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Objective Médecins Sans Frontières (MSF) runs a malaria control project in Bo and Pujehun districts (population 158 000) that includes the mass distribution, routine delivery and demonstration of correct use of free, long-lasting insecticide–treated nets (LLINs). In 2006/2007, around 65 000 LLINs were distributed. The aim of this follow-up study was to measure LLIN usage and ownership in the project area.
Methods Heads of 900 randomly selected households in 30 clusters were interviewed, using a standardized questionnaire, about household use of LLINs. The condition of any LLIN was physically assessed.
Results Of the 900 households reported, 83.4% owning at least one LLIN. Of the 16.6% without an LLIN, 91.9% had not participated in the MSF mass distribution. In 94.1% of the households reporting LLINs, the nets were observed hanging correctly over the beds. Of the 1135 hanging LLINs, 75.2% had no holes or 10 or fewer finger-size holes. The most common source of LLINs was MSF (75.2%). Of the 4997 household members, 67.2% reported sleeping under an LLIN the night before the study, including 76.8% of children under 5 years and 73.0% of pregnant women.
Conclusion Our results show that MSF achieved good usage with freely distributed LLINs. It is one of the few areas where results almost achieve the new targets set in 2005 by Roll Back Malaria to have at least 80% of pregnant women and children under 5 years using LLINs by 2010.
Utilisation de moustiquaires imprégnées d’insecticide durable dans l’est de la Sierra Leone - Le succès de la distribution gratuite
Objectif: Médecins Sans Frontières (MSF) mène un projet de lutte antimalarique dans les districts de Bo et Pujehun (population 158,000) qui comprend la distribution de masse, la livraison en routine et la démonstration de la correcte utilisation de moustiquaires gratuites imprégnées d’insecticide durable (LLINs). En 2006-2007, près de 65.000 moustiquaires ont été distribuées. L’objectif de cette étude de suivi était de mesurer l’utilisation et la possession de moustiquaires LLINs dans le sud-est de la Sierra Leone.
Méthodes: Les chefs de 900 ménages choisis aléatoirement dans 30 groupes ont été interviewés, en utilisant un questionnaire standardisé, sur l’utilisation de LLINs par les ménages. L’état de toute LLIN a été physiquement examiné.
Résultats: 83,4% des 900 ménages ont déclaré posséder au moins un LLIN. Des 16,6% de ménages sans LLIN, 91,9% n’avaient pas participéà la distribution en masse effectuée par MSF. Dans 94,1% des ménages possédant des LLINs, les moustiquaires observées pendaient correctement au-dessus des lits. Sur les 1135 LLINs accrochées, 75,2%) n’avaient pas de trous ou avaient moins de dix trous de la taille d’un doigt. La source la plus commune des moustiquaires était MSF (75,2%). Sur les 4997 membres du ménage, 67,2% ont déclaré dormir sous une moustiquaire imprégnée d’insecticide durable la nuit précédant l’étude, y compris 76,8% des enfants de moins de 5 ans et 73,0% des femmes enceintes.
Conclusion: Nos résultats montrent que MSF a atteint le bon usage des moustiquaires distribuées gratuitement. Il s’agit d’un des rares domaines où les résultats ont presque atteint les nouveaux objectifs fixés en 2005 par ‘Roll Back Malaria’ d’avoir au moins 80% des femmes enceintes et des enfants de moins de 5 ans utilisant des moustiquaires en 2010.
Uso de mosquiteras impregnadas con insecticida de larga duración en Sierra Leona del este – el éxito de la distribución gratuita
Objetivo: Médicos sin Fronteras (MSF) tiene un proyecto de control de la malaria en los distritos de Bo y Pujehun (población 158.000) que incluye la distribución masiva y gratuita, entrega rutinaria, y demostración del uso correcto de mosquiteras impregnadas con insecticida de larga duración. En 2006/2007, se distribuyeron alrededor de 65,000 LLINs. El objetivo de este estudio de seguimiento fue medir el uso y tenencia de LLIN en el sudeste de Sierra Leona.
Métodos: Se entrevistó a los jefes de 900 hogares elegidos al azar en 30 conglomerados, utilizando un cuestionario estandarizado, sobre el uso de LLINs en sus hogares. La condición de cualquier LLIN fue evaluada físicamente.
Resultados: Un 83.4% de los 900 hogares reportaron tener al menos una LLIN. De los 16.6% sin una LLIN, un 91.9% no habían participado en la distribución masiva de MSF. En un 94.1% de los hogares que reportaron poseer una LLINs, se observó que las redes estaban correctamente colgadas sobre las camas. De las 1135 LLINs colgadas, un 75.2% o no tenían huecos o tenían diez o menos huecos del tamaño de un dedo. La fuente más común de LLINs era MSF (75.2%). De los 4997 miembros de los hogares incluidos en el estudio, un 67.2% reportaron haber dormido bajo una LLIN la noche antes de realizar la encuesta, incluyendo un 76.8% de los niños menores de 5 años y un 73.0% de las mujeres embarazadas.
