Ownership Of Insecticide-treated Nets Research Articles

Changing Patterns of Malaria Epidemiology between 2002 and 2010 in Western Kenya: The Fall and Rise of Malaria

BackgroundThe impact of insecticide treated nets (ITNs) on reducing malaria incidence is shown mainly through data collection from health facilities. Routine evaluation of long-term epidemiological and entomological dynamics is currently unavailable. In Kenya, new policies supporting the provision of free ITNs were implemented nationwide in June 2006. To evaluate the impacts of ITNs on malaria transmission, we conducted monthly surveys in three sentinel sites with different transmission intensities in western Kenya from 2002 to 2010.Methods and FindingsLongitudinal samplings of malaria parasite prevalence in asymptomatic school children and vector abundance in randomly selected houses were undertaken monthly from February 2002. ITN ownership and usage surveys were conducted annually from 2004 to 2010. Asymptomatic malaria parasite prevalence and vector abundances gradually decreased in all three sites from 2002 to 2006, and parasite prevalence reached its lowest level from late 2006 to early 2007. The abundance of the major malaria vectors, Anopheles funestus and An. gambiae, increased about 5–10 folds in all study sites after 2007. However, the resurgence of vectors was highly variable between sites and species. By 2010, asymptomatic parasite prevalence in Kombewa had resurged to levels recorded in 2004/2005, but the resurgence was smaller in magnitude in the other sites. Household ITN ownership was at 50–70% in 2009, but the functional and effective bed net coverage in the population was estimated at 40.3%, 49.4% and 28.2% in 2010 in Iguhu, Kombewa, and Marani, respectively.ConclusionThe resurgence in parasite prevalence and malaria vectors has been observed in two out of three sentinel sites in western Kenya despite a high ownership of ITNs. The likely factors contributing to malaria resurgence include reduced efficacy of ITNs, insecticide resistance in mosquitoes and lack of proper use of ITNs. These factors should be targeted to avoid further resurgence of malaria transmission.

Success of Senegal's first nationwide distribution of long-lasting insecticide-treated nets to children under five - contribution toward universal coverage.

BackgroundIn 2009, the first national long-lasting insecticide-treated net (LLIN) distribution campaign in Senegal resulted in the distribution of 2.2 million LLINs in two phases to children aged 6-59 months. Door-to-door teams visited all households to administer vitamin A and mebendazole, and to give a coupon to redeem later for an LLIN.MethodsA nationwide community-based two-stage cluster survey was conducted, with clusters selected within regions by probability proportional to size sampling, followed by GPS-assisted mapping, simple random selection of households in each cluster, and administration of a questionnaire using personal digital assistants (PDAs). The questionnaire followed the Malaria Indicator Survey format, with rosters of household members and bed nets, and questions on campaign participation.ResultsThere were 3,280 households in 112 clusters representing 33,993 people. Most (92.1%) guardians of eligible children had heard about the campaign, the primary sources being health workers (33.7%), neighbours (26.2%), and radio (22.0%). Of eligible children, 82.4% received mebendazole, 83.8% received vitamin A, and 75.4% received LLINs. Almost all (91.4%) LLINs received during the campaign remained in the household; of those not remaining, 74.4% had been given away and none were reported sold. At least one insecticide-treated net (ITN) was present in 82.3% of all households, 89.2% of households with a child < 5 years and 57.5% of households without a child < 5 years. Just over half (52.4%) of ITNs had been received during the campaign. Considering possible indicators of universal coverage, 39.8% of households owned at least one ITN per two people, 21.6% owned at least one ITN per sleeping space and 34.7% of the general population slept under an ITN the night before the survey. In addition, 45.6% of children < 5 years, and 49.2% of pregnant women had slept under an ITN.ConclusionsThe nationwide integrated LLIN distribution campaign allowed household ITN ownership of one or more ITNs to surpass the RBM target of 80% set for 2010, though additional distribution strategies are needed to reach populations missed by the targeted campaign and to reach the universal coverage targets of one ITN per sleeping space and 80% of the population using an ITN.

