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Tanzania Vector Control Scale-up Project (TVCSP): Final Report March 9, 2010–September 30, 2016 Contract No. 621-A-00-10-00015-00 March 9, 2010–September 30, 2016 Prepared for: U.S. Agency for International Development/Tanzania Prepared by: RTI International 3040 Cornwallis Road Post Office Box 12194 Research Triangle Park, NC 27709-2194 December 29, 2016

This publication was produced for review by the U.S. Agency for International Development. It was prepared by RTI International.

Tanzania Vector Control Scale-up Project (TVCSP): Final Report March 9, 2010–September 30, 2016 Contract No. 621-A-00-10-00015-00 March 9, 2010–September 30, 2016 Submitted to: U.S. Agency for International Development/Tanzania ATTN: Naomi Kaspar, Jennifer Norling, Moses Busiga 2140 Dar es Salaam Place Washington, DC 20521-2140 E-mail: [email protected], [email protected], [email protected] Submitted by: RTI International 3040 Cornwallis Road Post Office Box 12194 Research Triangle Park, NC 27709-2194 Submitted on: December 29, 2016

RTI International is one of the world’s leading research institutes, dedicated to improving the human condition by turning knowledge into practice. Our staff of more than 3,700 provides research and technical services to governments and businesses in more than 75 countries in the areas of health and pharmaceuticals, education and training, surveys and statistics, advanced technology, international development, economic and social policy, energy and the environment, and laboratory testing and chemical analysis.

The author’s views expressed in this publication do not necessarily reflect the views of the U.S. Agency for International Development or the U.S. Government.

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Tanzania Vector Control Scale-up Project iii

Table of Contents List of Annexes ......................................................................................................................... iv List of Tables ............................................................................................................................ iv List of Figures ............................................................................................................................ v List of Acronyms ..................................................................................................................... vii EXECUTIVE SUMMARY ....................................................................................................... 1 I. BACKGROUND .............................................................................................................. 3 II. IRS RESULTS 2010–2015 ............................................................................................... 4

IRS Targets, Operational Sites (OSs), Wards/Shehias, Villages and Hamlets ................. 4 Summary Operations Staff ................................................................................................ 5 Summary of Household Characteristics and Population .................................................. 5

III. ACTIVITIES IN ZANZIBAR .......................................................................................... 9 Component 1—IRS ........................................................................................................... 9

IRS Performance in Zanzibar by District (2010–2015) .............................................. 9 Preparatory Activities for IRS Operations ................................................................ 12 Insecticide Resistance Mitigation Management Plan ............................................... 19 IRS Logistical Arrangements .................................................................................... 22 Information, Education, and Communication (IEC) for IRS .................................... 25 M&E ......................................................................................................................... 26

Component 2—Environmental Compliance Strategies and Monitoring Plans .............. 28 Environmental Assessment ....................................................................................... 28 Insecticide Management and Environmental Management Plan (EMP) .................. 28 Environmental Monitoring and Inspections.............................................................. 29 IRS Waste Disposal Arrangements ........................................................................... 29

Component 3—Malaria Surveillance, Epidemic Preparedness, and Rapid Response ... 29 Malaria Early Epidemic Warning System ................................................................ 30 Passive Surveillance—MEEDS ................................................................................ 30 Production of MEEDS Weekly Report ..................................................................... 30 Active Surveillance—MCN ...................................................................................... 32 Outbreak Investigation and Response Activities ...................................................... 36

IRS Sustainability and Projections for Future Needs in Zanzibar .................................. 39 IV. ACTIVITIES IN MAINLAND TANZANIA ................................................................. 39

Component 1—IRS ......................................................................................................... 39 IRS Performance in the Lake Zone by District (2010–2015) ................................... 40 Preparatory Activities for IRS Operation ................................................................. 46 Insecticide Resistance Mitigation Management Plan ............................................... 46 IRS Logistical Arrangements .................................................................................... 47 IEC for IRS ............................................................................................................... 51 M&E ......................................................................................................................... 53

Component 2—Environmental Compliance Strategies and Monitoring Plans .............. 54 Environmental Assessment ....................................................................................... 54 Insecticide Management and EMP ........................................................................... 54 Environmental Monitoring and Inspections.............................................................. 55 IRS Waste Disposal Arrangements ........................................................................... 55

Component 3—Sustained Entomologic Monitoring System on the Mainland .............. 56 Support for Operation and Maintenance of Entomological Laboratory ................... 56 Support Longitudinal Entomological Monitoring in the Lake Zone ........................ 56 Cone Bioassays Surveys in the Lake Zone ............................................................... 57

iv Tanzania Vector Control Scale-up Project

National Survey of Malaria Vector Resistance to Insecticides ................................. 57 Component 4—SNP2...................................................................................................... 58

Logistics Assessment ................................................................................................ 59 Advocacy Meetings .................................................................................................. 59 Training ..................................................................................................................... 59 Community Sensitization Activities ......................................................................... 60 LLIN Net Issuance at Schools .................................................................................. 60

Component 5—Malaria Surveillance, Epidemic Detection, and Response ................... 63 MEEDS Reporting within IDSR System .................................................................. 63 Other Surveillance Activities: Operational Research ............................................... 70 Monitoring Parasitemia Prevalence among Pregnant Women and Children in 54 RCH Sites in the Lake Zone ..................................................................................... 70 Investigating the Prevalence of SP-resistant Malaria Parasites in the General Population ................................................................................................................. 71

Component 6—RSS ........................................................................................................ 75 Planning Phase .......................................................................................................... 75 Implementation ......................................................................................................... 76 Evaluation phase ....................................................................................................... 76

IRS Sustainability and Projections for Future Needs in Mainland Tanzania ................. 76 V. OTHER ACTIVITIES .................................................................................................... 78

Component 7—Capacity Building and Sustainability .................................................... 78 Human Resource Development ................................................................................ 78 Organizational/Institutional Development for IRS Implementation ......................... 78

Component 8—M&E ...................................................................................................... 79 Performance Monitoring Plan (PMP) ....................................................................... 79 Build Capacity: Strengthen M&E and Data Management System ........................... 79 DQA .......................................................................................................................... 79

Component 9—Cross-Cutting Activities ........................................................................ 79 Cross-cutting Issues—Gender .................................................................................. 79 Knowledge Management and Communication ......................................................... 80

Component 10—Management ........................................................................................ 89 Program Planning and Reports ................................................................................. 89 Support Provision of Short-term TA (STTA) ........................................................... 89

Fiscal Report ................................................................................................................... 89 VI. CHALLENGES AND RECOMMENDATIONS ........................................................... 90

Challenges Faced ............................................................................................................ 90 Recommendations for Future Implementation ............................................................... 90

List of Annexes

Annex 1. List of topics presented at scientific conferences .............................................. 92

List of Tables

Table 1. IRS Targets .................................................................................................................. 4 Table 2. Staff Summary ............................................................................................................. 5 Table 3. Household Characteristics and Population .................................................................. 6

