2021 was a busy year for the PMI VectorLink Project. Despite the ongoing COVID-19 pandemic and the challenges associated with it, the project continued to deliver high-quality malaria control interventions. We published articles, malaria fighter profiles, success stories, videos, as well as hosted four webinars to showcase our work. As we begin the new year, let’s look back at some of our achievements in 2021 that have helped reduce the burden of malaria.
The detection of the Asian malaria vector Anopheles stephensi in the Horn of Africa (HOA) more than 10 years ago has caused growing concern among malaria stakeholders about the invasive vector’s potential to spread malaria and the effect the vector could have on sustaining gains in malaria control in the region. In 2019, the World Health Organization identified An. stephensi as a “major potential threat” in the progress to control malaria and called for enhance surveillance in Africa.
A new study published in Parasites & Vectors, provides insight on the vector’s movement patterns and feeding preferences in Ethiopia. The authors’ findings, which analyzed the genetic variations in An. stephensi populations in Ethiopia, offer vector control decision makers crucial information on how far the vector has spread, where it is migrating, and what the vector prefers to feed on in the region.
In the new study, Genetic diversity of Anopheles stephensi in Ethiopia provides insight into patterns of spread, the authors note, “Since the identification of An. stephensi in Ethiopia, this vector has been detected in 10 additional sites in eastern Ethiopia as far north as Semera and as far south as Godey . Pastoralism is a common livelihood in Ethiopia and involves moving cattle, goats, sheep, and camels hundreds of kilometers every season . Movement may be driven by several factors including limited natural resources, conflicts, recurrent severe droughts, and extreme weather [20, 21].
The authors conclude that “future studies with expanded genomic analysis will further inform our understanding of migration rates and the role of local adaption on the spread of An. stephensi into and throughout the HOA. Collaboration across countries where this mosquito is well established and countries where it is emerging can facilitate a complete understanding of the spread of An. stephensi into Africa.”
The authors’ evidence shows both zoophagic (feeding on common livestock species such as cattle) and anthropophagic (feeding on humans) behaviors of the vector, supporting the need for additional studies into the potential for livestock movement to play a role in the vector’s spread in this region.
As early as 2018, the U.S. President’s Malaria Initiative (PMI) VectorLink Project began collecting mosquito samples of the species in Ethiopia during routine entomological monitoring to study more about the mosquito’s patterns and behavior. PMI provided the mosquito samples for the new study, which was conducted by Baylor University in partnership with Ethiopia’s Jigjiga University and Dire Dawa University.
PMI has also studied the potential impact of the vector’s establishment on the transmission of Plasmodium falciparum in Ethiopia, estimating that annual P. falciparum malaria cases could increase by 50% (95% CI 14-90) if no additional interventions are implemented. Read more here. To learn more about PMI’s findings on An. stephensi’s distribution, bionomics, insecticide susceptibility, and transmission potential, read here.
In 2012, Sokhna Tall joined the U.S. President Malaria Initiative (PMI) Africa Indoor Residual Spraying Project in Senegal. While working as an Assistant Accountant, she became interested in indoor residual spraying (IRS) technical work and began participating in various project training courses for IRS operations, including training of trainers, spray operators, team leaders, pump technicians, washers, and guards. In 2014, she was promoted to District Coordinator and has continued in that role with the PMI VectorLink Project. As a District Coordinator, Sokhna ensures the coordination of all IRS activities in Koungheul District, including logistics management, advocacy with the authorities, training of seasonal workers, monitoring of environment compliance and supervision of IRS operations. When not planning or carrying out IRS, she oversees supply logistics and distribution of insecticide-treated nets (ITNs) with the project. Recently, Sokhna took time to talk about her role in fighting malaria.
Do you have any personal experience with malaria?