Design, implementation and evaluation of a national campaign to distribute nine million free LLINs to children under five years of age in Tanzania

BackgroundAfter a national voucher scheme in 2004 provided pregnant women and infants with highly subsidized insecticide-treated nets (ITNs), use among children under five years (U5s) in mainland Tanzania increased from 16% in 2004 to 26.2% in 2007. In 2008, the Ministry of Health and Social Welfare planned a catch-up campaign to rapidly and equitably deliver a free long-lasting insecticidal net (LLIN) to every child under five years in Tanzania.MethodsThe ITN Cell, a unit within the National Malaria Control Programme (NMCP), coordinated the campaign on behalf of the Ministry of Health and Social Welfare. Government contractors trained and facilitated local government officials to supervise village-level volunteers on a registration of all U5s and the distribution and issuing of LLINs. The registration results formed the basis for the LLIN order and delivery to village level. Caregivers brought their registration coupons to village issuing posts during a three-day period where they received LLINs for their U5s. Household surveys in five districts assessed ITN ownership and use immediately after the campaign.ResultsNine donors contributed to the national campaign that purchased and distributed 9.0 million LLINs at an average cost of $7.07 per LLIN, including all campaign-associated activities. The campaign covered all eight zones of mainland Tanzania, the first region being covered separately during an integrated measles immunization/malaria LLIN distribution in August 2008, and was implemented one zone at a time from March 2009 until May 2010. ITN ownership at household level increased from Tanzania's 2008 national average of 45.7% to 63.4%, with significant regional variations. ITN use among U5s increased from 28.8% to 64.1%, a 2.2-fold increase, with increases ranging from 22.1-38.3% percentage points in different regions.ConclusionA national-level LLIN distribution strategy that fully engaged local government authorities helped avoid additional burden on the healthcare system. Distribution costs per net were comparable to other public health interventions. Particularly among rural residents, ITN ownership and use increased significantly for the intended beneficiaries. The upcoming universal LLIN distribution and further behaviour change communication will further improve ITN ownership and use in 2010-2011.

Community trial of insecticide-treated bed net use promotion in southern Ghana: the Net Use Intervention study

Insecticide-treated nets (ITNs) reduce malaria transmission and related morbidity and child mortality; however, incorrect and inconsistent use limits their protective factors. This community trial titled the Net Use Intervention study sought to bridge the gap between ITN ownership and use in southern (coastal) Ghana and to determine the best mix of communication tools to affect behavior of ITN owners to consistent use while maintaining optimal internal and external validity. This two-group, non-randomized experiment evaluated a multichannel, multisector intervention process over the course of 8weeks. A longitudinal cohort was scientifically sampled from six intervention and six control communities for both baseline and posttest surveys. The posttest survey showed no change in knowledge of ITNs in the intervention or control. In terms of use the previous night, there was a strong and statistically significant intervention effect (OR = 1.67; p < .05) within the intervention communities. The overall increase in ITN coverage was approximately one person per night per every two households. The promotion efforts succeeded well beyond the planners' expectations, not only promoting usage but also dramatically increasing demand for new ITNs.

Equity implications of coverage and use of insecticide treated nets distributed for free or with co-payment in two districts in Tanzania: A cross-sectional comparative household survey

BackgroundIn Tanzania, the distribution and coverage of insecticide-treated nets (ITNs) is inequitable. Arguments about the most effective and equitable approach to distributing ITNs centre around whether to provide ITNs free of charge or continue with existing social marketing strategies. The Government has decided to provide free ITNs to all children under five in the country. It is still uncertain whether this strategy will achieve equitable coverage and use. This study examined the equity implications of ownership and use of ITNs in households from different socioeconomic quintiles in a district with free ITNs and a district without free ITN distribution.MethodsA cross-sectional comparative household survey was conducted in two districts: Mpanda in Rukwa Region (with free ITN roll out) and Kisarawe in Coast region (without free ITNs). Heads of 314 households were interviewed in Mpanda and Kisarawe. The concentration index was estimated and regression analysis was performed to compare socioeconomic inequalities in ownership and use of ITNs.ResultsOwnership of ITNs increased from 29% in the 2007/08 national survey to 90% after the roll out of free ITNs in Mpanda, and use increased from 13% to 77%. Inequality was considerably lower in Mpanda, with nearly perfect equality in use (concentration index 0.009) and ownership (concentration index 0.010). In Kisarawe, ownership of ITNs increased from 48% in the 2007/08 national survey to 53%, with a marked inequality concentration index 0.132. ITN use in Kisarawe district was 42% with a pro rich concentration index of 0.027.ConclusionsThe results shed some light on the possibilities of reducing inequality in ownership and use of ITNs and attaining Roll Back Malaria and Millennium Development Goals through the provision of free ITNs to all. This has the potential to decrease the burden of disease and reduce disparity in disease outcome.

