A group of entomologists from the PMI VectorLink Cote d’Ivoire team. This photo was taken prior to the COVID 19 pandemic.
A new study funded by the U.S. President’s Malaria Initiative (PMI) and led by the PMI VectorLink Project found that new vector control tools, such as insecticide-treated nets (ITNs) treated with chlorfenapyr and the synergist piperonyl butoxide (PBO), may help to provide better protection against malaria in Côte d’Ivoire than those currently used. Previously, ITNs treated with pyrethroids alone were the primary net choice in Côte d’Ivoire because they were the only type of ITN available and the pyrethroid insecticide was effective in killing vector mosquitoes on contact. The nets provided additional benefits by serving as a physical barrier between people and malaria-carrying mosquitoes, protecting communities from malaria as they slept. Unfortunately, the widespread use of pyrethroid insecticides has resulted in mosquitoes building up resistance to the insecticide, making the pyrethroid-treated nets less effective.
The mosquito’s resistance to pyrethroid insecticides has had serious implications in the efforts made to control the Anopheles mosquito population in Côte d’Ivoire. As mosquitoes increasingly become resistant to all pyrethroid insecticides across the country and much of Africa, National Malaria Control Programs (NMCPs) are challenged with finding new ways to protect populations from malaria. This study, published in the Malaria Journal in December 2020, demonstrated the relative increase in effectiveness observed when exposing the pyrethroid-resistant mosquitoes to either PBO in combination with pyrethroids or to chlorfenapyr. Both options represent avenues for NMCPs to develop insecticide resistance management strategies. In Côte d’Ivoire specifically, Interceptor® G2 (IG2), a chlorfenapyr- and alpha-cypermethrin-treated net was identified as an option for a stratified distribution campaign in addition to PBO nets.
Despite multiple mass distribution and education campaigns to promote the continuous use of ITNs in country, malaria still accounts for about 33% of consultations in health facilities, with children and women being the most vulnerable populations. WHO 2019 (World Malaria Report) reports Côte d’Ivoire having an incidence of more than 250 cases per thousand people in at-risk populations. In the same period, malaria incidence has doubled in children under the age of five years old (NMCP Annual Report 2019). Given the variable insecticide resistance trends of vectors and the heterogeneity of malaria endemicity across the country, implementing a strategy for the distribution of the new nets required extra consideration. VectorLink Côte d’Ivoire provided technical support to the NMCP to conduct entomological monitoring to help select the most appropriate nets for use in country. Insecticide resistance data collected by the project and the country’s research institute consortium in previous years were used to profile the country and stratify districts for the upcoming 2021 mass net distribution campaign. Once the most appropriate nets were selected based on entomological findings, Global Fund, PMI, and NMCP allocated PBO and Interceptor G2 nets across districts where each type of net’s active ingredients was found to be efficacious against the local mosquito population.
With 113 health districts and varying resistance patterns across the country, PMI VectorLink’s ability to prioritize the districts based on mosquito susceptibility to insecticides used on the Interceptor G2 and PBO nets helped the country make the best use of limited resources. The NMCP Coordinator, Dr. Antoine Mea Tanoh, commended the project’s use of entomological and epidemiological data to guide the strategic deployment of insecticide-based vector control interventions to protect the population. Armed with the most accurate and relevant entomological data, Côte d’Ivoire was able to procure the necessary 19, 313,573 nets to ensure the entire population of nearly 28 million people across 113 districts received the most appropriate ITN intervention for the upcoming campaign.
The U.S. President’s Malaria Initiative (PMI) VectorLink Project promotes gender equity at every level of indoor residual spray (IRS) operations. IRS treats the inside walls of homes with long-lasting insecticides; it kills mosquitoes and disrupts the transmission of malaria. To celebrate International Women’s Day the PMI VectorLink Project is highlighting just a few of the women working hard to protect those most vulnerable from malaria. From supervisors to spray operators to truck drivers, women are doing it all.
When the COVID-19 global pandemic led to lockdowns and travel restrictions, the U.S. President’s Malaria Initiative (PMI) VectorLink Project adapted its work in the field to continue to protect people from malaria while mitigating the risk of COVID-19. Furthermore, the project modified its monitoring activities, including assessing the efficacy of vector control tools, such as insecticide-treated nets (ITNs).
The PMI VectorLink Project works with National Malaria Control Programs (NMCPs) to assess the durability and estimated average useful life of an ITN. These durability monitoring studies generate data on the survivorship, physical durability, and insecticidal effectiveness of ITNs over the three years following a mass distribution campaign.