Growing up in Dakar, Senegal, I had multiple experiences with malaria. The experience that really affected me was in August 2009 during the peak of malaria transmission in Senegal. My son, who was just one and a half years old at the time, fell sick with malaria. When I took him to the hospital, I was shocked by the high number of children suffering from malaria, some of them under IV treatment for severe malaria. The number of beds available was not sufficient for all the children. Some mothers were just seated on the floor with their children. This experience contributed to my decision to apply and work for a malaria prevention project as I was convinced that malaria was a real burden for mothers like me. Today, more than 10 years later, situations like this are no longer observed in Dakar and in many regions in Senegal as the incidence of malaria has decreased significantly due to the extensive use of ITNs and IRS in some districts.
Can you talk about how the project has worked to provide malaria services during the COVID-19 pandemic?
At the beginning of the pandemic, the project developed a contingency plan for IRS in the COVID context. This contingency plan follows Ministry of Health and PMI guidelines, which includes ensuring barrier and prevention methods for spread of the disease in all IRS activities. The project also includes COVID prevention measures in IRS workshops and trainings to ensure all participants are compliant with the guidelines. The project successfully carried out the IRS campaigns in 2020 and 2021, protecting approximately 571,600 people each year from malaria.
What impact has your job had on malaria in Senegal?
I can proudly say that the PMI VectorLink Project is contributing to the decreased density of malaria vectors in all sprayed areas of the district. Malaria incidence has reduced from 8.1 to 7.7 per 1000 from 2019 to 2020 in the Kaffrine Region, which includes Koungheul District where I supervise IRS. We have received lots of gratitude from communities who have let us know that they are sleeping quietly with no mosquito noise around. Medical professionals from the district have also reported a decrease of malaria cases in children specifically.
What changes have you seen in IRS implementation since the project began?
Many changes have been introduced since the beginning of the project but the most ones are related to the introduction and use of new information technologies, such as the use of smartphones for data collection and the introduction of mobile payments for seasonal workers. Previously, we used a paper-based data collection system, which was a source of constant headache, long working hours, and multiple discussions within the district team. Under the PMI VectorLink Project, data collection in Senegal is done through a smartphone and is a real relief for my work as a District Coordinator.
How does the project invest in local partners to lead malaria programs?
The project builds the skills of national partners like the National Malaria Control Program (NMCP), regional medical teams, district health teams, National Service of Hygiene, and environment officers to carry out IRS. For example, in 2021, the project conducted a Master Training workshop which trained national partners in the process of IRS planning, implementation, monitoring and all aspects of a campaign at the national and local levels. In addition, every year the project trains local leaders in IRS, from training of trainers to insecticide management, procurement, and so on. Local partners are the key to the success of the activities, and the partners are involved in all IRS implementation steps. All activities are conducted in collaboration with the local partners to ensure malaria prevention services can be sustained.
Community health workers are an important link because all activities are carried out at the community level. They know the field better, and are often the messengers, supervisors, and sometimes operators in IRS activities. Community health workers are strongly encouraged to apply to all positions of IRS activities. Once they are recruited, the project trains them and hires those who meet the criteria to be involved in IRS.
How does VL tailor its approach to ensure it fits Senegal’s needs?
PMI VectorLink adapts to the realities of the country, taking into consideration the concerns of the country’s health systems. The project’s work is aligned to the National Malaria Strategic Plan developed by NMCP. All activities (planning, operational activities, etc.) are discussed and done in concert with national and local partners.
The NMCP and the Vector Control Steering Committee choose which districts receive IRS services. These districts are in rural areas where access to care is not always easy. The project provides protection for everyone in these districts, particularly those most vulnerable to the malaria.
Duartina Francisco serves as Country Operations Director and Gender Focal Person for the U.S. President’s Malaria Initiative (PMI) VectorLink (VL) Project in Mozambique. She began working in vector control with the PMI Africa Indoor Residual Spraying (IRS) Project in 2012. Duartina holds an MBA in Management of Integrated Systems, Quality Environment and Safety from Mozambique’s Higher Institute of Science and Technology and a Bachelor in Environment Management, Planning and Community Development. She’s a trained nurse in maternal and infant health and previously worked as a field officer and trainer on a project that focused on orphans and people living with HIV. Recently, Duartina took time out of her busy day to talk about her work.
