republic of zambia, ministry of health...

Republic of Zambia, Ministry of Health

Guidelineson the Distribution and Utilization of

Insecticide-Treated Netsfor Malaria Prevention and Control

November 2008

Guidelineson the Distribution and Utilization of

Insecticide-Treated Netsfor Malaria Prevention and Control

National Malaria Control Centre November 2008National Malaria Control Centre

The Ministry of Health (MOH) wishes to express their sincere gratitude to all those whoassisted with the development and production of the National Insecticide Treated NetGuidelines. The guidelines were developed by the National Malaria Control Centre(NMCC) in collaboration with United Nations Children's Fund (UNICEF), World HealthOrganization (WHO), United States Agency for International Development (USAID)/Health Systems and Services Program (HSSP), the Malaria Control and EvaluationPartnership in Africa (MACEPA), Academy for Educational Development (AED)NetMark, Society for Family Health SFH), Churches Health Association of Zambia(CHAZ), Japan International Cooperation Agency (JICA), Zambia Malaria Foundation(ZMF), Zambia National Response to HIV/AIDS (ZANARA), private sector and DistrictHealth Management Teams (DHMTs).

Dr. Simon Miti,Permanent SecretaryMinistry of Health

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Acknowledgements

National Malaria Control Centre, Ministry of Health

Personal thanks go to the following whose invaluable contribution to the development ofthese guidelines is highly appreciated:

Name OrganizationDr. Victor Mukonka . . . . . . . . . . . . . . . . . . . . . .MOH

Dr. E. Chizema-Kawesha . . . . . . . . . . . . . . . . . . . .NMCCDr. Chilandu Mukuka-Mambwe . . . . . . . . . . . . . . . . .NMCC

Miss Cecilia Katebe . . . . . . . . . . . . . . . . . . . . . .NMCCMrs. Pauline Wamulume . . . . . . . . . . . . . . . . . . . .NMCC

Dr. Fred Masaninga . . . . . . . . . . . . . . . . . . . . . .WHODr. Rodgers Mwale . . . . . . . . . . . . . . . . . . . . .UNICEF

Mr. Glenn Shaw . . . . . . . . . . . . . . . . . . . . . . .UNICEFMr. Boniface Chiluba . . . . . . . . . . . . . . . . . . . .ZANARAMr. Kafula Silumbe . . . . . . . . . . . . . . . . . . . . .MACEPA

Mr. Charles Chinyama . . . . . . . . . . . . . . . . . . . . .CHAZDr. Michael McDonald . . . . . . . . . . . . . . . . . . . .USAID

Dr. Abdirahman Mohamed . . . . . . . . . . . . . . . . . .MACEPAMr. John Miller . . . . . . . . . . . . . . . . . . . . . .MACEPA

Mrs. Cynde Robinson . . . . . . . . . . . . . . . . . . . . . .SFHMr. Festus Lubinga . . . . . . . . . . . . . . . . . . . . . . .JICAMr. H. Kansembe . . . . . . . . . . . . . . . . . . . . . . .MOH

Mr. Killion Ngoma . . . . . . . . . . . . . . . . . . . . . . .MOHMr. Sadik Seedat . . . . . . . . . . .Melcome Marketing and Distributors

Mrs. Florence Chevembe . . . . . . . . . . . . . .Ecomed (Z) LimitedMr. Kennedy Siputuma . . . . . . . . . . . . . . . . . . . . .MOE

Mr. Malama Muleba . . . . . . . . . . . . . . . . . . . . . .ZMFMr. Paul Libizowski . . . . . . . . . . . . . . . . . . . .MACEPA

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Acronyms and Abbreviations


AED. . . . . . . Academy for Educational Development

ANC . . . . . . Ante-Natal Clinic

CBMPCP . . Community-based Malaria Prevention and Control Programme

CHAZ . . . . . Churches Health Association of Zambia

COMBOR . . Community Malaria Booster Response

CRAIDS . . . Community-based Response to HIV and AIDS

DDH . . . . . . District Director of Health

DHMT . . . . . District Health Management Team

DHS. . . . . . . Demographic Health Survey

EPI. . . . . . . . Expanded Programme for Immunization

HCP. . . . . . . Health Communication Partnership

HMIS. . . . . . Health Management Information Systems

HSSP . . . . . Health Systems and Services Program

IEC. . . . . . . . Information, Education, and Communication

IRS. . . . . . . . Indoor Residual Spraying

ITN . . . . . . . Insecticide-Treated Mosquito Net

JICA . . . . . . Japan International Cooperation Agency

LLIN . . . . . . Long-Lasting Insecticidal Net

MACEPA . . Malaria Control and Evaluation Partnership in Africa

M&E . . . . . . Monitoring and Evaluation

MoE. . . . . . . Ministry of Education

MoH . . . . . . Ministry of Health

NGO . . . . . . Non-Governmental Organization

NHC . . . . . . Neighborhood Health Committee

NMCC. . . . . National Malaria Control Centre

NMSP . . . . . National Malaria Strategic Plan

PHO. . . . . . . Provincial Health Office

PLWHA . . . . People Living with HIV and AIDS

RBM . . . . . . Roll Back Malaria Initiative

RHC. . . . . . . Rural Health Centre

UNICEF . . . United Nations Children's Fund

USAID . . . . United States Agency for International Development

VAT . . . . . . . Value Added Tax

WHO . . . . . World Health Organization

ZABCOM . . Zambia Business Coalition Against Malaria

ZMF . . . . . . Zambia Malaria Foundation

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Guidelines on the Distribution and Utilization of Insecticide-Treated Nets for Malaria Prevention and Control

Table of Contents

Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .i

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1

1. Goal and Objectives of Insecticide-Treated Net Guidelines . . . . .3

2. Taxes and Tariffs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3

3. Distribution Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4

Mass distribution . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4

Distribution through Antenatal Clinics and Expanded Programme for Immunization . . . . . . . . . . . . . . . . . . . . . .4

Commercial distribution . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5

Pricing for private sector Insecticide-Treated Nets . . . . . . . . . . . . . .5

Illegal trading of Insecticide-Treated Nets . . . . . . . . . . . . . . . . . . . .5

Sustainability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5

Community Malaria Booster Response . . . . . . . . . . . . . . . . . . . . . . .5

Malaria School Health Programme . . . . . . . . . . . . . . . . . . . . . . . . . .6

Health Facility Bed Nets . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6

Employer-based schemes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6

Zambia Business Coalition against Malaria . . . . . . . . . . . . . . . . . . . .7

Equity component of the Insecticide-Treated Net Programme . . . . .7

4. Re-treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8

5. Information, Education, and Communication . . . . . . . . . . . . . . . .8

6. Monitoring and Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8

7. Procurement of Insecticide Treated Nets . . . . . . . . . . . . . . . . . . . .9

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Table of Contents


8. Stakeholder Roles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9

Role of the Provincial Health Office . . . . . . . . . . . . . . . . . . . . . . . . .9

