Abstract
BackgroundThe National Malaria Control Programme (NMCP) of Mali has had recent success decreasing malaria transmission using 3rd generation indoor residual spraying (IRS) products in areas with pyrethroid resistance, primarily in Ségou and Koulikoro Regions. In 2015, national survey data showed that Mopti Region had the highest under 5-year-old (u5) malaria prevalence at 54%—nearly twice the national average—despite having high access to long-lasting insecticidal nets (LLINs) and seasonal malaria chemoprevention (SMC). Accordingly, in 2016 the NMCP and other stakeholders shifted IRS activities from Ségou to Mopti. Here, the results of a series of observational analyses utilizing routine malaria indicators to evaluate the impact of this switch are presented.MethodsA set of retrospective, eco-observational time-series analyses were performed using monthly incidence rates of rapid diagnostic test (RDT)-confirmed malaria cases reported in the District Health Information System 2 (DHIS2) from January 2016 until February 2018. Comparisons of case incidence rates were made between health facility catchments from the same region that differed in IRS status (IRS vs. no-IRS) to describe the general impact of the 2016 and 2017 IRS campaigns, and a difference-in-differences approach comparing changes in incidence from year-to-year was used to describe the effect of suspending IRS operations in Ségou and introducing IRS operations in Mopti in 2017.ResultsCompared to communities with no IRS, cumulative case incidence rates in IRS communities were reduced 16% in Ségou Region during the 6 months following the 2016 campaign and 31% in Mopti Region during the 6 months following the 2017 campaign, likely averting a total of more than 22,000 cases of malaria that otherwise would have been expected during peak transmission months. Across all comparator health facilities (HFs) where there was no IRS in either year, peak malaria case incidence rates fell by an average of 22% (CI95 18–30%) from 2016 to 2017. At HFs in communities of Mopti where IRS was introduced in 2017, peak incidence fell by an average of 42% (CI95 31–63%) between these years, a significantly greater decrease (p = 0.040) almost double what was seen in the comparator HFCAs. The opposite effect was observed in Ségou Region, where peak incidence at those HFs where IRS was withdrawn after the 2016 campaign increased by an average of 106% (CI95 63–150%) from year to year, also a significant difference-in-differences compared to the comparator no-IRS HFs (p < 0.0001).ConclusionAnnual IRS campaigns continue to make dramatic contributions to the seasonal reduction of malaria transmission in communities across central Mali, where IRS campaigns were timed in advance of peak seasonal transmission and utilized a micro-encapsulated product with an active ingredient that was of a different class than the one found on the LLINs used throughout the region and to which local malaria vectors were shown to be susceptible. Strategies to help mitigate the resurgence of malaria cases that can be expected should be prioritized whenever the suspension of IRS activities in a particular region is considered.
Highlights
The National Malaria Control Programme (NMCP) of Mali has had recent success decreasing malaria transmission using 3rd generation indoor residual spraying (IRS) products in areas with pyrethroid resistance, primarily in Ségou and Koulikoro Regions
The opposite effect was observed in Ségou Region, where peak incidence at those Health facility (HF) where IRS was withdrawn after the 2016 campaign increased by an average of 106% (95% confidence interval (CI95) 63–150%) from year to year, a significant difference-in-differences compared to the comparator no-IRS HFs (p < 0.0001)
Across all comparator health facilities where there was no IRS in either year (n = 238), peak malaria case incidence rates (September to February) fell by an average of 22% (CI95 18–30%) from 2016 to 2017 (Fig. 3)
Summary
The National Malaria Control Programme (NMCP) of Mali has had recent success decreasing malaria transmission using 3rd generation indoor residual spraying (IRS) products in areas with pyrethroid resistance, primarily in Ségou and Koulikoro Regions. Mali remains a highly malaria-endemic country, with an estimated 7.2 million cases in 2017 and 16.9 million people living in high-risk communities [1], the National Malaria Control Programme (NMCP) has recently demonstrated success in reducing morbidity and mortality: between 2013 and 2017 malaria deaths fell by an estimated 38% [1, 2] and nationwide malaria prevalence in children under 5 years old (u5) dropped from 52 to 32% [3, 4]. Recent studies using routine surveillance data from Ségou Region have shown that the IRS campaigns from 2012 to 2015, which utilized bendiocarb and PM to spray more than 200,000 structures each year, were good public health investments—protecting more than 500,000 people a year for around US$7.00 a person while simultaneously reducing indoor resting densities of An. gambiae sensu lato (s.l.), by around 80%, and passively reported confirmed malaria cases, by around 33% [9, 10]
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