What do you find most challenging about your job?
Convincing and mobilizing targeted populations to accept having their houses sprayed is the most challenging aspect (IRS involves spraying the inside walls and ceilings with an insecticide that kills the malaria parasite-carrying mosquitoes). There are lots of myths about IRS that make it challenging for people to accept IRS. The most recent widespread myth was that IRS spray operators were vampires and that mobilizers were marking houses to easily identify which households would have their blood sucked. This caused many households to remove all mobilization stickers and to wipe off any markings that mobilizers left on their houses as part of the house-to-house mobilization. IRS requires the entire community’s acceptance and efforts (The World Health Organization recommends higher than 85 percent coverage for IRS to be successful).
In Mozambique, community leaders are also political leaders and play a critical role in IRS. They are responsible for encouraging their community to stay at home and not to leave to farm on spray days so that they can have their houses sprayed. By involving local leaders before the IRS campaign began, we were able to dispel this myth.
Another challenge has been the impact of natural disasters, such as heavy rains and cyclones. While malaria incidence has decreased thanks to the project’s vector control interventions, the flooding and rains provide additional breeding grounds for mosquitoes, which results in higher abundance of mosquitoes and increased risk of malaria transmission.
What changes have you seen in IRS implementation since the PMI VectorLink Project began?
There has been an increase in the engagement of political leaders at all levels in malaria matters, especially for IRS. We have many political parties in country. In the past, it was difficult for a member of the opposition party to accept IRS because they saw it as political issue and not a health issue. This resulted in many refusals for spray in communities that were known to be affiliated with the opposition party. The project began having separate, focused meetings at both the provincial and local levels within the community structure to ensure that all political party leaders are involved in IRS. There used to be one central level meeting where leaders of the opposition political parties were not invited or represented. Once the meeting moved to different levels, it improved participation from all leaders.
How does the project reach the most vulnerable, particularly those not previously protected with vector control? Our target populations include those living in very remote places where it is difficult for them to reach basic health care services in time if they contract malaria and where there is little access to buy products to protect their houses against mosquitoes. We prioritize these areas for IRS first to ensure we reach them before it rains, when it becomes more difficult to travel. With the introduction of the IRS mobile soak pit, our work in remote areas is easier.
In IRS, spray operators rinse liquid waste from spray tanks and protective gear into soak pits that adsorb and safely degrade the traces of insecticide found in the wash-water. In most spray areas, soak pits are permanent installations in a central location that can be accessed at the end of the spray day. However, in some hard-to-reach areas, it is difficult and sometimes impossible for spray teams to return to a soak pit for clean-up purposes. The mobile soak pit, developed under the PMI Africa Indoor Residual Spraying Project, can be carried to a spray location, installed at a wash site in minutes, and used to catch and treat insecticide waste. When spray operations in the area are complete, the soak pit is dug-up and carried away for use at the next location, while the site is restored to its original condition.) We shared this innovation with other provinces, and they are using it, too, which helps us to ensure we don’t leave anyone behind.
Since the project began there has been a decrease in mortality from malaria. The reduction in malaria prevalence in Zambezia Province (where the project implements IRS) went from 68% to 44% between 2015 and 2018 in children under 5 years. At the Zambezia’s 2021 malaria provincial evaluation meeting, the Provincial Health Directorate reported a 9.1% reduction in malaria-related deaths in its eight-month Zambezia malaria progress report in the districts that receive IRS and insecticide-treated nets.
How does the project invest in local partners to lead malaria programs?
The project engages local partners to lead programs by sharing best practices in managing IRS activities. For instance, PMI VectorLink was the first project in the country to use checklists to supervise IRS activities. This best practice was adopted by the National Malaria Control Program (NMCP) and recommended to all partners to monitor IRS. The project also introduced the best practice of using the mobile soak pit in hard-to-reach areas, which is now being used by the government in three provinces.