Role of the District Health Management Team . . . . . . . . . . . . . . . . .9

Role of Health Centres . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10

Role of The Neighborhood Health Committee, Community Health Workers, Non-Governmental Organizations and other service groups . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10

Role of Non-Governmental Organizations . . . . . . . . . . . . . . . . . . .10

Role of commercial and private sector . . . . . . . . . . . . . . . . . . . . . .10

Role of the National Malaria Control Centre . . . . . . . . . . . . . . . . . .10

9. Misuse/Abuse of Insecticide-Treated Nets . . . . . . . . . . . . . . . . . .11

Illegal trading of Insecticide-Treated Nets in the private or commercial sector . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11

10. Approved Insecticide Treated Nets and Insecticides . . . . . . . . .11

11. Technical Working Group Facilitators . . . . . . . . . . . . . . . . . . . . .12

Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12

Annex 1: Mass Distribution Guidelines for Insecticide-Treated Nets . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13

Annex 2: Registers for Data Collection for Neighborhood Health Committee, Health Centre and District Management Health Team Levels . . . . . . . . . . . . . . . . . . . .19

Annex 3: Guidelines on Re-treatment of Insecticide Treated Nets . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .22

The World Health Organization (WHO)has defined the key elements of malaria control as follows:

• Early diagnosis and treatment.• Prevention, including vector control.• Early detection, containment, and

prevention of epidemics.• Strengthening national capacity for

malaria research and monitoring.Insecticide-Treated Nets (ITNs) are a cost-effective alternative to existing vectorcontrol methods. However, like any otherintervention, treated nets need to be part ofthe broader malaria control strategy.

ITNs, especially the Long-LastingInsecticidal Nets (LLINs), have greateradvantages over the untreated mosquitonets. It is for this reason that these guide-lines are dedicated to ITNs in line withthe national strategy. The advantages ofITNs include:

• Personal protection is improved becausemosquitoes are repelled or killed by theinsecticide before they can have accessto the person sleeping under the ITNs.Therefore, this reduces the risk ofmalaria.

• Community exposure to mosquitoes isreduced because, where whole com-munities are using treated nets, the num-ber of mosquitoes and the proportioninfected with malaria parasites arereduced. In this situation, even peoplesleeping without an ITN are less likelyto get malaria because there are fewermalaria-transmitting mosquitoes in thearea. Where ITN coverage is not highenough to have this 'mass effect', peoplesleeping without a net in rooms wheretreated nets are present may receivefewer mosquito bites, thereby reducingtheir risk of malaria.

• The effect of ITNs on malaria illness ishuge and is well-documented. ITNs alsoimprove child survival by greater mar-gins.

Zambia uses a mix of ITN delivery mecha-nisms to target different geographic,economic, and biologically vulnerable seg-ments of our society. Mechanisms in the

past have ranged from promoting commer-cial sales for those who can afford it to avariety of targeted subsidy mechanisms forthose who cannot afford the full marketprice, including a discount voucher pro-gramme for pregnant women in urbanareas and direct subsidized sales throughantenatal clinics (ANCs) in rural areas.There has also been a variety of subsidized'revolving fund' mechanisms managed byDistrict Health Management Teams(DHMTs) and non-governmental organiza-tions (NGOs) that involve free distributionto the most vulnerable populations, includ-ing people living with HIV/AIDS(PLWHA), orphans, and other especiallyvulnerable households. Additionally, therehas been ITN distribution to boardingschools and health facilities and promotionof employer-based ITN schemes.

During a series of strategic planningreviews in 2005, three issues emerged.First, in order to rapidly scale up ITN

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“Zambia uses a mix of ITN delivery mechanisms to

target different geographic,economic, and biologically

vulnerable segments of our society. ”

Introduction

access in rural communities, mass distribu-tions of ITNs at no cost to recipient house-holds would be necessary, and routine sys-tems needed to be strengthened in order tosustain ITN coverage in subsequent years.Second, ITN expansion has been severelyhampered by supply chain managementproblems, from the initial procurement tothe final point of distribution; these sys-tems need to be strengthened in order tomake the most timely and efficient use ofresources.

Third, while the emphasis of publicresources for ITNs is on rural communitiesnot covered by Indoor Residual Spraying(IRS), other existing schemes in urbanareas targeting vulnerable groups and pro-motion of commercial sales will continue.As malaria rates decline in urban areaswith less intense malaria transmission andgreater access to clinical services, and asITN coverage rises, environmental man-agement improves, and epidemiologicalsurveillance and reporting systems arestrengthened, it is hoped that dependenceon IRS can eventually be reduced and amalaria-free environment sus-tained through a multi-sectorIntegrated VectorManagement (IVM)approach.

Segmenting the market and making ITNsavailable on an equitable and sustainablebasis depends on close collaborationamong all partners, which in turn is basedupon a strong monitoring and informationmanagement system.

This balance of commercial sales and freeITN distribution requires a framework andguidelines for planning, implementation,and monitoring. Likewise, the insecticidere-treatment activities require the wide par-ticipation of NGOs and other servicegroups to reach all the nets requiring re-treatment. ITNs hold great promise for thepeople of Zambia. It is incumbent on all ofus to collaborate within this framework toensure an equitable and sustainable malar-ia-free future.

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Introduction


To provide a framework for managingimplementation of ITNs and insecticides formalaria prevention and control in Zambia,through a broad range of partnerships, inline with the vision of equity of access toquality-assured, cost-effective and sustain-able malaria prevention and control servicesas close to the family as possible.

Specific objectives• Ensure that 100% of household cover-

age is achieved in eligible ITN areas ofevery district by December 2008 withan 80% utilization rate.

• Provide a framework for partnerships byclarifying the complementary roles ofcivil society, the commercial sector, andthe public sector to ensure access toITNs in communities, especially for vul-nerable groups, through cost-effective,sustainable, and equitable ITN imple-mentation programs.

2. Taxes and Tariffs All insecticides specific for the treatment ofnets are duty free, and no value-added tax(VAT) should be charged as per StatutoryInstrument 15 of 16th February 2004.

Note to suppliers and procuring agents• All nets (cotton, synthetic fibre and

other textile materials) are duty free.• All suppliers of ITNs shall provide

accessories (extra strings, hooks etc) foreach ITN supplied.

• All suppliers to label each ITN"Property of Ministry of Health - ZAM-BIA, not for sale". This is a means ofreducing leakages into private sector.

