The IRS activities for the year 2020 was delayed, not yet done at the time of writing due to COVID-19 pandemic, hence the unavailability of 2020 IRS report.
IRS implementation schedule
In Buhera, IRS is implemented in twelve wards with high malaria perennial and high malaria sporadic as shown in Figure 1 camp wards. The reports show that the IRS is implemented in the form of teams and camps that are divided according to malaria prevalence in the wards. The number of teams and camps varies with respect to the implementation strategy. In some cases, the camps and teams were grouped into three camps of three teams each. The designated camps were Birchenough, Muzokomba and Mudawose as shown in Figure 1. Each camp was to cover four wards based at the same campsite. Three teams usually camp at Muzokomba covering wards 24, 25, 26, and 27. Another set of three teams usually camp at Betera covering wards 18, 20 and part of ward 23 then move to Masasa to cover ward 22 and part of ward 23, and four teams camp at Birchenough Bridge (BB) covering wards 28, 29, 30 and 33. The movement of IRS teams in their respective wards is shown in Figure 1. Malaria season is usually from November to April in Zimbabwe but in most cases, IRS is done during malaria peak time, that is, between January and April[21].
Five-year intermittent residual spraying (IRS) comparative ward coverage from 2015 to 2019
Table 1 shows IRS coverage from 2015 to 2019, with the total number of targeted rooms and sprayed rooms and their respective wards. IRS acceptance rate is the rate at which indoor residual spraying activities are accepted in the targeted rooms of the targeted area, while callbacks refer to the return of IRS activities for the second or more times, to improve coverage in the affected areas[24]. The IRS acceptance rate per ward and or per year was calculated by dividing the total number of targeted rooms by the total number of sprayed rooms and multiplies the result by 100 to get the percentage. Therefore, the overall IRS acceptance rate in 2015, 2016, 2017, 2018 and 2019 was 100%, 58.5%, 66.6%, 52.8% and 83.3%, respectively. The acceptance rate of sprayed rooms in ward 18 for the year 2015, 2016, 2017, 2018 and 2019 was 100%, 66.9%, 62.9%,0% and 92.3% respectively, while, ward 20 has acceptance rate of 100% in 2015, 66.9% in 2016, 75.1% in 2017 and 14.4% in 2019. Ward 22 has acceptance rate of 100% in 2015, 69.3% in 2016, 66.5% in 2017, 72.2% in 2018 and 88% in 2019. In 2017, there was not much difference between the targeted rooms and the rooms sprayed, with notable difference only in ward 33 which was influenced by accelerated growth. Acceptance was generally low across all the wards, except for ward 26 which had an acceptance of 84.27%. The lowest acceptance rate was in ward 23 which registered 56.72%. The absolute rooms sprayed in 2017 are 2.55% above those sprayed in 2016 but are 8.46% below those sprayed in 2015. Acceptance rate dropped in the two concurrent years, dropping from 71.72% in 2015 to 69.21% and 67.53% in 2016 and 2017 respectively. Callbacks were instituted in the wards with low coverage, wards 18, 20, 23, and ward 30, however, insignificant rooms were sprayed during callbacks as the community continued to resist despite prior engagement with the community leaders. In 2018, acceptance was generally low across all the wards, except for ward 26 which had an acceptance of 84.27%. The lowest acceptance rate was in ward 23 which registered 56.72%. In 2019, the overall sprayed rooms coverage was 83.3% against target and population protected was 95.5%. The coverage failed to reach impact levels in most of the wards due, but not limited, to inadequate community sensitization, as well as a competing programme which was running concurrently with IRS. Ward 33 and 30 are problematic wards since the community is preoccupied with their irrigation activities, hence refusal rate and the locked rate was very high.
Sprayed rooms
Figure 2 shows the distribution of sprayed rooms from 2015-2019. Ward 22 had the highest IRS coverage in terms of rooms sprayed from 2015-2019. This high distribution might be attributed to sensitization awareness, promotion and marketing of the programme, while ward 30 recorded slightly low sprayed rooms in 2015,2016, 2017,2018 and 2019. Ward 30 and 33 are problematic areas with very high refusal affected by competing farming and marketing activities. Ward 26 had a sudden decline in acceptance, compared to the previous years when the ward was one of the best performing wards with coverage above impact levels.