Rapid Scale-Up of Long-Lasting Insecticide-Treated Bed Nets through Integration into the National Immunization Program during Child Health Week in Togo, 2004

In December 2004, Togo was the first country to conduct a nationwide free insecticide-treated net (ITN) distribution as part of its National Integrated Child Health Campaign. Community-based cross-sectional surveys were conducted one and nine months post-campaign as part of a multidisciplinary evaluation of the nationwide distribution of ITNs to children 9-59 months of age to evaluate ITN ownership, equity, and use. Our results demonstrated that at one month post-campaign, 93.1% of all eligible children received an ITN. Household ITN ownership and equity increased significantly post-campaign. Nine months post-campaign, 78.6% of households with a child eligible to participate in the campaign retained at least one campaign net. Use by eligible children was 43.5% at one month post-campaign (during the dry season) and 52.9% at nine months post-campaign (during the rainy season). Household ownership of at least one ITN increased from 8.0% pre-campaign to 62.5% one month post-campaign. Together, these findings demonstrate that in this setting, increased household ITN ownership, equity, and retention can be achieved on a national scale through free ITN distribution during an integrated campaign.

Knowledge, attitudes and practices of local inhabitants about insecticide treated nets (itns) for malaria control in an endemic area of Ethiopia

The present study was conducted to assess the knowledge, attitudes and practices of local residents about insecticide treated nets (ITNs) for malaria control in an endemic area of Ethiopia. A descriptive cross-survey was conducted from July 2008 to September 2008. A structured questionnaire collecting sociodemographic, ITNs and malaria-related KAP information was administered to the representatives of households. Azendabo town, Ethiopia. 84% of the inhabitants had awareness about malaria transmission; mosquito bites were identified correctly as the cause of malaria. 85.2% respondents indicated that mosquitoes bite at night. ITNs awareness level of inhabitants was 92.4%; however, just 57.8% of them own ITNs. 96.2% and 91.5% of the inhabitants indicated the foremost reasons for nonpossession of ITNs were due to unaffordability and nonavailability. Inhabitants average monthly income significantly associated with the ITNs ownership at p<0.05 and, however educational status of the respondents and ITNs ownership was not significant (p=0.1). Indeed, respondents had adequate knowledge regarding ITNs and malaria related information. However, inhabitants had poor attitude and practice towards the ITNs utilization due to lack of availability and affordability. Therefore, besides health education campaign, distribution and promotion of ITNs to entire rural residents at free of charge may possibly bring constructive outcome in the near future.

Decreased motivation in the use of insecticide-treated nets in a malaria endemic area in Burkina Faso

BackgroundThe use of insecticide-treated nets (ITN) is an important tool in the Roll Back Malaria (RBM) strategy. For ITNs to be effective they need to be used correctly. Previous studies have shown that many factors, such as wealth, access to health care, education, ethnicity and gender, determine the ownership and use of ITNs. Some studies showed that free distribution and public awareness campaigns increased the rate of use. However, there have been no evaluations of the short- and long-term impact of such motivation campaigns. A study carried out in a malaria endemic area in south-western Burkina Faso indicated that this increased use declined after several months. The reasons were a combination of the community representation of malaria, the perception of the effectiveness and usefulness of ITNs and also the manner in which households are organized by day and by night.MethodsPermaNet 2.0® and Olyset® were distributed in 455 compounds at the beginning of the rainy season. The community was educated on the effectiveness of nets in reducing malaria and on how to use them. To assess motivation, qualitative tools were used: one hundred people were interviewed, two hundred houses were observed directly and two houses were monitored monthly throughout one year.ResultsThe motivation for the use of bednets decreased after less than a year. Inhabitants' conception of malaria and the inconvenience of using bednets in small houses were the major reasons. Acceptance that ITNs were useful in reducing malaria was moderated by the fact that mosquitoes were considered to be only one of several factors which caused malaria. The appropriate and routine use of ITNs was adversely affected by the functional organization of the houses, which changed as between day and night. Bednets were not used when the perceived benefits of reduction in mosquito nuisance and of malaria were considered not to be worth the inconvenience of daily use.ConclusionIn order to bridge the gap between possession and use of bednets, concerted efforts are required to change behaviour by providing accurate information, most particularly by convincing people that mosquitoes are the only source of malaria, whilst recognising that there are other diseases with similar symptoms, caused in other ways. The medical message must underline the seriousness of malaria and the presence of the malaria vector in the dry season as well as the wet, in order to encourage the use of bednets whenever transmission can occur. Communities would benefit from impregnated bednets and other vector control measures being better adapted to their homes, thus reducing the inconvenience of their use.