• Only WHO-approved nets and insecti-cides that have at least reached Phase IIof WHO Pesticides Evaluation Scheme(WHOPES) shall be used within thenationally-sanctioned programmes.Many other types of nets, includingthose of substandard quality, find theirway into the informal markets. While itwill be difficult to control, consumerswill be encouraged to purchase onlyquality materials. In line with the publi-cation by Africa Fighting Malaria(www.fightingmalaria.org), WHOPESInterim Recommendation of 2004-2007are as follows:

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1. Goals and Objectives of the Insecticide-Treated Net Programme and the Guidelines

Name of ITN/Type Stage of WHOPES InterimRecommendation Manufacturer

Permanet®/LLIN Phase III Vestergaard Frandsen

Olyset®/LLIN Phase III (Full) Sumitomo Corporation

Interceptor®/LLIN Phase II BASF AG

Duranet®/LLIN Phase II Clarke Mosquito Control

Net Protect®/LLIN Phase II Bestnet Europe Ltd

Net specificationsThe initial purchase price of recommendedLLINs is higher than that of conventionalnets, but requires less re-treatment as lessinsecticide is lost during washing. Theinsecticide will remain effective for 3 - 5years, which is the life span of the net.Other insecticide formulations are cur-rently under field evaluation to assess theirability to turn an ITN into an LLIN byusers.

Inexpensive, but poor quality nets on themarket should be avoided. Preferred netsare knitted, multifilament polyester/poly-ethylene (not monofilament like fishinglines) which are easier to treat than cottonnets. Denier is the fibre strength. All rec-ommended ITNs shall have fibre strengthno less than 75 denier, and this has guaran-teed durability.

3. Distribution MethodsMass distributionMass distribution aims at increasingnationwide access to ITNs in an effort torapidly scale up coverage. In line with theNMSP, the objective will be to ensure dis-tribution of a minimum of three ITNs perhousehold in all ITN-eligible areas. AllITNs being distributed through this pro-gramme shall be accessed without cost tothe households.

Micro planning for the distribution shall befacilitated at central level in collaborationwith the Provincial Health Offices (PHOs)and DHMTs, and distribution will be donein stages depending on logistics and avail-ability of ITNs until all eligible areas arecovered. Detailed guidelines for the distri-bution processes are found in Annex 1. Themost disadvantaged, hard-to-reach areaswith high malaria incidence rates will be

the priority. Distributions will be super-vised by partners from central level, PHO,DHMTs and Health Centres (HCs). Actualdistributions is conducted by DHMTs, HCsand Neighborhood Health Committees(NHCs) upon collection of data onhousehold requirements using registers(Annex 2). In collaboration with theDHMT, chiefs, village headmen, andNHCs shall encourage appropriate ITN uti-lization and discourage abuse.

Distribution through ANCs andExpanded Programme forImmunisationRoutine ITN distribution shall be undertak-en through ANCs and the (EPI). Targetgroups for this are pregnant women andchildren under 5 years old only.The programme guidelines are as follows:• Pregnant women and children under 5

years are a key ITN target group. • All ITNs to be distributed through this

programme shall be at no cost to the enduser.

• The PHOs shall play a supervisory roleand report to the National MalariaControl Centre (NMCC) on issues thatmay require their intervention.

• The District Directors of Health (DDHs)shall manage the day-to-day operationof the programme.

• The DHMTs shall ensure that there is nostock-out at the HC level and that abuffer stock is maintained at the districtsto facilitate quick re-supply to the HCs.

• The districts, in partnership with Societyfor Family Health (SFH) shall holdannual review meetings to reviewprogress.

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2. Taxes and Tariffs


Commercial distributionCommercial distribution of ITNs will con-tinue to be promoted to ensure wider,long- term access and replacement of oldnets. Partners distributing commercialITNs should work through and in line withthe NMCC guidelines and ensure that onlyrecommended ITNs are distributed.

Pricing for private sector Insecticide-Treated NetsDirect price controls in the private sectorare not feasible; low prices are achievedthrough competition and advertising.Individuals and commercial partners areencouraged to follow UNICEF/WHO spec-ifications for the type of ITNs to beimported into the country. These specifica-tions are available from NMCC, WHO orUNICEF.

Illegal trading of Insecticide-Treated NetsThe National Programme is workingtowards ensuring all ITNs are marked foridentification ("Property of Ministry ofHealth - ZAMBIA, not for sale"). Any ofthese ITNs found with a retailer, whole-saler or lodging facilities will be confiscat-ed with no compensation given. It is up toall partners to ensure these free ITNs arenot abused, stolen, or sold.

SustainabilityThe NMCP recognizes the need to ensureITN coverage is sustained andaccess increased. To accomplish this, anumber of sustainability programs havebeen put in place and these include:

Community Malaria BoosterResponse (COMBOR)Several efforts in the malaria control pro-gramme are being implemented inZambia currently, and with support fromthe World Bank, the NMCP is implement-

ing a community programme which isdemand-driven and focusing on communi-ty mobilization for activities such asre-treatment campaigns, IRS campaigns,sensitization, and dissemination of malariakey messages in order to promotebehavioral change and increase the rate ofutilization of all malaria related services.

The Community-Based Malaria BoosterResponse (COMBOR) was introduced toreplace the Community-Based MalariaPrevention and Control Programme (CBM-PCP), which was a programme based on apush strategy through which ITNs wereallocated to communities by central levelbased on availability. The project is cur-rently being implemented in four provinces(COMBOR), Western, Northern, Easternand Luapula, which were selected on thebasis of malaria prevalence. Plans areunderway to expand the programme toinclude other provinces.

To implement the programme, trainerswere trained in:• Community-based malaria prevention

and control and• Project facilitation cycle.

The purpose of this training was toempower a group of selected district staffin each of the four participating provinceswith knowledge and skills required inpreparing communities to participate in theidentification of anti-malaria interventionsto be funded, proposal writing, and appre-ciating the entire project facilitation cyclefrom project elaboration to project fundingand implementation.

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3. Distribution Methods

Malaria School Health ProgrammeThe Malaria School Health Programme(MSHP) was launched on Africa MalariaDay, 25th April 2004, at Saint Paul's MissionSchool in Kabwe, Central Province, and is aclose collaboration between the Ministry ofHealth (MoH) and Ministry of Education(MoE). The MSHP is a component of theSchool Health and Nutrition (SHN)Programme which aims at improving thehealth of children. The objectives of the pro-gramme include:• Increased awareness levels on causes,

symptoms and prevention of malaria byall school children.

• Scaled up use of ITNs nationwide. • Enhanced quality and access to education.• Reduced rates of absenteeism.

It is the mandate of the MoE to ensure thatthe ITNs are being appropriately used by allboarding students. ITNs become the proper-ty of a school (MoE) once distributed andwill be cared for by pupils just like any otherschool property. It is up to school manage-ment to come up with measures to ensureITNs are not misused. School managersshould ensure proper storage during schoolholidays so that nets can last 3 years beforethey are replaced. The MoH shall conductperiodic monitoring and evaluation (M&E)exercises in collaboration with the DistrictEducation Board Secretary's (DEBS) office.

School participation in commemorative daysSchool children are encouraged to activelyparticipate in malaria commemorative days

which are as follows:Activities scheduled for commemorativedays are:• Mass re-treatment campaign.• Advocacy and networking.• Social mobilisation.• Environmental management.

Health facility bednetsIn 2003 all public health facilities receivedfree ITNs to be used in the wards topromote the culture of ITN use.Distribution of ITNs to health facilitieswill continue depending on availability;however, monitoring appropriate use is apriority.

