Ghana’s Community Health Nurses Help Spread the Word about IRS

PMI VectorLink Ghana helps integrate IRS education into government-based health promotion campaigns.

Implementing health interventions can prove challenging in countries where a lack of resources poses limitations on what governments can do to help keep communities healthy. Working across 23 countries in sub-Saharan Africa and Cambodia, The U.S. President’s Malaria Initiative (PMI) VectorLink Project works to build the capacity of country governments to plan and implement safe, cost-effective vector control interventions to reduce the burden of malaria.

A community health nurse educating her community on the importance of indoor residual spraying.

Building capacity involves close collaboration with a country’s government and requires an in-depth understanding of a country’s unique health context. Working with Ghana’s Health Service (GHS), PMI VectorLink established the importance of IRS as a life-saving intervention and helped gain its acceptance in communities. To do this, VectorLink Ghana helped GHS, the national entity responsible for health promotion in the country, to integrate IRS messaging into their routine government health promotion activities in districts where IRS is conducted. VectorLink Ghana trained community health nurses (CHNs) from each of the project’s 25 operational sites on key messaging around IRS as key to malaria prevention. These messages served to promote the importance and benefit of the intervention, dispel myths and allay concerns about the IRS process, and to help prepare households appropriately to receive IRS on the day of spray.

Community health nurses in Ghana are at the foundation of the health promotion structure. CHNs routinely educate villages and communities on how to adopt healthy behaviors and encourage them to accept health interventions. After their training, the community health nurses were invited to experience an IRS campaign firsthand to understand the effect of their messaging on the community’s acceptance and readiness for spray. During the campaign, CHNs were able to answer questions and reduce the number of IRS refusals on the spot.

Community health nurses routinely educate their communities on the importance and benefits of IRS to encourage them to accept the intervention.

According to Ghana Health Service records, 46 of the PMI VectorLink-trained community health nurses conducted 920 IRS-related community engagement campaigns in March and April 2019. Half of the outreach was conducted in the communities while the other half was conducted in health facilities. In the 398 communities where the IRS promotion activities occurred, the average spray acceptance increased to 99.9% compared to 93.2% the previous year.

 

 

 

The PMI VectorLink Approach to Managing Insecticide Resistance

Managing Insecticide Resistance Starts with Entomological Monitoring & Surveillance

Since the launch of the U.S. President’s Malaria Initiative (PMI) in 2006, malaria control interventions across sub-Saharan Africa have scaled up dramatically, resulting in a significant decline in malaria burden. From 2010 to 2017, the number of people who died from malaria went down from 607,000 to 435,000 (WHO World Malaria Report, 2018).

Much of this progress can be attributed to the scale-up of vector control interventions like insecticide-treated nets (ITNs) and indoor residual spraying (IRS); two key components of the global malaria control strategy supported by the PMI VectorLink Project.

However, mosquitoes’ growing resistance to insecticides threatens further progress and could potentially reverse the gains made in malaria control recorded in the last decade.

As a step towards addressing the issue, PMI VectorLink implements a comprehensive insecticide resistance monitoring program across sub-Saharan Africa to understand the problem and guide vector control programming. Accordingly, insecticide resistance surveillance of the primary carriers of malaria; specifically Anopheles gambiae s.l. and An. funestus s.l. is part of PMI VectorLink’s vector control efforts in Africa. Data in each project country is systematically collected to account for the different types of malaria-carrying mosquito, a country’s insecticide use practices, and vector control interventions. In most cases, all classes of insecticides, including those approved by WHO, have been continuously monitored.

Given that mosquitoes have become resistant to pyrethroids (the insecticides used in standard ITNs) in some areas, the project performs further tests to understand the level of resistance and its potential impact on the effectiveness of ITNs and IRS being implemented.  The malaria-carrying mosquitoes are tested to higher concentrations of the most common pyrethroids used in bed nets. Tests are also regularly performed to understand the type of resistance involved. One such test involves exposing mosquitoes to a synergist that does not have insecticidal properties itself, but when combined with insecticides of a particular class, considerably enhances the insecticides potency. This test determines whether the combination of synergist and insecticide is potent enough to kill the otherwise resistant mosquito. The potential for new tools that include a synergist and an insecticide can significantly help in managing insecticide resistance.

