While the global community responds to the COVID-19 pandemic brought on by the novel coronavirus, the vector control community continues its commitment to fighting malaria. Although this pandemic may have changed the way that we live and work, our commitment to saving lives remains as strong as ever.
With support from the U.S. President’s Malaria Initiative (PMI), the PMI VectorLink Project continues to deploy life-saving interventions, like insecticide-treated bed nets (ITNs) and indoor residual spraying (IRS), to help reduce the overall strain on health systems by keeping the most vulnerable people malaria-free. Working in close collaboration with country governments, national malaria control programs, and ministries of health, we have been able to adapt our programming to adhere to social distancing guidelines and country-specific practices to continue to reduce the burden of malaria.
Dr. Oliver Lulembo has dedicated his life to treating and caring for people’s health. From his days as a pediatrician to his work as a public health practitioner, Dr. Lulembo has seen the rewards treatment and prevention can have in reducing the burden of malaria. He received his Master of Medicine in Pediatrics and his Bachelor of Medicine and Surgery from the University of Zambia in Lusaka and a Master of Public Health from San Diego State University in California. After years as a pediatrician and clinician, he shifted his career to designing, implementing and managing health programs in Zambia, Botswana and Malawi. From 2008-2012, Dr. Lulembo served as PMI Zambia’s Resident Advisor for USAID. In 2012, Dr. Lulembo retired from full-time work so he could spend more time with his four grandchildren. Now he works part-time as Senior Insecticide-Treated Net (ITN) Technical Advisor for the PMI VectorLink Project in Zambia. Recently, Dr. Lulembo took time late in his evening to talk about his current work with the PMI VectorLink Project.
Can you tell me about your role on the PMI VectorLink Project? In my previous role with PMI, I worked with the Zambia National Malaria Elimination Program (NMEP) on their strategy for vector control interventions to distribute nets, amongst other responsibilities. This was mostly with routine net distribution through antenatal care, the Expanded Programme on Immunizations and supported mass campaigns. Now I am working with the NMEP and the Ministry of Health to help build their capacity to plan, implement, monitor and evaluate the upcoming ITN mass distribution campaign. It’s a very exciting assignment. PMI plans to procure an estimated 2.1 million ITNs for the 2020 campaign targeting Eastern, Luapula, Northern, and Muchinga Provinces.
What is your experience with malaria?
I have experience from many perspectives. One, of course, is as a patient of malaria. Several times. As you grow older, the attacks get less severe because you develop a bit of immunity. So I don’t get many attacks now. Also, I live in Lusaka, which is an urban area. The incidence of malaria here is quite low.
My first born also had malaria, and it was quite a big deal as he became very, very sick. That’s quite typical of malaria. You never know how patients fare in a short period of time, especially if they have not yet developed any immunity. If you don’t intervene with medical treatment, they die. My youngest son also had very severe malaria, which was quite serious.
I also have experienced malaria as a pediatrician. I saw babies and young children who tend to get very severe cases of malaria. Sometimes they come for care very late with complications, with severe anemia, and you can lose them. It’s very sad when you’re working with children. The last thing you want is to lose a young life.
Can you talk about the importance of the ITN campaign in the face of COVID?
It’s extremely important, and the good thing is that the government, MOH and partners, such as PMI, are communicating that. We know that COVID-19 and malaria share symptoms, so you get things that are common in both the virus and malaria. Our messaging tries to address that. We cannot afford to let our guard down. We need to maintain our interventions to avoid or abate deaths. That’s been the message consistently. Let’s maintain the prevention control measures, the treatment and other things that make sure we control malaria in this country.
Unfortunately, COVID-19 has diverted part of the workforce from the key interventions related to malaria. It also has changed the way people seek healthcare. So we may not be seeing as many people coming through for care. The international supply chains, including nets, have been delayed slightly. We’ve also seen commodities for testing malaria delayed, so it’s worrisome. But the message has been very clear. We must maintain intervention services.
What has surprised you most about the project?
With the PMI VectorLink Project, the main program has been IRS. Now, it’s working in nets and that’s when I became involved. We are helping the NMEP to implement this huge campaign, which is very different from the previous campaigns that have been implemented before. The past campaign in 2017 was a universal campaign, so it was one net for every 1.8 people. This time around it’s a very special type of campaign. It’s complicated because there will be some communities that receive IRS and some that receive nets. Zambia’s vector control interventions include the use of ITNs, IRS, and, where applicable, larval source management. For the 2020 ITN mass campaign, the NMEP will implement a unique, data-driven approach to the deployment of IRS and distribution of ITNs in a “patchwork” or mosaic configuration.