Continued replacement of ITNs for healthfacilities should be supported throughdistrict basket funds, health facility runningcosts, and RBM partners when avail-able.All health facilities are advised to ensurethat the ITNs are kept clean if patient com-pliance is to improve. This will mean thatthe bed nets will be subjected tofrequentwashes and thus efficacy shall reducefaster than community nets. Re-treatmentsthus should be done as often as requiredand re-treatments can be accessed fromDHMTs whenever available.

Employer-based schemesITNs reduce both direct and indirect costsof malaria and increase productivity.Provision of ITNs makes good businesssense. Thus, employer-based schemes arestrongly encouraged. Some schemes havefull cost recovery, with the full price of theITN deducted from employees' salaries; oth-ers provide partial subsidies or free ITNs.

Increased coverage of ITNs shall besupported by the expansion ofemployer-based schemes in collabo-ration with the activities of theZambia Business Coalition againstMalaria (ZABCOM).

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Commemorative Day DatesWorld Malaria Day 25th AprilChild Health Week 2nd week of June or July

SADC Malaria Week 2nd week of NovemberChild Health Week 2nd week of December

Zambia Business Coalitionagainst Malaria ZABCOM was launched in November2005 and aims to strengthen the existingpublic-private sector partnerships as wellas encourage the participation ofcompanies that are not part of the RollBack Malaria (RBM) Partnership in malar-ia prevention and control activities. Themain objective of the coalition is to ensureboth public and private sectors work withthe RBM partnership to sustain malariapreven-tion, control and treatment inter-ventions in the country in an effort toreduce morbidity and mortality rates.

Equity component of Insecticide-Treated Net programmeThe ITN programme recognizes the groupsof people most vulnerable to malariabecause of compromised immunities orexposure to the malaria parasite. Amongthese groups are PLWHAs, the chronically

ill, the elderly through homes for the agedand orphans and vulnerable children. Thesespecial groups shall have increased accessto ITNs through the equity programmewhich is being coordinated by the ZambiaMalaria Foundation (ZMF), an umbrellaorganization for all NGOs implementingmalaria control programmes.

However, it should be noted that thesegroups shall not be supported asindividuals but through their supportgroups who are advised to send proposalsand letters to request ITNs from the ZMFwhich will provide them, depending onavailabil-ity, and then report to the NMCCquarterly. The distribution and utilizationof these ITNs shall be followed up bystakeholders; thus requesting organizationsare advised to ensure they demonstrateknowledge of distribution plans and uti-lization rates.

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Treatment of nets extends the useful life ofa net even when it is torn. A mosquitowhich lands on a treated net is repelled andeventually killed by the insecticide. It is forthis reason that an annual mass re-treatmentcampaign shall be conducted to ensure thatall nets in the country are impregnated withan insecticide for maximum protection.These annual campaigns will be supple-mented by routine re-treatments facilitatedby the DHMTs, at no cost to the communi-ties. Refer to Annex 3 for details.

5. Information, Education, andCommunicationInformation, education, and communica-tion (IEC) for ITN acquisition, appropriateuse, and re-treatment is essential, and mustbe included in district budgets. Key mes-sages include:

• ITNs are a cost-effective method ofmalaria prevention, and worth theinvest-ment.

• If there are limited ITNs in the house,priority should be given to pregnantwomen, children under 5, and PLWHAsand other chronically ill persons.

• The malaria mosquito bites late at night;generally between 22:00 and 05:00.

• ITNs should be used every night of theyear, not just during the rainy season.

• All nets that are not LLINs should bere-treated at least once a year.

A mixture of interpersonal communications(including drama groups, schools, andscouts) and mass media (including commu-nity radio) should be used to provide thisinformation. Youth and young families arethe primary target audience. The NationalCommunication Strategy (available fromthe NMCC) provides guidance on keymessages and effective communication forbehavior change. NGOs shall play a major

role in the dissemination of information tocommunities, using messages developed incollaboration with the NMCC.

6. Monitoring and EvaluationMonitoring is the routine tracking of the keyelements of programme performance (usual-ly inputs and outputs) through record keep-ing, regular reporting and surveillance sys-tems, as well as health facility observationand surveys. Monitoring helps to determinewhich areas require greater effort and identi-fy areas which might contribute to animproved response. Monitoring contributesgreatly towards evaluation. Therefore, it isvery important to select indicators to beused at district, HC, and community levels.Examples of monitoring indicators relatedto ITNs include:

• Number of ITNs distributed or sold.• Percentage of net ownership by house-

holds.• Utilisation rate of ITNs by households.It is important to determine the source ofthe data, frequency of data collection, andthe person responsible. This informationwill assist the district to manage the ITNprogramme well. The district may sharesuch information with the national levelthrough the provinces.

Evaluation is the episodic assessment ofthe change that the ITN intervention hasbrought after a period of time. Evaluationsare more technical because they oftenrequire population-based surveys or otherrigorous research designs. This is beingundertaken by the national level.

NGOs play an essential role to help moni-tor the distribution and use of ITNs. M&Eprocesses must be standardized so thatinformation can be combined in a unified,national system.

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4. Re-treatment


There are two aspects of monitoring ITNprograms in Zambia. The first involvescompiling information on ITN and re-treat-ment distributions. The NMCC maintains anational database on ITN and re-treatmentdistributions from the national to thedistrict level. This database, formatted inMicrosoft Excel, can be easily adapted foruse by provincial and district malaria focalpersons and information officers. Thedatabase is also available in "HealthMapper" format for those provinces anddistricts working with this GIS software.Please contact the NMCC to obtain a copyof the database and technical support.

The second aspect of monitoring ITN pro-grams in Zambia is monitoring ITNcoverage and usage rates within the house-hold. The Health Management Information Systems' HMIS/Surveillance Systemincludes questions on household ITN cov-erage, but household surveys are an addi-tional monitoring method. Questions relat-ed to ITNs must follow a standard formatso that results can be comparable. Full pro-tocols with sample questions are availablefrom the NMCC website,www.nmcc.org.zm.

7. Procurement of Insecticide-Treated Nets All ITNs for mass free distribution are pro-cured at the central level to ensure use ofrecommended ITNs and update the nation-al ITN database. DHMTs shall developbudgets to support the mass distributionand incorporate these in the DistrictMalaria Action Plans.

All former CBMPCP districts shall usefunds realized from the sale of CBMPCPnets within their accounts (ZANACO,Finance Bank, etc.) to support activities forthe mass distributions, including: transportof ITNs from district level to HC andcommunity levels, social mobilization, re-

treatment exercise (if any), training ororientation workshops, meetings with localpartners to support the activity, and M&E.

8.1 Stakeholder RolesRole of the Provincial Health OfficeThe role of the PHO is to coordinate DHMTactivities and ensure that programmes arebeing managed as stipulated in all availableguidelines through the following:

• Provide technical support to the districtsin the preparation of the Malaria ActionPlans and budgets.