Comparative analysis of wards IRS coverage and achievements at wards level
The overall acceptance rate stood at 67.42% and the overall coverage achieved was 66.58% as shown in Table 2. There was not much difference between the targeted rooms and the rooms sprayed, with notable difference only in ward 33 which was influenced by accelerated growth. Acceptance was generally low across all the wards, except for ward 26 which had an acceptance of 84.27%. The lowest acceptance rate was in ward 23 which registered 56.72%. The absolute rooms sprayed in 2017 are 2.55% above those sprayed in 2016 but are 8.46% below those sprayed in 2015. Acceptance rate dropped in the 2 concurrent years, dropping from 71.72% in 2015 to 69.21% and 67.53% in 2016 and 2017 respectively. Callbacks were instituted in the wards with low coverage, wards 18, 20, 23, and ward 30, however, insignificant rooms were sprayed during callbacks as the community continued to resist despite prior engagement with the community leaders.
In 2018, the acceptance was generally low across all the wards, with the highest coverage achieved in ward 26 with 75% as shown in Table 3. The lowest coverage was achieved in ward 30 which had 51%. Wards 18 and 28 were not sprayed as fuel shortage affected operations at Birchenough and Mudawose campsites. Ward 20 had only 21% of the rooms reached with only 14% being sprayed. The overall coverage for the targeted wards stood at 53% but the coverage for the sprayed wards excluding those not sprayed was 66%. Acceptance was greatly affected by poor warning and poor deployment, due to shortage of fuel. It was also affected by poor promotion and marketing of the programme and the new chemical.
In 2019, the overall sprayed rooms coverage was 83.3% against target and population protected was 95.5%. The coverage failed to reach impact levels in most of the wards because of limited inadequate community sensitization, as well as the competing programme which was running concurrently with IRS. Ward 33 and 30 are problematic wards since the community is preoccupied with their irrigation activities, hence refusal rate and the locked rate was very high.
There was a steady decline in coverage from 2016 to 2018, which can be attributed to several challenges including poor marketing of the programme, high refusal, and poor resource inflow especially operational resources among others. In the 2019 season, the coverage improved in some wards culminating to a better coverage than three preceding seasons though not enough to reach impact levels. Vigorous marketing and awareness of the programme at village/ward level are required to improve the uptake of the programme; however, poor resource inflows affect the implementation of the programme.
Distribution of malaria cases from 2015-2020
Malaria data from satellite health facilities are entered into district health information system 2(DHIS) on weekly basis. Satellite health centres report aggregated monthly malaria confirmed cases (tested positive) and suspected cases (tested by rapid diagnostic test or blood slide) using T5 forms[25]. Once data is entered, it then becomes accessible nationally through NHIS. Satellite health facilities report malaria cases using WhatsApp, SMS, phone call and frontline app. Once the malaria data is entered, it becomes accessible electronically at the district level, provincial level up to national level. This follows the malaria outbreak detection and response surveillance system reporting structure shown in Figure 3.
Following malaria outbreak detection and response surveillance system reporting structure shown in Figure 3, malaria cases collected from DHIS from 33 rural health facilities in Buhera rural district from 2015-2020 are shown in Table 6.
Low malaria confirmed deaths and cases were recorded in 2018 which shows a clear reduction in malaria burden, as shown in Table 6, which brought hope and prospects to policymakers, funders, healthcare professionals and the community to move towards malaria elimination[3]. However, there was a sharp increase of confirmed malaria cases in 2019 because of new challenges including changes in vector behaviour [26], high refusal of IRS activities, resistance to insecticides and anti-malarial medicines[27], invasion of new areas by vectors, vectors in various combination of sympatry, changes in vector proportions, outdoor malaria transmission, climate change[9], abuse of LLINs, lack of meticulousness of spray operators and lack of digital tools to sensitize affected communities about malaria as well as IRS activities[8]. Also, the outbreak of COVID-19 pandemic stalls the progress and gains achieved in the previous years as depicted in Table 6, although 2020 results alone may not be sufficient to warrant a trend. The confirmed malaria cases increased from 1376 cases in 2019 to 2981 cases in 2020. This is attributed by several factors including imposed COVID-19 stringent restrictions, delayed IRS activities, postponement of recruitment and training of IRS teams and disruption of movements of medical equipment [28,29].
