Malaria Matters: Issue 1, September 1997

Welcome to the first issue of Malaria Matters, featuring Netting News! We are proud to present you with a newsletter designed for health care workers and others involved with malaria control. In particular, it is aimed at those of you who use insecticide treated nets (ITNs) as part of your strategy.

This publication resulted from a recommendation made by the Net Gain for Africa Task Force, which envisioned a way to collect and distribute information concerning malaria and ITNs. Although there has been over ten years of rigorous research into their efficacy, there has been comparatively little about the operational aspects of promoting ITNs. One of our goals is to fill this void by providing access to operational research, technical advances and lessons learned.

Each issue of Malaria Matters will contain a feature article on current research, events or concerns; field articles providing summaries of projects, products and meetings; and reviews of recent articles, books or newsletters. We hope to utilize the new modes of communication, such as the Internet and e-mail, while maintaining traditional methods as well. We welcome contributions and suggestions from all our readers such as future topics and authors. You can contact us at our Ottawa office. For more detailed information concerning specific articles, please contact the author at the address provided.

Introduction to Net Gain

PATH Canada is pleased to announce that it will house the newly created Net Gain for Africa Task Force, a two-year programme to increase the availability of insecticide treated nets (ITNs) for malaria control in sub-Saharan Africa (SSA). The objective of the Net Gain for Africa Task Force is to reduce morbidity and mortality from malaria, particularly among women and children, by increasing the proportion of households in SSA that own mosquito nets and by treating the nets regularly with appropriate insecticide.

Malaria is a serious barrier to the health, productivity and development of a large and increasing proportion of the SSA population, especially women and children. In 1996, malaria was the leading cause of mortality and morbidity in Africa. Ninety per cent of the world’s malaria deaths occur in SSA. The overwhelming burden of malaria on mortality and morbidity in SSA, combined with increasing malaria drug resistance, has led to a growing interest in controlling malaria through the use of ITNs.

The Net Gain for Africa Task Force will develop a reference centre for ITN programming and information dissemination, and will provide strategic technical inputs to projects and research, with a view to developing innovative and cost-effective strategies for ITN interventions. Net Gain will generate special and unique expertise on how to work with the private sector and the market to enhance ITN delivery. Through its actions, Net Gain will contribute to making ITN technology more sustainable, as well as more widely available and affordable.

The Net Gain for Africa Task Force will work with local partners as well as individuals and agencies to overcome the prevailing lack of ITN application knowledge. This will be of great value in assisting African governments and international donors to define and implement sustainable ITN programmes. The initiatives of the Task Force will provide the foundation upon which a Net Gain Secretariat will be built.

The creation of the Net Gain for Africa Task Force has been made possible by a grant from the International Development Research Centre (IDRC), Ottawa, Canada.

Feature - Creating a New Tradition

Catherine Reed, PATH Canada

Insecticides treated nets (ITNs) are being promoted as part of most SSA countries malaria control strategies. But what are ITNs? Usually just mosquito nets adequately treated with insecticide.

In countries with an existing strong tradition of net use the vast majority of nets found in homes have been bought from a market or local shop. Most have been purchased to fend off the nuisance of mosquito bites which disturb sleep. Although mosquito nets are effective in providing a better night’s sleep and are better than nothing in controlling malaria, they are by no means as effective as a treated net.

The existing use of nets is an added bonus as they provide, in some countries, potentially millions of nets waiting to be treated as well as existing channels for net distribution. Unfortunately, though nets are mostly seen as desirable they do not have a high priority on most family shopping lists. First preference is food, clothes and school fees and often this is followed with other commodities such as lamps, radios, bicycles and new iron roofs. These items are more expensive but are seen as being more necessary to a household. This may be a rational decision if comparing the benefits of these commodities to those of an untreated net. Fortunately in countries with a strong history of net usage, net price does not discourage net purchase as much as it appears to do in areas without this existing tradition.

The challenge for health workers is to clearly define in our own minds the benefits of a treated net over an untreated net or no net at all. Experience has shown us that achieving reasonable rates of net retreatment in Africa is difficult. At present, periodic retreatment of a net is the only way an ITN remains effective. Future options may be an integrally treated net where treatment would remain effective for the life of the net, or a new process to make any insecticide last for a number of years.