• Conduct performance assessments to auditthe interventions focused on the preven-tion of malaria through the use of ITNs.

• Monitor and supervise the districts inprocuring, distributing and utilizing ITNs.

• Orient all stakeholders regarding theITN guidelines and disseminate infor-mation on ITNs.

• Collaborate with all the commercial,private, public and other agencies/ sec-tors dealing in ITNs.

8.2 Role of the District Health Management Team The role of the DHMT is to coordinate andmanage the various ITN distribution mech-anisms in their district. This will include:

• Procure additional nets, in collaborationwith central level, through the PHO;

• Supervise district public sector distribu-tion schemes, as well as promotionalprograms, IEC, M&E.

• Expand partnerships with schools, com-mercial retailers, employer-basedschemes, the private sector, NGOs,CBOs etc.

• Monitor and make available informationon commercial pricing.

9


6. Monitoring and Evaluation

• Facilitate identification of most vulnera-ble recipients when ITNs are insuffi-cient to cover entire district.

• Ensure adequate, steady supplies ofITNs and re-treatment kits;

• Provide regular feedback to NMCC,including an update of the ITN databaseon distribution and re-treatment.

• Work with NHCs to ensure proper uti-lization of ITNs in households.

• Assure storage and transport.

8.3 Role of Health CentresThe role of the Rural Health Centre (RHC)is to coordinate and manage the various ITNdistribution mechanisms in their catchmentarea as listed above for the district. TheRHC may also be more directly involvedwith the storage of ITNs for pregnantwomen and children under 5 years.

8.4 Role of the NeighbourhoodHealth Committee, CommunityHealth Workers and other service groups• Participate in advocacy and promote use

of ITNs. • Work with the RHC and DHMT to man-

age ITN distribution up to communitylevel.

• Help identify vulnerable groups, such asthose registered with home-based care, orother social welfare programs in caseswhere free ITNs are insufficient to coverthe whole district population.

• Participate in re-treatment campaigns androutine treatments.

• Coordinate with village headmen andchiefs in ensuring that ITNs are not beingabused, i.e., used for fishing or any otherunintended purpose.

8.5 Role of Non-GovernmentalOrganisations (NGOs)The MoH appreciates partnership in the dis-tribution of ITNs to communities by stake-holders such as faith-based organizationsand NGOs. However, this distributionshall, with immediate effect, be done afternotifying CHAZ and ZMF, who will inturn notify NMCC.

This process shall facilitate updating of theITN database and minimise duplication ofactivities. No organization shall donate orsell ITNs to communities without the priorknowledge of the national programme. Alldistributions within districts, no matter thesource, shall be controlled by the DHMT.

8.6 Role of the commercial andprivate sector• Stock and sell recommended good quali-

ty nets and approved insecticides. • Promote employer-based schemes.• Coordinate with the DHMT, RHC and

communities in planning for distributionand re-treatment M&E.

• Promote behavioral change and commu-nication.

• Reinforce public sector IEC messageswith brand advertising.

• Educate public on correct hanging ofITNs and utilization.

• Provide support by procuring hooks andstrings.

8.7 Role of the National MalariaControl Centre• Promote partnerships at all levels and

provide secretariat functions for partici-pants in the National ITN Theme Group.

• Provide policy, strategy, and technicalinformation to partners.

• Ensure that ITNs fit into comprehensiveIVM and malaria control strategy.

10

8. Stakeholder Roles


11


8. Stakeholder Roles

• Mobilize resources, materials, and sup-port from both domestic and externalsources.

• Provide M&E support to the nationalprogramme and provide feedback tonational policy makers.

• Coordinate ITN activities and provideguidelines on the implementation of ITNprograms to all districts.

9. Misuse/Abuse of Insecticide-Treated NetsProper utilization of ITNs has been a majorchallenge to the programme, and, as such,measures are being put in place to ensurethat all ITN misuse or abuse (i.e., use forfishing, selling nets that are supposed to beat no cost to communities) shall be reportedand proper action taken.

The MoH calls upon local leadership(chiefs, headmen, councilors, NHCs, etc.) toensure correct use of ITNs is promoted intheir communities.

Illegal trading of insecticide-treated nets into the private orcommercial sectorsAny retailer, wholesaler, or lodging facilitiesfound with ITNs identified as part of theconsignment intended for free distributionshall have those nets confiscated and norefunds shall be given. In the near future, thenational programme shall ensure that all thefree nets are marked for easy identification.

10. Approved Local Suppliers ofNets and Insecticides, 2007For guidelines on approved ITNs/insecti-cides kindly refer to the World HealthOrganization Pesticide Evaluation Scheme(WHOPES) website at, http://www.who.int/whopes/quality/en

12

11. Contact Details for Technical Working Group Facilitators


Name/Organisation

Dr. Elizabeth Chizema-Kawesha, National Malaria Control Centre

Ms. Cecilia N. Katebe, National Malaria Control Centre

Mr. Boniface Chiluba, ZANARA-CRAIDS

Dr. Rodgers Mwale, UNICEF

Mr. Festus Lubinga, JICA

Mr. Charles Chinyama, Churches Health Association of Zambia

Mr. Charles Kalanga, Society for Family Health

Dr. Fred Masaninga, World Health Organization

Mr. Malama Muleba, Zambia Malaria Foundation

ConclusionEventually, everyone in Zambia, especiallythose living in areas not covered by IRS,should have an ITN, but until there areenough, priorities have to be established.

For medical reasons, priority is given topregnant women, children under age 5years, and PLWHAs, as they are prone tosevere illness and death from malaria.

For social reasons, priority is given to vulner-able households, and the poorest of the poor,as they are least able to cope with illness.

For epidemiological reasons, priority isgiven to rural households rather thanurban, as the vector is more prevalent inrural environments, and some urban com-munities also receive IRS. Based on this,the mass distribution of free ITNs shallcommence with these factors in mind butwill eventually reach population in allITN-eligible areas.

1. National insecticide-treatednet objectiveEnsure 100% nationwide coverage with aminimum of three (3) ITNs per householdin all ITN-eligible areas (non-IRS) with atleast 80% utilization rates by December2008 and sustained to 2011.

2. StrategiesThere will be rapid scale-up of ITN cover-age using the following strategies: • Free mass distribution campaign shall

be employed in the strategic choice ofensuring access and utilization benefitsof using ITNs in the country. All netsshall be distributed and accessed at nocost to the households.

• Routine ITN distribution through ANCs topregnant women and children under fiveshall be at no cost to the target groups.

• Commercial distribution to increaseaccess.

3. Planned schedule of activities

4. Budget developmentAll districts are expected to have this activ-ity in their action plans and as such, fundsshould be allocated accordingly. All districtactivities will use the funds as per actionplan. Central level shall support provincialorientation workshops only.

However, note the following:• Two people are needed at each DHMT

and HC to participate in the exercise(total of 4).

• No more than 8 people are needed forthe entire process of net distribution.

• Social mobilisation can include theatregroups, dance troupes, or other.

