Angola

Malaria remains a serious public health problem in Angola despite sustained malaria control strategies. Malaria accounts for 35% of all-cause outpatient morbidity, 35% of mortality in children, 40% of prenatal mortality, and 25% of maternal morbidity, and causes 60% of hospital admissions in children under 5 and 10% of admissions of pregnant women. The vector-borne disease is endemic throughout the country and the entire population is at risk. According to the World Health Organization (WHO) 2017 World Malaria Report (WMR), the total number of malaria cases (suspected and confirmed) reported in the public health sector in 2015 was 3,254,270. This number increased by 32% in 2016 to 4,301,146, likely due to increased rainfall because of El Niño and stock-outs of anti-malarial drugs (FY2018 Malaria Operational Plan).

In 2014, PMI constructed and established an insectary in Huambo. It was the first insectary in Angola since the end of the civil war. PMI also supported the training of technicians on basic malaria entomology, including the sampling of aquatic and adult mosquitoes, rearing of adults from field-collected larvae/pupae, morphological species identification, ovary dissection, cone bioassays, susceptibility testing using U.S. Centers for Disease Control and Prevention (CDC) bottle bioassay and WHO tube test methods, preserving mosquito samples, and transport to a laboratory for molecular and biochemical assays. Insectary technicians also received on-the-job training and mentorship to support continuous improvement of their skills and competence. PMI also supported the training of provincial and municipal health authorities drawn from nine provinces (Benguela, Cunene, Huambo, Huila, Luanda, Malanje, Namibe, Uige, and Zaire) where insecticide resistance was evaluated in 2015-2016. These provinces represent three malaria transmission zones.

In year one of the PMI VectorLink Angola project (May 2019 to April 2020), entomological surveillance was conducted in two sites—one in Huambo Province and the other in Lunda Sul Province. (The original plan was to conduct entomological surveillance in three sites, but Luanda Province was postponed due to the COVID-19 pandemic.) VectorLink Angola conducted one month of entomological surveillance at each site during the peak mosquito season (January-March 2020) to determine species composition, vector behavior, and vector susceptibility to different insecticides. The project also hired a full-time Entomology Coordinator who facilitated preparations for data collection, including meeting with central, provincial, and district leadership, and obtaining ethical clearance from the Instituto Nacional de Saúde Publica (INSP). With the support from the PMI VectorLink home office and a consultant who stayed in Angola throughout the sampling season, the project trained a total of 15 people (including eight members of the Provincial mosquito brigades, five technicians, a Field Epidemiology Training Program fellow, and the Entomology Coordinator) on adult mosquito collection methods and morphological identification.

In year two (May 2020 – April 2021), the PMI VectorLink team worked to strengthen the entomological capacity of the VectorLink Angola technicians as well as Direcção Provincial de Saúde (DPS – Provincial Health Directorate) mosquito brigades in each province. The project piloted community-based entomological surveillance in Huambo Province and began collecting monthly trapping data in November 2020. VectorLink Angola also successfully collected insecticide susceptibility data from seven provinces (Huambo, Kwanza Norte, Luanda, Lunda Sul, Malanje, Uige, and Zaire), including data on the synergist piperonyl butoxide (PBO). This was the first wide scale insecticide susceptibility survey in Angola since 2016 and showed that malaria vectors are resistant to pyrethroid insecticides, but that PBO synergist produces substantial increases in mortality.

With the need for insecticide susceptibility data to drive decisions, including procurement and deployment of ITNs, VectorLink Angola targeted the collection of insecticide susceptibility data from eight provinces in year three (May 2021 – April 2022)—Huambo, Kwanza Norte, Luanda, Lunda Norte, Lunda Sul, Malanje, Uige, and Zaire). As of July 2022, testing had been completed in six sites (Huambo, Kwanza Norte, Lunda Sul, Malanje, Uige, and Zaire) using the priority vector species; insecticide resistance testing was conducted in Luanda on An. azevedoi. Also in year three, the project scaled up monthly community-based entomological surveillance to two additional sites—Luanda in July 2021 and Lunda Norte (pilot) in December 2021—while continuing monthly collections in Huambo.

In Year four (May 2022 – April 2023), the PMI VectorLink Angola project will continue to work with PMI Angola, the NMCP, DNSP/Instituto Nacional de Investigação em Saúde (INIS), and provincial/district authorities to conduct entomological monitoring. The team also plans to work with the Instituto de Combate e Controlo das Tripanossomíases (ICCT), engaging staff in field entomology and insectary activities as part of capacity strengthening and sustainability objectives. The project’s primary objective is to build sustainable entomological capacity within Angola. Key objectives are to:

• Strengthen entomological technical capacity in-country through short-term technical assistance from PMI VectorLink headquarters and regional staff, on-the-job training, and supervision of local personnel and DPS/NMCP brigade personnel. Conduct entomological activities throughout the year (versus seasonally), supported by five full-time staff, a part-time data clerk, as well as ICCT technicians to support field, laboratory, and insectary activities.
• Determine species composition in two provinces (Huambo and Luanda) through six routine surveillance collection efforts over the course of the work plan year (roughly every other month), and vector susceptibility to different insecticides in seven provinces (Kwanza Norte, Luanda, Lunda Norte, Lunda Sul, Malanje, Uige, and Zaire) during the peak mosquito season (November 2022-April 2023).
• As part of the capacity-strengthening plan, develop brief job aid for morphological identification of local Anopheles species, as well as stephensi.
• Sponsor one entomologist from NMCP/MOH to attend a project-wide regional entomology training, focused on topics of importance to NMCP staff. This training will include insecticide susceptibility testing, morphological identification, sample processing, and standardized data collection and management.
• Support attendance of one VectorLink Angola staff at a project-wide regional M&E/entomology training focused on increasing their capacity in entomological data use and analytical skills using VectorLink Collect, which can be cascaded to NMCP/MOH staff and applied to support evidence-driven decision.
• Support training of NMCP/MOH and VectorLink entomology technicians in insectary management through partnership with an active insectary in sub-Saharan Africa, with the end goal being sustained establishment of a susceptible gambiae colony in Angola.
• With remote support from the PMI VectorLink Molecular Biologist, continue to build molecular laboratory capacity in Angola and with INIS to perform polymerase chain reaction (PCR) for species identification and to determine resistance mechanisms, and enzyme-linked immunosorbent assays (ELISAs) to determine sporozoite infection rates.
• Conduct local and international procurement of entomological surveillance items required for working insectaries and selected entomological monitoring sites and to carry out laboratory activities at INIS, while providing technical support to local procurement staff on inventory management and exploring alternative routes for sustainable local procurement through regional vendors.
• Continue to collaborate with and provide technical assistance as needed to entomological monitoring conducted by Global Fund through the MENTOR Initiative in Benguela and Kwanza Sul Provinces.
• Liaise with WHO, NMCP and GEPE/GTI to facilitate the adoption of the WHO entomology metadata packages in the Angola DHIS2, including pre-programmed data collection forms and analytic dashboards. Facilitate stakeholder meetings to determine how to best ensure that VectorLink Angola entomological data from the VectorLink Collect system and entomological monitoring data from MENTOR can be shared with the Angola DHIS2 and used by the NMCP to inform decision-making. Support NMCP with technical assistance on the use and interpretation of entomological data in the Angola DHIS2. PMI VectorLink will share the minutes of these meetings with PMI and CDC in Angola and at HQ. Any developed documents, such as protocols or standard operating procedures, will also be shared.
• Develop a manuscript for a peer-reviewed journal and abstracts for presentation at international conferences to disseminate key findings on azevedoi collected in Luanda and other provinces.