,” she said. “When my father left the family two years ago, he took my baby brother to another district where there is not IRS. My brother got cerebral malaria and now has brain damage. He still suffers from what happened to him. My father didn’t want my brother anymore so now my mother and I take care of him. With my income, I’ve been able to buy a goat and I’m able to help my mom care for my brother. IRS not only helps us to be healthy, but it provides me an income and gave me the courage to dance.”

Twenty-four-year-old Charles Olupot, a spray operator and a member of the music group, said, “When I heard about the IRS program, I wanted to work to get well. I used to feel sick so much from malaria before IRS. Now my family doesn’t fall ill from it.” Before working as a spray operator, Olupot was unemployed. “I used to wear torn clothes and slippers. After two spray rounds, I was able to buy closed-toe shoes for the first time in my life. I have money and I’m enjoying it.”

The job not only provides the youth with much needed income but also with the work experience they need to pursue alternative income-generating opportunities.

“I’ve bought two dairy cows,” said Olupot. “All the members of my family are proud of me. I also want to be a musician. Before IRS, I could not even dance in front of people. Now it’s what I love. We mobilize in the market because we want our community to be healthy. They hear the music and they come, and then we tell them about IRS after we sing and dance.”

Continuing on the success of the PMI Uganda IRS Project, the PMI VectorLink Project will begin spraying in Uganda in April 2018.

Equal Opportunity, Equal Work

The President’s Malaria Initiative (PMI) Africa Indoor Residual Spraying (AIRS) Project’s article “Equal Opportunity, Equal Work: Increasing Women’s Participation in the U.S. President’s Malaria Initiative Africa Indoor Residual Spraying Project” was published in the December 2017 issue of the peer-reviewed journal Global Health: Science and Practice.

This important article discusses how the PMI AIRS Project’s gender policies are increasing the engagement of women in all aspects of spray operations, especially in supervisory roles.

One of the primary control measures for malaria transmission is indoor residual spraying (IRS). Historically, few women have worked in IRS programs, despite the income-generating potential. Increasing women’s roles in IRS requires understanding the barriers to women’s participation and implementing measures to address them. The U.S. President’s Malaria Initiative (PMI) Africa Indoor Residual Spraying (AIRS) Project is the largest implementer of IRS globally. To address gender inequity in IRS operations, PMI AIRS assessed the barriers to the participation of women and developed and implemented policies to address these barriers. Read more here.

Reducing Costs in IRS

Indoor residual spraying (IRS) has proven highly effective in reducing the burden of malaria. However, the high cost of IRS presents a challenge to scaling up protection in many countries. The President’s Malaria Initiative VectorLink Project is finding innovative ways to reduce operations costs without compromising the quality of the spray. PMI VectorLink hires local community members as seasonal spray operators. In 2018, PMI VectorLink will use bicycles for spray operators in Burkina Faso, Kenya, Rwanda, Tanzania and Uganda to reduce transportation costs.