Zimbabwe’s EmergencyIndoor Residual Spraying (IRS) Program

Allison Belemvire, Program Officer

BACKGROUND• 2 million people get malaria annually• 2nd leading cause of death in Zimbabwe• 50% of pop = mainly rural & malaria endemic areas • Cholera situation: realized a malaria epidemic could

potentially occur in the near future

020406080

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Inci

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2000 2001 2002 2003 2004 2005 2006 2007 2010

Year

Malaria Incidence Rates

WHY IRS?• IRS = Pillar of Zimbabwe’s Malaria Control Program• IRS = Application of long-acting chemical insecticides

on the walls and roofs of all houses and domestic animal shelters in a given area, in order to kill the adult vector mosquitoes that land and rest on these surfaces1 – to reduce the life span of vector mosquitoes – to reduce the density of the vector mosquitoes

1Indoor Residual Spraying: Use of indoor residual spraying for scaling up global malaria control and elimination. WHO Position Paper, 2006

EMERGENCY IRS OBJECTIVES: FEB-MAR 09

• To reduce the rate of malaria transmission & prevent malaria epidemics in the 20 districts most affected by malaria in Zimbabwe

• To achieve, by March 31, 2009, at least 85% room & population coverage of IRS in targeted malaria endemic areas

Malaria Stratification (2002)20 Emergency IRS Districts (Feb-Mar 2009)

EMERGENCY IRS PARTNERS• NMCP = Overall Coordination• USAID & USAID|DELIVER PROJECT = $200k

– Equipment Procurement: 250 Hudson X-Pert Sprayers, 25 Spares Kits, 200 Hardened Stainless Steel Nozzles, 190 Nozzle Body Caps

– PLAN Subcontract: National Assurance Coordinator– 2 Month STTA

• Monitoring & Supportive Supervision Field Visits

• DfID & Crown Agents = £ 200k– Payment of Spray Teams ($3/day; $1 for food)– District & Provincial Incentives– Fuel coupons, vehicle rentals and repairs– Food provisions

EMERGENCY IRS PARTNERS• PLAN Zimbabwe• WHO• Zimbabwe Defense Forces (ZDF)• Local communities and NGOs:

– District Development Fund (DDF)

– World Vision– Save the Children – IOM

RESULTS:NMCP FORMAT(as of mid-April 09)

Province DistrictTarget Wards

Target Rooms

Target Pop

Week 1-8 Totals Week 1-8 Coverage %

Rooms PopRooms Pop

Mash East Mudzi 10 76586 68508 58202 58541 76.0% 85.5%

  Murewa 10 41564 42968 30038 42119 72.3% 98.0%

  UMP 11 68967 92585 66931 86192 97.0% 93.1%

Mat North Binga 21 52386 128665 45234 68442 86.3% 53.2%

  Hwange 18 34000 142014 31653 51185 93.1% 36.0%

  Lupane 18 43000 105785 35131 62957 81.7% 59.5%

Midlands Gokwe N 10 28046 45828 25871 42581 92.2% 92.9%

  Gokwe S 5 42039 64992 25230 38514 60.0% 59.3%

Mash West Hurungwe 12 21829 27422 18933 21115 86.7% 77.0%

  Kadoma 12 19325 22260 16957 22037 87.7% 99.0%

Mash Central Centenary 11 41831 66075 35603 59139 85.1% 89.5%

  Guruve 4 16313 24338 15564 22486 95.4% 92.4%

  Mt Darwin 11 35000 58330 31306 49497 89.4% 84.9%

  Rushinga 19 53543 71320 47668 64371 89.0% 90.3%

  Mbire 11 35273 50978 28176 43497 79.9% 85.3%

Masvingo Bikita 7 29380 44070 28079 44736 95.6% 101.5%

Manicaland Chimanimani 10 40254 53745 31116 42004 77.3% 78.2%

  Nyanga 15 51566 70707 46221 62744 89.6% 88.7%

Mat South Beitbridge 12 19806 41862 15649 25567 79.0% 61.1%

  Gwanda 7 25233 29130 17778 21876 70.5% 75.1%

  TOTAL 234 775941 1251582 651340 929600 83.9% 74.3%

= Awaiting final update

= Achieved 85% target

RESULTS: PMI FORMAT (as of mid-April 09)

= Awaiting final update

ProvinceTotal rooms

sprayedTotal rooms

refusedTotal rooms

lockedTotal eligible rooms

encountered

Other structures sprayed

% Rooms sprayed

Mash East 155171 11501 10426 177098 40893 87.6%

Mat North 112018 7664 9214 128896 9975 86.9%

Midlands 51101 2404 2735 56240 5122 90.9%

Mash West 35890 3373 3635 42898 13479 83.7%

Mash Central 158317 No data No data No data No data No data

Masvingo 28079 532 781 29392 4170 95.5%

Manicaland 77337 No data No data No data No data No data

Mat South 33427 No data No data No data No data No data

Total 651340 25474 26791 434524 73639 88.9%

FIELD MONITORING ACTIVITIESIRS Teams• Supervise & provide on the job training of spray operators

(Observation of spray operators, and insecticide management)• Troubleshoot & provide recommendations; follow up on previously

noted challengesIRS Reporting• To review the record keeping of IRS teams (Spray Operator Record

Book, Team Leader Daily Worksheet, and Camp Guard Record Book)• To facilitate the collection of IRS data and timely submission to the