Heads of health posts, malaria focal point persons, environmental health officers, among others from the Ministry of Health, have received training from the project. These staff have gone on to train government spray operators who are now capable of supervising spray campaigns. Our project checklists also have been adopted by the Ministry of Health and other partners to manage the entire malaria program, including monitoring malaria indicators at the country level. The VL environmental compliance checklist was adopted and used as foundation for the NMCP, not only for IRS but all malaria strategies implemented in the country. The government’s training of trainers’ curricula was also adjusted based on the project’s curricula. This impact has been very notable as the project is a model for IRS implementation in three regions of the country.
The project also provides entomology support to six provinces, including Zambezia where the project implements IRS. The reported entomological data helps the National Malaria Control Program to make informed vector control decisions for areas where the malaria incidence is increasing.
What progress have you seen in gender equity as Gender Focal Person?
In 2015, when the AIRS Project began to actively promote gender equity and female empowerment at all levels of IRS operations, it seemed like an impossible task to achieve. We started with 7% female participation in IRS. Now we are at 33%. Apart from numbers, I have seen many women apply for different positions (that have traditionally been held by men), such as drivers, spray technicians, site supervisors, and team leaders. At the beginning of the project, women were predominantly working as washers with some working as spray operators. So there has been very good progress, and I am very happy to be part of that.
Can you talk about how the project supports systems to be resilient against the COVID-19 pandemic and other shocks?
Running the vector control activities during the ongoing COVID-19 pandemic has been a challenge. The PMI VectorLink Project works across 26 countries to protect people from malaria. With such a big project, there is diversity of ideas, contexts, and challenges. We learned lessons from other countries that sprayed under the pandemic before Mozambique. As a result, we adjusted our operating procedures, and with Mozambique’s Ministry of Health (MOH) guidance, we developed an action plan to ensure to minimize the spread of COVID-19 among the team. Continuous sharing of information and experiences will contribute to the project being resilient against pandemics and other shocks in the future.
Do you think Mozambique will ever be malaria-free?
Yes, by continuing to implement integrated vector control and management strategies, it can be. There are many interventions taking place at the national level, such as housing improvement, environment sanitization, and massive distribution of bed nets. The integrated vector control management model has shown progress towards elimination in the southern part of the country, which was declared to be in the malaria elimination phase by Southern Africa Development Community in 2020. My hope is that the NMCP continues making efforts in the adaptation/adoption of the tools and best practices used under VL to fight malaria and to expand IRS to other provinces, since the whole country is endemic for malaria.
Insecticide-treated nets (ITNs) are a proven vector control intervention for reducing malaria illness and death. The PMI VectorLink Project supports National Malaria Control Programs (NMCPs) and stakeholders to implement mass ITN distribution campaigns. In Ghana, the NMCP and partners have distributed ITNs through mass campaigns and routine channels to ensure high ownership. Since 2010, the country carried out four national mass campaigns, and implemented routine distribution of ITNs through health facilities (antenatal and child welfare clinics) and primary schools.
However, analysis of the 2016 Malaria Indicator Survey (MIS) showed that 24 percent of people who have ITNs don’t use them and Ghana has a use: access ratio (an estimate of the proportion of the population using nets, among those that have access to one within their household) of 63 percent. This prompted research to understand the motivators and barriers of ITN use. A 2018 qualitative study identified ITNs as a key method to protecting people from malaria, but heat, discomfort, and reaction to insecticides were identified as main barriers to use.