Tanzania Vector Control Scale-up Project v

Table 4. Spray Indicators ........................................................................................................... 7 Table 5. Population Protected by Broad Age Group ................................................................. 7 Table 6. LLIN/ITN Use in Population covered by TVCSP IRS Operations ............................. 8 Table 7. IRS Performance in Zanzibar, 2010–2015 ................................................................ 10 Table 8. Number of People Protected by IRS in Zanzibar, 2010–2015 .................................. 11 Table 9. Insecticide Used by Year, Type, Area, and Number of Sachets Used per Household Structure ................................................................................................................................... 20 Table 10. IRS Performance in the Lake Zone, 2010–2015 ...................................................... 41 Table 11. Number of People Protected from Malaria Infection by IRS in the Lake Zone, 2010–2015................................................................................................................................ 44 Table 12. Training Prior to LLIN Distributions for ToTs and ToIs Conducted in May 2014, by Gender and Region ............................................................................................................. 59 Table 13. Summary of LLINs Issued to Teachers and Students at Schools of Lindi, Mtwara, and Ruvuma Regions, August 2014 ......................................................................................... 61 Table 14. Health Workers Trained and HFs Reporting using eIDSR, November 2013‒July 2016.......................................................................................................................................... 68 Table 15. Summary Results of eIDSR Reports and Malaria Data, November 2013–July 2016.................................................................................................................................................. 69 Table 16. Summary of HF Reports, Attendance, Testing, and Malaria Positivity by Region, December 2012–November 2013 ............................................................................................ 70 Table 17. Number and Type of Presentations Delivered at Key Scientific Conferences ........ 80 Table 18. Summary of Key Research Findings ....................................................................... 82 Table 19. STTA Trips Approved in the Original CA .............................................................. 89 Table 20. Funding Provided for Each Program Component .................................................... 90

List of Figures

Figure 1. Malaria morbidity on Unguja and Pemba Islands, 2011 MEEDS............................ 13 Figure 2. Areas targeted for one and two rounds of spraying during 2012, Unguja and Pemba Islands ...................................................................................................................................... 14 Figure 3. Malaria morbidity on Unguja and Pemba Islands, 2012 MEEDS............................ 15 Figure 4. Shehias targeted during 2013, Unguja and Pemba Islands ....................................... 15 Figure 5. Malaria morbidity on Unguja and Pemba Islands, 2013 MCN ................................ 16 Figure 6. Malaria morbidity on Unguja and Pemba Islands, 2014 MCN ................................ 17 Figure 7. Shehias targeted for IRS during 2013–2014, Unguja and Pemba Islands ................ 18 Figure 8. Shehias targeted for IRS during 2014–2015, Unguja and Pemba Islands ................ 18 Figure 9. Organizational structure of IRS teams ..................................................................... 23 Figure 10. M&E framework for IRS ........................................................................................ 26 Figure 11. Malaria positivity and rainfall data, January 2010–July 2016* ............................. 31 Figure 12. MEEDS malaria testing and malaria positivity by age group, January 2010–July 2016*........................................................................................................................................ 31 Figure 13. Trends in malaria cases notified and followed up, September 2012‒July 2016 .... 33 Figure 14. Household members that were tested and that tested positive, September 2012‒July 2016 ........................................................................................................................ 33 Figure 15. Malaria case distribution, January 2013–July 2016 ............................................... 34 Figure 16. Proportion of all malaria cases with a reported history of travel outside Zanzibar 35 Figure 17. Shehias where response activities were conducted between January 2013 and June 2016.......................................................................................................................................... 38

vi Tanzania Vector Control Scale-up Project

Figure 18. IRS scale up in the Lake Zone, 2006–2010 ............................................................ 40 Figure 19. IRS OSs location in the Lake Zone ........................................................................ 49 Figure 20. Copy of a registration and issuing booklet ............................................................. 60 Figure 21. School children who received LLINs in Lindi ....................................................... 60 Figure 22. Updated malaria section in the weekly IDSR forms .............................................. 64 Figure 23. Materials and tools developed to facilitate eIDSR implementation at the HF, district, and regional levels ...................................................................................................... 65 Figure 24. Map showing regions implementing eIDSR .......................................................... 67 Figure 25. Reports received from HFs implementing eIDSR, November 2013–July 2016 .... 72 Figure 26. Malaria testing and cases trends in HFs implementing eIDSR, November 2013–July 2016 .................................................................................................................................. 73 Figure 27. Trends of confirmed malaria cases and clinical malaria cases in the eIDSR, November 2013–July 2016 ...................................................................................................... 74

Tanzania Vector Control Scale-up Project vii

List of Acronyms

ANC antenatal clinic

AJSC Annual Joint Scientific Conference

ASTMH American Society of Tropical Medicine and Hygiene

BCC behavior change communication

CA cooperative agreement

CBIRS community-based indoor residual spraying

CBO community-based organization

CDC United States Centers for Disease Control and Prevention

CHMT Central Health Management Team

CI confidence interval

DBS dried blood spot

DDT dichlorodiphenyltrichloroethane

DHIS District Health Information System

DHIS2 revised version of District Health Information System

DITT District IRS Technical Team

DMO District Medical Officer

DMSO District Malaria Surveillance Officer

DQA data quality assessment

DSHC District School Health Coordinator

DVCO District Vector Control Officer

eIDSR electronic Integrated Disease Surveillance and Response

ELISA enzyme-linked immunosorbent assay

EMP environmental management plan

FAQ frequently asked question

GIS Geographical Information System

Global Fund Global Fund to Fight AIDS, Tuberculosis, and Malaria

HF health facility

HMIS Health Management Information System

IDSR Integrated Disease Surveillance and Response

IEC information, education, and communication

IQK insect quantification kit

IRS indoor residual spraying

viii Tanzania Vector Control Scale-up Project

ISO International Standards Organization

ITN insecticide-treated net

JHU-CCP Johns Hopkins University-Center for Communication Programs

JSI John Snow Inc.

kdr knock-down resistance

LLIN long-lasting insecticide-treated net

M&E monitoring and evaluation

MCN malaria case notification

MEEDS malaria epidemic early detection system

MoH Ministry of Health (indicates either MoHCDGEC or MoHSW)