Malaria hotspots and distribution in Buhera rural district
After collecting confirmed malaria cases from 2015-2020, we mapped malaria hotspots using QGIS 3.10.5 software. Cumulative confirmed malaria cases per each health facility were mapped into their respective wards in Buhera district. Health facilities were grouped into several categories such as malaria-free, low malaria sporadic, high malaria sporadic and high malaria perennial as shown in Figure 4. These categories are based on malaria prevalence rate on each health facility. Figure 4`shows that high malaria perennial wards are ward 28 (Chapanduka) and ward 33 (Birchenough Bridge). Ward 30, 29, 25,21,23,20 and 23 were identified as high malaria sporadic wards and low malaria perennial wards, respectively. This means that indoor residual spraying activities and resources should be intensively done in high malaria perennial wards and high malaria sporadic wards. However, there are some low malaria sporadic wards with low transmission and reported cases as well as malaria-free wards which are close to malaria elimination as shown in Figure 4.
Social and behaviour change communication (SBCC) in changing malaria landscape in Buhera rural district
SBCC is one of the malaria control strategies in Zimbabwe aimed at increasing utilization of correct malaria prevention and control measures. After programme inception, data indicated high refusal rates and locked rooms especially in wards 28,23,24,18 and 33 as shown in Table 2. The correlation between high refusals and locked rooms suggested that the locked rooms could have been just smart refusals linked to fear of the impact of chemical spraying, ignorance, uncertainty, perceived side effects of the insecticide[30], odour, and conspiracy theory about the chemical affecting fertility and people exposing their poor quality household possessions. After SBCC campaigns communities anticipated chemical change, though it was based on resistance management.
The new strategy to involve and engage the local leadership, chiefs, headman, village heads and the community might reduce resistance. The phenomenon primarily focused on problem identification, analysis and possible solutions in a participatory manner to enhance community engagement in order to reduce high IRS refusals. This was employed in all areas targeted for callbacks and all areas to be covered by the IRS. Principally communities agreed to work together and to provide guides in most instances. SBCC activities in rural health centres are carried out by nurses and environmental health technicians through scheduled and ad-hoc health education sessions to patients and vulnerable populace[31]. In some instances, malaria posters and pamphlets written in local languages are used to relay malaria messages in hard-to-reach areas. In urban areas, walls at local shops and branded public transport vehicles also facilitate SBCC[31]. However, the effectiveness of these SBCC malaria interventions is not yet known or document especially in high malaria risk zones. Therefore, introducing mobile technology to complement existing strategies is seen as a positive move to enhance malaria control.
Challenges of malaria elimination strategies in Buhera district
Despite the remarkable progress in combating malaria in Buhera district, the district is faced by multiple challenges. These include the shortage of resources, low or non-response to field challenges including high refusal of IRS, competing programme and activities such as farming and food distributions demanding same resources ( i.e human and time) also affected acceptance, inconsistent SBCC messaging threatening the success of the programme and poor programme promotion, awareness and marketing strategies among others. Buhera district’s malaria elimination progress is also threatened by other challenges affecting the NMCP as explained by [21]These challenges include changes in vector behaviour, resistance to insecticides and anti-malarial medicines, invasion of new areas by vectors, vectors in various combination of sympatry, changes in vector proportions, outdoor malaria transmission, climate change, lack of meticulousness of spray operators, lack and inconsistency of funding, lack of political-will[12], low utilization and distribution of treated nets in the district, outdoor transmission, lack of community engagement, lack of information and commitment, lack of mapping malaria models in low-transmission settings[32]. These challenges are likely to slow down malaria elimination in Buhera district.