Using the findings of the 2018 study and analysis of the 2019 MIS data, which also showed 24% of people with ITNs do not use them, the PMI VectorLink Project, NMCP and the Central Regional Health organized a workshop to design behavior change interventions that could increase ITN use in households and communities in December 2019. The project, working with the local nonprofit Total Family Health Organization (TFHO), trained 175 midwives and community health nurses from 114 health facilities in five districts as ITN use and care champions in the Central Region. The aim was to promote positive ITN use and care behaviors among pregnant women, caregivers of children under five, and the entire community. The champions pledged to promote consistent use of ITNs and were provided with a badge and pledge form to display. Additionally, they were equipped with a radio to play recorded messages and other job aids to educate the targeted beneficiaries on ITN use and care. Key messages discuss the benefit of ITNs, their cost effectiveness compared to other tools favored by the population like mosquito coils, proper use of ITNs, and misuse of ITNs.
Edith Asare, a midwife with more than 30 years of experience and a trained ITN champion through PMI VectorLink Ghana, now plays the messages during antenatal care or child welfare sessions, where women have access to ITNs as part of routine channels, to stimulate lively discussions among pregnant women. The pregnant women often leave the antenatal clinic at the Swedru Hospital in the Central region of Ghana with a pledge to sleep under an ITN every night and to become an ITN use and care champion in their communities.
“This intervention is a very positive one. I don’t see this as a [short-term] project but should be part of our approach to continuously educate pregnant women to use ITNs to protect themselves and their unborn baby. This is important as we give out ITNs as part of our routine care to registrants. It should form part of what we do daily. I’ll always promote ITN use,” said Edith.
PMI VectorLink Ghana is working with TFHO and the Eastern and Central region health directorates to scale up implementation to additional 40 districts. They aim to train 2,713 midwives and community health nurses and 4,976 community health management teams (CHMTs)/opinion leaders as ITN champions.The addition of CHMTs is to ensure the community members are involved in planning and implementation of interventions that will promote ITN use and care and to ensure ownership.
 Ahorlu, C.S., Adongo, P., Koenker, H. et al. Understanding the gap between access and use: a qualitative study on barriers and facilitators to insecticide-treated net use in Ghana. Malar J 18, 417 (2019). https://doi.org/10.1186/s12936-019-3051-0
The COVID-19 pandemic continues to challenge public health workers implementing malaria interventions across the globe. In Mali, ongoing civil unrest added to those challenges, putting critical vector control services at risk. The U.S. President’s Malaria Initiative (PMI) VectorLink Project supports countries to conduct indoor residual spraying (IRS) to kill and repel the mosquitoes that carry the malaria parasite, which can infect people and cause serious illness and death. PMI VectorLink Mali collaborated closely with communities to ensure people were protected from malaria despite these challenges.
PMI VectorLink Mali communicated regularly by phone with local administrative authorities and community leaders to effectively monitor the security situation in the areas it sprays. When security issues prevented spray teams from adhering to the planned spray operations, the village chiefs were contacted by the spray team to reschedule the spray date, and the project closely tracked the ongoing security situation.
The local administrative authorities also played an important role in increasing community awareness and acceptance of IRS. For example, PMI VectorLink Mali engaged village chiefs and their deputies to ensure homeowners were prepared to accept IRS. One day before the arrival of the spray team, under the authority and direction of the village chief, the Information, Education and Communication (IEC) mobilizer went door to door providing important information to the community about IRS and reminded homeowners how to prepare their houses for spraying.
In previous years, PMI VectorLink Mali came across homes in rural areas that were locked due to people working in agricultural fields when the spray teams arrived. However, this year, thanks to community collaboration, homeowners were well prepared, and PMI VectorLink Mali was able to safely conduct the spray campaign. As a result, PMI VectorLink Mali successfully completed the 2021 IRS campaign, protecting approximately 233,663 people, including 45,249 children under five years old, and 17,768 pregnant women. The team exceeded its target spray coverage of 85% to reach 96.7% spray coverage during the campaign as a result of the strong relationship and trust the project has built with local partners and beneficiaries.
“We trust that once again this year, thanks to IRS, there will be fewer and fewer cases of malaria in our community,” said Sogoba Dembele, President of the Women’s Association in Bounguel, Djenne District. “As mothers, we are very pleased for that because it will prevent us from spending our time in hospitals, which gives us time for taking care of our daily business for the well-being of the whole family.”