MoHCDGEC Ministry of Health, Community Development, Gender, Elderly and Children

MoHSW Ministry of Health and Social Welfare

MOP Malaria Operational Plan

mRDT malaria rapid diagnostic test

MSAT mass screening and treatment

MSP Malaria Strategic Plan

NGO nongovernmental organization

NIMR National Institute for Medical Research

NMCP National Malaria Control Programme

OPD outpatient department

OS operational site

PCR polymerase chain reaction

PEA Programmatic Environmental Assessment

PEPFAR United States President’s Emergency Plan for AIDS Relief

PfPR Plasmodium falciparum prevalence rate

PMI United States President’s Malaria Initiative

PMORALG Prime Minister’s Office Regional Authority and Local Government

PPE personal protective equipment

PPP public-private partnership

PRISM Performance of Routine Information System Management

PSI Population Services International

RCH reproductive and child health

RDT rapid diagnostic test

RHMT Regional Health Management Team

Tanzania Vector Control Scale-up Project ix

RSS routine system strengthening

SEA Supplemental Environmental Assessment

SMS Short Message Service

SNP School Net Program

SNP2 Second Round of the School Net Program

SOP standard operating procedure

SP sulfadoxine-pyrimethamine

STTA short-term technical assistance

TA technical assistance

TMA Tanzanian Meteorological Agency

TOI training of implementers

TOT training of trainers

TRCS Tanzania Red Cross Society

TVCSP Tanzania Vector Control Scale-up Project

UDSM University of Dar es Salaam

U.S. United States

USAID United States Agency for International Development

USG United States Government

USSD Unstructured Supplementary Service Data

VCO Vector Control Officer

WEC ward education coordinator

WHO World Health Organization

WHOPES World Health Organization Pesticide Evaluation Scheme

ZAMEP Zanzibar Malaria Elimination Program

ZMCP Zanzibar Malaria Control Programme

Tanzania Vector Control Scale-up Project 1

EXECUTIVE SUMMARY

The goal of the Tanzania Vector Control Scale-up Project (TVCSP, 2010-1016) was to contribute to the reduction of the malaria burden by interrupting malaria transmission though indoor residual spraying (IRS) and to the prevention of adverse effects of malaria epidemics through focal spraying. The program’s objectives included the following:

Scale up IRS in Mainland Tanzania and maintain high IRS coverage in Zanzibar;

Establish an epidemic detection and focal spraying response strategy for Zanzibar and Mainland Tanzania;

Develop an environmental compliance strategy and monitoring plan for Zanzibar and Mainland Tanzania;

Develop the capacities of the Zanzibar Malaria Elimination Program (ZAMEP), National Malaria Control Program (NMCP), and districts to plan and implement IRS; and

Establish a viable and sustained entomological monitoring system for Zanzibar and Mainland Tanzania.

TVCSP had the following overall targets:

85% of structures in IRS target areas sprayed

85% of population protected through IRS in the targeted geographic area

In Zanzibar, the project obtained between 93-98% coverage of targeted structures over the life of the project, spraying a cumulative total of 517,060 structures. In Mainland Tanzania, the project obtained between 92-95% coverage of targeted structured over the life of the project, spraying a cumulative total of 4,055,823 structures. At the peak of spraying activities, more than a million people in Zanzibar and 6.3 million people in Mainland Tanzania were protected.

IRS operations complied with the environmental laws and regulations of Tanzania and USAID, and the project conducted pre-, mid-, and post-spray inspections at all IRS sites. The project also established a compliant insecticide waste management system, which included the installation of an incinerator for the disposal of insecticide-contaminated solid wastes.

Over the course of IRS operations, TVCSP, in collaboration with NMCP, supported the National Institute for Medical Research (NIMR) to establish an entomology laboratory and insectaries and scale up from 14 to 26 national surveillance sites in the country. This support was intended to help NIMR continuously monitor malaria vectors; assess entomological parameters, such as mosquito abundance and infectivity in the Lake Zone; and conduct annual nationwide monitoring of insecticide resistance among local malaria vector populations in the country.

Via its previous project, RTI assisted ZAMEP in establishing a malaria epidemic early detection system (MEEDS) in 2008, starting with 10 public health facilities (HFs) and gradually scaling up to all 142 public HFs by the end of 2012. Using MEEDS, malaria cases detected in HFs were reported weekly via cellular phone. Through TVCSP,

2 Tanzania Vector Control Scale-up Project

RTI continued to support ZAMEP in scaling up MEEDS to cover 100% of all public HFs and 77 private HFs.

In August 2012, TVCSP supported ZAMEP in introducing individual malaria case notification (MCN). Each malaria case notified via MEEDS was followed up at the household level, and patient’s family members were tested for malaria (i.e., re-active case detection). From September 2012 to July 31, 2016, a total of 12,704 malaria cases were notified through the MCN system, and 10,384 (82%) of them were followed up at the household level. Additionally, 43,178 (90.8%) household members were tested, and 2,304 (5%) tested positive and received treatment with artemisinin-based combination therapy.

In Year 3, TVCSP expanded its mandate and supported NMCP in establishing a malaria surveillance system using the existing weekly electronic Integrated Disease Surveillance and Response (eIDSR) platform of the Ministry of Health (MoH) epidemiology unit1. HFs use mobile technology to report IDSR diseases, including g malaria, on a weekly basis. Thus far, TVCSP has supported the progressive scale up of this system from 67 HFs in 2013 to over 2,194 HFs by July 31, 2016 in eight regions: Kagera, Mwanza, Mara, Geita, Dar es Salaam, Dodoma, Manyara, and Singida. Overall, the reporting rate is 41%, and approximately 12% of reports are received on time (by Monday at 3:30pm). The reported findings indicate that out of the 5,665,748 (90%) people tested, 1,875,052 (34%) were positive for malaria.

In Year 4, TVCSP began to support to NMCP through a routine system strengthening (RSS) project to improve the quality and use of malaria data obtained via the Health Management Information System (HMIS) and eIDSR in the country.

In Year 5, additional scope was added to TVCSP to support NMCP in conducting a second round of school-based long-lasting insecticide-treated net (LLIN) (Second Round of the School Net Program [SNP2]) distribution in 19 districts in Lindi, Mtwara, and Ruvuma Regions. Overall, LLINs were issued to 464,893 (98%) students out of the 474,094 students who were registered in school.

For capacity building and sustainability, TVCSP conducted several trainings at the national, regional, and district levels. Several policy and strategy documents were developed, including national malaria vector control guidelines, malaria surveillance guidelines for NMCP and ZAMEP, a training package for IRS facilitators, and an insecticide resistance mitigation plan

TVCSP also conducted operational research as part of its malaria surveillance activities in Mainland Tanzania: (1) monitoring malaria parasitemia prevalence among pregnant women and infants eligible for measles vaccination at reproductive and child health (RCH) sites in the Lake Zone and (2) investigating the prevalence of sulfadoxine-pyrimethamine (SP)-resistant malaria parasites in the general population.

1 Over the course of the project, the full name of the Ministry of Health (MoH) changed from the Ministry of Health and Social Welfare (MoHSW) to the Ministry of Health, Community Development, Gender, Elderly and Children (MoHCDGEC). Because many TVCSP activities spanned both names, we simply use MoH throughout this report.


I. BACKGROUND

On March 9, 2010, the U.S. Agency for International Development (USAID)—under the U.S. President’s Malaria Initiative (PMI)—awarded RTI a cooperative agreement to provide technical support to Mainland Tanzania’s National Malaria Control Programme (NMCP) and the Zanzibar Malaria Elimination Programme (ZAMEP) to implement IRS and other vector control interventions as well as malaria surveillance and operational research activities. The Tanzania Vector Control Scale-up Project (TVCSP) was initially for a five-year duration; in March 2015, the project received an 18-month costed extension until September 30, 2016. TVCSP followed the successful implementation of RTI’s previous project, Malaria Control in Mainland Tanzania and Zanzibar (2006-2010).