However, the COVID-19 pandemic presented serious challenges to implementing durability monitoring since data is gathered using an in-depth household survey, net assessments, cone bioassays, and chemical content testing. The PMI VectorLink Project had to adapt quickly to mitigate the risk of COVID-19 for study participants and field teams so ITN durability monitoring activities could continue in nine countries.
These adaptations included wearing masks and gloves while in the field, frequent use of hand sanitizer, switching from written to oral consent to participate in the study round, limiting the number of individuals in field vehicles, and altering the method of net assessment by measuring holes with a ruler on the outside of the net to minimize contact with it.
Training processes were also altered in response to COVID-19. In all nine countries, PMI VectorLink Project conducted online training-of-trainers (TOT) followed by an in-person field worker training. In total, 162 hours of virtual TOT were conducted with 78 individuals from local data collection agencies, NMCPs, VectorLink, and global partners. Following TOT, local study leads conducted in-person fieldworker trainings to prepare fieldworkers for data collection. In-person activities reinforced COVID-19 mitigation measures, with trainings conducted outdoors where possible, participants maintaining physical distancing guidelines, and masks worn by all participants.
Burundi, Ghana, Liberia, Madagascar, and Niger were all scheduled to conduct data collection before August 2020, but a variety of in-country COVID-19 restrictions prevented activities from being carried out as planned. As soon as country restrictions were lifted, fieldwork continued with only minimal delays. Between September and December 2020, Burkina Faso, Kenya, Rwanda, and Sierra Leone conducted data collection as scheduled. By the end of 2020, PMI VectorLink had effectively and efficiently carried out all planned 2020 activities over five months rather than the originally planned 10 months.
For all nine countries combined, over a period of 140 days, data collectors visited 314 clusters where 126 fieldworkers were involved in administering surveys and assessing cohort mosquito nets. To date, 3,600 households have been visited, data has been collected on 7,600 nets, and more than 3,500 nets have been assessed for holes.
In addition to the household surveys and cohort nets, fieldworkers also collected 630 campaign nets to undergo bioassay analysis. These tests were conducted by seven different partners in Burkina Faso, Burundi, Ghana, Kenya, Liberia, Madagascar, and Niger.
Bioassays were also performed on new types of nets (piperonyl-butoxide [PBO] and Interceptor G2 brand [IG2]) for the first time as a part of the Burkina Faso study. PBO and IG2 nets are likely to play an important role in controlling pyrethroid-resistant malaria vector species and were distributed in Burkina Faso in 2019. Bioassay standard operating procedures (SOPs) for PBO and IG2 brand nets were developed by PMI, and Burkina Faso was the first PMI VectorLink-supported country to conduct durability monitoring of both PBO-synergist and dual active ingredient nets, in addition to standard pyrethroid nets. The Research Institute of Health Sciences (IRSS) in Bobo-Dioulasso successfully conducted cone bioassays of pyrethroid and PBO nets and tunnel tests with IG2 nets using well-characterized pyrethroid resistant and susceptible colonies of An. gambiae s.l. Experience from baseline tests led to SOP revisions, including a standardized approach to characterization of pyrethroid resistant Anopheles for use in bioassays and increasing the number of positive control new nets to quantify any loss of efficacy more accurately in field nets.
Dr. Gauthier Tougri, Medical Epidemiologist and Program Coordinator for the Burkina Faso NMCP said, “Burkina Faso introduced new generation ITNs [PBO and IG2 nets] for the first time during the universal ITN distribution campaign in 2019. It was therefore timely to conduct this durability study which should allow us to confirm not only that the insecticides used remain effective on existing Anopheles in areas where resistance had been observed, but also that these nets can indeed remain effective during the time interval between distributions.”
In 2021, PMI VectorLink will be conducting durability monitoring studies in 11 countries (Burkina Faso, Burundi, Cote d’Ivoire, Ghana, Liberia, Madagascar, Niger, Rwanda, Sierra Leone, Uganda, and Zambia). In addition, VectorLink will prepare for streamlined durability monitoring activities in Malawi and Nigeria to begin in 2022. VectorLink will draw on its COVID-19 lessons learned to successfully manage these studies: remote training of trainers’ sessions will be conducted to support local study teams, and all in-person trainings and fieldwork will comply with COVID-19 mitigation measures. VectorLink has strengthened in-person training guidelines to further minimize risks to participants and presenters. With advanced COVID-19 planning, all 2021 studies are expected to be conducted on schedule, continuing PMI’s commitment to support NMCPs to generate data on ITN durability.
