Zimbabwe’s Emergency Indoor Residual Spraying (IRS) Program

1. Zimbabwe’s EmergencyIndoor Residual Spraying (IRS) Program Allison Belemvire, Program Officer

2. 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

3. 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

4. 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

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

6. 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

7. EMERGENCY IRS PARTNERS • PLAN Zimbabwe • WHO • Zimbabwe Defense Forces (ZDF) • Local communities and NGOs: • District Development Fund (DDF) • World Vision • Save the Children • IOM

8. = Awaiting final update = Achieved 85% target RESULTS: NMCP FORMAT (as of mid-April 09)

9. = Awaiting final update RESULTS: PMI FORMAT (as of mid-April 09)

10. FIELD MONITORING ACTIVITIES IRS 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 challenges IRS 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 equipment Case 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

11. 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

12. 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

13. 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

14. 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

16. 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

17. 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

18. WARNING TEAM Teams used bicycles, motorcycles and by foot Inconsistencies: Notebook usage Data collected Setting of daily targets Challenges: Fuel Tires for bikes, motos

19. 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.)

20. 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

21. 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

22. *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

23. * 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)

24. 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

25. 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

26. 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

27. THANKYOU! Acknowledgements: Martin Netsa, Wilson Chauke and Jasper Pasipamire