Insecticide-treated nets (ITNs) are a proven intervention in malaria vector control. To date, the U.S. President’s Malaria Initiative (PMI) VectorLink Project has conducted ITN activities in 17 countries in sub-Saharan Africa, in coordination with National Malaria Control Programs (NMCP). These activities range from ensuring state-of-the-art ITN delivery through continuous distribution channels and mass campaigns, to implementing essential research activities such as durability monitoring of ITNs. PMI VectorLink also provides technical assistance and capacity strengthening to NMCPs, sometimes through embedded staff members, and works on social and behavior change activities to improve ITN use.
ITN Continuous Distribution
Continuous distribution refers to additional channels that are used for distributing ITNs to a population, such as antenatal (ANC) clinics and health centers that provide the Expanded Program on Immunization (EPI), which pregnant women and mothers of young children routinely visit. The WHO recommends that countries combine delivery mechanisms like continuous distribution with mass campaigns (see below) to achieve and maintain universal access to ITNs. School-based distribution of ITNs is another channel for continuous distribution. It was first implemented in Ghana in 2012, followed by Tanzania in 2013, and both countries have gone to scale. Several other countries have implemented school-based distribution pilots.
ITNs may also be distributed through community-based programs (see continuousdistribution.org).
School Distribution in Zambia
To implement school-based distribution, PMI VectorLink Zambia worked with the National Malaria Elimination Program (NMEP) through the Ministry of Health (MOH), Ministry of Education (MOE), the PMI-funded PAMO+ project (supported social behavior change activities) and USAID-funded GHSC-PSM project (worked with third party logistics organizations to transport the nets from the central level to the schools). The team also supported the NMEP in the planning of the school-based distribution, provided orientation and cascade training sessions for MOH and MOE staff at provincial, district, zonal and school levels, along with supervision during distribution. Over five-days, in October 2021, 51,000 ITNs procured by PMI were distributed to pupils in Grades 1 and 4 across 426 schools in Chadiza, Chipangali, Katete, and Petauke districts.
ITN Mass Campaigns
The World Health Organization (WHO) recommends that ITNs be distributed free of charge to those at risk of contracting malaria. Mass distribution campaigns—when ITNS are systematically given out across a country or specific regions of a country—have been a major part of malaria prevention efforts for more than a decade. ITNs are commonly distributed through mass campaigns around every three years. PMI VectorLink provides technical assistance for mass distribution campaigns led by NMCPs in coordination with national, regional, and local stakeholders in-country. This support may include coordination, distribution, social and behavior change communications, community mobilization, monitoring and evaluation, and other types of assistance.
Close coordination between the NMCP and all implementing partners in the mass campaign is critical, especially on key decisions and timelines; ensuring the quality of the microplanning by using updated demographic data is essential to ensure sufficient ITNs are procured for the current population size; involving local transporters in the preparation of the net pre-positioning plan and other tracking tools is important to avoid distribution delays; ensuring consistent messaging can prevent rumors, especially for multi-product campaigns and finally, if the population data is up to date, then a single registration and distribution phase would be feasible for a mass campaign if that approach is chosen by the NMCP.
ITN Mass Distribution in Cote d’Ivoire
In Cote d’Ivoire, PMI VectorLink provided technical assistance for the distribution of 3,074,527 PBO-ITNs in 11 districts over about a week in April 2022. These PBO-ITNs covered 5,479,980 people and 1,017,457 households, representing respectively 96.31% and 94.81% of the people and households registered. To facilitate ongoing improvements during the campaign–as well as implementation of future ITN mass campaigns, PMI VectorLink, in collaboration with the NMCP Vector Control Technical Group, identified key successes, lessons learned and recommendations.
One of the keys to the success in PBO focus districts involved the hiring and training of PMI VectorLink District Focal Points positioned in all 11 districts. These Focal Points supported planning, registration, supervision, delivery of ITNs to distribution sites, monitoring of campaign data, and effective distribution. The 11 District Focal Points were also responsible for ensuring individuals respected COVID-19 prevention measures.
ITN Durability Monitoring
Since project inception, PMI VectorLink has supported durability monitoring of ITNs through a standard methodology to provide country and global stakeholders with actionable evidence on median ITN life and insecticide effectiveness collected under real-life use conditions. Recently, PMI VectorLink has developed a more streamlined protocol for durability monitoring for countries that have already generated considerable ITN durability data and have more focused questions, particularly around physical and chemical durability of new types of nets. Streamlined durability monitoring is being implemented in Liberia and Madagascar. PMI VectorLink in Nigeria and Cameroon planning to roll out the new methodology in the coming year.
Through both standard and streamlined durability monitoring, the project collects data on attrition, physical integrity, bio-efficacy, use, and care and repair behaviors of pyrethroid-only ITNs alongside new piperonyl-butoxide (PBO) and dual-active ingredient ITNs to inform procurement and programmatic decisions and develop effective, evidence-based integrated vector management strategies. PMI VectorLink uses World Health Organization-endorsed ITN durability monitoring resources, which are available at https://www.durabilitymonitoring.org/
Social and Behavior Change Communication (SBCC)
Social and behavior change communication (SBC) is a critical component of effective malaria control strategies. Where needed, PMI VectorLink partners with in-country stakeholders to support activities to assess the barriers and facilitators of behaviors linked to ITN usage, lead or support the design of interventions to address the identified barriers and facilitators, and drive innovation in ITN-related SBC activities.
In Ghana, PMI VectorLink, in partnership with Ghana’s NMCP, the Central and Eastern Regional Health Directorate, and local nonprofit Total Family Health Organization is training midwives, community health nurses, and community health management teams to champion use of insecticide-treated nets and promote effective use and care of the nets among pregnant women and caregivers of children under five during routine care visits.
The project applies malaria SBC global best practices and draws from resources developed by the Roll Back Malaria Partnership to End Malaria SBC working group. Learn more at endmalaria.org.