Traditional community leaders improve quality of life through their support of IRS
Malaria is an endemic disease in Ghana. This makes any effort which reduces malaria worth celebrating. Among the interventions used to help in the reduction of malaria is Indoor Residual Spraying (IRS). IRS involves spraying an insecticide on the ceilings and walls of homes, where the malaria-carrying mosquitoes rest after feeding. The insecticide kills the mosquitoes, preventing the further spread of the disease. The US President’s Malaria Initiative (PMI) directly supports IRS implementation in selected districts in the Northern Region of Ghana.
Over the years, a number of studies and observations made by community leadership reflect the impact made by IRS in the society. A recent study published in the Malaria Journal [Coleman S.et al., Malar J (2017) 16:324] shows that IRS reduced malaria transmission in the districts studied as compared to the districts where IRS was withdrawn.
Another study conducted jointly by the World Health Organization (WHO) and the Ghana National Malaria Control Program [Aregawi et al. Malar J (2017) 16:177] corroborates these findings. In the study, the researchers reviewed all health records from 2005 to 2015. In districts where IRS was implemented, a significant reduction (47%) over a the ten-year period in the number of malaria cases, and a greater impact on key malaria indicators was observed as compared to non-IRS districts. Malaria admissions decreased by 68%, malaria deaths reduced by 88% and test positivity rate (TPR) reduced by 89%. In non-IRS regions, the reduction in malaria admissions was 35%, and malaria deaths and TPR decreased by only 44% and 38%, respectively.
Traditional leader Mba Tarana said, “Since you [PMI IRS] began spraying our communities, we rarely see mothers rushing their children who have severe malaria and are convulsing to the hospital.” Community leaders such as Mba Tarana have contributed to the significant impact made by IRS through mobilization and monitoring of spraying in their towns and villages. Their involvement in and support of IRS have been critical to the success of IRS as they encourage the full participation of all stakeholders, resulting in reduced prevalence of malaria and the improved health and livelihood of those living in the PMI-supported districts.
Peace Dellor began working on the PMI Africa Indoor Residual Spraying Project (AIRS) in 2015 as a Data Entry Clerk in Ghana. Due to her diligence and hard work she was promoted to be the Monitoring and Evaluation (M&E) Assistant for Kumbungu District, one of the seven districts targeted by PMI VectorLink, which followed after the AIRS Project ended in 2017. Peace, who comes from Keta in the Volta Region of southeastern Ghana, studied at the Intercom Programming and Manufacturing Company Limited in Tamale and holds a diploma in Database Technology. Dellor recently talked about her experience with malaria and her role on the PMI VectorLink Project.
PMI VectorLink: Have you had any experience with malaria?
Dellor: Yes, I remember when I was admitted to the hospital for days because I had malaria. This caused me to miss classes. It took me time to recover and go back to school to catch up with my colleagues.
PMI VectorLink: What are your duties as the M&E Assistant for the Kumbungu District?
Dellor: My role is critical as I have to ensure that accurate data is reported to the project. Here are some of my core duties:
Train Spray Operators on spray data recording at the district level.
Supervise Data Entry Assistants to enter data on a daily basis.
Verify data cards by using the error eliminator.
Sample some compounds to verify spraying.
Assist the District Operations Coordinator in planning.
Supervise Spray Operators’ data recording in the field.
For malaria prevention, I visit some of the difficult communities (that tend to refuse spraying) to talk to them about the benefits of the project. I go the extra mile in helping them to pack their belongings and get a Spray Operator to spray their rooms.
PMI VectorLink:Do you think Ghana will ever be malaria free?
Dellor: Yes, because if we can sustain the effort and also if we can be as resilient as the malaria parasite, we can make Ghana malaria free.
PMI VectorLink:What has surprised you most about working with the PMI VectorLink Project?
Dellor: I am always surprised about the energy and the zeal some workers and community members who understand the aim and benefits of the project apply to their work.
PMI VectorLink:What do you find most challenging about your job?
Dellor: In my line of work, I do need a means of transportation to carry out field supervision. However, this was not always readily available. Dialects of the language commonly used in the district, Dagbanli, sometimes serve as a barrier and lead to misperceptions about the project
PMI VectorLink: How did the project address these issues?
Dellor: The project provided a motorbike to enable me to carry out my duties.
In dealing with the dialect problem, I was able to get other people in the area to help me to communicate and overcome the language barrier.