Integration of insecticide‐treated net distribution into routine immunization services in Malawi: a pilot study

To determine the feasibility of distributing insecticide-treated nets (ITNs) through routine immunization services, to increase ownership and use of ITNs among high-risk groups, whereas maintaining or improving timely completion of routine vaccinations. Free ITNs were provided with timely completion of routine vaccinations in two intervention districts in southern Malawi for 15 months. Cross-sectional baseline and follow-up household surveys were conducted in the two intervention districts and one control district. Insecticide-treated nets utilization among children aged 12-23 months roughly doubled in the two intervention districts and did not change in the control district. Timely vaccination coverage increased in all three districts. The percentage of children aged 12-23 months who were both fully vaccinated by 12 months and slept under an ITN the night prior to the interview increased from 10-14% at baseline to 40-44% at follow-up in the intervention districts (P < 0.001), but did not change significantly in the control district. This study is the first to evaluate the provision of free ITNs at completion of a child's primary vaccination series, demonstrating that such a linkage is both feasible and can result in improved coverage with the combined services. Additional studies are needed to determine whether such a model is effective in other countries, and whether integration of other health services with immunization delivery could also be synergistic.

How equitable is bed net ownership and utilisation in Tanzania? A practical application of the principles of horizontal and vertical equity

BackgroundStudies show that the burden of malaria remains huge particularly in low-income settings. Although effective malaria control measures such as insecticide-treated nets (ITNs) have been promoted, relatively little is known about their equity dimension. Understanding variations in their use in low-income settings is important for scaling up malaria control programmes particularly ITNs. The objective of this paper is to measure the extent and causes of inequalities in the ownership and utilisation of bed nets across socioeconomic groups (SEGs) and age groups in Tanga District, north-eastern Tanzania.MethodsA questionnaire was administered to heads of 1,603 households from rural and urban areas. Households were categorized into SEGs using both an asset-based wealth index and education level of the household head. Concentration indices and regression-based measures of inequality were computed to analyse both vertical and horizontal inequalities in ownership and utilisation of bed nets. Focus Group Discussions (FGDs) were used to explore community perspectives on the causes of inequalities.ResultsUse of ITNs remained appallingly low compared to the RBM target of 80% coverage. Inequalities in ownership of ITNs and all nets combined were significantly pro-rich and were much more pronounced in rural areas. FGDs revealed that lack of money was the key factor for not using ITNs followed by negative perceptions about the effect of insecticides on the health of users. Household SES, living within the urban areas and being under-five were positively associated with bed net ownership and/or utilisation.ConclusionThe results highlight the need for mass distribution of ITN; a community-wide programme to treat all untreated nets and to promote the use of Long-Lasting Insecticidal nets (LLINs) or longer-lasting treatment of nets. The rural population and under-fives should be targeted through highly subsidised schemes and mass distribution of free nets. Public campaigns are also needed to encourage people to use treated nets and mitigate negative perceptions about insecticides.

Use of insecticide treated nets by pregnant women and associated factors in a pre‐dominantly rural population in northern Ethiopia

To describe the use of insecticide treated nets (ITNs) among pregnant women and examine factors associated with its access and use. Community-based cross-sectional study of 815 pregnant women in eight malarious kebeles in northern Ethiopia based on two-stage cluster design from May to June 2006. Knowledge on malaria, its cause and preventive measures; treatment seeking behaviour; possession and use of ITNs by pregnant women and under-five children were ascertained through interview and observation. Logistic regression was used to determine factors associated with ITNs use. Knowledge about the cause, transmission and preventive measures of malaria was relatively good; 90.2% of women associated malaria with mosquito bites and 94.2% with living near water ponds. Ten per cent reported malaria illness within the 14 days before the survey, and sought treatment mainly from public health facilities (56.5%) and community health workers (37.6%). Of 815 households surveyed, 59% owned at least one non-long lasting or long-lasting ITN (59.5% rural vs. 54.5% urban; P = 0.401). Lack of access to ITNs (68.3%) and the perception that nets could not prevent malaria (27%) were the main reasons for non-ownership of nets. A total of 58.4% of 481 pregnant women from households owning at least one ITN had slept under it during the previous night. Fewer rural (56.7%) than urban women (76.2%) used ITNs (P = 0.001). In 57.6% of households with at least one ITN, under-five children had used it the night before. Higher educational attainment was an important predictor of ITNs use (OR = 3.1, 95% CI = 2.1, 4.6). Household ownership of ITNs and their use by pregnant women is promising with the current efforts to scale-up ITNs implementation, but the gap between ownership and use remains high. Consistent and proper use of nets by pregnant women should be ensured through information campaigns. Rapid expansion of access to long lasting ITNs requires that government and NGOs supply them in adequate numbers.