PMI VectorLink strives to stay ahead of the curve by working with global organizations and the private sector to test new insecticide and synergist products like clothianidin and chlorfenapyr. PMI VectorLink has not only developed and shared protocols for field testing these new insecticides but has also produced a significant amount of data that now informs decisions on insecticide resistance management. 

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The PMI VectorLink Approach to Managing Insecticide Resistance Includes:

  • Database: PMI VectorLink generates a large amount of multidimensional data on insecticide resistance, its intensity, and mechanism.
  • Share: The project stores, analyzes, and presents insecticide resistance data in a way that information becomes readily available for making decisions by the project and national malaria control programs. PMI VectorLink is widely known as a reliable source for insecticide resistance data among national and international stakeholders.
  • New Products: PMI VectorLink takes a leading role as a source for up-to-date information on the susceptibility of mosquitoes to new products.
  • Decisions: Several countries are now making decisions on the deployment of different types of vector control tools based on the information PMI VectorLink is generating. For example, PMI VectorLink data is helping countries decide which next-generation insecticide products to deploy.
  • Rotate and Stop the Spread of Insecticide Resistance: Rotation or large scale mosaic spray of different classes of insecticides are now being increasingly practiced as insecticide resistance management strategies in several countries. PMI VectorLink has developed a rotation plan of insecticides used for indoor residual spraying in each country it works in. Rotation is being utilized as a pre-emptive measure to slow down the development or prevent the spread of insecticide resistance and relies on credible data. 
  • Capacity Building: The project works with local universities, research institutions and other partners in the development of local capacity to advance molecular surveillance of insecticide resistance.
  • Sustainability: PMI VectorLink is developing local capacity in insecticide resistance monitoring at all levels of the health system and transferring ownership of the program to national health leaders.

 

 

 

PMI VectorLink Study Published in Malaria Journal

The PMI VectorLink manuscript “susceptibility testing of Anopheles malaria vectors with the neonicotinoid insecticide clothianidin; results from 16 African countries, in preparation for indoor residual spraying with new insecticide formulations” was recently published in the peer-reviewed journal, Malaria Journal on August 1, 2019.

While the World Health Organization (WHO) continues to develop a suitable bottle bioassay procedure, there is currently no published guidance regarding clothianidin susceptibility procedures or diagnostic concentrations. The PMI VectorLink Project, therefore, developed a protocol for impregnating filter papers with 2% w/v SumiShield™ 50WG dissolved in distilled water. Susceptibility tests were conducted using insectary-reared reference Anopheles and wild-collected malaria vector species. All tests were conducted within 24 hours of treating papers, with mortality recorded daily for 7 days, due to the slow-acting nature of clothianidin against mosquitoes. Anopheles gambiae sensu lato (s.l.) adults from wild-collected larvae were tested in 14 countries, with wild-collected Anopheles funestus s.l. tested in Mozambique and Zambia.

Read more about the study in the publication here.

For more information, contact:

Richard_Oxborough@abtassoc.com
PMI VectorLink Project, Abt Associates, 6130 Executive Blvd, Rockville, MD 20852, USA

Mobile Data Collection for Rapid Decision Making

PMI VectorLink Burkina Faso is our first IRS country to pilot and implement mobile data collection by the Spray Operator at the household level. 547 Spray Operators collected IRS data on tablets across all the VL Burkina Faso spray districts! The Burkina Faso M&E team worked for months with NMCP and District Health Officials to design the data collection tool.

M&E Manager Asseta Sigue and Database Manager Jean Dieudonne Damiba developed the new training tool, working with former SOPs to improve its usability, and then trained Supervisors how to use it. 

Asseta Sigue (right) works with a former SOP on how to fill in the tablet.

 

The mobile data collection enabled the M&E team to quickly inform the Operations team and Supervisors in the field on spray progress, coverage, and reasons for non-spray cases. In turn, those in the field could make rapid decisions to correct course. Congratulations to the team on a job well done!

 

Gender Success in Ghana

PMI VectorLink Promotes Safety and Inclusion of Women in the Workplace.

“I observed and learned the roles and responsibilities of a site manager in the course of previous campaigns. Deep within me, I was confident I would be able to carry these roles out successfully” – Warihana Amadu, IRS Site Manager

Warihana Amadu, a native of Gushegu in the Northern Region of Ghana, is a site manager and among many women who have been able to secure leadership positions on the U.S. President’s Malaria Initiative (PMI) VectorLink Project. Her first experience on the program was in 2017 when she was hired as a washer. She applied for the job because, as a woman, she believed it was the only job she was qualified for. “Coming from a matrimonial home, women were mostly relegated to the background,” Warihana said. As a result, many women forgo certain opportunities due to the perception that they are reserved for men. 

