Sustaining fragile gains: the need to maintain coverage with long-lasting insecticidal nets for malaria control and likely implications of not doing so.

Global commitment to malaria control has greatly increased over the last decade. Long-lasting insecticidal nets (LLINs) have become a core intervention of national malaria control strategies and over 450 million nets were distributed in sub-Saharan Africa between 2008 and 2012. Despite the impressive gains made as a result of increased investment in to malaria control, such gains remain fragile. Existing funding commitments for LLINs in the pipeline to 2016 were collated for 40 sub-Saharan African countries. The population-based model NetCALC was used to estimate the potential LLIN coverage achievable with these commitments and identify remaining gaps, and the Lives Saved Tool (LiST) was used to estimate likely consequences for mortality impact if these gaps remain unfilled. Overall, countries calculated a total need of 806 million LLINs for 2013-16. Current funding commitments meet just over half of this need, leaving approximately 374 million LLINs unfunded, most of which are needed to maintain coverage in 2015 and 2016. An estimated additional 938,500 child lives (uncertainty range: 559,400-1,364,200) could be saved from 2013 through 2016 with existing funding (relative to 2009 LLIN coverage taken as the 'baseline' for this analysis); if the funding gap were closed this would increase to 1,180,500 lives saved (uncertainty range: 707,000-1,718,900). Overall, the funding gap equates to approximately 242,000 avoidable malaria-attributable deaths amongst under-fives. Substantial additional resources will need to be mobilized to meet the full LLIN need of sub-Saharan countries to maintain universal coverage. Unless these resources are mobilized, the impressive gains made to date will not be sustained and tens of thousands of avoidable child deaths will occur

Ten countries with highest mortality gap due to current unmet LLIN funding need.

<p>Ten countries with highest mortality gap between what could be achieved if all LLINs were funded versus what will be achieved with current country specific funding for LLINs (CAR = Central African Republic; DRC = Democratic Republic of Congo). These ten countries account for almost 90%, or 211,380 (uncertainty range: 132,061 – 301,810) of these deaths and Nigeria alone accounts for approximately 40%, or 101,008 deaths (uncertainty range: 66,871 – 141,625). Individual country estimates of avoidable deaths (with uncertainty ranges): DRC: 28,000 (14,180 – 42,980); Mozambique: 18,569 (11,594 – 26,260); Angola: 13,779 (7,814 – 20,615); Niger: 13,409 (8,604 – 19,357); Sierra Leone: 9,023 (5,873 – 13,120); Burkina Faso: 7,856 (4,617 – 11,228); Guinea: 7,784 (5,117 – 10,786); Zambia: 5,761 (3,795 – 8,373); CAR: 5,391 (3,596 – 7,466).</p

Sensitivity analyses of the predicted number of under-five lives that could be saved with full funding for all LLINs needed versus currently funded LLINs, depending on malaria mortality assumptions.

<p>NOTES: *Baseline mortality impact assumptions: PE of LLIN 0.55; default proportion of post-neonatal deaths due to malaria; **Lower mortality impact assumptions: PE of LLIN 0.49; lower uncertainty limit for proportion of post-neonatal deaths due to malaria. Upper mortality impact assumptions: PE of LLIN 0.60; upper uncertainty limit for proportion of post-neonatal deaths due to malaria.</p

Estimated under-five lives saved with LLINs needed or in the pipeline (2010–2016).

<p>Estimated number of under-five lives saved with LLINs distributed between 2010 and 2012, and predictions of the lives that could be saved with full funding for all LLINs needed versus currently funded LLINs in 2013-16.</p

The Effect of Single or Repeated Home Visits on the Hanging and Use of Insecticide-Treated Mosquito Nets following a Mass Distribution Campaign - A Cluster Randomized, Controlled Trial

<div><p>Background</p><p>Study objective was to evaluate the effectiveness of commonly used post-campaign hang-up visits on the hanging and use of campaign nets.</p><p>Methods</p><p>A cluster-randomized trial was carried out in Uganda following an ITN distribution campaign. Five clusters (parishes, consisting of ∼11 villages each) were randomly selected for each of the three study arms with between 7,534 and 9,401 households per arm. Arm 1 received one hang-up visit, while Arm 2 received two visits by volunteers four and seven months after the campaign. Visits consisted of assistance hanging the net and education on net use. The control arm was only exposed to messages during the campaign itself. Three cross-sectional surveys with a two-stage cluster sampling design, representative of the study populations, were carried out to capture the two key outcome variables of net hanging and ITN use. Sample size was calculated to detect at least a 15 percentage-points change in net use, and was 1811 at endline. The analysis used an intention-to-treat approach.</p><p>Findings</p><p>Both hanging and use of ITN increased during follow-up in a similar way in all three study arms. The proportion of the population using an ITN the previous night was 64.0% (95% CI 60.8, 67.2), for one additional visit, 68.2% (63.8, 72.2) for two visits and 64.0% (59.4, 68.5) for the control. The proportion of households with all campaign nets hanging increased from 55.7% to 72.5% at endline (p<0.0005 for trend), with no difference between study arms. Financial cost per household visited was estimated as USD 2.33 for the first visit and USD 2.24 for the second.</p><p>Conclusions</p><p>Behavior change communication provided during the campaign or through other channels was sufficient to induce high levels of net hanging and use and additional “hang-up” activities were not cost-effective.</p></div

Total LLINs needed and funded for 40 malaria-endemic countries in sub-Saharan Africa (2010–2016).

<p>Total LLINs needed and funded for 40 malaria-endemic countries in sub-Saharan Africa (2010–2016).</p

Evaluation of a continuous community-based ITN distribution pilot in Lainya County, South Sudan 2012–2013

Abstract Background Continuous distribution of insecticide-treated nets (ITNs) has now been accepted as one way of sustaining ITN universal coverage. Community-based channels offer an interesting means of delivering ITNs to households to sustain universal ITN coverage. The objective of this study was to provide proof of concept for this channel. Methods A 9-month, community-based, distribution pilot was implemented beginning 1 year after a mass campaign in Lainya County, South Sudan from 2012 to 2013. Following social mobilization, community members could request an ITN from a net coupon holder. Eligibility criteria included having lost an ITN, giving birth outside of the health facility, or not having enough ITNs for all household members. After verification, households could exchange the coupon for an ITN at a distribution point. The evaluation was a pre/post design using representative household surveys with two-stage cluster sampling and a sample size of 600 households per survey. Results At endline, 78% of respondents were aware of the scheme and 89% of those also received an ITN through community-based distribution. Population access to ITNs nearly doubled, from 38% at baseline to 66% after the pilot. Household ownership of any ITN and enough ITNs (1 for 2 people) also increased significantly, from 66 to 82% and 19 to 46%, respectively. Community-based distribution was the only source of ITNs for 53.4% of households. The proportion of the population using an ITN last night increased from 22.7% at baseline to 53.9% at endline. A logistic regression model indicates that although behaviour change communication was positively associated with an increase in ITN use, access to enough nets was the greatest determinant of use. Conclusions ITN access and use improved significantly in the study area during the pilot, coming close to universal coverage targets. This pilot serves as proof of concept for the community-based distribution methodology implemented as a mechanism to sustain ITN universal coverage. Longer periods of implementation should be evaluated to determine whether community-based distribution can successfully maintain ITN coverage beyond the short term, and reach all wealth quintiles equitably