TVCSP’s implementation was fully aligned with Tanzania’s and Zanzibar’s National Malaria Strategic Plans (MSPs), as well as guided by PMI’s annual Tanzania Malaria Operational Plans (MOPs).

Reflecting the project’s result framework, activities were divided into the following components:

Component 1—IRS;

Component 2—Environmental compliance strategies and monitoring plans;

Component 3—Entomologic monitoring systems;

Component 4—SNP2 (added in Year 4);

Component 5—Malaria epidemic surveillance and rapid response;

Component 6—RSS pilot (added in Year 4);

Component 7—Capacity building;

Component 8—Cross-cutting activities;

Component 9—Monitoring and evaluation (M&E); and

Component 10—Management activities.

Through its previous project, Malaria Control in Mainland Tanzania and Zanzibar, RTI had conducted four blanket IRS rounds (December 2006−January 2010) in all 10 districts of Zanzibar, spraying approximately 200,000 household structures per round and achieving an overall spray coverage of 95%. In Mainland Tanzania, IRS was introduced to control malaria outbreaks in malaria-unstable areas in Muleba and Karagwe Districts in Kagera Region (approximately 130,000 structures in total). In 2009, operations were scaled up in the five remaining districts of Kagera Region, increasing the total number of household structures sprayed to 413,000 and maintaining an overall spray coverage of 94%. The population protected from malaria infection in targeted Kagera districts increased from approximately 170,000 in 2007 to over 2.1 million in 2009.

In Year 1 of TVCSP, another round of blanket IRS was conducted. From Year 2 (2012) onwards, in Zanzibar, IRS shifted from blanket to target spraying, and in each round, more than 62,000 household structures were sprayed. An overall spray coverage of 93% was maintained, and over 312,000 people were protected from malaria infection after each IRS round. In Mainland Tanzania, TVCSP, in


collaboration with NMCP, supported districts in Kagera, Mwanza, and Mara Regions to scale-up IRS operations. As a result, an estimated 1.3 million household structures were sprayed (93.2% coverage), protecting a population of approximately 6.5 million people from malaria infection. By Year 3, IRS had completely transitioned from blanket to targeted spraying, and 871,791 household structures were sprayed, protecting approximately 4 million people from malaria infection.

This final report presents a summary of TVCSP’s key activities and accomplishments between March 10, 2010 and September 30, 2016 in Zanzibar and Mainland Tanzania. This report is presented in five sections. Section II gives the overall results for IRS during 2010‒2015. Section III includes the activities implemented in Zanzibar, Section IV presents the activities implemented in Mainland Tanzania, and Section V discusses general crosscutting activities and management. Section VI summarizes the challenges encountered over the life of the project and recommendations for future IRS programs.

II. IRS RESULTS 2010–2015

This section presents summary results for IRS over the life of the project, in both Zanzibar and Mainland Tanzania. Details on specific components and activities are included in Sections III and IV for each respective location.

IRS Targets, Operational Sites (OSs), Wards/Shehias, Villages and Hamlets

Table 1 shows that in the second year of TVCSP (2011–2012), a maximum of 1,314,005 household structures were targeted for IRS in the Lake Zone, with potentially over seven million people protected from malaria infection in 1,982 villages. 2011-2012 and the previous 2010–2011 period were the blanket era of IRS in the Lake Zone. However, in subsequent years, the number of household structures and people targeted by IRS decreased as operations scaled down because of the necessity to use different insecticide classes for IRS as resistance to previously used insecticides expanded.

In Zanzibar, the first year of TVCSP saw the maximum eligible household structures and population targeted by IRS. Similar to operations on Mainland Tanzania, Zanzibar transitioned to more targeted IRS operations, with the number of eligible household structures and population covered by IRS gradually decreasing over subsequent project years.

Table 1. IRS Targets

Area Project

Year

Eligible Household Structures

Eligible Population

# Sites # Wards

(Shehias)#

Villages #

hamlets

Lake Zone

2010–2011 1,211,596 6,636,706 173 460 2,024 10,912

2011–2012 1,314,005 7,419,435 176 541 1,98 10,810

2012–2013 817,836 4,505,752 167 457 1,294 7,536

2013–2014 420,903 2,233,708 54 161 568 2,733

2014–2015 445,796 2,370,880 198 193 646 3,212

Zanzibar 2010–2011 204,087 1,087,327 18 335 NA NA


Area Project

Year

Eligible Household Structures

Eligible Population

# Sites # Wards

(Shehias)#

Villages #

hamlets

2011–2012 121,471 619,243 14 281 NA NA

2012–2013 53,955 259,899 10 108 NA NA

2013–2014 70,160 329,354 10 120 NA NA

2014–2015 66,808 306,639 10 113 NA NA

Summary Operations Staff

Table 2 shows that, on average, 5,000 spray operators in the Lake Zone and 700 in Zanzibar were employed temporarily each year over the course of TVCSP. Other support staff, including team leaders, site managers, and drivers, were also crucial for successful implementation of IRS operations.

Table 2. Staff Summary

Are

a

Pro

ject

Yea

r

# o

f S

pra

y

Op

erat

ors

Tea

m

Lea

der

s

Sit

e M

anag

ers

Dri

vers

Pu

mp

T

ech

nic

ian

Cle

aner

s

Su

it W

ash

ers

Wat

chm

en

Wat

er

Fet

cher

s

La

ke Z

on

e

2010–2011 6,208 776 172 398 245 172 344 344 344

2011–2012 7288 911 20 456 176 176 352 352 176

2012–2013 4873 608 167 303 224 166 166 332 383

2013–2014 2686 336 54 161 89 64 128 106 64

2014–2015 3510 604 64 44 65 438 195 253 14

Za

nzi

ba

r

2010–2011 897 121 18 67 38 19 41 34 0

2011–2012 749 107 14 107 17 28 28 28 28

2012–2013 609 87 10 91 24 9 25 18 20

2013–2014 489 70 12 71 23 5 20 19 26

2014–2015 658 100 10 0 22 0 0 0 0

Summary of Household Characteristics and Population

Table 3 shows that a maximum of 1,237,353 and 205,892 household structures were visited in the Lake Zone and Zanzibar, respectively. The majority of the household structures reached by the project during IRS implementation were in rural areas and typically had mud walls. The wall characteristics were not recorded in Zanzibar. Approximately five to six people per household were present in Zanzibar and the Lake Zone, respectively. In terms of high risk populations, between 17% and 22% were children under 5 years of age in Zanzibar and the Lake Zone, whereas 2% to 3% were pregnant women.


Table 3. Household Characteristics and Population

Area Project

Year

Household Structures

Visited

Wall Materials

Average Rooms

per House

Total Pop.

