Prevention of malaria in Afghanistan through social marketing of insecticide‐treated nets: evaluation of coverage and effectiveness by cross‐sectional surveys and passive surveillance

Abstract

SummaryMalaria is often a major health problem in countries undergoing war or conflict owing to breakdown of health systems, displacement of vulnerable populations, and the increased risk of epidemics. After 23 years of conflict, malaria has become prevalent in many rural areas of Afghanistan. From 1993 to the present, a network of non-governmental organizations, co-ordinated by HealthNet International, has operated a programme of bednet sales and re-treatment in lowland areas. To examine whether a strategy based on insecticide-treated nets (ITN) is a viable public health solution to malaria, communities were given the opportunity to buy nets and then monitored to determine population coverage and disease control impact. This was carried out using two contrasting methods: cross-sectional surveys and passive surveillance from clinics using a case-control design. Nets were purchased by 59% of families. Crosssectional surveys demonstrated a 59% reduction in the risk of Plasmodium falciparum infection among ITN users compared with non-users (OR 0.41; 95% CI 0.25-0.66). The passive surveillance method showed a comparable reduction in the risk of symptomatic P. falciparum malaria among ITN users (OR 0.31; 95% CI 0.21-0.47). The cross-sectional method showed a 50% reduction in risk of P. vivax infection in ITN users compared with non-users (OR 0.50; 95% CI 0.17-1.49) but this effect was not statistically significant. The passive surveillance method showed a 25% reduction in the risk of symptomatic P. vivax malaria (OR 0.75; 95% CI 0.66-0.85). ITN appeared to be less effective against P. vivax because of relapsing infections; hence an effect took more than one season to become apparent. Passive surveillance was cheaper to perform and gave results consistent with cross-sectional surveys. Untreated nets provided some protection. Data on socioeconomic status, a potential confounding factor, was not collected. However, at the time of net sales, there was no difference in malaria prevalence between buyers and non-buyers. The abundance of Anopheles stephensi, the main vector, did not appear to be affected by ITN. ITN constitute one of the few feasible options for protection against malaria in chronic emergencies.keywords insecticide-treated bednets, malaria, Plasmodium falciparum, Plasmodium vivax, Pakistan correspondence Mark Rowland,

Malaria prevention among afghan refugees in a malarious area, southeastern Iran

“…More Beluchi people attended to local Health Services for treatment for In addition, 77.1% of the native resident believed bed nets to be effective in preventing malaria transmission, while the majority of Afghani participants did not believe selfprotection to be effective (Table 3). Similar beliefs and behavior were previously reported in Afghanistan [10]. Nevertheless, the majority of participants and particularly Afghanis did not use bet nets or even window screen.…”

Malaria in camps for internally-displaced persons in Uganda: evaluation of an insecticide-treated bednet distribution programme

“…There are few data on the effect of ITNs in refugee camps (Rowland et al, 1996) or IDP camps, which are estimated to concentrate more than 21 million people worldwide (USCR, 2000). In east Afghanistan, the year following resettlement, a reduction of 59% (95% CI 25-66%) in P. falciparum parasitaemia was observed among ITN users versus non-users (Rowland et al, 2002). Our evaluation has shown that community-wide distribution of ITNs may be useful for people living in settings such as Bundibugyo, even when the results of the distribution are far from ideal.…”

“…Our judgement does not apply to other settings like rural villages in stable conditions where social-marketing of ITN proved to be a good alternative to free distribution (Armstrong Schellenberg et al, 2001;Rowland et al, 2002).…”

“…However, uncertainties remain about the effectiveness of ITNs when implemented in operational settings. To our knowledge, few studies have investigated the operational effectiveness of bednets (Armstrong Schellenberg et al, 2001;D'Alessandro et al, 1995;Guyatt et al, 2002;Maxwell et al, 2002), and very few data are available on the use of this control measure in camps for refugees or displaced persons (Dolan et al, 1993;Rowland et al, 1996Rowland et al, , 2002. We investigated this problem in Bundibugyo camps, an area of southwest Uganda experiencing recurrent insecurity, where the humanitarian organization Médecins Sans Frontières (MSF) works in collaboration with the Ugandan Ministry of Health (MoH) to provide health care for IDPs.…”

An Application of Cultural Model to Assess and Compare Malaria Prevention Among Afghani Migrant and Baluchi Resident in the Endemic Area, Southeastern Iran

“…They possess their own traditional beliefs regarding the causation, transmission, treatment, prevention disease [9]. During 23-year conflict in Afghanistan, more than one-third of the Afghan population (about 6.2 million) fled the war to Pakistan and Iran [10]. The cross-border traffic of Afghanis is an important factor for persistence of malaria in south and southeast of Iran [9].…”