Conclusión: Nuestros resultados demuestras que MSF logró un buen uso de las LLINs con su distribución gratuita. Esta es una de las pocas áreas en donde los resultados obtenidos casi han alcanzado los objetivos propuestos en el 2005 por Roll Back Malaria de tener al menos un 80% de las mujeres embarazadas y niños menores de 5 años utiliznado LLINs antes del 2010.
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Malaria still threatens the lives of millions, particularly in lower-income countries where it is endemic. Approximately half the world’s population is at risk from this preventable, treatable and curable disease. In 2006, 247 million malaria cases caused nearly 1 million deaths, mostly in children under 5 years (WHO 2008). A major interdisciplinary strategy to control malaria is underway, based on prevention and prompt and effective treatment (Anonymous 2008; WHO 2008). Long-lasting insecticide–treated nets (LLINs) are part of the prevention strategy.
Across a range of transmission settings in Africa, high levels of LLIN use have been shown to reduce malaria-related mortality, especially in children under 5 years (Lengeler 2004). Achieving such levels is a goal in the malaria control efforts of the Roll Back Malaria (RBM) Partnership (WHO 2008). The 2000 RBM Summit in Abuja, Nigeria, set a target for 2005: 60% of those most vulnerable to malaria (children under 5 years and pregnant women) should have access to and sleep under LLINs (WHO 2000; Rowe et al. 2006). In 2005, RBM raised this target to 80% to be reached by 2010 (RBM 2005). There is no clear consensus on the most suitable and effective way of achieving socio-economic equity in distribution and full population ownership (possession of an LLIN) and usage (sleeping under an LLIN). Opinions differ on the benefits of mass distribution versus routine delivery and free distribution versus cost-sharing (Curtis et al. 2003; Cohen & Dupas 2008; Khatib et al. 2008). To determine the effectiveness of distribution channels, assessments of LLIN ownership are important. However, usage rather than ownership is the crucial indicator for whether distribution will lower the burden of malaria (Baume & Marin 2007).
In southeast Sierra Leone, malaria is hyper-endemic with perennial transmission. It is the main cause of morbidity and mortality especially for children under 5 years (Ministry of Health and Sanitation 2007). Médecins Sans Frontières (MSF) has run a health project in this area since 1995. Since 2006, a major focus of the project has been malaria control, with free rapid diagnostic tests, treatment and prevention activities. Severe malaria was the principal cause of morbidity in the area, accounting for 54.3% (3733/6875) of all admissions in the paediatric department of the MSF referral hospital in 2008 (A. Mukhtar & S. Dunkley, personal communications).
In 2006 and 2007, MSF organized a mass distribution of LLINs using deltamethrin-impregnated PermaNet® 2.0 (Vestergaard Frandsen, Switzerland) which has a WHO Pesticide Evaluation Scheme (WHOPES) recommendation, declaring it safe and effective for the prevention and control of malaria (WHO 2007). Around 65 000 LLINs were distributed using two strategies: free mass distribution and routine delivery of free LLINs for patients discharged from the referral hospital and for women attending antenatal care in the primary health structures. In the mass distribution, LLINs were distributed to households with pregnant women (one per woman) and children under 5 years. Households with 1–2 children under 5 years received one LLIN; a maximum of two LLINs was given to households with three or more children under 5 years. In each village, a reference person was chosen from the community and trained by the distribution team to work as a volunteer to help calculate the number of LLINs needed for the village, facilitate the distribution process and support villagers in correctly hanging and using LLINs.
Before the mass distribution, at least two education and awareness meetings were held with the head of the village and village opinion leaders with the help of a health educator. A theatre performance took place in each village demonstrating how to hang and use LLINs. Malaria education sessions were held at least weekly in the primary and secondary health structures to coincide with antenatal clinics.
The aims of this follow-up study were to measure the usage and ownership of LLINs and to see whether these results met the RBM Abuja targets.
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In a resource-limited and difficult setting, our distribution strategy resulted in high ownership and usage of LLINs: 84% of households owned at least one LLIN, almost all these households (94%) had hung their LLINs correctly and almost two-thirds (67%) had slept under an LLIN the night before the study. Usage was even higher for the most malaria-vulnerable groups – children under 5 years (77%) and pregnant women (73%). Only 12% of households eligible for mass distribution did not own an LLIN. According to the WHOPES Working Group, an LLIN should retain biological activity for at least 20 washes and 3 years of use (WHO 2007). Most LLINs were assumed to be still biologically active; households had received them between 2006 and 2008 and only around 1% had been washed more than 20 times. Many were in good condition – two-thirds had no holes or fewer than 10 finger-sized holes.