The ITN campaign will be a door-to-door distribution. We’ve determined quantities of nets for districts and how they flow to the health centers and then to the communities. We’ll have community-based volunteers to register the households and then those volunteers will return to distribute the nets while observing COVID-19 precautions. We had planned this campaign to occur before the rainy season and before the IRS campaign. Because of COVID-19, there’s been a disruption to the supply chain, so it looks like both IRS and ITN campaigns will happen at the same time.
Was this door-to-door approach decided on because of COVID?
This approach came as a lesson from the 2017 campaign, which used fixed distribution points. Communities were primed and sensitized to come to the distribution points to receive their nets. Back in 2013, we did a door-to-door campaign that seemed to work better because the net use-to-access ratio was better. So we’ve gone back to the door-to-door approach.
In this country, malaria incidence is plateauing and we really want to drive down that incidence. Last year’s floods brought an upsurge in malaria incidence and rise in deaths, so that’s worrisome, and we are trying to address that. It has not only affected Zambia but the entire region.
Is there anything else you’d like to add?
As a pediatrician, you see patients with malaria come into the hospital. When you treat them and then they go home ok, the feeling is really good. It’s a special feeling you get. It’s out of this world. Then, when you switch over to public health, you are part of planning, implementing, and evaluating strategies that affect not one patient but communities. You are talking in terms of thousands, millions of people who benefit from the work that you are a part of, and that special feeling is magnified so many, many more times. So this work becomes extremely addictive. It’s a privilege and an honor to be part of the work to protect people against malaria. In the malaria world, I think I’m in this for the long, long haul.
PMI VectorLink Project Operations Analyst Bezhan Muradi won 2nd and 3rd place in the Abt Associates 2020 Photo Contest. With four photos among the top ten finalists, Bezhan was a clear winner and helped to further highlight the wonderful work PMI VectorLink is carrying out every day to reduce the burden of malaria. All four photos come from his trip to Tanzania where VectorLink conducts IRS and supports broad access to ITNs at health facilities and through mass campaigns and school-based distribution. Congratulations to Bezhan!
Joséphine Tossa has spent the past 12 years fighting malaria in Benin on projects supported by the U.S. President’s Malaria Initiative. As a child growing up in southern Benin’s Mono District, Tossa suffered from malaria more than once and saw many others suffer as well.
“After my academic studies,” Tossa said, “I worked in many organizations in the field of community development. It was during this journey that I realized that malaria was not only a disease but also a cause of underdevelopment in underprivileged areas. That’s when I became interested in working in the field of malaria prevention.”
In her career with malaria prevention projects, particularly those managed by Abt Associates, Tossa has served as Finance & Administrative Manager as well as the Gender Focal Point for VectorLink Benin. Tossa shared a few of her insights about her work, the project and malaria in Benin.
VL: What impact has PMI VectorLink had on malaria in your country?
Tossa: Benin has all the environmental conditions for endemic malaria. The burden of malaria was such that health services were almost overwhelmed. With malaria interventions, such as indoor residual spraying (IRS) and insecticide-treated nets (ITNs), some severe forms of malaria have decreased, allowing health services to have time to deal with other diseases. Vector control interventions are implemented in areas that have extensive agriculture. Therefore, malaria prevention activities allow people to stay active and maintain economic growth.
VL: What changes have you seen in malaria prevention since the project began?
Tossa: Thanks to information, education, and communication activities, populations are increasingly aware of the risk factors for malaria. Increasingly, people are protecting themselves by properly using ITNs, and accepting the spraying of their houses. If these trends continue, Benin can expect a significant reduction in the burden of morbidity and mortality attributable to malaria by the end of this decade.
VL: Can you tell us a bit about your job?
Tossa: As F&A Manager, I ensure finance and administrative requirements are strictly followed. Most of the malaria prevention activities are carried out in campaign mode. Managing financial, administrative, and procurement aspects of thousands of seasonal workers requires a lot of work.
Also, VectorLink Benin is promoting cost-saving initiatives to cope with the increasing prices of new and more effective insecticides. I adopted a systematic approach to cost control, categorizing expenses according to whether they are fixed or variable, direct or indirect to spraying. Cost reduction efforts are now better targeted so they do not impact efficiency in implementation.
VL: Can you tell us about your role as Gender Focal Point on the project?