Gains in awareness, ownership and use of insecticide-treated nets in Nigeria, Senegal, Uganda and Zambia

BackgroundIn April 2000, the Roll Back Malaria (RBM) "Abuja Summit" set a target of having at least 60% of pregnant women and children under five use insecticide-treated nets (ITNs). Thereafter, programmes were implemented to create demand, reduce taxes and tariffs, spur the commercial market, and reach vulnerable populations with subsidized ITNs. Using national ITN monitoring data from the USAID-sponsored AED/NetMark project, this article examines the extent to which these activities were successful in increasing awareness, ownership, and use of nets and ITNs.MethodsA series of surveys with standardized sampling and measurement methods was used to compare four countries at two points in time. Surveys were conducted in 2000 and again in 2004 (Nigeria, Senegal, Zambia) or 2006 (Uganda). They contained questions permitting classification of each net as untreated, ever-treated or currently-treated (an ITN). Household members as well as nets owned were enumerated so that households, household members, and nets could be used as units of analysis. Several measures of net/ITN ownership, plus RBM ITN use indicators, were calculated. The results show the impact of ITN activities before the launch of massive free net distribution programmes.ResultsIn 2000, treated nets were just being introduced to the public, but four to six years later the awareness of ITNs was nearly universal in all countries but Nigeria, where awareness increased from 7% to 60%. By any measure, there were large increases in ownership of nets, especially treated nets, in all countries. All countries but Nigeria made commensurate gains in the proportion of under-fives sleeping under a net/ITN, and in all countries the proportion of pregnant women sleeping under a net/ITN increased greatly.ConclusionA mix of demand creation, a strengthened commercial sector, reduced taxes and tariffs, and programmes making ITNs available at reduced prices resulted in impressive gains in awareness, ownership, and use of nets and ITNs in Nigeria, Senegal, Zambia, and Uganda between 2000 and 2004–2006. None of the countries reached the ambitious Abuja targets for ITN use, but they made substantial progress towards them.

Utilization of insecticide-treated nets by under-five children in Nigeria: assessing progress towards the Abuja targets.

BackgroundThe Abuja target of increasing the proportion of people sleeping under insecticide-treated nets (ITNs) to 60% by the year 2005, as one of the measures for malaria control in Africa, has generated an influx of resources for malaria control in several countries in the region. A national household survey conducted in 2005 by the Malaria Control Programme in Nigeria assessed the progress made with respect to ITN ownership and use among pregnant women and children under five years of age since 2000. The survey was the first nationally representative study of ITN use assessing progress towards the Abuja target amongst vulnerable groups.Population and MethodA cross-sectional survey of a sample of 7,200 households, selected by a multistage stratified sampling technique from 12 randomly selected states from the six geopolitical zones of the country. Data collection was done during the malarious rainy season (October 2005) using a modified WHO Malaria Indicator Survey structured questionnaire about household ownership and utilization of mosquito nets (treated or untreated) from household heads.ResultsHousehold ownership of any net was 23.9% (95% CI, 22.8%–25.1%) and 10.1% for ITNs (95% CI, 9.2%–10.9%). Education, wealth index, presence of an under-five child in the household, family size, residence, and region by residence were predictive of ownership of any net. The presence of an under-five child in the household, family size, education, presence of health facility in the community, gender of household head, region by residence and wealth index by education predicted ITN ownership.Utilization of any net by children under-five was 11.5% (95% CI, 10.4%–12.6%) and 1.7% (95% CI, 1.3%–2.2%) for ITN. Predictors of use of any net among under-five children were fever in the previous two weeks, presence of health facility in the community, caregiver's education, residence, and wealth index by caregiver's education; while religion, presence of health facility and wealth index by caregiver's education predicted the use of ITN among this group.ConclusionThis study demonstrated that the substantial increase in ITN utilization among children under five years of age in Nigeria is still far from the Abuja targets.

