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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 14^th 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.

PMI VectorLink Published in Malaria Journal

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.”

Read the full article here.

“Indoor residual spraying for malaria control in sub‑Saharan Africa 1997 to 2017: an adjusted retrospective analysis“

An article recently published in the Malaria Journal shows the importance data can have on improving studies on the impact of indoor residual spraying (IRS) on malaria incidence and its role in helping to guide future malaria control efforts. The research article draws on data from indoor residual spraying campaigns funded by the U.S. President’s Malaria Initiative from 2012 to 2017.

From the article: “IRS is a vital prevention measure for controlling and eliminating malaria by targeting vectors. To support the development of effective intervention strategies it is important to understand the impact of vector control tools on malaria incidence and on the spread of insecticide resistance. In 2006, the World Health Organization (WHO) stated that countries should report on coverage and impact of IRS, yet IRS coverage data are still sparse and unspecific. Here, the subnational coverage of IRS across sub‑Saharan Africa for the four main insecticide classes from 1997 to 2017 were estimated.”

“Data on IRS deployment were collated from a variety of sources, including the President’s Malaria Initiative spray reports and National Malaria Control Programme reports, for all 46 malaria‑endemic countries in sub‑Saharan Africa from 1997 to 2017. The data were mapped to the applicable administrative divisions and the proportion of households sprayed for each of the four main insecticide classes; carbamates, organochlorines, organophosphates and pyrethroids was calculated.

The number of countries implementing IRS increased considerably over time, although the focal nature of deployment means the number of people protected remains low. From 1997 to 2010, DDT and pyrethroids were commonly used, then partly replaced by carbamates from 2011 and by organophosphates from 2013. IRS deployment since the publication of resistance management guidelines has typically avoided overlap between pyrethroid IRS and ITN use. However, annual rotations of insecticide classes with differing modes of action are not routinely used.

This study highlights the gaps between policy and practice, emphasizing the continuing potential of IRS to drive resistance.”

Read the article here.

 

During this past World Malaria Day, celebrated on April 25^th, the global community was tasked with responding to the COVID-19 pandemic brought on by the novel coronavirus while maintaining its commitment to fighting malaria. With support from the U.S President’s Malaria Initiative (PMI), The PMI VectorLink Project continued to deploy life-saving interventions like indoor residual spraying (IRS) to help reduce the overall strain on health systems by keeping the most vulnerable people malaria-free.

In collaboration with Ghana Health Service, PMI VectorLink Ghana commemorated World Malaria Day by calling attention to the importance of reducing malaria across the country in a radio program hosted on April 28, 2020.

Panelists during the discussion included, Regional Malaria Focal Person Dr. Barikisu Seidu, former Director of Health Services, Abdul-Rahman, and Abukari Yakubu, the Environmental Compliance Officer for PMI VectorLink Ghana.

Dr. Barikisu Seidu made a call to action, describing a malaria-free Ghana as everyone’s responsibility, noting the importance of accepting malaria interventions like insecticide-treated bed nets (ITNs) and IRS. She indicated that in Ghana, out of every 100 outpatient healthcare visits, 22 are malaria cases, and out of 10 patients admitted, three are malaria cases with two of those three more likely to be children under 5.

As a result of PMI VectorLink’s IRS interventions, the Ghana Health Service has indicated that malaria incidences in IRS districts have reduced by half and are below the northern regional average. This data is further supported by a study* conducted by The World Health Organization (WHO)  during a review of health records in facilities across the country. As PMI VectorLink Ghana continues to achieve and go beyond its IRS targets, we are hopeful to further drive down malaria cases in IRS districts.

*Reference: WHO study published by Aregawi et al. Malar J (2017) 16:177 (A total of 210,709 hospital and laboratory records from 2005 to 2015 examined.)

Our Commitment to Saving Lives

April 25th is World Malaria Day, and while the global community responds to the COVID-19 pandemic brought on by the novel coronavirus, it is vital that the vector control community continues its commitment to fighting malaria. The interventions used to combat malaria also help strengthen countries’ capacity to respond to other health threats and public health emergencies, like COVID-19. 

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 and indoor residual spraying, to help reduce the overall strain on health systems by keeping the most vulnerable people malaria-free.
 
As we know, malaria disproportionately affects the poor – particularly pregnant women and children under five years of age across sub-Saharan Africa – and traps families in a cycle of disease and poverty.
 
In 2019, the PMI VectorLink Project:

• Sprayed 5.5 million structures with an insecticide that kills the malaria-carrying mosquito
• Helped distribute over 7 million insecticide-treated bed nets
• Protected 20.1 million people from malaria including over 584,000 women and 3.3 million children under five years of age

The PMI VectoLink Project conducts indoor residual spraying to help kill malaria-carrying mosquitos – here’s how it works!