Passionate. That’s how one would describe Prince Owusu’s commitment to fighting malaria. For nearly two decades, Prince has promoted the use of bed nets across Ghana. With a Master of Science in Development Management from Kwame Nkrumah University of Science and Technology and a Master of Business Administration from the University of Wales, Prince is deeply dedicated to bringing insecticide-treated nets (ITNs) to those most vulnerable to the deadly disease. Recently, Prince talked about his work as PMI VectorLink’s ITN Lead and what led him here.
What is your personal experience with malaria?
In the past, I experienced at least two episodes of malaria a year. However, I’ve had no malaria for the past 5-6 years. As a parent, I’ve had a few unpleasant experiences with my children suffering from malaria. Fortunately, they hardly ever get malaria now. Our household malaria prevention does not only revolve around sleeping in ITNs but also ensuring a minimum or no entry of mosquitoes indoors. I make sure doors are closed when not in use and that the window screens have no holes. We also make sure there are no stagnant waters around the house that could serve as breeding places for mosquitoes.
Additionally, my work interactions with pregnant women and children suffering from malaria has made me very passionate about promoting malaria prevention efforts among households. I have a strong passion in seeing malaria-free healthy households so that children, pregnant women and all members are healthy and can go about their normal duties.
What is your role as the ITN Lead for the PMI VectorLink Project?
My role is to ensure all ITN-related malaria prevention planned activities are implemented and achieve high quality results. I work with the National Malaria Control Program (NMCP) vector control team to ensure households obtain ITNs through mass campaigns and routine channels, such as health facilities and schools. I also develop social and behavior change interventions to promote consistent ITN use and care among household members in efforts to reduce malaria. A key intervention being implemented is encouraging school children to drive ITN use and care among their peers, parents and in communities through drama and other community engagements.
How did you get involved with malaria prevention?
I’m a trained agriculturalist and started my career as an agricultural marketer. In that role, I was introduced to insecticides for bed net treatments. At the time, we didn’t have long-lasting insecticide treated nets. Increasingly, I became more interested in public health.
What do you find most challenging about your job?
There are basically two challenges: ensuring ITNs reach every household and closing the gap between ITN ownership and use.
What is challenging about reaching every household?
If we distribute ITNs through the routine channel of health facilities, we are targeting children receiving immunizations and pregnant women. We can miss a lot of people that way. Also, in remote areas, the terrain can be rough. Health workers will often use motorbikes when larger vehicles can’t travel the roads. There are times that the motorbikes don’t have the capacity to carry the adequate number of nets needed.
During mass distribution of nets, we have to think about how we can reach every household. Households need to be registered in advance so that we know how many nets are needed. Registration officers are allocated to communities. If community boundaries aren’t well-marked, pockets of households may not be registered, and they can miss out on receiving a net. Other times, people may not be home during the days to be registered. So, we have to be sure we return to these households in the evenings or on the weekends. Furthermore, the most vulnerable may not have houses.
How does someone without a house get and use a net?
We demonstrate how nets can be used in open spaces. For instance, long distance truck drivers often park by the roadside and sleep under their trucks near a fuel or police station for security reasons. We show the drivers how they can hang the net under the truck to protect themselves from mosquitoes.
Can you talk about the barriers to closing the gap between ownership and use of ITNs?
The project has developed behavior change interventions to increase use. For example, in the central region of Ghana, we’ve trained community health workers and midwives to serve as ITN champions. They model good ITN behavior and wear a badge that says, “I sleep under an ITN every night, and I recommend you do the same to protect yourself and your household.”
We also use posters to communicate the information. When communities meet, we ask influential leaders, such as the village chief, to promote positive ITN behavior among community members.
What has surprised you most about working with PMI VectorLink?
The level of dedication and passion that drives what we do as a project. I call it the VL work culture that ensures each employee is motivated to bring out his/her best. This culture also has room for creativity rather than micromanagement.
What impact have ITNs had in Ghana?
Ghana has seen tremendous decline in malaria morbidity and mortality. This can be attributed to multiple malaria prevention and control interventions, with the distribution of ITNs as a key intervention. ITNs provide a physical barrier so the mosquito can’t reach you. ITNs also repel mosquitoes and knock them down, which reduces the number of mosquitoes.
How has distribution changed with COVID-19?