Committed to bridging the gender gap, PMI VectorLink actively promotes gender equality and female empowerment by increasing the role of women at all levels of its operations. To encourage women’s participation, PMI VectorLink Ghana has put in place a number of initiatives that advance female staff into supervisory roles. Ensuring women have the training and opportunities they need to succeed helps to build their confidence in executing higher-demand positions that carry more responsibility. PMI VectorLink Ghana went even further to create a female-friendly work environment by taking into consideration the unique needs of women to inform project policy and guidelines at all levels. From providing female staff with sanitary pads to working with colleagues in Kenya to design and implement a harassment-free policy that is now used in each of the countries we work, VectorLink Ghana has made sure that women feel safe and included at the workplace.

“Deep within me, I was confident I would be able to carry these roles out successfully.” – Warihana Amadu, IRS Site Manager

These initiatives have paid off tremendously, especially during the 2019 spray campaign when VectorLink Ghana saw a significant increase in the number of women hired. The number of women hired into supervisory roles increased from 36 in 2018 to 54 in 2019, while the total number of women hired to support IRS activities increased by 23.4 % from 380 in 2018 to 469 in 2019.

PMI VectorLink Ghana emphasizes women’s safety and involvement at all levels of spray operations.

Increasing women’s involvement in IRS not only increases their economic empowerment but positions them as role models for other women and young girls in their communities. Motivated to move up in responsibility on the project, Warihana applied for the position of a site manager for the 2019 spray campaign. “I observed and learned the roles and responsibilities of a site manager in the course of previous campaigns,” she said. 

Warihana was successfully recruited and assigned to an operational site in Gushegu District, where she successfully managed IRS spray operations, covering 2,995 homes and protecting 35,315 people.

Reducing Costs and Expanding Coverage

PMI VectorLink Rwanda Goes Beyond the Call to Action to Protect More People from Malaria.

Indoor residual spraying (IRS) is one of the most effective vector control interventions that kills malaria-carrying mosquitoes by spraying insecticide on walls, ceilings and other indoor resting places of those mosquitoes. Since 2006, the President’s Malaria Initiative (PMI) has protected millions of people in Africa from malaria through IRS. Though effective, IRS is also a costly and complex operation that requires rigorous planning, supervision, and monitoring to ensure its success.

Reducing the operational costs of IRS while maintaining coverage, and protecting as many people as possible from malaria is a fine balance – a balance that the PMI VectorLink team in Rwanda was able to strike in their most recent 2018 spray campaign. As a result of various cost-saving measures, the Rwanda team was able to support additional activities to further our impact in the lives of Rwandans at risk of malaria.

Home to over 54,000 Burundian refugees, Mahama Camp is commonly referred to as Kirehe’s ’13th Sector’ and once contributed to 50% of the district’s malaria cases. Photo by Cheyenne Cook/Abt Associates.

In a collaborative effort with the Rwandan Ministry of Health’s (MOH) Malaria and Other Parasitic Diseases Division (MOPDD), the PMI VectorLink Project was able to expand its coverage beyond Nyagatare and Kirehe Districts to also conduct a spray campaign in Rwanda’s Mahama Refugee Camp. Home to over 54,000 Burundian refugees, Mahama Camp is commonly referred to as Kirehe’s ’13th Sector’ and once contributed to 50% of the district’s malaria cases. 

As a humanitarian response to thousands of Burundians fleeing violence in their country, the Mahama Refugee Camp was established in April 2015. Today over 50,000 refugees live in the camp – almost half of whom are children, who are particularly vulnerable to malaria.

“Before IRS, it was rare to pass 5 houses without coming across someone who was suffering from malaria.”

To reduce the burden of the disease at Mahama Camp, the MOPDD provided insecticide while PMI VectorLink provided technical and operational support during spray activities. By using spray operators hired and trained to spray the project’s original target districts, PMI VectorLink reduced costs from nearly $45,000 originally budgeted to spray the camp, to just $8,000. As a result, PMI VectorLink was able to protect an additional 53,325 people from malaria, including 1,328 pregnant women and 9,810 children under 5. 