To address misconceptions about the project, I used IRS messaging, such as the benefits and effectiveness of IRS, and worked with advocates of the project in the communities to help change false perceptions.
PMI VectorLink:What impact has the entomological monitoring had on malaria in Ghana?
Dellor: The entomological monitoring team selects the correct insecticide to be used for spraying each year and monitors how the program is affecting the mosquito population and their ability to transmit malaria. This monitoring is critical in helping us make informed decisions on the appropriate measures to take in helping to reduce malaria prevalence.
PMI VectorLink:What changes have you seen in IRS implementation since the project began?
Dellor: There have been some impressive changes in IRS implementation because the acceptance rate has increased, support from some communities is very high and the passion of workers on this project has also increased.
PMI VectorLink:How has the incidence of malaria changed since you began working for this project?
Dellor: There is a remarkable report by Ghana Health Service on how malaria has reduced at the number of out-patient cases, and my personal encounter with some community members tells me that there has been a significant reduction in reported malaria cases.
PMI VectorLink:What do you wish people knew about the project?
Dellor: PMI VectorLink is a project one has to embrace because it comes with personal hygiene in that community members use it as an opportunity to clean up their rooms. Aside from targeting mosquitoes, the chemical kills some other insects which are nuisance to the communities. This project aims at protecting our people.
PMI VectorLink:What might someone be surprised to know about you?
Dellor: I am very friendly despite the rigorous nature of my role.
PMI VectorLink:What is your hope from the project?
Dellor: My hope for the project is that in some years to come Ghana will be malaria free and in the unlikely event when PMI pulls out, the Ghana government will be able to take over.
PMI VectorLink:What kind of impact have you seen from the project?
Dellor: PMI VectorLink has not only reduced malaria cases but has also reduced the unemployment rate. It serves as a source of income for many who use money earned from the project to finance their education, purchase inputs for their farms, set up a business or learn a trade.
PMI VectorLink Innovates, Transforms Shipping Containers into IRS Stores
In the West African country of Benin, the U.S. President’s Malaria Initiative (PMI), working in partnership with the Government of Benin, has conducted large-scale indoor residual spraying (IRS) operations since 2008. The PMI VectorLink Project works in 23 countries across the continent to prevent the spread of malaria and implements IRS in 14 countries. IRS kills the mosquitoes that transmit malaria through spraying insecticide on the walls, ceilings and indoor surfaces where the mosquitoes rest.
The Government of Benin contributes to the spray campaign by providing storage facilities in operational sites for the insecticide and supplies used for operations. Safe and easily accessible storage is essential to the success of the IRS campaign.
In 2017, the Government of Benin shifted IRS operations from seven communes in Atacora Department to two other departments of northern Benin: Alibori and Donga. Alibori and Donga were designated as their own departments as recently as 2016. As a result, the departments still lack the necessary buildings needed for their contribution to the IRS operations. To address storage needs, the PMI VectorLink Project transformed six shipping containers into temporary stores (two at the operational site of Djougou1, one at the site of Barienou, one at Kassakou and two at the central store of Natitingou to increase its storage capacities.
The PMI VectorLink Project creatively designed the narrow, 40-foot steel shipping containers to ensure the best use of space. To manage extreme temperatures, the project equipped the store containers with a thermal regulation system consisting of a triplex roof (wooden boards) with openings for the circulation of ambient air and added windows and front doors. The store containers were placed on cement-concrete bases and the waterproofing of the pavements was guaranteed by a plastic sheeting to prevent any flow of liquid product that could contaminate the soil.
Converting a container to a store costs around 2,240,000 CFA ($4,000), which is far more economical compared to the building a permanent structure/store with the same capacity, which can cost more than 10 million CFA or nearly $18,000. Thanks to this innovation, PMI VectorLink has been able to comply with best management practices for IRS in vector control and achieve its spraying coverage targets in the new intervention area during the 2018 IRS campaign.
In addition to the cost-efficiency of using containers as stores rather than permanent structures, the project also has the ability to move the containers to different operational sites, further minimizing expenses in setting up operational sites. Finally, the project is reducing overall environmental impact as the containers are being repurposed rather than discarded.
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.
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.”
Despite Political Unrest in Kenya, PMI AIRS Provides 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.
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).
First New WHO-Recommended Insecticide in 40 Years Piloted
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.”
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.
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.