New findings from the U.S. President’s Malaria Initiative (PMI) VectorLink Project published in Scientific Reports today show the potential for reducing costs of indoor residual spraying while retaining efficacy in killing the mosquito species known to spread malaria. Over the past two decades, massive reductions in deaths and illnesses from malaria have come from IRS, which uses insecticides to kill the mosquitoes that carry the malaria parasite. Increasingly, those gains are threatened as widespread resistance to commonly used pyrethroid insecticides calls for the use of new and costly insecticides for IRS. Faced with increasing operational costs, the PMI VectorLink Project led a study in Ghana in collaboration with Noguchi Memorial Institute for Medical Research and Imperial College London to find innovative ways to effectively combat malaria with the reduced use of insecticide. In a village-wide trial in northern Ghana using experimental huts and houses, the team evaluated the efficacy of reducing the area of wall sprayed with the insecticide pirimiphos-methyl against Anopheles gambiae s.l., the primary vector that spreads the disease.
The transmission model “predicts that the efficacy of partial IRS against all-age prevalence of malaria after six months would be broadly equivalent to a full IRS campaign in which 40% reduction is expected relative to no spray campaign. At scale, partial IRS in northern Ghana would have resulted in a 33% cost savings ($496,426) that would enable spraying of 36,000 additional rooms. These findings suggest that partial IRS is an effective, feasible, and cost saving approach to IRS that could be adopted to sustain and expand implementation of this key malaria control intervention.”
PMI VectorLink Senior Technical Advisor Aklilu Seyoum said, “This very important study strongly indicated that partial IRS could be a good alternative to the current practice of full IRS. This has the potential to increase the population protected by IRS and save more lives in malaria-endemic countries. A more rigorous randomized control trial is now being planned by the PMI VectorLink Project before large-scale application of this important approach can be used in the control programs.”
To learn more, read the article here.
The U.S. President’s Malaria Initiative (PMI) VectorLink Project collaborates with national and local governments to identify, study, and record where malaria-transmitting mosquitoes live, how they feed, when they rest, and the density of their population. In Kenya, PMI trained community health volunteers on how to catch and monitor mosquitoes, expanding the national government’s geographical reach to collect critical data on mosquitoes from two counties. This data will help to inform vector control decision making in the fight against malaria.
From the Field to the Lab, Women Fight to End Malaria
Gains in reducing morbidity and mortality from malaria depend on the use of effective insecticides in vector control measures, such as IRS and ITNs. With more people qualified to carry out entomological monitoring, PMI is equipping country partners with the tools and knowledge needed to fight this deadly disease. This World Mosquito Day, PMI VectorLink celebrates the women in science who find, share, and use entomological evidence to fight malaria in their own countries. Read about them here.
WORLD MOSQUITO DAY: FOCUSING ON THE INVASIVE AN. STEPHENSI IN ETHIOPIA
An Asian malaria vector is invading Ethiopia and other parts of sub-Saharan Africa. If this invasive vector continues to spread, large parts of Ethiopia could see dramatic increases in incidence of malaria.
Lives are at stake. Where do we go from here?
The U.S. President’s Malaria Initiative VectorLink Project’s Senior Entomologist Aklilu Seyoum will host a compelling discussion with leading entomologists as they share their latest research on the An. stephensi mosquito and what it means for those most vulnerable to malaria in Ethiopia.
- Dr. Fitsum Girma (Lead Scientist, Armauer Hansen Research Institute) from Ethiopia’s Ministry of Health
- Dr. Meshesha Balkew (Vector Monitoring Director, PMI VectorLink Ethiopia)
- Dr. Thomas Churcher (Reader in Infectious Disease Dynamics) from Imperial College
JOIN US (French translation provided. See links below.)
Friday, August 20, 2021 at 8:00 am
Eastern Daylight Time (New York, GMT-04:00)
This is an open webinar. Please share the link with partners and vector control stakeholders.
French: Meeting Information