• Transportation should reflect the costsof shipping the nets from the district tothe HC up to household level.

• Fuel for transporting support personnelto the HC from surrounding villagesshould be included in district budget.

• Equipment can include items needed forre-treatment and passing the nets (dis-tricts/HC should have some re-treatmentbuckets in stock if not the equipmentcan be procured by DHMT using fundsearmarked for malaria).

• Allowances for NHCs should be stan-dard in all districts of a province.

13


Annex 1: Mass Distribution Guidelines for Insecticide-Treated Nets

Task Responsibility When1. Collect data on names and exist-ing nets per household (Annex 2) HC and NHCs Two weeks before the distribution

2. Consolidate data at the districtlevel to determine net and treatment

kit requirements (from Form 1)DHMT One week before the distribution

3. Social mobilisation DHMT One week before the distribution4. DHMTs deliver ITNs to HCs

accord-ing to data provided DHMT Two days before distribution

5. HCs/NHCs supply ITNs tohouse-holds and re-treat existingnets. NHCs to help with hanging

of ITNs

HC/NHCs The day of the distribution

6. Monitor presence and utilisationof ITNs at household level

DHMTs, HCs and NHCs Two to four weeks after distribution

Process• All purchased ITNs should be delivered

directly to the districts by suppliers. Tsshall be informed through the office ofthe Permanent Secretary on the ex-pect-ed delivery dates for the ITNs to enablethem prepare adequate storage space.

• The bales of nets should be deliveredwith a delivery receipt that needs to besigned and a copy should be maintainedwith the district.

• Confirm that the number of bales deliv-ered corresponds to the number indicat-ed on the GRV from MSL or whicheverpartner delivers.

• If the number of bales is not the same,note the actual number of balesreceived on the receipt and have thedelivery person sign the notation.

• DHMTs should make necessary arrange-ments for distribution of ITNs to HCs.Work closely with local partners, e.g.,ministries, NGOs, and private sector etc.for distribution support.

• A copy of delivery note to be main-tained by DHMT and copy forwarded toNMCC through the office of thePermanent Secretary.

• HCs should also be informed to preparestorage space by DHMT based on ITNsto be delivered to the particular HC.

• DHMTs to account for all ITNs withindistricts.

• All excess ITNs to be stored at DHMTand kept for emergency requests (epi-demics) or replacements for most vul-nerable populations and report forward-ed to NMCC.

• Net reallocation between districts toadapt to areas with surplus and deficit.

6. Site preparationNet receptionThe nets are delivered in bales of 50 or100 nets. • Identify a secure location in the district

for storing the bales of nets. • Nets should be stored on pallets to pre-

vent seepage of any liquid that may beon the floor.

Opening the bales of nets

• Each bale is tightly compacted and heldtogether by thick, industrial grade, plas-tic or metal, packing string which makesopening the bales difficult, requiringtime and effort.

• Bales should be opened just before thenets are to be distributed.

• A sharp cutter, scissors, pliers or razorblade is needed to open the bales.

• Before distribution begins, open enoughto satisfy minimum expected demand.

• Always insure that adequate supplies ofnets in open bales are available forimmediate distribution so that nobody iskept waiting while bales are opened,and no long queues occur due to thebale opening process.

• The bales need to be opened carefully toavoid accidents.

14

5. District distribution and storage


• Work with local partners to organiselocal theatre groups, dance troupes, orother social mobilisation available topublicize the net distribution.

• Organize groups to perform before andduring the distribution process.

• Messages can highlight malaria preventionand control, net usage, and re-treatment.

• Use a megaphone to announce the distri-bution effort. Have NeighbourhoodHealth Committee personnel go roundcommunities announcing the day'sevents and explain the process forreceiving nets.

• Households with problems in hangingthe ITNs should be assisted by NHCs.

• Hang posters around the distribution area.• Distribute malaria leaflets and brochures,

if available, during the exercise.• Use local leadership to sensitize

communities.• Schools and churches.

8. Registration post• Identify at least one table and two chairs

that can be used for registration.• Place them in a shaded area in view of

the distribution stations. If possible,allow for a shaded area for recipients towait in line.

• Verify that an adequate number offorms, tickets and pens are available.

Data collection sheets andforms • Nets are distributed on the basis of need.

Once need has been determined by theappointed individual through the DHMT,the number of nets to be distributed iscommunicated in writing on the datacollection sheets and forms.

• Data collection sheets and forms areused for distributing the appropriatenumber of nets in order to assure that

15


7. Social mobilisation

the maximum number of persons inneed of one or more nets receives nets.

• The net distributor distributes only thenumber of nets indicated on the sheetsand forms.

• The sheets and forms are only filled outby the appointed individual by the DHMT.

• If a stamp is available, the sheets andforms can be additionally validated bythe appointed individual by the DHMTby putting a stamp on the back of theticket. When nets are received, the doc-ument is turned over to the distributor inorder to justify the nets given (foraccountability).

• A safe place is needed to keep and holdthe sheets and forms received. Keep it ina secure but accessible location. Makean identifiable mark on used documentsto ensure that they can not be reused.

ITN distribution stationIdentify a secure space (lockable, with lim-ited access) where stocks of ITN bales canbe stored in security but accessed easilyduring distribution. This could be a roomwith a window or doorway through whichthe nets can be passed from the bales to therecipients.

9. Re-treatment station (for non-LLINs only)Complete national guidelines for net re-treatment can be found in Annex 3.

Replacement of worn out ITNs• Nets are prone to wear and tear, espe-

cially in rural settings where reed mats(impasa) are used for sleeping. Smokeand dust can also make the ITNs dirty.

• It is up to the team at the distributionpoint to be able to analyse and suggestthat a net be exchanged for a new oneduring the distribution/re-treatmentexercise.

• The physical state of the net must beexamined to determine whether it is safefor sleeping under and keeping mosqui-toes away. Nets that have holes whichcannot be sewn should be exchanged.

• All old nets shall be replaced at the dis-cretion of the NHCs who will destroythem accordingly.

10. Site preparation checklistfor ITN distributionAssign roles• Review the roles and responsibilities

(see below).• Identify good candidates for each of the

roles.• Verify that they understand the roles and

responsibilities and are willing to per-form the designated role.

• Plan an initial meeting with members ofthe distribution team.

Team members' roles and responsibilitiesA minimum distribution team consists ofthe following five roles:

Roles at the registration postCoordinator/team leader• Responsible for explaining process to

recipients. • Distribute forms for re-treatment.• Assure client flow.• Maintain orderly process.• Through knowledge of the community,

assures that recipients provide validinformation and receive appropriatenumber of nets.

Appointed individual by the DHMT/registrar• Keep track of records.• Determine number of nets to be given

and re-treated (if required).