Cedric Niyonkuru, a 25-year-old refugee who fled his home in Burundi during his second year at university, is now living at Mahama Camp. Photo by Cheyenne Cook/Abt Associates.

Cedric Niyonkuru, a 25-year-old refugee who fled his home in Burundi during his second year at university, is now living at Mahama Camp. He has seen firsthand how destructive malaria can be to a community. “Before IRS, it was rare to pass 5 houses without coming across someone who was suffering from malaria. Everyone in the family would get sick – so much so, that no one would be able to care for one another,” he said. “It was terrible. Because of this, other health complications came up. Every day people were dying.”

Since IRS has been introduced at Mahama Refugee Camp, Niyonkuru said, “the community has seen a huge reduction in malaria cases. Now it’s rare to come across anyone who suffers from the disease.”

Mobilizing the Masses Against Malaria

A Collaborative Commitment to Health Helps Rwanda Drastically Reduce Malaria Cases and Related Deaths.

Imagine. It is coming toward the end of a stressful week, and you have finally made it home after a long day at work. You remember that today is trash day, but cannot be bothered to separate out your recycling. Saturday morning approaches and you wake to a surprise visit from your city’s mayor who noticed that you failed to recycle properly. She gently reminds you that recycling is important to the health and cleanliness of your community and hopes that you will make every effort to do your part. That is how committed Rwanda’s district officials are to protecting communities from malaria.

The PMI VectorLink Rwanda team works closely with Nyagatare District Health Officials to mobilize communities against malaria. Photo by Cheyenne Cook/Abt Associates

Since 2017, the United States President’s Malaria Initiative (PMI) VectorLink Project has worked closely with district health officials throughout Rwanda’s Eastern Province to deploy indoor residual spraying (IRS) to kill malaria-carrying mosquitoes. Mobilizing communities to gain their support and participation is essential to successfully conducting an IRS campaign to protect individuals from malaria. According to Nyagatare District’s Health Director Elia Kamanzi, mobilizing communities is the most important component of IRS.

When a district prepares for an IRS campaign, it’s all hands on deck as health officials, village leaders, and members of the community work together to ensure the community is appropriately prepared for the life-saving intervention. It is essential that everyone understands what indoor residual spraying is, how it is conducted and how to prepare one’s home properly for spray. Nyagatare District takes this mobilization effort to the next level.

 “IRS doesn’t just save lives, it changes lives. When there is a political will, anything is possible. Not just possible, but easy.”- Nyagatare District Mayor David-Claudian Mushabe.

To reach the most people, district officials host mobilization campaigns during Umuganda, a nationwide day of community service that takes place the last Saturday of every month, and where every single member of the community is present. The PMI VectorLink Project establishes a comprehensive understanding and acceptance of IRS activities that village leaders pass on to their communities to ensure that every household accepts spray operators when they arrive. In the rare event that a household refuses IRS on the day of spray, it is not uncommon for district health officials – or even the mayor – to pay that household a visit. Health officials will emphasize the importance of IRS in preventing malaria and will often liaise with spray operators to reschedule a better time for spray should the head of the household be at work that day.

Not only are community leaders and health officials well versed in IRS operations,  government officials also have a working knowledge of the intervention, its importance, and its effectiveness in reducing malaria prevalence.

When asked about Nyagatare’s collaborative approach to mobilization, District Mayor David-Claudian Mushabe said, “Everyone is called and tasked in IRS mobilization – each person has a part to play. Everyone is involved down to the security guard.” Nyagatare is the largest and second most populous district in Rwanda. Located in the northern part of the country’s Eastern Province, Nyagatare borders Uganda in the North and Tanzania in the East. The district once saw nearly 65,000 cases of malaria a year. Thanks to a collaborative mobilization effort from district health officials, the Government of Rwanda, and PMI, Nyagatare had a 99% IRS acceptance rate that resulted in the protection of over 550,000 people from malaria during the most recent 2018 IRS campaign.

Fighting Malaria and Poverty

Kirehe District in Rwanda Thrives as Indoor Residual Spraying Keeps Community Healthy and Malaria-Free.

Before the sun meets the sky, indoor residual spraying (IRS) spray operators make their way from their home to the local IRS operations site where they gather for a filling breakfast. At 5:30 am, they collect their IRS supplies: a daily allotment of insecticide bottles, personal protective equipment, and their spray pumps. By 6:00 am they set off to the communities to begin the day’s work.