Found

Family Size

Risk Group

Five Years and Above

Mud (%)

Cement (%)

Other (%)

Children under 5 years of

age

% Pregnant Women

% Male % Female %

La

ke Z

on

e

2010–2011

1,177,022 82% 15% 3% 3.5 6,452,577 5.5 1,408,536 22% 188,941 3% 2,431,013 38% 2,424,088 38%

2011–2012

1,237,353 81% 17% 2% 3.7 6,992,727 5.7 1,514,867 22% 198,224 3% 2,615,175 37% 2,664,460 38%

2012–2013

776,425 82% 16% 2% 3.5 4,277,436 5.5 888,822 21% 146,018 3% 1,607,182 38% 1,635,414 38%

2013–2014

389,759 82% 16% 2% 3.5 2,073,673 5.3 448,297 22% 81,419 4% 766,955 37% 777,002 37%

2014–2015

422,711 82% 16% 2% 3.5 2,242,531 5.3 459,909 21% 63,126 3% 851,117 38% 868,379 39%

Za

nzi

ba

r

2010–2011

205,892 NA NA NA 4.5 1,092,559 5.3 271,819 25% 34,966 3% 602,374 55% 600,061 55%

2011–2012

121,471 NA NA NA 4.4 619,243 5.1 109,562 18% 14,899 2% 248,027 40% 246,755 40%

2012–2013

53,955 NA NA NA 4.9 259,899 4.8 45,208 17% 5,913 2% 105,450 41% 103,328 40%

2013–2014

70,160 NA NA NA 4.7 329,354 4.7 56,241 17% 8,784 3% 133,838 41% 130,491 40%

2014–2015

66,808 NA NA NA 4.9 306,639 4.6 53,271 17% 6,452 2% 124,554 41% 122,362 40%


Table 4 shows that in Year 2 of TVCSP, a maximum of 1,224,095 household structures were sprayed in the Lake Zone, whereas in the first year of the project, Zanzibar saw the most household structures sprayed at 194,898. In all operation years, the spray coverage was always above 90%, indicating that the majority of the households were successfully reached and sprayed by the spray operators.

Table 4. Spray Indicators

Area Project

Year Eligible

Households Households

Visited

Households

Visited %

Sprayed Visited and not Sprayed

Not Reached

Spray Coverage

(%)

Lake Zone

2010–2011

1,211,596 1,177,022 97% 1,144,621 32,401 34,574 95%

2011–2012

1,314,005 1,237,353 94% 1,224,095 13,258 76,651 93%

2012–2013

350,191 332,934 95% 331,907 1,027 17,257 95%

2013–2014

420,903 389,759 93% 385,252 4,507 31,144 92%

2014–2015

445,796 422,711 95% 419,753 2,958 23,085 94%

Zanzibar

2010–2011

205,892 205,892 100% 194,808 11,084 - 95%

2011–2012

121,471 121,471 100% 114,858 6,613 - 95%

2012–2013

53,955 53,955 100% 51,904 2,051 - 96%

2013–2014

70,160 70,160 100% 66,328 3,832 - 95%

2014–2015

66,808 66,808 100% 62,391 4,417 - 93%

Table 5 shows that over 7 million people per year were protected from malaria infection in both the Lake Zone and Zanzibar during the first two years of TVCSP, including two million children under five years of age and pregnant women. In the final year of TVCSP, 2.4 million people were protected from malaria infection by IRS in both the Lake Zone and Zanzibar.

Table 5. Population Protected by Broad Age Group

Area Project

Year

Total Population High Risk Population Five Years of Age

and Above

Protected %


age

Pregnant Women

Male Female Protected

Lake Zone

2010–2011

6,095,891 92% 1,330,674 178,497 2,296,631 2,290,088 4,586,720

2011–2012

6,518,120 93% 1,412,532 184,844 2,437,440 2,483,305 4,920,745


Area Project

Year

Total Population High Risk Population Five Years of Age

and Above

Protected %


age

Pregnant Women

Male Female Protected

2012–2013

4,052,354 88% 841,451 138,281 1,523,034 1,549,588 3,072,622

2013–2014

1,918,180 86% 415,581 75,293 708,741 718,565 1,427,306

2014–2015

2,110,198 89% 431,365 59,175 801,635 818,023 1,619,658

Zanzibar

2010–2011

1,033,742 95% 180,995 23,458 414,493 414,797 829,290

2011–2012

586,657 95% 103,984 14,080 234,945 233,649 468,594

2012–2013

250,505 96% 43,635 5,703 101,645 99,523 201,167

2013–2014

312,340 95% 53,338 8,271 127,032 123,699 250,731

2014–2015

286,823 95% 49,817 6,029 116,536 114,441 230,977

During IRS, TVCSP also collected information on other secondary indicators for potential use by the project, including on LLIN/ITN use. While LLIN/ITN use in children under 5 years of age and pregnant women was near or exceeded the 80% target in all years in Lake Zone and Zanzibar (with the exception of 2014–2015 in Lake Zone), LLIN/ITN use in the population over 5 years of age was much more variable, ranging from 42–80% in Lake Zone and 66–80% in Zanzibar. Lower LLIN/ITN use rates between years and in the population above 5 years of age are likely due to fewer nets than required being available in the communities (Table 6).

Table 6. LLIN/ITN Use in Population covered by TVCSP IRS Operations

Area Project

Year

Children Under 5 Years of Age Pregnant Women Population Over 5 Years

Slept Under LLIN/Insecticide-treated Net (ITN)

the Previous Night

LLIN/ITN Use

Slept Under LLIN/ITN the

Previous Night

LLIN/ITN Use


Previous Night

LLIN/ITN Use

Lake Zone

2010–2011 1,102,499 79% 152,591 81% 2,413,391 50%

2011–2012 1,430,675 94% 198,224 93% 4,224,870 80%

2012–2013 818,455 92% 136,184 93% 2,542,888 79%

2013–2014 372,101 84% 73,838 91% 1,038,567 69%

2014–2015 269,257 59% 41,915 67% 695,124 42%

Zanzibar 2010–2011 146,465 81% 18,082 77% 541,236 66%

2011–2012 89,449 82% 11,572 78% 350,873 71%


Area Project

Year

Children Under 5 Years of Age Pregnant Women Population Over 5 Years

Slept Under LLIN/Insecticide-treated Net (ITN)

the Previous Night

LLIN/ITN Use


Previous Night

LLIN/ITN Use


Previous Night

LLIN/ITN Use

2012–2013 39,222 90% 5,082 89% 155,641 80%

2013–2014 46,920 86% 6,833 82% 188,218 72%

2014–2015 39,948 78% 4,726 74% 154,532 66%

III. ACTIVITIES IN ZANZIBAR

Component 1—IRS

RTI began supporting IRS operations in Zanzibar in 2006 under PMI’s Malaria Control in Mainland Tanzania and Zanzibar project, which was implemented from 2006 to 2010. Through this project, RTI supported ZMCP in conducting five rounds of blanket IRS in all 10 districts of Zanzibar (i.e. 6 on Unguja Island and 4 on Pemba Island). On average, approximately 200,000 household structures were sprayed in each round of IRS, resulting in over 1.2 million people being protected from malaria infection each year.