We’ve had to make a lot of adjustments to the way we plan and implement malaria prevention activities. Key among these is the adoption of virtual trainings for regional and district level officers. During the implementation of the 2020 schools ITN distribution, training of regional and district officers was done virtually. We had to conduct in-person trainings for circuit officers with strict handwashing protocols and social distancing (2m apart). Additionally, masks were provided to all participants.
PMI VectorLink Study Finds New ITNs Effective Against Pyrethroid-Resistant Mosquitoes in Côte d’Ivoire
A new study conducted by the U.S. President’s Malaria Initiative (PMI) VectorLink Project found that new vector control tools, such as chlorfenapyr- and the synergist piperonyl butoxide (PBO)-combination insecticide-treated nets (ITNs) may help to provide better protection against malaria in Côte d’Ivoire than those currently used.
Pyrethroid-treated mosquito nets are currently the mainstay of vector control in Côte d’Ivoire. As mosquitoes increasingly become resistant to all pyrethroid insecticides across the country and much of Africa, National Malaria Control Programs (NMCPs) are challenged with finding new ways to protect populations from malaria. This study, which was published in the Malaria Journal in December, demonstrated the relative increase in effectiveness observed when exposing the pyrethroid-resistant mosquitoes to either PBO in combination with pyrethroids or to chlorfenapyr. Both options represent avenues for many African country NMCPs to develop insecticide resistance management strategies. In Côte d’Ivoire, Interceptor® G2, a chlorfenapyr- and alpha-cypermethrin-based ITN could therefore be considered for a stratified distribution campaign in addition to PBO ITNs. The data gathered across the country within this study could also support the determination of the diagnostic concentration for testing the susceptibility status of An. gambiae s.l. against chlorfenapyr while the molecule is still being tested for appropriate concentrations in ITNs and IRS.
Read about the study here.
Learn more about the PMI VectorLink Project’s innovative efforts in mobile data collection.
In the third episode of the PMI VectorLink Podcast, our technical experts discuss recent innovations in mobile data collection to better track, monitor, and implement our IRS campaigns.
PMI VectorLink’s Collaboration with Communities, Civil Society, and Government Leads to Success
At 72 years old, Vwawa Village Chief Rachel Longwe walked more than 10 hours over two days to ensure her whole village knew the U.S. President’s Malaria Initiative’s VectorLink Project was coming to spray their homes with an insecticide that kills malaria-carrying mosquitoes. Having lost two children and one grandchild to malaria, Chief Vwawa is adamant that everyone accept indoor residual spraying (IRS) because of the impact it has on reducing malaria.
Vwawa Village is located in Malawi’s Nkhotakota District along the shores of Lake Malawi, Africa’s third largest lake. In this lakeside district, malaria profoundly affects communities. The economic hardships associated with malaria include loss of income for both the sick and the caregiver, transport expenses to clinics for those in hard-to-reach areas, and missed days of school for children.
In 2018, the U.S. President’s Malaria Initiative VectorLink Project began implementing IRS in the district to reduce the burden of malaria.
“The children in the village were suffering from malaria frequently, almost three times a year,” said Chief Vwawa. “Things have changed with IRS. Before the project began, a lot of people were going to hospital for malaria, particularly pregnant women. Now people are living happily, busy with their economic activities. Now I’m able to cultivate maize and a variety of crops.”
Chief Vwawa, who has 24 grandchildren, also takes part in the project’s entomological studies, allowing her house to be used for mosquito collection to help the project’s entomologists study the behavior of malaria-carrying mosquitoes.
Support and participation from communities is vital for protecting the health of individuals and achieving IRS objectives. While PMI VectorLink has always engaged communities, the project scaled up its engagement efforts when the number of refusals increased during the last campaign and resulted in a drop in spray coverage from 94.9% in 2018 to 88.8% in 2019.
Nkhotakota Director of Health and Social Services (DHSS) Dr. Wezi Mumba said that communities began to believe myths around IRS, such as the idea that IRS brings bedbugs. IRS can cause existing bedbugs to crawl out of walls and surfaces as they try to avoid the insecticide.
“In remote districts, such as Nkhotakota, people’s education is a bit low. A lot of times, people don’t know how to protect themselves from getting sick. For instance, bedbugs often result from lack of hygiene. Communities need information and sensitization. Education is key,” said Dr. Mumba.
In 2020, the PMI VectorLink Project began working more closely with village chiefs as well as with Traditional Authorities (TAs), group village headmen, and community health action groups to ensure higher acceptance of IRS. The project also includes community-based mobilizers on the spray teams to help notify and prepare households for the arrival of the spray teams.