IRS kills mosquitoes that transmit malaria by spraying insecticide on the walls, ceilings, and other indoor resting places of mosquitoes inside peoples’ homes. The United States President’s Malaria Initiative (PMI) has supported IRS in Rwanda since 2007, to reduce the burden of malaria. Following the success of the predecessor PMI Africa IRS project, PMI VectorLink now conducts IRS in Rwanda’s Eastern Province, an area that accounts for nearly 60% of the country’s disease burden.

Blandina Mukabanya lives in Rwanda’s Kirehe District. Now malaria-free, she continues to make a living by farming corn. Photo by Cheyenne Cook/Abt Associates.

Blandina Mukabanya, lovingly referred to as Mama, has lived in Eastern Province’s Kirehe District, in the same house where her first son was born over 30 years ago. Though she can’t remember the last time she had malaria since IRS was introduced in her village, Blandina vividly remembers the devastating effects it had on her family and community. In addition to severe illness and loss of life, malaria places an economic strain on individuals and community resources. 

Members of the community gather to discuss the importance and benefits of indoor residual spraying. Photo by Cheyenne Cook/Abt Associates.

Before IRS was implemented in 2015, Kirehe District had over 41,000 cases of malaria a year. The sheer volume of cases put such a strain on the District Health Centers’ resources that caregivers were unable to effectively treat everyone. The ill would be too sick to work, and caretakers would miss work to care for family members suffering from malaria. The burden of this disease created an economic strain that prevented the community from thriving.

Since IRS has been introduced, malaria cases and related deaths have been significantly reduced. Kirehe District now has less than 5,000 mild cases of malaria a year.  People now spend less time in health centers seeking care for themselves or their family. Fewer sick days allow people to work more, save more, and invest in their futures. Liberta Kayitesi has worked with The PMI VectorLink project since 2017, healthy and able to work consistently, Liberta not only gained skills in her role as a Spray Operator, but she was also able to pay off her bank loans with her earnings – she’s now debt free! “We’re fighting malaria and poverty at the same time,” she says.

“[Kirehe] had the highest number of malaria cases, but now that we spray, we haven’t had it for years. To see fewer sick people in my village keeps me hopeful.” – Josette Munyana, Community Mobilizer and Head of Social Affairs.

From September to October 2018, The PMI VectorLink Project conducted its most recent IRS campaign in Kirehe District. Over a 20-day period, PMI VectorLink sprayed over 88,000 structures protecting 411, 261 people from malaria.

PMI VectorLink in Rwanda – A Photo Story

Indoor Residual Spraying Doesn’t Just Save Lives, It Changes Them.

The U.S President’s Malaria Initiative (PMI) VectorLink Project deploys indoor residual spraying (IRS) in Kirehe and Nyagatare District located in Rwanda’s Eastern Province. These districts once carried the highest malaria burden in the country, but have since made remarkable progress in reducing malaria cases and related deaths. During the September-October 2018 spray campaign, The PMI VectorLink Project worked closely with Rwanda’s district health officials in a campaign effort that protected over 840,000 people from malaria, thus improving the quality of life of many families and communities. We recently spoke to some of the beneficiaries to hear their stories. Here’s what they have to say about the impact IRS has had on their lives. Photos by Cheyenne Cook/Abt Associates. 

This is Blandina Mukabanya, lovingly referred to as Mama. She has lived in Rwanda’s Kirehe District in the same house where her first son was born over 30 years ago. Blandina vividly remembers how malaria devastated her community with illness and death. Now, she’s happy to say that she can’t remember the last time she or a loved one suffered from malaria since IRS was introduced in 2015.

“After people have their homes sprayed and notice that there are no more mosquitoes,” Blandina says, “they come running after spray operators, greeting them and asking them to please spray their houses again next time.” IRS cards like the ones pictured here are provided to each household to keep track of when the home is sprayed. Blanida proudly displays the IRS cards she’s kept since 2015 when she first received IRS in her home.

The importance and benefits of IRS are often communicated by word of mouth in many villages where we work. Beneficiaries often share testimonies with their neighbors about how IRS reduced the number of malaria cases in their homes. The PMI VectorLink Project also works closely with village leaders to establish a comprehensive understanding and acceptance of  IRS so that the community is properly informed and ready on the day of spray.