Tossa: Given the low female participation in malaria prevention, I’ve actively advocated with IRS stakeholders at the national and departmental level for the removal of cultural and social barriers to increase the involvement of women in spraying campaigns. When procuring overalls, boots and other personal protective equipment for IRS campaigns, I always ensure that the gender dimension is taken into account. During spray campaigns, women have easy access to sanitary pads provided by the project, which was not guaranteed two years ago because of cultural barriers. In 2008, around 10% of women were involved in the IRS campaign. Today female participation has almost doubled.
VL: What kind of impact have you seen from the project?
Tossa: The project contributes to a reduction in morbidity due to malaria in rural areas less covered by health services, and provides income opportunities to the local population as seasonal workers, which helps them to improve their living conditions every year.
VL: What has been one thing you’ve learned or loved about working with PMI VectorLink?
Tossa: PMI VectorLink offers safe working conditions and professional development for all its staff. This makes VectorLink a great place to work and have a professional career.
VL: How do you see the country moving forward with malaria prevention or mosquito control?
Tossa: Most vector control interventions take place inside houses. Previously, Benin had lacked interventions that protected people while they are outside. Recently, the country has put a lot of effort in improving the living environment, repairing roads and clearing gutters. Cleaning up the environment to rid it of stagnant water would help to improve protection from malaria. Also, educating and informing the populations on the causes and preventive measures of malaria would enable them to participate and take ownership of the fight against malaria vectors. These activities will optimize the existing interventions, namely ITNs and IRS.
Join PMI VectorLink as we discuss ways in which the U.S. President’s Malaria Initiative has worked to ensure that women and men are able to participate fully and equally in vector control programming. Abigail Donner, Gender Advisor for the PMI VectorLink Project, and two of the project’s most seasoned Gender Focal Points, Zeddy Bore in Kenya and Helen Amegbletor in Ghana, talk about some of the ways the project has addressed inequality in vector control and how the project can move further toward gender equality and female empowerment.
PMI VectorLink Country Teams Build Capacity in Mobile Data Collection
The PMI VectorLink Project works across 24 African countries to fight malaria. A large part of the project’s mission is to carry out indoor residual spraying (IRS), which is proven to reduce the burden of malaria. IRS entails spraying the interior walls and ceilings with an insecticide that kills malaria-carrying mosquitoes. IRS requires high-quality data to plan, implement, and track progress during a spray campaign.
PMI VectorLink Project implemented a mobile data collection strategy in Burkina Faso during the 2019 spray campaign to allow spray teams to make quick and informed decisions to improve spray performance, by immediately intensifying mobilization activities in response to high refusals in certain areas with specific and adapted messages. Having real-time data readily available and accessible facilitates reporting and decision-making on the ground without delay, and more quickly mitigates operational challenges. Improving processes and procedures increases efficiency and save costs.
With the success of the Burkina Faso pilot, PMI VectorLink moved to scale mobile data collection in 2020 IRS campaigns in Benin, Cote d’Ivoire, Mali, and Senegal, as well as continue its use in Burkina Faso. The first large-scale roll out was scheduled for Benin in April, and initially, the VectorLink Burkina Faso Database Manager was to travel to Benin to provide hands-on training. Due to travel restrictions across borders, however, that was not possible.
VectorLink Burkina Faso M&E team adapted the training to remote sessions with the Benin Database Manager, M&E Manager and IT Specialist. The remote feature via Skype, WebEx and WhatsApp allowed the Benin team to maintain close communication with the Burkina team so that they could fully comprehend all aspects of mobile data collection. VL Burkina Faso conducted practical demonstrations on the different mobile data collection tools and applications that enabled the Benin team to configure over 1,600 data collection phones and to train the spray teams on the use of the phones. Weekly meetings were held to track progress and troubleshoot any issues that arose.
This close south-to-south collaboration among the different VectorLink country teams combined with technology allowed for increased capacity among the teams to identify and respond to problems. In turn, PMI VectorLink Benin was better able to serve the community by protecting them more effectively from malaria. VectorLink Benin targeted more than 387,711 structures for IRS in 2020 in efforts to protect more 1,218,679 people.
Les équipes nationales de PMI VectorLink renforcent les capacités des intervenants dans le domaine de la collecte de données par la technologie mobile
Le projet PMI VectorLink lutte contre le paludisme dans 24 pays africains. La mission a notamment pour but de déployer la pulvérisation intra domiciliaire d’insecticide à effet rémanent (PID), méthode qui a fait ses preuves pour réduire le paludisme. La PID consiste à la pulvérisation sur les murs intérieurs et les plafonds d’un insecticide à effet rémanent qui tue les moustiques porteurs des parasites du paludisme. Des données fiables et complètes doivent être disponibles pour planifier, mettre en œuvre et suivre les progrès d’une campagne de pulvérisation.