Insecticide‐treated net ownership and usage in Niger after a nationwide integrated campaign

In December 2005 and March 2006, Niger conducted nationwide integrated campaigns to distribute polio vaccine and long lasting insecticide-treated nets (LLINs) to children <5 years of age. We evaluated the campaign effectiveness, net retention, insecticide-treated net (ITN) ownership, and usage. Two nationwide cross-sectional surveys in January 2006 (dry season) and September 2006 (rainy season), using a stratified two-stage cluster sampling design. We mapped selected communities, selected households by simple random sampling, and administered questionnaires by interviewers using personal digital assistants. The first survey showed that ITN ownership in all households was 6.3% prior to the campaign, increasing to 65.1% after the campaign in the second survey. The second survey also showed that 73.4% of households with children <5 received an LLIN and that 97.7% of households that received > or = one LLIN retained it. The wealth equity ratio for ITN ownership in households with children <5 increased from 0.17 prior to the campaign to 0.79 afterward. During the dry season, 15.4% of all children <5 and 11.3% of pregnant women slept under an ITN, while during rainy season, 55.5% of children <5 and 48.2% of pregnant women slept under an ITN. Free distribution during the integrated campaign rapidly increased ITN ownership and decreased inequities between those in the highest and lowest wealth quintiles. Retention of ITNs was very high, and usage was high during malaria transmission season. However, ITN ownership and usage by vulnerable groups continues to fall short of RBM targets, and additional strategies are needed to increase ownership and usage.

PREVENTION AND TREATMENT PRACTICES AND IMPLICATIONS FOR MALARIA CONTROL IN MUKONO DISTRICT UGANDA

Available data in Uganda indicate a resurgence of malaria morbidity and mortality countrywide. This study assessed the burden of malaria, treatment and prevention practices in order initiate a policy debate on the scaling-up of current interventions. A triangulation of methods using a cross-sectional survey and key informant interviews was used to assess self-reported malaria at a household level in Mukono District, Uganda. A total of 5583 households were surveyed, and a high proportion (2897, 51.9%) reported a person with malaria two weeks prior to the survey. Only 546 households (9.8%) owned and used insecticide-treated nets (ITNs) for malaria prevention. Similarly, only a few households (86, 1.5%) used indoor residual spraying. Self-treatment with home-stocked drugs was high, yet there was low awareness of the effectiveness of expired drugs on malaria treatment. Self-reported malaria was associated with socioeconomic, behavioural and environmental factors, but more especially with household ownership of ITNs. These results will contribute to the current debate on identifying new approaches for scaling-up prevention interventions and effective case management, as well as selection of priority interventions for malaria control in Uganda.