Opportunities for integrating mobile phones in malaria prevention and elimination in Buhera rural district
Since the country is prepared to introduce Integrated Vector Management (IVM) as part of the vector management and elimination, there is a need to adopt and utilize mobile phones to strengthen BSCC and malaria information, education, and communication irrespective of locality. Also, [8] stated that there was a notable decline in exposure to malaria messages despite relatively high ownership of radios, televisions and mobile phones among the households sampled in the malaria indicator survey conducted in 2016. This affects the knowledge of people living in high malaria incidences as it correlates to lack of information such as signs and symptoms of malaria as well as perceived dangers of malaria. In addition, COVID-19 presents a challenge to disseminate information while maintaining physical distancing especially in rural communities where inequality in access to information and the digital divide is common. Hence, the need for best alternative solutions to information, education, and communication such as low cost-effective mobile technologies including mobile phones to disseminate malaria information. Studies by[33–36] indicated that integration of mobile phones in malaria prevention and elimination strengthens information, education and communication as well as improve case detection and management of malaria. The high mobile phone penetration of over 90 per cent makes mobile phones a readily available means of communication even in Zimbabwe`s resource-constrained areas[37]. Malaria vector prevention could focus on disseminating malaria information and knowledge of the symptoms and danger signs of malaria as well as the importance of indoor residual spraying[8] because of their pervasiveness and ubiquity. For instance, [38]suggested that mobile phones connected to the existing technologies such as cloud computing, geographical information systems, could be utilized to map malaria hotspots, migration patterns of infected people, malaria detection and reporting. Also, [39]identified vertebrate blood meals in the malaria vector (Anopheles arabiensis) using mid-infrared spectroscopy, while[40] applied GIS and machine learning classifiers to understand spatial variations of malaria that are linked to remotely sensed data in Vietnam. Also, [41] also applied the convolutional neural network (CNN) image analysis for malaria diagnosis, and detect malaria from microscopic images. However, the integration of these existing technologies and mobile phones to tackle malaria may be independent; and could be utilized for various purposes such as predicting malaria incidences[9], malaria diagnosis[41], detecting malaria, identification of malaria-infected cells, malaria screening, predicting insecticide resistance[42], predicting of mosquito species, mapping malaria hotspots and associated climatic factors[10], malaria cell image classification[43] among others. This shows that there are so many unprecedented opportunities to embrace emerging technologies in malaria prevention and control strategies in Zimbabwe.
How COVID-19 slows down malaria control and prevention measures in Zimbabwe?
COVID-19 pandemic continues disrupting international, regional, national, provincial and districts malaria control programmes complicating malaria surveillance and monitoring activities as well as slowing down planning and resource mobilization processes, especially in low-income tropical malaria-endemic countries [44]. Considering that the malaria burden is highest in low-income tropical countries with little capacity to fund malaria control and eradication programs, the fight against malaria in these regions is likely to be hampered[45]. Access to healthcare has generally been limited, while malaria interventions, such as seasonal malaria chemotherapy and distribution of insecticide-treated bed nets, have been suspended due to lockdowns[46]. Likewise, the repurposing of anti-malarials for treatment of COVID-19 shared symptoms and the shift in focus from the production of malaria rapid diagnostic tests (RDTs) to COVID-19 RDTs is a cause for concern in malaria-endemic regions[47]. The use of chloroquine and its derivatives in COVID-19 treatment is likely to facilitate the rebound of chloroquine-resistant malaria parasites. This will hinder the possible use of chloroquine and its derivatives in the fight against malaria in the future and thus further dampen the prospects of malaria elimination from Africa.
Recently, WHO emphasized that malaria control programmes in malaria-endemic countries should be done while protecting the vulnerable communities and healthcare professionals against COVID-19 pandemic[48]. Despite WHO’ recommendations, sub-Saharan African countries including Ghana, Côte d'Ivoire and Comoros deferred the insecticide-treated bed nets and indoor residual spraying campaigns amid COVID-19 pandemic[49]. However, the current COVID-19 pandemic continues disrupting malaria prevention and control programme, movements of medical equipment and recursive national lockdowns with stringent access to health care could lead to additional loss of life[50]. Also, WHO warned that up to 769 000 people could die of malaria this year in sub-Saharan Africa, more than double the number of deaths in 2018, if the focus on COVID-19 leads to a disruption of interventions for malaria[51]. Also, [49,52] state that the association between malaria and COVID-19 pandemic is devastating in malaria-endemic countries with myriad health problems such as fragile healthcare system, scant healthcare professionals, poor healthcare facilities and infrastructure and limited financial resources. This threatens progress made towards malaria elimination in malaria-endemic countries in the past years[53,54]. Such progress was largely successfully because of the effective implementation of malaria control and prevention measures, including the distribution of long-lasting insecticide-treated bed nets, indoor residual spraying, and antimalarial treatments. In the context of the ongoing pandemic, implementing and sustaining these malaria control and prevention measures require innovative measures to save both vulnerable communities and healthcare professionals especially in vulnerable rural resource-constrained areas.