Le projet PMI VectorLink a conduit une stratégie de collecte de données par la technologie mobile au Burkina Faso dans le cadre de la campagne PID de 2019 pour aider les équipes de pulvérisation à prendre des décisions rapides et éclairées visant à l’amélioration de leurs performances. À cet égard et face à un taux de refus important dans certaines zones, les activités de mobilisation ont été renforcées avec des messages spécifiques et adaptés. La disponibilité et l’accessibilité de données en temps réel facilitent la communication, accélèrent la prise de décision sur le terrain et diminuent rapidement les défis opérationnels. L’amélioration des processus et des procédures permet d’optimiser l’efficacité et de réduire les coûts de l’intervention.
Suite à la réussite de l’expérience pilote au Burkina Faso, PMI VectorLink a élargi la collecte de données par la technologie mobile lors des campagnes PID de 2020 au Bénin, en Côte d’Ivoire, au Mali et au Sénégal. Le premier déploiement à grande échelle était prévu au Bénin pour le mois d’Avril 2020 et le gestionnaire de la base de données VectorLink du Burkina Faso devait se rendre au Bénin pour dispenser des formations pratiques. Cela n’a toutefois pas été possible suite aux restrictions des voyages trans-frontaliers.
L’équipe de suivi-évaluation du programme VectorLink Burkina Faso a alors mis en place des séances de formation à distance avec le gestionnaire de la base de données du Bénin, le responsable suivi-évaluation et le spécialiste de l’informatique. Echangeant par Skype, WebEx et WhatsApp, l’équipe du Bénin est restée en étroite communication avec l’équipe du Burkina Faso, ce qui leur a permis de découvrir tous les aspects de la collecte de données par la technologie mobile. VL Burkina Faso a organisé des démonstrations pratiques à distance des différents outils et applications de collecte de données par la technologie mobile pour aider l’équipe du Bénin à configurer plus de 1 600 téléphones mobiles et à former les équipes de pulvérisation à la collecte de données en utilisant cette technologie. Des réunions d’étapes ont eu lieu hebdomadairement pour suivre les progrès et résoudre progressivement les problèmes rencontrés.
Alliée à la technologie, cette étroite coopération Sud-Sud entre les différentes équipes nationales de VectorLink a renforcé les capacités de tous les intervenants en les aidant à identifier et résoudre les difficultés rencontrées dans la gestion des données. L’équipe PMI VectorLink Bénin, quant à elle, est parvenue à mieux servir sa communauté en la protégeant plus efficacement contre le paludisme. En 2020, VectorLink Bénin a ciblé plus de 387 711 structures dans le but de protéger du paludisme environ 1 218 679 personnes par la PID.
Fighting Insecticide Resistance to Ensure Reduction in Malaria Burden
Since 2006, global malaria cases have dropped by 27 percent, while malaria death rates have declined by 60 percent in PMI focus countries (PMI 14th Annual Report). Much of this progress can be attributed to the scale-up of life-saving interventions, such as indoor residual spraying (IRS) and long-lasting insecticide-treated nets (ITNs), key components of PMI’s vector control strategy, as well as national malaria control strategies across sub-Saharan Africa. IRS and ITNs have proven effective for their use of insecticides that kill and repel mosquitoes that carry the malaria parasite.
Vector mosquito resistance to insecticides is growing, which threatens the impact of malaria control strategies and could increase the spread of the disease. PMI monitors for insecticide resistance of malaria vectors, sharing that data with National Malaria Control Programs (NMCPs) to help support vector control decision making, ensuring that the most effective insecticide is used to reduce the burden of malaria.
In Liberia, PMI collaborates closely with the NMCP, National Public Health Institute of Liberia (NPHIL) and staff from the University of Liberia to conduct entomological surveillance, including longitudinal surveillance and insecticide resistance (IR) testing. Longitudinal surveillance is done monthly and allows entomologists to determine species composition of malaria vectors by season and area, seasonal changes in vector density, peak mosquito season, and the optimal time for vector control interventions, as well as enabling entomologists to assess the impact of those interventions. IR testing is done annually at each site against a number of insecticides to test main malaria vector susceptibility to insecticides used in vector control interventions. Since 2015, the number of surveillance sites in Liberia that PMI supports has increased from two to eight sites, helping to improve the overall IR and vector bionomics data, which include the vector’s behavior and susceptibility to insecticides, which can help to determine the appropriate vector control strategies.