If an untreated net is traditionally seen as an optional luxury item then the image of a treated net must be different. Promotion and marketing needs to emphasize properties and associations of a treated net which are meaningful to the community being targeted. Marketing a branded product offers the opportunity to position nets and insecticides as a priority health product.

The long-term goal is to create a tradition of treated net users. The practice of net usage has developed through the private sector rather than the public health sector. Thus, it is likely the private sector will continue to play an important role, in providing products and services which are desirable, convenient and affordable. It is likely that a great deal of effort will be needed by those concerned with public health, and those involved in manufacturing, to educate and inform people of the role ITNs can take in controlling Africa's malaria into the 21st Century.

In the Field

Points to consider if "Dip-It-Yourself" is to be a practicable solution for net treatment

J.E. Miller, C.O.H. Jones and J. Lines

Enough evidence has shown that pyrethroid treated nets dramatically reduce malaria morbidity and mortality in children in Africa, to justify making nets and net treatment available on a large scale.

In many parts of Africa the public health infrastructure is either too weak, or too poorly funded to deliver a communal net treatment service effectively or sustainably. Consequently, there is enormous interest in a treatment package containing a single-net dosage which could be used by the net owner at home, i.e. a "Dip-it-Yourself" Kit.

The three most important factors to consider for such a kit are: safety, dosage and instructions/packaging.

The safest formulations to use in a home treatment kit are the water-based formulations, e.g. micro-encapsulated, suspension concentrate and oil-in-water formulations.

The dosage must be related to washing of the nets; if nets are only washed once or twice a year, their dosage requirements will be different to those which are washed fortnightly.

If dipping is to be carried out by untrained and unsupervised people and kits are to be sold freely in shops, then the message of how to dip must be communicated entirely through the instructions included in the kit. Instructions must be made easily recognizable and appropriate for local education levels. There is concern that confusion and mishandling of the insecticide could result from the supply and selling of home-treatment kits with inadequate instructions.

For more information, please contact:

Caroline Jones & Jane Miller
LSHTM, Keppel St., London, WC1E 7HT
Fax: 44 171 436 4230
E-mail: carol.jones@LSHTM.uk.ac

K-O TAB - A New Presentation of Deltamethrin for Treatment of Bednets

John Goose

Deltamethrin, as K-Othrine SC, is already a leading insecticide for treatment of bed nets. Continuing formulation research has now yielded a new presentation of deltamethrin which is essentially a dried suspension concentrate made into a tablet.

For use, one tablet, containing 400 mg deltamethrin, is added to water (the quantity of which depends on the absorption level of the net). The resulting suspension is used to treat one mosquito bed net in the normal way, giving a nominal treatment rate of 25 mg/m2. A single treatment provides up to twelve months’ protection and will resist up to three washes. Other insects such as sandflies, lice and bedbugs are controlled as well as mosquitoes.

This one tablet per net formulation avoids problems with calculating insecticide dosage. The treatment is completely aqueous, odourless, non-staining and nonflammable. There are also considerable transport and storage savings as each tablet weighs only 1.6 g and takes up very little space.

Most importantly, it is not possible to dilute or adulterate the tablet as with liquid products.

K-O Tab can be provided in a kit containing an AgrEvo bednet, two tablets for two years’ protection, gloves, a measuring bag for 0.5 litres water, and a large polythene bag for treating the net, together with full instructions. Alternatively, the tablets can be provided in bulk.

For more information, please contact:

AgrEvo South Africa (Pty) Ltd.
Attention: Allan Pope,
P.O. Box 6065, Halfway House 1685, South Africa
Fax: 00 27 11 313 8359

AgrEvo Region International
Attention: John Goose,
Hauxton, Cambridge CB2 5HU, England
Fax: 00 44 (0) 1223 252175

Update

Press Release

On July 14, 1997, UNICEF announced a major project to help prevent malaria and to care for its victims. This initiative confirmed what scientists and development agencies already know: malaria has reached epidemic proportions and death rates are rising, especially among children.

UNICEF will work with and support the World Health Organization and other UN agencies involved in the campaign against malaria. Their aim is to reach the global target of a 20% cut in malaria deaths by the year 2000 in at least 75 per cent of affected countries.