16

8. Registration post


Roles at the ITN distribution stationFacilitator• Responsible for distribution of the nets.• Collect sheets/forms. • Give number of nets noted on the form

to the recipients.• Mark form to indicate that nets have

been delivered.• Assure that stock is kept secure.• Keep form if no re-treatment needed,

return form if re-treatment needed.• Direct recipients to animators that

explain net usage.Sensitisation person• Hang posters on walls.• Hang sample net. • Explain net usage, hanging, need for

re- treatment.• Support facilitator, making sure of

availability of nets.

Roles at the ITN re-treatment stationPlease note that national guidelines forITN re-treatment are found in Annex 3.Re-treatment person • Responsible for use of re-treatment kits. • Verify that all equipment needed for re-

treatment is available and ready.• Wear gloves.• Know re-treatment process. • Put wet nets into plastic.• Collect forms and mark them as used.• Explain drying process and need for

periodic re-treatment.• Provide support to facilitator if backups

occur.

11. Distribution process

Announcement

1 Selected health post leader or NHCmember uses the megaphone or standsin raised location to explain what isgoing to happen.

2 Explain the process of registering, gettinga form, going to the net distribution sta-tion, and going to the re-treatment station.Subjects mentioned can include malariacontrol and prevention, what nets are usedfor, how they are used and re-treated.

Registration post

1. If a list of recipients is available begincalling out each name.

2. Fill out information required for regis-tration on the form provided.

3. Ask for the information required on theregistration form.

4. Determine the number of nets to begiven and re-treated (see number of netsguidelines).

5. Fill out a form with the name and num-ber of nets to be given and re-treated.

6. Give the ticket to the recipient andexplain what they should do next.

7. Check the name off on the list when theperson has been registered.

Net distribution1. Give the number of nets indicated on

the form to the recipient. 2. Mark the ticket to show that the nets

have been distributed. 3. If the form shows nets to be re-treated,

hand the form back to the recipient. 4. When the recipient leaves with the nets,

make sure she/he visits the personexplaining how to hang and use the nets.

17


10. Site preparation checklist for ITN distribution

Net re-treatment (if required)

Please note that national guidelines for netre-treatment are in Annex 3.1. Take the form from the recipient.2. Confirm that the number of nets to be

re-treated corresponds to the number ionthe ticket. If it doesn't, speak to the indi-vidual appointed by the DHMT.

3. Prepare the re-treatment solution.4. Dip the net and let it soak up the solution.5. Put the net in a plastic bag and give it to

the recipient,6. Explain the drying process and the peri-

odicity of need for future re-treatment.

Note:1. In some instances, ITNs delivered may

temporarily not be sufficient to achieve100% household coverage with threeITNs. For this reason, it is important fordistricts to have as much information aspossible about how to locate the popula-tions most vulnerable to malaria so thatthey may be targeted first.

2. Law enforcement agencies in the districtshould be informed of the pending dis-tribution in case of an uncontrollable sit-uation evolving.

18

11. Distribution process Announcement


Annex 2: Registers for data collection for NHC, HC and DHMT levels

NATIONAL MALARIA CONTROL CENTREMASS DISTRIBUTION DATA COLLECTION REGISTER

COMMUNITY LEVEL

Community/ Health Centre Catchment Area:Name of Village:Name of Data Collector:Date of Collection:

No. Name of head of HH No. of people in HH

No. of ex-isting nets

in GOOD condition

No. of SLEEPINGstructures

in HH

No. of netsto

GIVE

No. of nets to

RE-TREAT

1

2

3

4

5

6

7

Total



HEALTH CENTRE LEVEL

Name of Health Centre:Name of Data Collector:Date of Collection:

No. Name of catchment areaTotal # of

HH in catch-ment area

Total # of netsGIVEN

Total # of

EXISTING nets

Total # of nets

RE-TREATED

1

2

3

4

5

6

7

8

9

10

Total



DHMT LEVEL

Name of District:Data Aggregator:Date of Aggregation:

No. Name of Health Centre Total # ofHH in HC

Total # of netsGIVEN

Total # of

EXISTINGnets

Total # of nets

RE-TREATED

1

2

3

4

5

6

7

8

9

10

Total

1. BackgroundThe National Malaria Strategic Plan(NMSP) 2006-2011 focuses on scaling upfor impact all malaria prevention and con-trol interventions. The country targets toachieve 100% coverage with a minimumof three (3) ITNs per household with atleast 80% utilisation rate by December2008 and maintained through to 2011.

Not all nets in the country are ITNs; distri-bution of untreated nets has occurredpreviously and thus the need to re-treatthese nets. National ITN coverage inZambia is currently 44% and the NMCPhas the mandate to ensure that all thesenets as well as the untreated nets are treat-ed to ensure efficacy. Studies have shownthat a person sleeping under an ITN isprotected twice as much as one sleepingunder an untreated net. It is in line withthis that measures are being put in place toensure that all nets being used are ITNs.

A treated net not only provides a barrier forthe person sleeping under it, but alsorepels and in some cases kills the mosquitoas well as other insects. One cannot over-emphasize the importance of having netstreated if we are to reduce on the vectorpopulation as well as the number of malariacases.

These guidelines have been developed tohelp districts ensure that during the plannedannual mass re-treatment campaign, in linewith the 2006-2011 NMSP, all the requiredcommodities are in place and all people tobe conducting the re-treatments are educat-ed on the re-treatment process and knowtheir roles in the campaign.

2. Resource mobilisationRe-treatment kitsKits will be sourced centrally through theNMCC and distributed through MSL to allDHMTs. Allocations are based on the num-ber of existing ITNs within a district. Thekits should reach the DHMTs a monthbefore the campaign week. Excess kitsshall be kept by the DHMT and used toconduct routine re-treatments as needed.

EquipmentEquipment for use during the campaignwill be supplied by the DHMT/HCs. Suchequipment includes basins, gloves, scis-sors/blades, measuring jugs and plasticbags for community members to carry theirre-treated nets back home.

FundsMalaria remains the number one cause ofmorbidity and mortality in Zambia. AllDHMTs are expected to allocate fundsfrom their grants towards malaria preven-tion and control including re-treatment ofnets. The NMCC will mobilize funds cen-trally to augment the districts resources.The funds will be used to support pre- andintra- campaign activities including but notlimited to planning, training, suppliesdistribution, social mobilization, personnelcosts, M&E.

22

Annex 3: Guidelines on Re-treatment of Insecticide-Treated Nets


Zambia only uses insecticides that havebeen approved by WHO for the treatmentof mosquito nets. These include:deltamethrin; alpha-cypermethrin andlambda-cyhalothrin. Formulations for agri-culture or indoor residual spraying (IRS),even with the same active ingredient, mustnever be used on nets. For guidelines onapproved ITNs/insecticides kindly refer tothe World Health Organization pesticideevaluation scheme website at, http://www.who.int/whopes/quality/en

4. ActivitiesNeeds assessmentThe assessment will ensure that the num-ber of ITNs existing within a communitythat require re-treatment is determinedprior to the re-treatment campaign. Theseshould be ITNs that have not been treatedwithin the past six (6) months. The district-level distribution of kits to HCs, thus tospecific catchment areas, will depend onthis assessment. Further, the M&E processwill utilize the needs assessment data tomeasure progress during and after the cam-paign.

