Many malaria vectors are considered “endophilic”; that is, the mosquito vectors rest inside houses after taking a blood meal. These mosquitoes are particularly susceptible to control through indoor residual spraying (IRS).IRS involves coating the walls and other surfaces of a house with a residual insecticide. For several months, the insecticide will kill mosquitoes and other insects that come in contact with these surfaces. IRS does not directly prevent people from being bitten by mosquitoes. Rather, it usually kills mosquitoes after they have fed if they come to rest on the sprayed surface. IRS thus prevents transmission of infection to other persons. To be effective, IRS must be applied to a very high proportion of households in an area (usually >80%).
History of IRS
IRS with DDT was the primary malaria control method used during the Global Malaria Eradication Campaign (1955-1969). The campaign did eliminate malaria from several areas and sharply reduced the burden of malaria disease in others. It is proven to be an effective malaria prevention tool. Primary malaria prevention on a large scale depends on two vector control interventions: indoor residual spraying (IRS) and insecticide-treated mosquito nets (ITNs). Historically, IRS has reduced malaria transmission in many settings in the world. The evidence from randomized comparisons of IRS versus no IRS confirms that IRS reduces malaria incidence in unstable malaria settings.
THE AGAMal SYSTEM FOR INDOOR RESIDUAL SPRAYING
- Historical Perspectives
AGAMal received its first Global Fund Grant in 2008 as the first private sector principal recipient of the Grant. This Grant was an amount of US$133M. After an initial delay, AGAMal implemented its first Global Fund Grant and took IRS to 11 districts across the country in 2011. This number was made up of 4 districts in Ashanti, 1 district in Central, 3 districts in Western, and 3 districts in Upper West Regions. The number of districts was supposed to have been scaled up to a total of 40 districts in 6 regions in Ghana for over 5 years. However, due to the late start of the implementation of the Global Funded IRS program, in 2012, the Global Fund approved a grant revision from the initial 40 to 35 districts. In 2014, the reduction in IRS funding from $133million to $15.5million under a New Funding Model for 2015-2016, led to the decommissioning of 16 operational districts. AGAMal, therefore, was forced to operate only in the 10 districts of Upper West Region and Obuasi Municipal.
The Demographic and Health Survey (DHS) report (2014), however, showed a significant reduction of malaria prevalence in the Upper East and Upper West Regions; nevertheless, the new funding model could not take care of the Upper East Region. AGAMal, therefore, initiated a campaign to raise additional funding to sustain gains made in the Upper East Region. A Memorandum of Understanding was signed in 2016 with Unitaid’s NgenIRS project to subsidize the cost of insecticides for the IRS. Under the arrangement, IRS insecticides received a 30% subsidy to reduce the overall cost of the IRS and drive down the prices of insecticides over time. Another key objective was to accelerate the introduction of 3rd generation IRS insecticides and facilitate program expansion. This cost-sharing made it possible for AGAMal to extend IRS to 3 districts in the Upper East Region in 2017 to date.
Currently, AGAMal, in partnership with Ghana Health Service (GHS), National Malaria Control Program (NMCP), Municipal and District Assemblies and with support from AngloGold Ashanti, Ghana, the Global Fund and Innovative Vector Control Consortium (IVCC) through its NgenIRS project, is, therefore, implementing Indoor Residual Spraying (IRS) program in Obuasi Municipality and Obuasi East District in Ashanti Region, all 11 districts in Upper West Region, and Kassena Nankana, Builsa North and Builsa South districts in Upper East Region of Ghana.
- Operational Details
This section provides operational details as to what is involved in embarking on IRS campaigns to understand the complexities of the campaign. Indoor residual spraying (IRS) is a relatively new concept for most Ghanaians. It requires a lot of discipline to do it effectively. Community awareness and support are critical factors that influence the effectiveness of IRS programs. To ensure that the local population accepts the IRS program, community education and communication campaigns must be implemented. Various stakeholders are strategically engaged throughout the life cycle of the operations. Some of these include representatives of the Government of Ghana at the National, Regional and Local levels, Regulatory Bodies, Funding partners, Community Leaders, Media, Academic community and Research partners, and the entire workforce. These engagements range from structured one on one meetings, Community fora, Media Briefings, as well as Web & social media publications.
The IRS Campaign
The IRS process starts with notification of beneficiary communities and the recruitment of operational staff. This is followed by the SBCC campaign. The SBCC activities are organized into three sub-activities:
- Pre-Operational, Operational and Post Intervention Activities
These activities are geared towards addressing concerns, misconceptions, and fatigue from previous operations and to give general education on Malaria and Indoor Residual Spraying. It is also a means to sustain gains, improve, and collaborate with stakeholders to achieve the maximum program impact.
These activities are conducted early in the season so that the communities are fully sensitized before the spray operators go into the communities to spray. A movement and community communication work plan, which shows the general plan of work to be done, the operational team /teams (District Operation Officers, Supervisors, Team leaders, Spray operators, Implementers, and Community Volunteer advocates) and the timelines for delivery are developed.
The Pre-Operational Activities include:
- Community entry in new and already existing communities
With the benefit of already documented information about the community, key opinion leaders/influential people are identified and their support is sought for successful program implementation. These include the traditional authorities, religious leaders, heads of regulatory and partnering institutions, the District Chief Executive, and heads of other institutions.
- Recruitment & capacity building for staff
There is training for the entire operational staff. The recruits get a longer training period than staff who were engaged in the previous season. While these pieces of training are going on, the SBCC team starts with targeted SBCC in communities that recorded a lot of refusals from previous spray season’s records.