Part of the new strategy will involve greater use of insecticide treated bed nets (ITNs) that are safe for both humans and the environment. UNICEF’s programme will help ensure that children and pregnant women sleep under ITNs and regularly re-dip their nets.

In areas prone to malaria, UNICEF has set three goals. First, to have a fifth of children under five years old sleeping under a bed net or an impregnated material. Second, to have this number rise to one half by the year 2005. Third, to give all children access by the year 2010. UNICEF estimates that if these bed netting targets are met, a half a million African children alone will be saved every year by the early 21st century.

For more information, please contact:

UNICEF, 3 United Nations Plaza, New York, 10017, U.S.A.
http://www.unicef.org, or contact your local UNICEF office.

June 2, 1997 saw the Heads of State and Government attend the Thirty-third Ordinary Session of the Organization of African Unity (OAU), in Harare, Zimbabwe. Malaria was prominent on the agenda.

In the "Harare Declaration on Malaria Prevention and Contol in the context of African Economic Recovery and Development", a commitment was made by the OAU to make malaria control in Africa an urgent priority. A few examples include: supporting the global and regional stategies; implementing well planned programmes; allocating sufficient human, financial and material resources; mobilizing external resources from international agencies, governments and NGOs; and support for malaria prevention through well defined policies and appropriate legislation.

For more information, please contact:

Robert Mshana, M.D., Ph.D, Assistant Executive Director, OAU
Scientific, Technical & Research Commission
P.M.B. 2359, Lagos, Nigeria
Fax: 234-1-2636093
Email: oaustr.Lagos@rcl.dircon.co.uk

Suggested Reading:

Approaches to Malaria Control in Africa.

Edited by J. Hill, S. Lake. S. Meek, S. Mehra, and H. Standing. Malaria Consortium, Liverpool School of Tropical Medicine, 1996.

This report was prepared by the Malaria Consortium in an effort to convince potential international donors of the need for more support for malaria control. Malaria kills between 1.5- 2.7 million people annually, including an estimated one million children under five. At present, 90% of the world’s malaria cases are found in sub-Saharan Africa. The report focuses on eight countries representing all four regions: Ghana, Kenya, Malawi, Namibia, Tanzania, Uganda, Zambia and Zimbabwe. Despite evidence that malaria is sub-Saharan Africa’s most serious health problem, donations to malaria control are insignificant compared to investments in other health projects. To attract the attention of international donors, the report carefully outlines and analyzes the main issues surrounding malaria and emphasizes the areas most in need of funding.

For more information, please contact:

Teresa Jackson
Liverpool School of Tropical Medicine, Pembrooke Place, Liverpool, L3 5QA, U.K.
Fax: 44 (0) 151 707 1766
Email:j.hill@liv.ac.uk

To order:

For developing countries: no cost. Donor agencies/NGOs and other institutions: £6.00 per copy plus £2.50 postage and packing.

Net Gain, A new method for preventing malaria deaths

Edited by Christian Lengeler, Jacqueline Cattani, and Don de Savigny. WHO/IDRC, 1996.

In recent years, insecticide-treated mosquito nets (ITNs) have emerged as a promising tool to control malaria. Large-scale studies in The Gambia, Ghana, and Kenya have confirmed a substantial reduction in mortality rates in children as a direct result of ITN use.

Net Gain, published jointly by the World Health Organization and Canada’s International Development Research Centre, reviews the development of ITNs, and examines their technology, implementation and promotion.

For more information, please contact: PATH Canada To obtain copies at a 40% discount see the flier. Now also available in French.

Insecticide Incidents

Please contact us if you have experienced a problem with an insecticide. For example: Severe side effects; accidental or deliberate poisoning; spillage or leakage.

We will track such events and share them with other programmers and the manufacturers.

Many National Malaria Control Programs (NMCPs) have been revising their malaria control guidelines during 1997. It is important to be aware of the guidelines in any country where you are working. Do you have a copy?

People wash nets more frequently than we would like and in places we don’t like! If anyone has experiences or ideas regarding net washing and would like to share them in the next edition, please contact PATH Canada.