Social mobilisationThis is a very important activity that canactually lead to the success or failure of acampaign. DHMTs should ensure that allthe necessary and most effective tools areused to inform communities about thecampaign. Social mobilization shouldcommence at least one or two months priorto the campaign, be intensified two weeksbefore, and continued during the cam-paign/exercise.

Various communication tools should beused including megaphones, communityradio stations, posters, drama, mobile videounits, schools, church/gatheringannouncements, and door-to-door commu-nication by NHCs. Clear and briefinformation should be given to the commu-nity. The message should include thefollowing details:

• Seriousness of malaria.• Importance of using ITNs.• Importance of treating ITNs.• Availability of free re-treatments.• Location of re-treatment points.• Date(s) of re-treatment.• Time for re-treatment.• Washing ITNs prior to re-treatment.• Re-hanging the nets after re-treatment.

Re-treatment exerciseDHMTs/HCs should identify an appropri-ate location for re-treating nets. Avoidlocations near unstable walls or fenceswhich may endanger lives in cases of poorcrowd control. Try to set up at a locationunder shade and close to a supply of water.

Ensure that all necessary equipment andinsecticides are available prior to theexercise. Community members should notbe kept waiting due to lack of prior plan-ning. Keep to the communicated time; oth-erwise, community members will leave.Determine how much water will be needed,and arrange for the water to be stored at there-treatment station prior to starting theexercise. Keep all equipment and suppliesin secure but easily accessible locations.

23


3. Approved insecticide formulations

SupervisionEach re-treatment point should have asupervisor (from the NHC) whose mainrole will be to ensure that all supplies forthe exercise are available prior to the activ-ity, organize trained people to conductthe exercise, collect all used sachets ofinsecticides, and collect data on all ITNsbeing brought in for re-treatment.

This person shall either be from theDHMT, HC or NHC. NHCs should betrained to provide such supervision.

Waste disposalInsecticides used for the re-treatment ofnets should be handled in a manner thatwill not pollute the environment. Thesupervisor at each re-treatment point willbe responsible to make sure that all usedsachets of insecticides are collected anddisposed of by burying. This informationshould be provided to community memberswho may decide to re-treat their own ITNsat home. No sachets should be foundlying around the re-treatment area after theexercise. Detailed guidance on environmen-tal safeguards can be obtained from the

WHO website at www.afro.who.int/vbc/and the Environmental Council of Zambiadeveloped generic guidelines under theToxic Substances Regulations atwww.necz.org.zm.

5. Roles of stakeholdersThe re-treatment exercise is a huge taskwhich will require all NMCP partners toparticipate. DHMTs shall collaborate withlocal partners and share responsibilitiesbased on comparative advantages. Partnersthat have been identified by central leveland can be invited by DHMT includeZambia Scouts Association, SFH, RedCross, Reaching HIV and AIDS AffectedPeople with Integrated Development andSupport (RAPIDS), Care International,World Vision, Africare, Catholic ReliefServices, Expanded Church Response,Salvation Army, Health CommunicationPartnership (HCP), Health Systems andServices Program (HSSP), ZMF, and allNGOs conducting malaria activities.Private sector partners available withinspecific districts should be approached andencouraged to participate in the exercise.

24

4. Activities


Data collectionData collection before re-treatmentData shall be collected prior to the activity,at least two weeks before, on the numberof existing nets in each household, and thisshall be done by NHCs under thesupervision of DHMT/HC. HCs will com-pile data from all NHCs in their catchmentarea. The DHMT will receive and accumu-late all HC data which will assist in theallocation of re-treatment kits. (Annex 2)

Data collection after re-treatmentTo be able to ascertain the number of ITNsre-treated, data should be collected by thesupervisor (Annex 2, community level).This activity is very important and shouldbe done with maximum concentration. Allcollected data should be forwarded to theHCs who shall consolidate for the entirecatchment area using the provided format(Annex 2, health centre level) then forwardto the DHMT who shall in turnconsolidate for the entire district using pro-vided format (Annex 2, DMHT level).

The DHMT shall send all the collecteddata (Annex 2, DMHT level) together witha report to the PHO where it shall be com-piled and sent to NMCC for incorporationinto the database. The nationwide re-treat-ment rates shall be communicated througha report to all PHOs. NMCC and partnersshall hold a post-campaign meeting to lookinto the challenges and recommendationsas a way of improving planning forsubsequent campaigns.

All data and reports from the DHMTsshould be sent to NMCC a month after thecampaign. DHMTs failing to provide thisinformation shall be left out the followingcampaign as NMCP shall take it that noactivity had taken place and as such thatparticular DHMT still has kits available.

7. Routine re-treatmentsAfter the mass re-treatment campaign,DHMTs shall conduct routine re-treatmentsas a way of ensuring that ITNs within a dis-trict are always treated. This activity shouldbe done when the need is identified andshould be planned and budgeted for in theDistrict Malaria Action Plans. Insecticidesfor this exercise shall be requested fromNMCC by DHMTs through the PHO uponconsolidation of requirements. Distributionshall be based on availability.

8. How to re-treat a netRe-treatment procedure1. Wear gloves.2. Using provided plastic bag measure, fill

with clean water up to 500ml mark.3. Add contents of measuring bag to basin

to be used for treating the net.4. Tear open sachet of binding agent and

add to the water (use a scissors orblade).

5. Stir the water to mix binding agent.6. Add the tablet to the mixture in the basin.7. Stir the mixture until the tablet is com-

pletely dissolved.8. Dip the net into the solution.9. Ensure the net is thoroughly wet.10. Do not wring the net (Takuli ukukama

net). 11. Lay the net flat down in a shade to dry

(Do not hang on a line to dry).

NOTE: You should only follow steps 4and 5 if you are using a long-lastingre-treatment insecticide.

It is very important that the instructions inthese re-treatment guidelines are followedif the re-treated nets are to provide theintended efficacious protection to commu-nity members who will sleep under them.

25


6. Monitoring and evaluation

Developed and printed with assistance from

Republic of Zambia, Ministry of Health

Malaria is the leading cause of illness and death in Zambia everyyear. The highest incidents of malaria are found among childrenunder the age of five, as well as pregnant women. As a result, thedisease preys upon the weakest and most vulnerable to threatenhealthy and productive lives. Nevertheless, malaria is a preventableand treatable disease.

The Guidelines on the Distribution and Utilization of Insecticide-treated Nets for Malaria Prevention and Control has been producedin order to support health workers in Zambia, as well as providegeneral information on the manufacture, distribution, treatment and utilization of insecticide-treated nets. Implementation of thisinformation works to facilitate healthier living practices in Zambia, and ultimately save lives. By facilitating partnerships, sharing knowledge and working together, we can roll back malariain Zambia.

These Guidelines were produced by the National Malaria ControlCentre in 2008.

republic of zambia, ministry of health...

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