Starting in March 2010, RTI continued supporting ZAMEP in implementing IRS operations, now under the newly awarded TVCSP. In September 2010, a sixth round of blanket IRS was conducted in all 10 Zanzibar districts. Beginning in 2012, the IRS approach in Zanzibar shifted from blanket to targeted/focal spraying. Two ad hoc focal spray operations (i.e. in Tumbe, 2011; and Finya, 2013) were also conducted following abnormal increases of malaria cases in those wards (shehias). In 2013, RTI and ZAMEP conducted another round of targeted and focal IRS in select areas of Zanzibar, which was followed by subsequent rounds of targeted IRS in 2014 and 2015, the most recent one, as highlighted in Table 1.

Between 2006 and 2011, all spray rounds were performed using pyrethroid insecticides. In the 2012 and 2013 IRS operations, bendiocarb was used, whereas in 2014 and 2015, IRS operations used pirimiphos-methyl. Together with other malaria prevention and control interventions (i.e. LLINs, case management, surveillance) implemented by ZAMEP and stakeholders, IRS contributed significantly to reducing malaria prevalence from more than 30% in 2006 to less than 1% by 2010, setting Zanzibar up for malaria elimination.

IRS Performance in Zanzibar by District (2010–2015)

Table 7 summarizes the household structures sprayed and the spray coverage by district and intervention year. Table 8 presents the numbers of people protected from malaria infection. Throughout the project, spray coverage consistently exceeded 90%.


Table 7. IRS Performance in Zanzibar, 2010–2015

Location

Round Six Focal Spray

Targeted Spray

Targeted Spray

Targeted Spray

Focal Spray

Target Spray

Target Spray Target Spray

2010–2011 2010–2011 2011–2012 2011–2012 2012–2013 2012–2013

2013–2014

2013–2014 2014–2015

Unguja

Central 14,883 (94%)

— 15,392 (93%)

4,536 (92%)

10,171 (95%)

— 11,138 (95%)

— 9,399 (92%)

North A 21,524 (100%)

— 18,274 (93%)

— 3,102 (94%)

— 11,508 (95%)

2,003 (96%) 9,784 (94%)

North B 11,480 (97%)

— 11,294 (99%)

2,653 (95%)

8,288 (95%)

— 9,642 (99%)

— 11,007 (96%)

South 8,472 (94%)

— 5,644 (93%)

1,840 (90%)

2,264 (94%) — 5,460 (94%)

— 6,321 (94%)

Urban 23,127 (87%)

— — — — — — — —

West 40,422 (95%)

— 24,463 (90%)

3,065 (92%)

4,702 (96%)

— 8,536 (83%)

— 15,165 (90%)

Pemba

Chakechake 16,866 (94%)

— 8,682 (98%)

2,461 (93%)

1,406 (95%)

— 929

(98%) —

1,546 (96%)

Micheweni 20,305 (96%)

2,003 12,744 (98%)

7,230 (99%)

12,157 (99%)

501 6,353 (98%)

— 4,794 (99%)

Mkoani 18,267 (100%)

— 10,047 (100%)

1,497 (95%)

2,506 (99%)

— 4,696

(100%) 332 (100%)

1,208 (100%)

Wete 19,462 (93%)

— 8,318 (98%)

2,988 (98%)

7,308 (96%)

— 4,481 (96%)

1,250 (100%) 3,167 (95%)

Total 194,808 (95%)

— 114,858 (95%)

26,270 (95%)

51,904 (96%)

501 62,743 (94%)

3,585 (98%) 62,391 (93%)


Table 8. Number of People Protected by IRS in Zanzibar, 2010–2015

Location

Round six Focal Spray Targeted

Spray Targeted

Spray Targeted

Spray Focal Spray

Target Spray

Target Spray

Target Spray

2010–2011 2010–2011 2011–2012 2011–2012 2012–2013

2012–2013

2013–2014

2013–2014 2014–2015

Unguja

Central 64,886 — 65,561 18,864 45,021 20,327 48,141 — 38,573

North A 102,851 — 85,181 — 13,856 2,130 57,140 8,942 48,003

North B 51,464 — 53,506 11,153 36,342 2,939 42,557 — 46,533

South 35,503 — 23,651 7,501 9,652 15,775 23,020 — 25,713

Urban 145,985 — — — — — — — —

West 236,604 — 131,894 13,280 21,922 7,160 36,337 — 71,213

Pemba

Chakechake 91,377 — 49,498 12,795 7,578 — 4,852 — 8,813

Micheweni 110,381 10,933 69,567 39,424 66,285 10,078 33,591 — 25,178

Mkoani 99,706 — 59,725 8,314 13,548 3,512 25,904 1,771 6,764

Wete 94,986 — 48,074 15,221 37,301 — 23,145 6,942 16,033

Total 1,033,742 10,933 586,657 126,552 250,505 61,921 294,687 17,665 286,823


Preparatory Activities for IRS Operations

Before executing IRS operations, a number of preparatory and foundational activities were conducted to ensure the optimal spray quality and successful outcomes.

Selection of Eligible Spray Areas and Logistic Assessment

After the last blanket round of IRS in 2010, in which all eligible household structures in rural areas of Zanzibar were targeted (with the exception of Stone Town), operations shifted to a more targeted approach. By 2011, the malaria surveillance system in Zanzibar had become robust. Additionally, LLIN mass distribution and the development of an interim insecticide resistance mitigation plan enabled Zanzibar to shift its IRS strategy from blanket to targeted and, subsequently, focal spraying.

The selection process for targeted spraying, which was developed by ZAMEP and its partners, considered a number of criteria (including operational, epidemiological, entomological, and socioeconomic ones, as shown in Box 1), and specific criteria were selected based on the evidence needed to identify high- and low-risk areas and, thus, determine eligibility.

Box 1. Criteria for selecting targeted areas in Zanzibar

Operational costs: This criterion considered the established number of structures that ZAMEP would target for IRS. Based on the PMI’s MOP for different years, starting in 2012, funding was reduced to support IRS operations, and thus, the number of structures that could be targeted by IRS also decreased.

Socio-demographic indicators: These indicators included the type of housing and the population density.

Malaria transmission risk: PMI’s MOPs from 2014 onward stated that the aim was to support focal spraying in those villages (shehias) with malaria incidence exceeding two cases/1,000 population. Factors that could potentially induce higher (or lower) transmission patterns, such as precipitation levels, house characteristics (specifically, the type of wall surface), and urban vs. rural settings, were considered for inclusion or exclusion in IRS operations.

Epidemiological factors: According to retrospective reference data, such as those from MCN, malaria epidemiology is highly seasonal, peaking after the rainy periods and showing inter-peak caseloads that are lower than those in 2008 and before. Stratification of the cases showed that cases originated in specific locations in certain shehias, which could be targeted for IRS.