NMCP• To review the stock records for insecticide, fuel & inventory of

equipmentCase Management• To collect current data on malaria trends at the district level • To confirm ACTs and RDTs consumption rates, stocks & expiry dates • To assess the progress of the training rollout for RDTs and ACTs• To facilitate the re-distribution of RDTs and ACTs, where necessary• Assess progress of drug efficacy monitoring in sentinel sites, if

applicable

HR: RECRUITMENT & TRAINING• Recruitment of experienced spray operators

– Diverse, gender sensitive– General hands from hospitals & air force

members• 3 day crash training (typical training is 10 days)• Emphasis on practical work• 1:3 Supervisor to operator ratio• Provincial teams • Insufficient training manuals printed

ACCOMODATION• Primary schools & Clinics• District Development Fund (DDF) buildings• Tents & Stretcher Beds: Leaking & inadequate

tents;

broken stretcher beds• LLINs provided for only a couple of spray teams

EQUIPMENT & PPC• Inadequate PPC

– Lack of face masks & gloves

– Only 1 pair of work suit– Shortage of shoe sizes

• Equipment– Cholera spraying damaged

brass fittings & nozzles– Shortage of equipment for

sprayers in some districts– Quality of water =

blockages in nozzles– Poor service history for

spray pumps; compromise quality of spray swath

TRANSPORTATION & FUEL• District vehicles: 1 functioning vehicle;

constant breakdowns, cholera use • Hired lorries (7-9 ton lorries) too large for

small village paths; missing parts (starters)• Rain: washed out bridges, inaccessible

roads, mud• Expired fuel coupons: difficult to get both

coupons & fuel @ service stations

INSECTICIDE MANAGEMENT

Pyrethroids: DeltaGuard & ICON; NMCP Procured

• Min/Average = 8 sachets/day

• Camp guard records: control of empty sachets to minimize leakage

• “Excess” insecticide:– Variation of recording

structures like chicken houses and latrines

– Disposal of insecticide

FOOD ALLOCATIONS• $1/day for food hamper

– Mealie meal, oil, beans, sugar, salt • Teams took extra food home after campaign • Generally appreciated by all• Some districts/ NGO’s provided meat• Comments: beans; sugar but no tea• Transport Challenges:

– Misallocation of food– Rain spoiled mealie meal

WARNING TEAM• Teams used bicycles,

motorcycles and by foot

• Inconsistencies:– Notebook usage – Data collected– Setting of daily

targets• Challenges:

– Fuel– Tires for bikes,

motos

IEC & COMMUNITY MOBILIZATION

• Some teams met w/ village chiefs

Limited comm. participation:• Inadequate IEC materials• Materials not delivered before

spraying • Agriculture activities• Food distribution

Limited district participation:• Cholera outbreak• Incentives & resources (per

diem, fuel to supervise etc.)

SPRAY TECHNIQUES• Good techniques due to experienced operators• Spray operators sensitized communities before mixing insecticide & spraying• Bio-assays: assess quality of insecticide application• Poor service record for spray pumps; not often

calibrated

DATA COLLECTION & RECORD KEEPING

• District Level– Communication challenges– Incomplete & late reporting

• Spray Team Level– Maps & daily targets

available– Spray operators = good

records

• Challenges– Not enough notebooks– Inconsistent record keeping

for supervisors– Revision of target rooms and

population

*ACT & RDT CASE MANAGEMENT• Shipment

– 1 bulk shipment of 1.6 million ACT treatments arrived Nov 2007

– Possible over quantification of commodities

• Training– Case Mgmt. TOT carried out in Feb & Oct 2007– Rollout training began in Nov

2008

* ACT & RDT CASE MANAGEMENT• Timing

– ACTs/RDTs pushed to districts before trainings (due to delayed release in GF funds)• SP & CQ still circulating in provinces

– Short shelf life: ACTs expire in July 2009 & RDTs expire in Sept 2009

• Information– No consumption data or information basis for

the “push”– Unaware of current stock status in districts &

clinics (i.e. Gokwe S = overstocked, Binga = stock out)

RECOMMENDATIONS: OVERALL• Develop clear National IRS policy; support with

research • Start up logistics: central distribution of

equipment, food, supplies & forms• Strengthen provincial involvement & link b/t

districts & national level– Increase provincial/district motivation & innovation

• Reports = uniform format & schedule – Revisit calculation of targets & thresholds

• Improve communication chain

RECOMMENDATIONS: SPRAY TEAMS• More training for teams; including supervisors• Emphasize mop up activities for locked rooms• Insecticide management: use 2 types, not 4 types• Service spray pumps routinely• Work contract for spray operators• Trucks: pay on mileage rate, not daily rate;

specify type of truck needed• IEC materials for year round awareness

LESSONS LEARNED• Logistical Challenges

– “Come & Get” Logistics = delayed start– Cholera spraying damaged pumps– Communication breakdown (no landlines, mobiles,

email)– Lorries & vehicles to support the program

• Timing of Emergency IRS Activities– Rains– Agriculture – Food Distribution– Cholera

• Data Collection & Reporting– Poor adherence to weekly reporting schedule;

incomplete reporting– Modification of original targets– Communication breakdown

THANKYOU!

Acknowledgements: Martin Netsa,

Wilson Chauke and Jasper Pasipamire