LONG LASTING INSECTICIDES TREATED NETS UNIVERSAL

COVERAGE : THE SENEGALESE EXPERIENCE

Mamadou Lamine Diouf1, Mike Toso2, Celine Ziegers de Beyl3, Hannah Koenker3, Joan Schubert3, Debbie Gueye4, Mame Birame Diouf4, Youssoufa Lo3, Mady Ba1 , Pape Moussa Thior1, Ousmane Faye5, Julie Thwing4, Medoune Ndiop1, Oulèye Bèye1,

1 Senegal Ministry of Health and Social Action: National Malaria Control Program2 American Peace Corps /Senegal

3 NetWorks project for John Hopkins University, Baltimore4 PMI/USAID/Senegal

5 Entomolgy Service, Univdersity Cheikh Anta Diop Dakar

ASTMH 62nd annual meeting, Washington November 15, 2013

OUTLINE• CONTEXT• EVOLUTION OF ITN DISTRIBUTION STRATEGIES• UC DISTRIBUTION ROLL OUT• EVALUATION METHODOLGY• RESULTS• DISCUSSIONS• MAINTAIN UC• NEXT STEPS

CONTEXT

• Great progress from 2005 to 2010 in malaria control – scale up of malaria prevention and

treatment interventions – decrease in all cause child mortality of

40% 2005 to 2010 National Strategic Plan 2011-

2015: Ambitious objectives for pre elimination

Sustain gains/Improve performances

Short timeframe to achieve MDGs Intensify activities and innovative

strategies

EVOLUTION OF ITN DISTRIBUTION STRATEGIES

2002-2007: combination of Untargeted/targeted subsidized distribution in health facilities and community based organizations

2008: subnational free distribution targeting under 5 years old through integrated campaigns

2009: nationwide free distribution targeting under 5 years old through integrated campaign

2009-2010: pilot universal coverage development in 2 districts based on sleeping spaces (by Peace Corps)

2010-2013: staged nationwide rolling LLINs UC distribution (completed in march 2013)

UC DISTRIBUTION ROLL OUT

Universal coverage defined by the NMCP as one LLIN per sleeping space (1/1.8)

Senegal strategy includes a household census of people, sleeping spaces and existing nets in good conditions

Door to door census conducted by community volunteers

Coupon given to household/redemption with net Coordinating committee at each level (national,

regional, district, village, etc.) Strong partnership on funding and on field

implementation Training, monitoring, supply and communication

activities Procurement and supply system dedicated to UC Evaluation after each phase to improve next

phase

UC DISTRIBUTION ROLL OUT (2)

Evaluation - survey methodology

• Cross sectional cluster sample household survey• Conducted in the six phase 1 and phase 2 regions

during early rainy season 2011• Survey conducted one year after phase 1 and 6

months after phase 2• 60 clusters x 26 households per cluster = 1560

households• Questionnaire included questions on household

demographics, census, distribution, sleeping space, and net use

RESULTS: Household characteristics

Household (HH) characteristics

Phase Total

1st 2nd

Mean people per HH 11.6 10.9 11.2

Mean sleeping spaces (SS) per HH*

6.4 6.2 6.3

HH visited by a census team

85% 95% 91%

HH that received at least one LLIN

84% 94% 89%

HH ownership of ≥ 1 ITN / SS post-campaign

33% 51% 42%

Retention of campaign nets

93% 97% 95%

Retention of pre-existing nets

46% 51% 49%

• Large HH size with many sleeping spaces

• Improvements were seen from phase 1 to phase 2 in terms of households visited and LLINs received

• 42% of households had ≥ 1 ITN / SS

• Campaign net retention 95%, but pre-existing retention 49%

RESULTS: Net useUse indicators Phase Total

1st 2nd

Among HH with ≥ 1 ITN, % with ≥ 1 ITN hanging

90% 94% 92%

% of HH with all ITNs hanging

71% 60% 65%

% of campaign ITNs hanging

86% 80% 83%

% of SS protected by ITN (all HH)

65% 76% 71%

% of population using an ITN in all HH

62% 75% 69%

% of population using ITN in HH with ≥ 1 ITN/SS

92% 89% 90%

% of children < 5 under ITN

64% 80% 72%

% of pregnant women under ITN

65% 80% 74%

• >80% of campaign ITNs hanging

• In all HH, 71% of sleeping spaces and 69% of people were protected by an ITN

• In HH achieving UC (1 ITN/SS), 90% were protected

• 72% of children under 5 years and 74% of pregnant women slept under an ITN

Supporting data from DHS surveys

2010 DHS

2012 DHS*

HH ownership of ≥ 1 ITN

63% 73%

Dakar 37% 24%

North 66% 83%

Center 79% 80%

South 88% 70%

ITN use by general population

29% 41%

Dakar 14% 24%

North 46% 61%

Center 37% 48%

South 50% 40%

• Data from the classic DHS in 2010 and the first year of the continuous DHS in 2012

• South and most of center covered by 2010 DHS• High ownership in

south and center (use higher in south)

• Remainder of center and north done by the time of the 2012 DHS• High ownership and use

in north and center, falling in south

DISCUSSIONS• Universal coverage mass distributions greatly improved

coverage and use compared to non-UC regions • Sleeping spaces census – Definition of SS– Household acces by volunteers– Low retention rate of prexisting nets– Nets hidden by people

• Nets supply– Accuracy of LLINs quantification– Effective supply chain (transportation and storage)

• Intensive effort requiring significant involvement at all levels

HOW TO MAINTAIN UC? • Universal coverage mass distributions greatly improved

coverage and use compared to non-UC regions • UC mass campaign is labor intensive, costly and cannot

be rolled annually in the same regions• Multi-channel Routine distribution to maintain high

coverage (piloted in 2 regions)– Distribution through health facilities

• Distribution of LLINs through antenatal consultations (free) • Distribution of LLINs through general health consultations

(subsidized)– Distribution through community-based organizations

(subsidized)– Distribution through primary schools (free)– Distribution through the private sector (subsidized)

NEXT STEPS• Restart universal coverage with the same

chronology to replace the nets distributed 3 years ago

• Scale up Routine Multi-channel countrywide• Reinforce communication and sensitization to

encourage use year-round and by all household members (Three T)

THANKS FOR YOUR ATTENTION

Ministère de la Santé et de l’Action Sociale