Kala-azar Control, Uganda

To the Editor: Much of the leishmaniasis in Africa is concentrated in East Africa. In this region, visceral leishmaniasis (kala-azar) is caused by Leishmania donovani and is endemic in remote parts of Somalia, Sudan, Ethiopia, Kenya, and Uganda (1). In Uganda, kala-azar is transmitted by the sandfly Phlebotomus martini, and transmission is thought to be anthroponotic. Studies in Sudan and Kenya have detected L. donovani in domestic animals (2,3), but whether these play a role in Uganda is unknown. In Uganda, the disease appears to be restricted to Pokot County, a semiarid lowland area in Nakapiripirit District (Appendix Figure). This focus is an extension of a larger focus in West Pokot District in Kenya (4). The area is mainly inhabited by the Pokot, a seminomadic tribe of pastoralists. Nakapiripirit is one of the most underserved districts of Uganda, plagued by tribal clashes. Though kala-azar has been reported in East Africa since the early 1900s, it was not described in Uganda until the 1950s (5) and remained largely unnoticed until 1997, when Medecins Sans Frontieres (MSF, Swiss Section) began to provide assistance to Amudat Health Centre in Pokot County. In 2000, MSF initiated a kala-azar control program, focusing on passive case detection and treatment. From January 2000 to February 2006, a total of 3,645 patients suspected of having kala-azar were screened at Amudat Health Centre by using the direct agglutination test or rK39 antigen–based dipsticks (6); 2,088 patients with confirmed disease were treated with daily intramuscular injections of sodium stibogluconate or meglumine antimonite, 20 mg/kg bodyweight, for 30 days. Overall, 80% of the patients were <15 years of age, 75% were male, and 70% were from Kenya. From 2000 through 2005, the number of patients treated more than tripled, from 175 to 690 cases per year. Although this increase likely results, at least in part, from greater case detection due to the availability of treatment, we cannot exclude a real increase in disease because kala-azar prevalence in the area is unknown. Information on local vector behavior and risk factors for infection or disease (e.g., malnutrition and HIV coinfection) is limited, and which potential interventions are appropriate is unclear. A pilot entomologic study in 2004 (J. Stevenson, master’s thesis) demonstrated that termite mounds (Figure) are important vector breeding and resting sites and that the practice of sitting on termite mounds while guarding livestock might increase the risk for infection. In contrast, humans may be protected from kala-azar when in close proximity to livestock (i.e., because of diversion of sandflies to alternative hosts) or when lighting fires indoors (smoke acts as a repellant to most biting flies). Ownership of insecticide-treated nets, which could protect persons from sandfly bites and reduce kala-azar transmission (7), was low. Although most of the local population had heard of kala-azar, known locally as termes, and regarded it as potentially fatal, few were aware of how kala-azar is transmitted (J. Stevenson, master’s thesis). Figure A large termite mound occupies the central area of this characteristic Pokot compound. The mound provides a resting and breeding site for the sandly vector of visceral leishmaniasis. Photographer: J.H. Kolaczinski. MSF’s treatment of kala-azar is crucial because it reduces the human reservoir and hence transmission. However, current control activities only reach the tip of the iceberg: a large, underlying pool of infected and infectious persons likely exists (8,9). Kala-azar in Uganda will not likely be controlled unless the epidemiology of the disease is better understood and preventive activities are undertaken. This knowledge gap is being addressed by a partnership among the Malaria Consortium, MSF, the London School of Hygiene and Tropical Medicine, and the Vector Control Division of the Ugandan Ministry of Health. A case-control study to determine the local risk factors of kala-azar is almost completed and will be followed by seroprevalence studies in several Pokot villages, using a similar approach to recent work in the Baringo District, Kenya (9). The results will be used to formulate an integrated control strategy aimed at achieving our ultimate goal of eliminating kala-azar from Uganda.

Using schoolchildren's reports of bed net use monitored by schoolteachers as a proxy of community coverage in malaria endemic areas of Uganda

Community-based information on the delivery and use of health interventions is important to monitor the effectiveness of the Roll Back Malaria programme. However, community surveys to determine coverage for insecticide-treated bed nets are time-consuming and costly. We wanted to assess whether schoolchildren's reports of household ownership of a bed net and coverage among high-risk groups monitored by schoolteachers through a questionnaire could be used as a proxy of household ownership of bed net and coverage at community level, for routine monitoring of malaria control programmes. 3602 schoolchildren in 39 randomly selected schools and 2798 heads of households in 39 villages were interviewed about their use of either insecticide-treated or untreated bed nets. The overall household ownership of any kind of bed net was 35% in school surveys and 31% in household surveys (P < 0.001). Household ownership of insecticide-treated nets was 23% and 22%, respectively (P = 0.4); household ownership of untreated nets was 15% and 9%, respectively (P < 0.001). There was significant correlation between estimates of any bed net and treated net ownership based on household surveys and estimates based on school surveys (P < 0.01 for both). In areas with high school attendance rates, schoolchildren's report of bed net use monitored by schoolteachers through a questionnaire could give a good approximation of household ownership of bed net at community level with about +/-5% difference between community and school surveys. However, further operational research is required to investigate how the feasibility of large-scale implementation might be, by sending the questionnaire to the schools through routine channels and by independent handling by the school administration and teachers.

Delivery of insecticide‐treated net services through employer and community‐based approaches in Kenya

Many approaches have been used to deliver insecticide-treated nets (ITNs) to African communities in different settings. Between 1992 and 2002, the African Medical and Research Foundation (AMREF), Kenya, used two ITN delivery models: the employer-based approach and the community-based approach. These two approaches have never been compared in order to inform their potential for future ITN delivery. We aimed to (1) compare the extent of ITN ownership, use and retreatment coverage in different population groups in the employer and community-based models and (2) identify options for improving people's acceptance and use of treatment/retreatment services. Qualitative and quantitative methods for data collection and analysis. A total of 2095 household heads were interviewed in the quantitative study, while purposively selected groups and key informants participated in the qualitative study. Net coverage (both treated and untreated nets) and retreatment rates with insecticides were significantly higher at employer-based sites (54.3%) than at community-based sites (35.0%). Bed net ownership has increased significantly since the start of AMREF interventions in 1998 in employer-based sites (from 27% to 61.1%); in community-based sites, it has either decreased (urban area, from 29.0% to 16.5%) or increased (rural area, from 17.0% to 49.1%). Retreatment rates in all sites were negatively influenced by the lack of information, cash and availability of insecticides. Satisfaction with the form of payment and services delivered was higher in employer-based sites. This was attributed to employers providing credit for the purchase of nets and retreatment kits and the employers' medical teams giving information on malaria and making follow-up visits on workers who fell ill. Employer-based delivery of ITNs was more successful than community-based delivery in attaining both high coverage with ITNs and higher rates of net retreatment. Methods used for the retreatment of nets, forms of payment and communication strategies should be convenient to communities. Organized community groups may continue to play an important role in remote rural areas.