Sub-Traditional Authority Andrew Thupilauma, for the Kalimanjira area has 198 village chiefs under his leadership with a population of approximately 20,000. “Previously, coordination between the project and community and the chiefs wasn’t as strong,” he said. “Now, VectorLink starts with Traditional Authorities (TAs). We pass the messages to the village chiefs and at funerals and other community meetings. The village chiefs then pass the messages to community members. This year communication is so much better. When community members receive messages from trusted sources, acceptance of IRS goes up.”
Working in collaboration with the National Malaria Control Program, PMI VectorLink crafts custom messages to increase the acceptance of IRS and ensure community members are prepared for spray and adhere to safety precautions after their home is sprayed. Through radio talk shows and community meetings, the project can answer community’s questions and concerns.
“We emphasized figures, such as deaths due to malaria before and after IRS,” said Dr. Mumba. “The numbers encourage people to accept IRS and gives communities encouragement. With IRS we’ve decreased the number of deaths by half since 2018. IRS is helping to keep people from getting sick and reducing the cost of expenditures for the hospitals. With the money saved, we can save more people.”
In addition to consulting with TAs during community mobilization, the project’s site managers and team supervisors check in with the village chiefs when entering and exiting the village for the spray campaign. The project also ensures spray operators are recruited locally to promote further trust and buy-in from the community while also bringing income opportunities to the community.
Support for this year’s IRS campaign came from all levels of government, including from Malawi’s Minister of Health, Honorable Khumbize Kandodo Chiponda, who visited the project site on the last day of spray in early December 2020. “The Government is very grateful to PMI VectorLink for the intervention,” she said. “This project will help reduce malaria cases, which are high in the district. We understand IRS is expensive but life has no price tag.”
PMI VectorLink Zambia Implements COVID-19 Mitigation Measures and Successful 2020 IRS Campaign
When cases of COVID-19 were first recorded in Zambia, the Ministry of Health quickly established strict guidance to prevent the spread of the virus. These measures were received with some apprehension about the prospect of continuing malaria prevention activities during COVID-19. The PMI VectorLink Project, funded by USAID and the US President’s Malaria Initiative (PMI), supports the implementation of both indoor residual spraying (IRS) and distribution of insecticide-treated nets (ITNs), along with entomological monitoring to guide vector control decision making. After extensive consultation and in alignment with national as well as PMI and global guidelines, VectorLink developed tailored adaptations to mitigate the risk of COVID-19 infection while protecting the communities from malaria in the three IRS target provinces, and four ITN target provinces where the project works. This guidance was shared with and validated by key stakeholders – the National Malaria Elimination Program (NMEP) and PMI – before implementation.
In accordance with the guidance, recruitment and training of hundreds of seasonal workers was conducted outdoors (in some cases under open tents) to allow for proper ventilation. Hand wash stations were set up at the entrance. All participants had their temperature checked upon arrival, were required to wear facemasks and maintain social distancing throughout the duration of the training. Advocacy meetings with district and traditional leaders adhered to the same measures.
During IRS implementation in 15 districts across three provinces, the same safety standards of daily temperature checks, provision of hand washing facilities, outdoor assemblies, adhering to full PPE use including N95 facemasks, were replicated. VectorLink also secured additional vehicles to ensure that spray teams maintained social distancing while being transported to and from the communities. COVID-19 posters were displayed at all 70 IRS operation bases. Spray teams were also provided with hand sanitizing wipes to wipe down their gloves after spraying each house. All mobilizers who worked with spray teams in the communities were provided with facemasks.
Other members of the project team also adhered to the same safety standards. Project data entry clerks waited a minimum of 24 hours to process data collection forms, entered spray data under open tents, and wiped down their dedicated laptops prior to and at the end of each work day. The project entomology team, whose role is to assess the quality of spray using mosquitoes and follow up on how long the spray insecticides lasts on the sprayed surfaces, observed the same standards.
These rigorous safety measures, which cut across every aspect of implementation, ensured that the 2020 IRS campaign, which utilized more than 2,500 seasonal staff over a 30-day period, sprayed more than 640,000 structures (96% spray coverage), and protected more than 2.7 million Zambians from malaria, did not record one incident of COVID-19. The Head of Vector Control at the NMEP, Dr. Emmanuel Kooma, summed it up thus…“it was a tense situation conducting IRS under the COVID environment. However, I thank VectorLink for strictly observing the COVID prevention guidelines such that we never recorded a single case of COVID. The job is done – a huge relief on my part.”