POST 00763E : MEASLES CAMPAIGN AND ITN DISTRIBUTION
16 March 2005
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We start publishing a discussion between colleagues and some malaria
experts that has been taking place since the last few months. We hope that
more contributions will be made to the debate that starts by a message from
Michael Macdonald (mailto:[email protected]) sent to Robert Steinglass
(mailto:[email protected]). Follows a message from Robert.
The subject line of all messages exchanged was "What do the malaria experts
have to say about mass distribution of ITNs through measles SIAs?"
Michael's message contains a number of acronyms and we apologize if members
are unfamiliar with them.
Those interested in reading the most recent update on long-lasting
insecticidal nets can access it at : http://rbm.who.int/docs/UpdateLLIN_5.pdf
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Hello Robert January 05
Thanks for forwarding the email from Gerhard Hesse from BAYER; we know each
other well. The launch of their new "Long-lasting treatment" is welcomed.
The BAYER product is using the chemical 'deltamethrin' plus a binding agent
- this is the same active ingredient in the Vestegaard-Frandsen
"Permanet". The two other large producers of insecticides for mosquito
nets, Syngenta (who make lambda-cyhalothrin, or "ICON") and BASF (who make
alphacypermethrin, or "Fendona") are also making long-lasting formulations.
So we hope that within the next year we will have three "long-lasting field
treatments" in addition to the two factory-pretreated brands - the
Vestegaard-Frandsen "Permanet" and the Sumitomo "Olyset" net.
The expanding technology will help in at least four ways. First, it will
help us deal with all those "conventional" nets that were not one of the
two factory pre-treated ITNs (the Olyset and the Permanet). Second, it
will relieve a severe supply shortage - there is a 9 month waiting list for
on orders for the "Permanet", and there is still not a lot of confidence in
the community acceptability of the "Olyset" net. Third, and in the longer
term - long lasting field treatments will allow more quality net
manufacturers to remain in business, and not lose out on all the tenders
for long-lasting nets to Vestegaard. Finally, and most relevant to the
measles/malaria debate, it allows provides more value to existing systems
and nets that are already in the community.
I remain strongly against the idea of blitz ITN distributions. The
arguments that NIDs undermine immunization programs goes double for malaria
programs, where targeting is important and continue follow-up
essential. In the end, dumping nets through an immunization campaign does
more harm than good.
There are various distribution channels here in Zambia. The country is
committed to a sustainable and equitable ITN program, and to that end,
strives for market segmentation - that we can maintain a sustainable supply
of ITNs and at the same time make them available at reduced cost or free to
those who most need them.
The country has made considerable gains in building systems for subsidized
and free ITNs. For the subsidized nets, Exxon-Mobil last week donated
$80,000 for the NetMark voucher program, - a strategy that will both make
delivery of ITNs at logistics cost to the public health system, and
stimulate a commercial market for ITNs. In areas with a less vibrant
commercial market, the national program is working with partners (including
PSI) to deliver subsidized ITNs through Ante-natal Clinics, Community
Health Agents and NGOs.
There has also been a rapid expansion of systems for delivering free
ITNs.The national program has begun to work with the HIV Home-based Care
programs, including the Catholic Diocese, CRS, and the numerous NGOs
supported through the new USAID 'RAPIDS' project and PEPFAR. The policy is
that every person living with HIV and AIDS should have an ITN. Zambia has
dozens of organizations involved with PLWHA and OVCs who are receiving free
nets from UNICEF and the National Malaria Program for distribution to their
target populations. Much of this is being coordinated through the 'Zambia
Malaria Foundation" which is an outgrowth of the original CORE - NGO
Malaria Secretariat.
Putting the ITNs through these existing systems is slower than a one-week
distribution campaign. However, it empowers the CBO delivering the ITN to
continue follow-up with the recipient household and ensures that the ITN
will be used properly and not just taken by dad, sold, used for fishing, or
folded away.
We do joint campaigns with EPI for ITN retreatment during child health week
in June and December. Here we use both static health posts, where mothers
who bring their children for Vit A, deworming and immunization also bring
nets for free retreatment. We also support door-to-door retreatments
through community agents, boy scouts/girl guides, and other volunteer
service organizations. The value of these retreatment campaigns will be
greatly increased when we begin to use the KO-Tab 123 and other
long-lasting net retreatments. (This will also remove the argument that we
can only supply Permanets through these campaigns).
These systems for ITN delivery and retreatment are working and are
sustainable. Those that favor the blitz strategy of dumping nets during the
measles vaccination campaigns say that we are not attaining coverage
quickly enough to meet the "Abuja Targets". That may be true, but I like
to say that Zambia will attain, "and sustain" these targets by building the
system, long after the campaigners have departed. Abuja is a marathon, not
a sprint.
Finally, claims that ITN dumps during immunization campaigns are more
'cost-effective' than routine systems in terms of "cost per net delivered"
are dubious. First, ITNs in the routine system are targeted and followed
up, and not just given indiscriminatingly, to houses that already have
them, can afford to buy them, or who don't use them properly. Second, we are
trying to build an integrated service delivery system, which includes not
just ITN delivery, but maternal/child health, and now, home-based care for
PLWHA and OVCs. Putting the ITNs through existing systems achieves a
greater good than just 'the cost per net delivered' through a campaign.
In summary, we have the systems to sustainably and equitably deliver ITNs
that should be supported, and not undermined, by untargeted, one-off, dumps
during immunization campaigns.
Robert, I am sure these are the same arguments you use for building routine
immunization programs. Building routine systems may not provide the same
photo-opportunities for the donors, but will be there when their attention
moves on. Let us join EPI for net retreatments, but not for delivery of
the nets themselves.
Good Luck!
Michael
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Michael Macdonald is a well-known and highly-regarded malaria expert based
in Zambia.
I firmly believe that there should be a vigorous debate about ITN
distribution during SIAs among malaria and immunization experts, including
some of the anticipated negative consequences of mass distribution. I had
asked him for his views in the hopes that some of them would be raised at
the recent Measles Partnership meeting, which I was unable to attend this
year due to duty travel.
Robert Steinglass
Technical Director
IMMUNIZATION Basics
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