 

Kigali, Rwanda

Jean-Pierre Rucakibungo, Senior Finance and Administration Manager, oversees all the financial, accounting, and compliance aspects for PMI VectorLink Rwanda. Born and raised in Rwanda’s capital city of Kigali, Rucakibungo is fluent in English, French, Swahili and Kinyarwanda and holds a Bachelor of Science from the National University of Rwanda and an MBA from the University of Roehampton, London. In his spare time, he enjoys studying the history and culture of Rwanda in his mother language (Kinyarwanda). Recently, Rucakibungo took time to talk to us about his work.

VL: How did you get started working with malaria?

JPR: After the genocide, we had a lack of people who were qualified in finance. There were many NGOs, so I started with Médecins sans Frontières in finance. I continued working with projects in finance, and in 2011, I started working with the PMI Africa Indoor Residual Spraying (AIRS) Project. I ensure that the office management, budgeting, operations, procurement, financial, subcontracting, and human resources systems are compliant with USAID rules and regulations.

VL: Do you have any personal experience with malaria?

JPR: When I was a child, we all used to have malaria. Anytime someone wasn’t well, we would think it was malaria. Our mother used to give us Nivaquine, which is a preventative medicine that my siblings and I had to take it daily. It was very bitter, so we had to take it in front of her. When we used it, we tended not to get malaria. If someone had a fever and tested positive for malaria, then he/she was treated with a more effective drug. The last time I had malaria was in 2001. When I’m traveling to those districts with high malaria, I’m afraid to see mosquitoes. It’s a bad illness. After you have it, you have to build up your strength. Everybody should sleep under a mosquito net to protect themselves from contracting it.

VL: What has surprised you most about working with PMI VectorLink (or AIRS)?

JPR: When IRS first came to Kigali, I was not aware that malaria was an illness that could be eliminated. I knew people were doing research on mosquitoes but I didn’t know it was to reduce malaria. It’s a disease that can be controlled, but it’s very costly. Elimination will require coordination with Burundi and the DRC to sustain the gains we are making in Rwanda.

VL: What do you find most challenging about your job?

JPR: The most challenging aspect is eliminating mistakes from the field, such as ensuring that the mobile phone numbers we collect for mobile money payments are registered to the corresponding seasonal workers. In the past, there have been discrepancies and it resulted in delayed payments. After every campaign we look at the challenges we faced and develop a strategy to ensure we don’t make mistakes. Most of the time, the budget is 96-98 percent on target. I use the budget tracker and can manage activities not planned. For instance, the Government of Rwanda has sought our assistance in protecting Mahama Refugee Camp with IRS. While not in the initial work plan budget, we were able to make this happen in 2018 and 2019 by covering operational costs while the government provided the insecticide.

In 2018, we moved to mobile payments for seasonal workers. We had the training for a week. I was excited to know that these things could happen. At the time, I had finished my MBA and I had worked on eMoney with businesses in Kigali. I had the knowledge of how things work. When I was asked to implement online payments for the project, I really understood them well.

By paying our accounts and staff with mobile money I was able to move around the country and follow training for seasonal staff, which helped me to better understand what was happening in the field. As I managed the budget over the years, I’ve learned a lot about IRS and entomology outside of finance, such as when we rehabilitated an entomology laboratory and managed entomological monitoring sentinel sites.

VL: What kind of impact have you seen on malaria in Rwanda from IRS?

JPR: In 2010, the district with the most burden was Nyagatare with 45% of the country’s cases. We’ve sprayed Nyagatare since the beginning of AIRS in 2011. With epidemiological data, the impact is very visible. They now have few cases. Ngoma District was first sprayed in 2019 by the Government of Rwanda. They saw right away the impact of IRS. So when PMI VectorLink sprayed there this year, everyone wanted their homes sprayed. We were impressed to see how much the people liked IRS because they understand the impact.

VL: What do you wish other people knew about the project?

JPR: Most people know there is a project spraying houses to fight malaria. I often explain the impact the spray can have. We explain that we are not eliminating all mosquitoes rather mosquitoes that carry the malaria parasite. I’m often explaining the impact of IRS and why we spray the walls and ceilings of every house. When the insecticide we had been using previously was shown to have reduced efficacy, we changed to a bendiocarb insecticide. People were happy because they could see it was working. Later, when we started spraying with the organophosphate Actellic, the population could see it was killing the mosquitoes and other insects. Before people used to tell stories that the pyrethroid insecticide brought fleas into the house, but now they do not. They don’t hear mosquitoes in the house at night, so they can sleep. With the new insecticide, people like it more. When people aren’t experiencing malaria, they don’t understand why we are still spraying. So we often have to explain why we need to continue with IRS in order to maintain control.