Insecticide costs: This criterion overlapped with operational costs. The cost of the currently used pirimiphos methyl (Actellic 300CS, US$24 per bottle) is twice the price of bendiocarb (US$12) and eight times the price of previously used pyrethroids (e.g., lambda-cyhalothrin and deltamethrin). This cost difference became a major driver in reducing IRS geographical coverage, despite other operational costs being optimized through improved operational efficiencies.

Malaria control coverage: This criterion considered other control interventions (specifically, LLIN coverage and larval source management) that can be compared across districts and other areas to prioritize IRS in locations where exposure to multiple interventions is low.

Insecticide selection and duration: This criterion considered the relatively long residual period of the currently used insecticide, pirimiphos methyl, on treated wall surfaces

Entomological factors: This criterion included a number of key parameters (such as the variation in vector densities recorded in some areas) that could be useful in decision-making for targeted spraying. Unfortunately, the lack of timely data limited the use of this criterion.

Insecticide resistance: By rotating different classes of insecticide when spraying across areas, the pace of mosquitoes developing resistance to insecticides used in IRS can be slowed. This criterion was applied specifically to areas where resistance to pyrethroid insecticides existed and that continued being considered for IRS.

Behavior change communication (BCC): This criterion was important to consider because it had implications for the populations included and excluded from IRS. A well-defined, thoroughly understood BCC strategy had to be developed to address the concerns or questions of the public residing within and outside of the area targeted for spraying.

In January 2012, following extensive analysis of the available information and thorough discussions between malaria stakeholders, ZAMEP proposed primarily


using epidemiological data to establish the eligibility of areas targeted for IRS. Using MEEDS retrospective data covering the four years prior to 2011 (weekly aggregated cases from over 140 health facilities [HFs] in 10 districts), MEEDS reporting was analyzed and stratified according to the HF catchment area malaria incidence. The catchment areas comprised shehias that were within the service areas of particular HFs. This approach generated a more specific value of the malaria morbidity variance and, thus, facilitated more precise decision-making regarding eligible targeted areas.

The malaria risk was ranked by shehia, and areas with the highest malaria burden were prioritized for targeted spraying. The malaria morbidity on Unguja Island (Figure 1, below) reflected the variance in different areas in and within the districts, with West, Central, and South Districts showing very diverse risks in terms of the defined catchment areas. Similarly, the malaria morbidity on Pemba Island also exhibited varying values in the defined catchment areas in the four districts (Figure 1, right).

Figure 1. Malaria morbidity on Unguja and Pemba Islands, 2011 MEEDS

Using the annual morbidity rate of 1,000 persons for each allocated HF catchment area, 123,000 household structures were selected to be sprayed in a single round of IRS (incidence > 0.3 per 1,000 population); 15,000 household structures were targeted to be sprayed twice, with one spray round following the other to cover the peak transmission periods after seasonal rains (refer to the spray timing section) in areas with incidences exceeding 15 cases per 1,000 population.

Based on these criteria, approximately 137,000 household structures were eligible for spraying. The areas targeted for one and two rounds are illustrated in Figure 2.


Figure 2. Areas targeted for one and two rounds of spraying during 2012, Unguja and Pemba Islands

In 2013, the same methodology was applied to identify eligible areas for IRS. However, because of a decrease in funding; only approximately 54,000 were operationally targetable. Using the annual morbidity rate of 1,000 persons for each allocated HF catchment area, approximately 54,000 household structures were selected to receive one round of IRS (rate >2 per 1,000 population). Figure 3 illustrates the variation in the malaria morbidities for Unguja (left) and Pemba (right) according to the defined catchment areas, whereas Figure 4 shows the areas that received IRS and those that were excluded.


Figure 3. Malaria morbidity on Unguja and Pemba Islands, 2012 MEEDS

Figure 4. Shehias targeted during 2013, Unguja and Pemba Islands


In addition to the MEEDS data of weekly malaria cases reported by the HFs, the implementation of MCN represented an improvement to the malaria surveillance system in Zanzibar. The MCN was established in August 2012 but did not become fully operational until 2013. This system, which runs parallel to MEEDS, can track individual cases as part of the notification and follow-up process. Because of its ability to pinpoint cases up to the shehia and sub-shehia levels, the malaria burden can be visualized with more granularity. Hence, for the 2014 and 2015 IRS campaigns, the MCN was primarily used to create the selection process used to prioritize areas for spraying. Thus, instead of using HF-based catchment areas, the malaria incidence was calculated directly for each shehia and then stratified from highest to lowest malaria risk. Thus, the MCN increased the resolution of malaria transmission in Zanzibar, thereby also improving the selection process used to target geographic areas with IRS.

The 2013 malaria morbidity for Unguja Island (Figure 5, left) illustrates the variance in different areas within the districts, and that for Pemba Island also shows varying morbidity in the defined catchment areas of the four districts (Figure 5, right). Figure 6 presents the variance in the malaria morbidity observed in 2014.

Figure 5. Malaria morbidity on Unguja and Pemba Islands, 2013 MCN


Figure 6. Malaria morbidity on Unguja and Pemba Islands, 2014 MCN

Based on the annual morbidity rate of 1,000 persons of each shehia, approximately 65,000 household structures were selected to be sprayed in both the 2014 and 2015 IRS campaigns (rate >2 per 1,000 population).

Areas that did and did not receive IRS during the 2014 and 2015 campaigns are illustrated in Figures 7 and 8, respectively.


Figure 7. Shehias targeted for IRS during 2013–2014, Unguja and Pemba Islands

Figure 8. Shehias targeted for IRS during 2014–2015, Unguja and Pemba Islands


Insecticide Selection, Quality Assurance, and Use

From 2010 to 2011, lambda-cyhalothrin capsulated suspension (ICON® 10CS) was used in all IRS operations. In 2012, a carbamate (bendiocarb; FICAM® WP) was introduced in all districts of Zanzibar, and in 2014, pirimpiphos-methyl (Actellic® 300 CS), an organophosphate, began to be used. The classes of insecticide introduced and used over subsequent project years were selected in conjunction with ZAMEP and have received World Health Organization (WHO) Pesticide Evaluation Scheme (WHOPES) approval, insecticide registration status in the country, and the availability of entomological data. Once these insecticides reached regional warehouses, samples were collected and sent to an International Standards Organization (ISO)-accredited laboratory—AgriQ Lab—for quality analysis. Samples were also sent to Zanzibar’s Food and Drug Administration for quality analysis. The analysis results were used to determine whether the insecticide was suitable for IRS operations. In total, 5,453 liters of lambda-cyhalothrin, 7,603 kg of bendiocarb, and 36,937 liters of pirimiphos methyl were used in Zanzibar over the duration of the project (Table 9).