Zimbabwe with no exception especially the vulnerable rural communities, mosquito vector control largely depends on indoor residual spraying and also the mass distribution of long-lasting insecticide-treated nets[20]. Indoor residual spraying is the most dominant vector control intervention that has been implemented by the Ministry of Health and Child Care to reduce malaria in malaria-endemic districts. However, indoor residual spraying poses the highest risk of exposure to COVID-19 because IRS teams frequently and physically engage with the community when recruiting participants, training, meeting authorities, executing household visits, and in some instances conduct contaminated objects and surfaces[44]. Also, the imposed by COVID-19 measures restrict movements of people both rural and urban areas making it difficult to recruit IRS operators, training, conduct meetings and gather the community. COVID-19 restrictions also cause delays in the procurement of resources and planning for seasonal IRS. Typical delays caused by COVID-19 include increased time taken to deliver personal protective equipment and IRS chemicals, and other consumables[55], postponement of recruitment and training of IRS teams due to disruption in the movements of medical equipment, closed borders and recursive national lockdowns. Owing to COVID-19 restrictions especially movements of people[56], the recruitment and training of IRS teams require a new different approach and innovative means. Coupled with a lack of adequate personal protective equipment and the scarcity of knowledge on the possible interaction between malaria and COVID-19 both in terms of presentations and shared symptoms, this has left many frontline health workers with fears and anxieties[28]. It is therefore imperative for both health workers including IRS teams and community to receive training and information pertaining to COVID-19 and IRS activities that impose risks and how to mitigate them effectively. This increases the cost of additional resources and training required to fight both the pandemic and elusive malaria, without redirecting resources.
Notably, IRS coverage is done based on classifying areas into different malaria risk zones in a stratified manner, prioritizing malaria hotspots areas followed by lower-risk areas. This should be done timeously usually from early November to April to spray mosquito breeding sites. However, due to the postponement of the recruitment and training process, IRS activities were delayed leading to malaria outbreak. For instance, as of April 2020, few months after the pronouncement of COVID-19 national lockdown, Zimbabwe recorded a cumulative 135,585 malaria cases and 131 deaths, mostly from malarious provinces such as Manicaland, Masvingo and Mashonaland East[57]. This calls for the need for robust and resilient innovative measures to expedite IRS activities and equip communities with knowledge of malaria and COVID-19 prevention measures.
Potential integration of IRS and mobile phones in malaria control to enhance IEC in Buhera rural district
Moving from malaria prevention to complete elimination is a daunting task that requires collaborative efforts from regulators, institutions, funders, researchers, community among others to integrate and coordinate malaria prevention and control strategies. To achieve complete malaria elimination, the inclusion of emerging technologies and computational models in the future national malaria communication strategy is inevitable. This means re-establishment of sound e-health strategy in collaboration with the Ministry of ICT, Postal and Courier Services. The following suggestions can be incorporated in the future malaria information, education and communication programmes:
- Integration of mobile phones to create malaria awareness, community engagement, communicate IRS chemical changes and LLINs to avoid high refusal when executing IRS activities
- Re-establishment of e-health strategy which might lead to e-health policy in Zimbabwe.
- Mobile phones enhance real-time reporting, monitoring and surveillance of malaria cases because of their pervasiveness and ubiquity.
- Resource mobilization through funding and research collaborations with local and international institutions
- Development of multi-sectoral (Ministry of ICT, Postal and Courier Services, Ministry of Health and Child Care and other stakeholders) framework and guidelines for the adoption and use of ICTs in the health sector to facilitate the adoption of e-health for easy monitoring, diagnosis and surveillance of malaria and other preventable and treatable pandemics.
- Creating malaria awareness and promote IRS and LLINs, strengthening information, education, and communication on malaria through low-cost and feasible information dissemination platforms.
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Recommendations for malaria control at ward level are as follows
- IRS is field-based and in the event of challenges should seek field solutions
- Conduct client satisfaction survey and feedback meetings to note areas of improvement and identify areas which were missed during the IRS and or LLINs programme
- Community dialogue especially pre and post IRS meetings in areas with high refusal rates to come up with a plan to address issues surrounding refusals
- Baseline data verification is needed.