IR data collected under the PMI Africa Indoor Residual Spraying Project (2014-2016) revealed significant and widespread pyrethroid resistance among the populations of Anopheles gambiae s.l., the major malaria vector in Liberia, signifying that standard pyrethroid nets may not be effective in protecting populations in Liberia. PMI supports ITN access for pregnant women and infants in Liberia through continuous distribution at antenatal clinics and facility delivery. ITNs physically block mosquitoes at night, when they are most likely to bite, and kill mosquitoes that land on them.
New types of nets that are more effective against pyrethroid-resistant mosquitoes have recently become available. One of those nets combines standard pyrethroids with piperonyl-butoxide (PBO) and was considered for use in Liberia. However, data collected through the PMI VectorLink Project from 2017-2019 showed while PBO improves the killing effect on mosquitoes, it does not fully restore susceptibility to pyrethroids. These findings suggest that PBO nets would provide more effective, but not optimal, vector control over standard pyrethroid ITNs in Liberia.
As a result, PMI VectorLink and NMCP conducted tests with chlorfenapyr, the active ingredient in the new Interceptor G2 nets. Chlorfenapyr is a new generation of insecticides that have proven to be effective against mosquitoes that are resistant to conventional insecticides, as well as being safe and easy to use.
The initial test results show complete susceptibility (100% mortality) of malaria vector mosquitoes in those sites where testing has been completed. Given that chlorfenapyr is a novel insecticide for public health use, widespread susceptibility is expected throughout the country.
This data was used to support the Government of Liberia’s decision to participate in the New Nets Project, which is piloting ITNs with new insecticide combinations in moderate to high malaria transmission areas throughout sub-Saharan Africa. This includes the procurement and distribution of Interceptor G2 nets in the next mass campaign in 2021.
“It’s an excellent move now that the Government of Liberia has switched from standard ITNs to the new type of nets (Interceptor G2). This decision was made based on evidence-based data collected by the National Malaria Control Program with support from PMI USAID through PMI VectorLink. We expect that the introduction of new nets will help sustain the gains made in reducing the malaria burden in country,” said Chrispin Williams, NMCP Vector Control Coordinator.
PMI VectorLink Liberia will continue to work with partners to gather data on weather patterns, case management, vector control practices and entomology to assess the impact of Interceptor G2 after mass distribution in 2021.
PMI VectorLink Insecticide Resistance Study in Mali Shows New Generation Nets Could Provide Greater Protection from Malaria
PMI VectorLink recently published an article in Parasites & Vectors on the malaria vector Anopheles gambiae’s high level of resistance in Mali to the pyrethroid insecticide and how PBO nets or next generation long-lasting insecticide-treated nets (LLINs) could provide greater malaria control.
The study reported that “Millions of pyrethroid LLINs have been distributed in Mali during the past 20 years which, along with agricultural use, has increased the selection pressure on malaria vector populations. This study investigated pyrethroid resistance intensity and susceptible status of malaria vectors to alternative insecticides to guide choice of insecticides for LLINs and IRS for effective control of malaria vectors.”
The study concluded that “Widespread high intensity pyrethroid resistance was recorded during 2016–2018 and is likely to compromise the effectiveness of pyrethroid LLINs in Mali. PBO or chlorfenapyr LLINs should provide improved control of An. gambiae (s.l.). Clothianidin and pirimiphos-methyl insecticides are currently being used for IRS as part of a rotation strategy based on susceptibility being confirmed in this study. Read the article here.
A recent article published in Malaria Journal, which included authors from the PMI VectorLink Project, showed that moderate or high intensity pyrethroid resistance was detected nationwide in in the Democratic Republic of Congo (DRC) and is a serious threat to sustained malaria control with pyrethroid-treated long-lasting insecticidal nets (LLINs). Based on the findings, the authors suggest that next generation nets (PBO nets or bi-treated nets) be considered for mass distribution.
The article reports, “Between 2011 and 2018, an estimated 134.8 million pyrethroid LLINs were distributed nationwide for malaria control. Pyrethroid resistance has developed in DRC in recent years, but the intensity of resistance and impact on LLIN efficacy was not known. Therefore, the intensity of resistance of Anopheles gambiae sensu lato (s.l.) to permethrin and deltamethrin was monitored before and after a mass distribution of LLINs in Kinshasa in December 2016, and in 6 other sites across the country in 2017 and 11 sites in 2018.”