MALARIA PREVENTION DURING PREGNANCY: ASSESSING THE DISEASE BURDEN ONE YEAR AFTER IMPLEMENTING A PROGRAM OF INTERMITTENT PREVENTIVE TREATMENT IN KOUPÉLA DISTRICT, BURKINA FASO

The World Health Organization recommends that pregnant women in malaria-endemic areas receive >or= 2 doses of intermittent preventive treatment with sulfadoxine-pyrimethamine (IPTp/SP) in the second and third trimesters of pregnancy to prevent maternal anemia, placental parasitemia, and low birth weight (LBW). In 2001, a program evaluation in Koupéla District, Burkina Faso demonstrated that despite widespread use of chloroquine chemoprophylaxis, the burden of malaria during pregnancy remained high. In 2003, the Burkina Faso Ministry of Health piloted a program of IPTp/SP (three doses) and accelerated distribution of insecticide-treated nets (ITN) to pregnant women in Koupéla District. In 2004, a follow-up program evaluation was conducted. Coverage with >or= 1 doses of IPTp/SP was high among women attending antenatal clinics (ANCs) (96.2%) and delivery units (DUs) (93.5%); ITN ownership was moderately high (ANC = 53.9%, DU = 61.6%). In multivariate analysis, >or= 1 dose of IPTp/SP was associated with a significant reduction in the prevalence of peripheral parasitemia at ANCs (risk ratio [RR] = 0.49, P = 0.008), >or= 2 doses of IPTp/SP were associated with a reduction in the prevalence of placental parasitemia (RR = 0.56, P = 0.02), and three doses of IPTp/SP were associated with a reduced risk of LBW (RR = 0.51, P = 0.04). The proportions of women at ANCs with peripheral parasitemia and anemia were significantly lower in 2004 than in 2001 (RR = 0.53, P = 0.001 and RR = 0.78, P = 0.003, respectively). The proportions of women at DUs with peripheral and placental parasitemia were also significantly lower in 2004 than in 2001 (RR = 0.66, P < 0.0001 and RR = 0.71, P = 0.0002, respectively). These data suggest that a package of IPTp/SP and ITNs is effective in reducing the burden of malaria during pregnancy in Burkina Faso.

Rolling out insecticide treated nets in Eritrea: examining the determinants of possession and use in malarious zones during the rainy season

This paper describes determinants of insecticide treated net (ITN) ownership and use in malarious areas of Eritrea. With ITN distribution and re-treatment now free for all living in these areas, we examine barriers (other than cost) to access and use of ITNs. We explore the differences between use of an ITN as a proportion of all households in the survey (the roll back malaria indicator), and use of an ITN as a proportion of those households who already own an ITN. A modified two-stage cluster design was used to collect data from a sample of households (n = 2341) in the three most malarious administrative zobas (zones or provinces). Logistic regression was used to analyse the data. Our findings suggest environmental heterogeneity among zobas (including program effects specific to each zoba), perception of risk, and proximity to a clinic are important predictors of ITN possession and use. Among households with at least one ITN, 17.0% reported that children under five were not under an ITN the night before the survey, while half of all such households did not have all occupants using them the night before the survey. The number of ITNs, as well as zoba, was also significant determinants of use in these households with at least one ITN. Current efforts to disseminate ITNs to vulnerable populations in Eritrea are working, as suggested by high ITN ownership and net-to-person ratios inside households. However, the gap between ITN ownership and use, given ownership, is large, and may represent lost opportunities to prevent infection. Closing this gap requires concerted efforts to change behaviour to ensure that all household members use ITNs as consistently and correctly as possible during and following the rains.