Edward Salambo, a farmer from Kirehe, hasn’t experienced a case of malaria in the last five years, thanks to IRS. He used to spend the majority of his earnings on malaria medication and treatment. Now, Edward is able to save that money and invest it in grain for his farm. In addition to loss of life, malaria places an economic burden on the people it effects — mostly poor, rural households that don’t have immediate access to prevention and treatment services. Interventions like IRS keep people healthy and communities thriving.

This is Cedric Niyonkuru. He is a 25-year-old refugee who fled his home in Burundi during his second year at university. He is now living at Mahama Refugee Camp, often referred to as the “13th sector” of Kirehe District. Cedric has seen firsthand how destructive malaria can be to a community. “Before IRS, it was rare to pass 5 houses without coming across someone who was suffering from malaria. Everyone in the family would get sick – so much so, that no one would be able to care for one another,” he said. “It was terrible. Because of this, other health complications came up. Every day people were dying.”

The PMI VectorLink Project has deployed indoor residual spraying in Mahama Refugee Camp since 2017, thus drastically reducing the prevalence of malaria in the camp by nearly 90%.  The camp, located in Kirehe District in Eastern Province, Rwanda, was once responsible for over 50% of the malaria cases reported in the district. Pictured above (from left to right) is Cedric Niyonkuru, a member of the camp’s youth committee; Jean-Claude Nzeyimana, apostle and owner of the camp’s church; Chantal Bibonimana, director of health and social affairs; and Clementine Mukabano, vice president of Mahama Refugee Camp.

In addition to the 53,325 people protected from malaria at Mahama Refugee Camp, the PMI VectorLink Project protected 9,810 children under five and 1,328 pregnant women. Children under five and expecting mothers are particularly vulnerable to illness and death caused by malaria. PMI VectorLink makes it a priority to protect them and their loved ones from malaria so that the entire family can live a happy and healthy life.

It Takes A Village to Fight Malaria

PMI VectorLink Gains Community Support for IRS and Malaria Control Interventions in Uganda.

Maria Wamagali is no stranger to malaria and the deepest sorrow it can bring having lost four children to the disease. In fact, in her village of Busibira in Butaleja District in Eastern Uganda, malaria is one of the leading causes of death among young children. According to the World Malaria Report 2018[1], malaria remains the leading cause of morbidity in Uganda, accounting for 4% of all estimated malaria cases worldwide in 2017. The high burden of malaria exceptionally affects children and women, particularly pregnant mothers.

Since 2006, the United States President’s Malaria Initiative (PMI) has supported the Ministry of Health (MOH) in Uganda to fight this deadly disease. In 2017, the PMI VectorLink Project began implementing an integrated vector control approach in collaboration with the MOH with the overall goal of reducing the burden of malaria in the country. The project conducts indoor residual spraying (IRS) in 15 high disease burden districts, including Butaleja District. 

Maria Wamagali and two of her grandchildren. Photo by Daniel Eninu/Abt Associates.

In Uganda, the PMI VectorLink Project works directly with Butaleja District’s local government to raise awareness about the disease and the benefits of IRS. The project mobilizes communities to prepare for spray and supervises and monitors the implementation of IRS with a focus on spray techniques, compliance to environmental safety, data management, and reporting.

Before PMI VectorLink began working in the village, Maria Wamagali saw many people die from malaria. A mother of 10 surviving children, she was so afraid of the disease she did not allow her sons and daughters to bring their children to her home for fear of the children being infected

“Since indoor residual spraying was introduced to us in this village with the continued community engagement and sensitization outreach and dialogue, there has been a huge change in the health of my family,” she said.

Through the support of PMI, Wamagali says she now understands how to prevent malaria and welcomes IRS. As a result, there are fewer hospital visits and her grandchildren are safe. She said that children in her village no longer die of malaria like they had before and that now she visits the health center with the children only for immunizations. Wamagali also added that spraying has not only reduced malaria in the community but has also reduced the number of crawling insects, such as cockroaches and flies, in her house.

Wamagali urges the community to fill in ditches which could contain stagnant water and thus be potential breeding grounds for mosquitoes and to always sleep under mosquito nets, especially children. She also encourages them to allow their houses to be sprayed to help eliminate malaria.

[1]World Health Organization. (2018). World Malaria Report 2018. World Health Organization. http://www.who.int/iris/handle/10665/275867.