Mass educational campaigns for awareness creation using megaphones and Public Address systems mounted on vehicles and electronic media are conducted concurrently. Participation in traditional, religious, and national festivals and celebrations to help strengthen stakeholder ties, as well as to enhance corporate image, is done. Customary items and token amounts are presented to the chiefs and their elders. Media Campaign continues on FM stations which are selected based on listenership, coverage, community acceptability, location, and credibility; service providers are contracted for weekly panel discussions. The panel is drawn from the District teams, GHS, and allied partners, when necessary.
- Media Campaign To Support Spraying Initiative
The contracted stations transmit jingles, announcements and do Live Presenter Mentions (LPM) daily and hold weekly panel discussions to educate the communities and get the necessary feedback for program improvement. Community announcements (gong-gong beating, mosques & churches) mass announcements (using Public Address systems fixed on vehicles) are also used at the community level for information dissemination and education.
- School Health Programs are organized in schools for sensitizing students and staff. Other educative programs such as quiz and debate competitions among schools are also organized.
- Evening Mobilization Programs Such As Video Shows are held in targeted communities with the express approval of traditional leaders.
- Mobilization for Revisits in low coverage communities is done periodically through mop-ups sessions.
- The house to house mobilization/sensitization and spraying.
The actual spraying of communities occurs in this phase. At the end of the training of spray operators, the spray teams move from house to house in the communities to spray. The SBCC teams adequately prepare householders. The spray operator on reaching the house introduces himself with the Identification Card. With the permission of the householder, the spray operator together with the householder enters to inspect the rooms to be sprayed which are usually prepared as directed by the SBCC team. The operator then comes out to mix his insecticide, explaining every step to the householder after which he asks the householder to stay at a safe distance for spraying to be done in the rooms. Afterward, the spray operator reminds the householder to stay outside for a minimum of two hours. Household data, as recorded on the SP1 card, is submitted to the team leader who in turn collates and submits to the group supervisor. At the end of the day’s work, the spray operator returns to sprayed houses and does the final inspection of rooms to ensure the householder is satisfied with work done. The householder then signs the card. Communities earmarked for IRS are appropriately entered and prepared for at least three (3) days before spraying takes place.
- Debriefing for District Teams
At the end of the spray period, district teams meet to evaluate their performance, reflect on their successes and challenges, and suggest ways of improving the operations in the next season.
- Post Intervention Stakeholders’ Review Meetings (District Level) A day’s meeting is arranged for all stakeholders to meet and discuss the season’s performance.
- Community exit and decommissioning are done with the entire management team. They book appointments with all major stakeholders to thank them for their contributions during the spray period and officially inform them of their exit from the district for the particular year. All logistics are packed back to the warehouse for safekeeping. Regional Post Intervention Stakeholders’ Meeting is organized to debrief relevant stakeholders and to bring a decent closure to the program.
IRS Operations Monitoring
Supervision of spray operations is a very important activity to ensure that spray operations are carried out according to correct technical procedures, which are essential for taking corrective action to achieve program goals. Supervision is carried out at all levels of the IRS operations by AGAMal to ensure the quality of IRS in the area of training, implementation, the effectiveness of supervision, IRS communications and community awareness, compliance with stock management, and record-keeping requirements. Each team supervisor is held accountable for the insecticide used per day and is required to return all sachets to the stores at the end of each day where they will be counted and recorded. Empty sachets are disposed of following the Environmental Protection Agency (EPA) requirements and internal Standard Operation Procedures (SOPs).
Supportive supervision of the IRS operations is conducted at the district and zonal level to monitor program performance (i.e. inputs, process & output) by the district Monitoring & Evaluation (M&E) and IRS teams (i.e. Operations Manager, IEC Coordinator, and Entomological technicians). Some of the parameters that are looked out for on these routine visits are nozzle discharge rate, condition of spray pumps, preparation of insecticide mix, actual spraying operation including the technique, speed, and coverage among others, as has been communicated in the standard operating procedures. Continuous supervision of the spray operations is essential to ensure high quality, coverage, and effectiveness within the stipulated spray cycle.
Consecutive supervision and evaluation are also conducted as independent appraisal by the M&E Unit of AGAMal through review meetings with stakeholders at all levels, and comprehensive reports on the implementation of various components of the IRS operations and IEC are compiled for future program decision making.
Monitoring & Evaluation
The primary aim of the Monitoring and Evaluation department of is to monitor progress towards the attainment of the goals and objectives and evaluate the outcomes and impact of the Indoor Residual Spraying. This is achieved through the systematic collation of information on the input, process, output, outcome and impact indicators and by tracking progress towards set targets.
The AGAMal M&E system covers four areas including:
- Supervision of IRS field operations
- Entomological and insecticide resistance surveillance among Anopheles vector population
- Epidemiological surveillance
- IRS Data Management and Storage
There are two sections under the M&E Department
- Data Management
This department is primarily responsible for collecting, validating, processing and storing all IRS and related data in manner that is reliable, accessible and timely to facilitate effective decision making and track progress towards program objectives.
The Entomology provides data on vector transmission dynamics, insecticide resistance profiles, insecticide batch potencies, effectiveness of spray applications, efficacy of insecticides used for the IRS operations on sprayed surfaces and the elucidation of mechanisms of insecticide resistance and its impact on the vector control.
The staff consists of an Entomologist, Entomological Technologists and Insectary Technicians who coordinate all activities in a well-equipped insectary and molecular laboratory.
The molecular laboratory has a state-of-the-art equipment for undertaking a wide range of analysis on mosquitoes collected from the field. The entomology team is adequately equipped with a range of requisite analytical skills to undertake morphological identification and molecular assays to differentiate sibling species of Anopheles gambiae s.l and also determine kdr and Ace-1 mutations in insecticide resistant vectors. There is also the capacity to carry out enzyme-linked immunosorbent assays (ELISAs) to detect sporozoite infections in the vectors of malaria, among others.