Our results surpassed the 2005 RBM target of at least 60% of pregnant women and children under 5 years using LLINs (WHO 2000) and were close to the 2010 target of 80% (RBM 2005). The impact on malaria prevention is limited if LLIN usage does not match LLIN ownership. In contrast to our findings, a discrepancy of 20–55% between ownership (usually relatively high) and usage of LLINs (usually low) has been seen in Ethiopia (Fettene et al. 2009), Ghana (Grabowsky et al. 2007), Sudan (Hassan et al. 2008) and Niger during the dry season (Thwing et al. 2008). One reason for this discrepancy could be the lack of educational campaigns accompanying LLIN distributions (Gikandi et al. 2008; Hassan et al. 2008; Pare Toe et al. 2009). The strong educational component of the MSF distribution campaign might have increased usage of LLINs in our study. Another reason for high usage could be seasonality since people tend to use LLINs more during the rainy season. However, as Sierra Leone has a perennial humid climate with continuous rainfall, this factor would not affect our results.
Discrepancies between LLIN usage and ownership will persist even if ownership of at least one LLIN per household is attained (Eisele et al. 2009). Only when distribution programmes achieve a greater net-to-person ratio inside households can adequate intra-household access be guaranteed. In our study, on average, three household members theoretically shared one correctly hanging LLIN. Although other studies suggest a maximum of two people per LLIN per household as close to ideal, our reported usage rates were very good (Korenromp et al. 2003; Macintyre et al. 2006; Baume & Marin 2007; Killeen et al. 2007; Eisele et al. 2009).
The MSF distribution strategy of handing out free-of-charge LLINs during mass distribution in the villages and routine free delivery at health facilities achieved high ownership: 75% of LLINs had been received via these channels. Recent studies have supported our assumptions that distributing free LLINs results in greater ownership, equal or even better usage and increased socio-economic equity in distribution than that achieved by selling LLINs. In Kenya, a comparison of three strategies showed that free mass distribution resulted in a dramatic increase of LLIN ownership and near equality between all socio-economic classes (Nooret al.2007). In Kinshasa, an increase of 54% in LLIN use was seen in women after distribution of free LLINs at the time of delivery (Pettifor et al. 2009). In Tanzania, the largest increases in ownership of LLINs occurred in districts that received free nets during a vaccination campaign (Hanson et al. 2009). Again in Tanzania, all delivery methods underserved the poorest, especially the sale of nets at full market price; there was a 20% increase of LLIN use for each higher socio-economic class (Khatib et al. 2008; Bernard et al. 2009; Matovu et al. 2009). In Nigeria, the wealth index predicted LLIN ownership (Oresanya et al. 2008). In Zanzibar, free LLIN distribution was related to higher child survival rates (Bhattarai et al. 2007), and in rural Kenya, free LLIN distribution was related to lower child mortality and morbidity (Fegan et al. 2007; Noor et al. 2007). In Kenya, people who received free LLINs were no less likely to use them than those who had paid for them (Cohen & Dupas 2008). A positive correlation between LLIN ownership and free distribution was seen in a comparison of survey data from 40 malaria-endemic countries in Africa (Noor et al. 2009a).
Finally, free distribution seems the only way to abolish inequalities in ownership and to achieve high LLIN usage. Some countries such as Senegal, Zambia and Uganda have achieved substantial increases in LLIN usage (Baume & Marin 2008). Nevertheless, there remain many areas where usage is low. In 2007, only 18.5% (20.3 million) of African children living in areas of stable malaria transmission were protected by an LLIN (Noor et al. 2009a). By 2007, 130–264 million LLINs would have been required to reach 80% coverage in malaria-vulnerable population groups (Miller et al. 2007). However, at the end of 2006, only 72 million effective LLINs were in circulation in Africa (WHO 2008).
Long-lasting insecticide–treated nets at high ownership and usage levels affect vector population survival, and even those not sleeping under a net will benefit, thus achieving mass protection (Noor et al. 2009b). A relatively low usage of 35–65% gives community-wide benefits (Killeen et al. 2007). Our LLIN usage and ownership rates therefore should give protection to the whole community.
There are some limitations in generalizing our usage and ownership results. We did not include a control area. Therefore, it is difficult to extrapolate our results to other areas and other malaria settings, and we cannot conclusively link our results with our intervention. However, a multi-cluster indicator survey by UNICEF in Sierra Leone in 2005 showed that only 5% of children under 5 years had slept under an LLIN (UNICEF 2007), a much lower rate than we observed.
The study was conducted in an area where for some years MSF has offered free malaria prevention, diagnosis and treatment embedded in a system of free primary heath care, and the population is therefore used to high quality free service. The costs for the mass distribution were around US$10 per LLIN. We are aware that in resource-limited settings and for other regional, national and international organizations, these costs might be difficult. However, LLIN distribution is cost-effective. In Togo, distribution of LLINs within the Togo Integrated Child Health Campaign resulted in costs in terms of cases, deaths and disability-adjusted life years (DALY) averted being well within commonly agreed benchmarks set by other malaria prevention studies (Mueller et al. 2008). It has been estimated that universal coverage with LLINs in Africa is achievable by 2010, at the minimal cost of $3 billion per year (Sachs 2005; Teklehaimanot et al. 2007).
In conclusion, ownership and usage of LLINs in our study population almost achieved the 2010 RBM target of 80% LLIN usage in vulnerable population groups. To reach the 2010 RBM targets, we recommend the use of mass distribution and routine delivery of LLINs with an entirely free-of-cost approach.