VL: What is your hope from the project?

JPR: As we start the third year of the project, I see that we have a well-equipped laboratory, so the entomology is going well. But we don’t have enough entomologists and continued efforts are needed to build local capacity. With project trainings and time, we will be better able to fight malaria. One thing I’ve seen is the increased use of mosquito nets. We are moving more toward using nets for fighting malaria. The Government of Rwanda is now distributing nets across the country. We are combining IRS with nets, and in the three years, we will see where we will be.

VL: What could other countries learn from Rwanda?

JPR: The one number one thing is how we implement IRS as a team. Since we started, our entire operations staff is involved in all aspects of the project. While our environmental compliance officer conducts environmental assessments, she’s not the only person who knows how to do the job. We work as a team, so when I’m in the field I can support the team. Or if we’re spraying in two districts at the same time, we can support each other. The teamwork makes IRS in Rwanda successful.

Impact of indoor residual spraying with pirimiphos-methyl (Actellic 300CS) on entomological indicators of transmission and malaria case burden in Migori County, western Kenya

A study conducted by the U.S. President’s Malaria Initiative VectorLink Project (the follow-on project to the PMI Africa Indoor Residual Spraying Project) in western Kenya shows that IRS with pirimiphos-methyl was highly effective for the control of indoor biting and indoor resting, pyrethroid-resistant An. funestus mosquitoes and resulted in substantially reduced numbers of this primary vector species coupled with reduced malaria cases. The study found that due to the long residual effect of pirimiphos-methyl, it was possible to achieve year-round protection with a single round of IRS. Sustaining these gains is a priority for the Kenya National Malaria Control Program and development partners. The authors of the study say that IRS should continue to be implemented to sustain the impact on An. funestus. Because there was less of an impact of spraying on An. arabiensis populations, likely due to their exophilic (outdoor-biting and resting) nature, additional control measures are needed to control outdoor biting and resting An. arabiensis. The peer-reviewed Scientific Reports is the 11th most cited journal in the world, with more than 300,000 citations in 2018*, and receives widespread attention in policy documents and the media. 

*2019 Journal Citation Reports® Science Edition (Clarivate Analytics, 2019)

 

https://rdcu.be/b2Pdr 

 

Field-Based Mobile Data Collection in Burkina Faso Helps Improve Spray Coverage

Indoor residual spraying (IRS), proven to reduce the burden of malaria, 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. Having real-time data readily available and accessible facilitates reporting and decision-making on the ground without delay, and more quickly mitigates operational challenges. Until recently, field teams relied on paper data collection forms, which required an additional step of manually entering data into an electronic system, delaying the time between collection and the data being processed for use in decision making. That all changed when the PMI VectorLink Project piloted its mobile data collection strategy in Burkina Faso during the 2019 spray campaign.

Traditionally, spray operators serve as the primary point of data collection. Once they’ve sprayed a house, they record the home on their data collection form. If a home could not be sprayed (e.g. the head of the household was not home to accept IRS), the spray operator would note that on the data collection form. At the end of each day, spray operators would return their data collection forms at the operation site where data clerks then entered the information into a computer. The data is then cleaned, analyzed, processed, and sent to a global server where the information can be accessed from a real-time database.

Now, with mobile data collection, the need to manually enter data is removed – along with potential data entry errors that can skew the data overall and influence results. During the pilot, 547 spray operators across all three spray districts (Kongoussi, Solenzo, and Kampti) collected their household data using mobile tablets, each set up with the Open Data Kit (ODK) application. The ODK application was configured specifically for household-level data based on the standard, the paper form that spray operators were familiar with and formatted to reduce data entry error. Once collected via the mobile tablets, data is then synced to the project’s DHIS 2-based VectorLink Collect server on a daily basis for analysis and reporting.

IRS can require thousands of people to work together in a short period of time to reach a set of targets. Improving processes and procedures to increase efficiency and save costs is essential for sustainability. Field-based mobile data collection speeds up the team’s ability to identify and respond to problems, allowing the team to better serve the community by protecting them more effectively from malaria.

For instance, the VectorLink team was able to make quick and informed decisions in regards to the improvement of spray performance, by immediately intensifying mobilization activities in response to high refusals in certain areas with specific and adapted messages. The project plans 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.

While conducting this pilot, VectorLink Burkina Faso sprayed more than 200,000 structures, protecting more than 580,000 people, including 92,000 children under five years of age and 11,000 pregnant women.