Insecticide Resistance Mitigation Management Plan

To mitigate the vector resistance to pyrethroid insecticides, TVCSP, in collaboration with ZAMEP, embarked on developing an insecticide resistance management plan in the project’s second year. The interim plan adopted in 2012 recommended replacing pyrethroids with carbamates for IRS according to a rotational strategy for at least two years until new formulations became available. Therefore, carbamates were used for IRS in 2012 and 2013. Because of the limited residual efficacy of carbamates, conducting two IRS rounds (especially in areas with high malaria incidence) each year was required to protect communities throughout the malaria transmission season. To further mitigate insecticide resistance, pirimiphos methyl was introduced into the rotation in 2014 to reduce pyrethroid resistance and maintain the efficacy of the various classes of insecticide for public health use. A long-term insecticide resistance management plan was developed in partnership with ZAMEP and other stakeholders. The plan was finalized in 2015 and will serve as a useful guide for resistance management for the implementation of IRS and other vector control interventions in Zanzibar.


Table 9. Insecticide Used by Year, Type, Area, and Number of Sachets Used per Household Structure

Area Year Sachets/ Bottles

Household Structures Sprayed

Sachets Used per

House

Insecticide (liters or

kgs) Type of Insecticide Remarks

Mainland Tanzania

2010–2011

492,811 1,144,621 0.43 30,801 liters Lambda-cyhalothrin Blanket IRS in all 18 districts of Kagera, Mara, and Mwanza Regions

2011–2012

528,599 1,224,095 0.43 27,640 liters Lambda-cyhalothrin Blanket IRS in 16 districts

10,765 kgs Bendiocarb Muleba and Karagwe

2012–2013

320,539 773,929 0.41

11,117 liters Deltamethrin Targeted IRS in all 11 districts in Mara and Mwanza Regions

18,842 kgs Bendiocarb Targeted IRS in all 7 districts in Kagera and select areas of Mara and Mwanza Regions

2013–2014

129,537 385,252 0.34 114,381 liters Pirimiphos-methyl Targeted IRS in 6 districts of Mara and Mwanza Regions

2014–2015

156,171 419,753 0.37 137,898 liters Pirimiphos-methyl Targeted IRS in 7 districts of Kagera, Mara, and Mwanza Regions

Mainland Tanzania Total

2010–2015

1,627,657 3,947,650 0.41

58,441 liters Lambda-cyhalothrin

– 29,607 kgs Bendiocarb

11,117 liters Deltamethrin

252,279 liters Pirimiphos-methyl

Zanzibar

2010–2011

87,241 194,808 0.45 5,453 liters Lambda-cyhalothrin

All 10 districts

2011–2012

45,939 114,858 0.40 5,742 kgs Bendiocarb

Targeted IRS in 9 districts

2012–2013

14,882 51,904 0.35 1,861 kgs Bendiocarb


2013–2014

22,332 62,743 0.35 19,719 liters Pirimiphos-methyl



Area Year Sachets/ Bottles

Household Structures Sprayed

Sachets Used per

House

Insecticide (liters or

kgs) Type of Insecticide Remarks

2014–2015

19,500 62,391 0.33 17,218 liters Pirimiphos-methyl


Zanzibar Total 2010–2015

189,894 486,704 0.39

5,453 liters Lambda-cyhalothrin



Tanzania Total

2010–2015

1,817,551 4,434,354 0.41

63,894 liters Lambda cyhalothrin


11,117 liters Deltamethrin



IRS Logistical Arrangements

Establishment of District IRS Technical Teams (DITTs)

In Zanzibar, the functional IRS management and implementation unit was the DITT. Each DITT was located at the zonal level in the ZAMEP offices in Zanzibar (Unguja) and Wete (Pemba). The DITT was chaired by the District Medical Officer (DMO) with support from the Zonal Medical Officer. Members included the District Health Officer, District Administrative Secretary, and four additional district technical staff. RTI supported the DITTs by providing initial training in IRS implementation and allocating supervisors and consultants during IRS operations for further on-the-job training and mentoring.

Implementation teams (sub-units) for advocacy and health education, vector control, and M&E met daily during the IRS operations, whereas the DITT was scheduled to meet weekly.

Transportation and Storage of IRS Commodities

Three logistics levels were operational under this project: (1) a zonal warehouse located in Urban District that also served as a district warehouse, (2) one district warehouse located in each of the remaining nine districts in Zanzibar, and (3) a total of eight temporary storage sites to serve the satellite islands in the allotted districts of Micheweni, North A, and South during IRS operations.

The storage of other IRS materials was organized according to the established four levels

The zonal warehouse, which was the highest level, received supplies from domestic and international suppliers and served Central, North A, North B, South, West, and Urban Districts on Unguja Island and Chakechake, Micheweni, Mkoani, and Wete Districts on Pemba Island

From the zonal level, supplies were distributed to district warehouses one month before IRS

The district warehouses also served as staging sites for IRS operations and as distribution points to sites in the satellite islands attached to Micheweni, North A, and South Districts. For these satellite sites, the supplies were transported from the district stores two weeks before IRS operations.

Throughout IRS operations, distribution was guided by the quantification of needs at each level.

RTI contracted private vendors to ship insecticides and equipment directly to the Zanzibar seaport and then to the zonal warehouse. From there, the IRS commodities were transported to the respective district warehouses (and temporary sites) as per the quantified needs.

Pumps, personal protective equipment (PPE), and other IRS supplies were procured directly by RTI in accordance with USAID regulations. As an example of the logistical resources needed to implement spraying, a total of 76 vehicles and seven water craft were used to transport spray operators and commodities and for supervision during the


peak TVCSP spray period in 2011. The procurement of transport services was arranged in the respective districts in collaboration with district health authorities.

Organization of Spray Sites

RTI continued to maintain the IRS delivery model initiated in 2006, which involved the extensive use of human resources and deployment logistics. Thus, the program required a high degree of organization and capacity (Figure 9).

Figure 9. Organizational structure of IRS teams

The general TVCSP IRS design was based on the OS. Each site had an operational target that ranged from 1,500 to 11,500 household structures. The OS received adequate infrastructure for effluent waste disposal, sanitary accommodations for operators, and storage facilities. The OS effort was led by a site manager supported by, on average, four spray teams (two–eight persons per team) and four–eight site attendants, depending on the size of the site. The time of operation per site, number of operation days, and allocated resources (e.g., human resources, insecticide, equipment,


and consumables) were calculated based on the targets. On average, the duration of operations was determined to be approximately 11 days per site.

There were seven operators per team in Zanzibar, with an average of 70 spray operators per site. Each team was headed by a team leader. The team leaders and spray operators were selected from the targeted communities. The OS manager was assisted by support staff who maintained the spray equipment, washed the suits, cleaned the site, fetched water, and handled security. A level of effort of 10 sprayed household structures per operator per day was used to develop the spray schedule and monitor progress. At the OS, an average of 30 liters of water per each operator per day was calculated to be needed for suit washing and pump rinsing. Water for charging spray pumps was provided by households as operators moved from one household structure to the next.

All sites were refurbished/renovated before the start of the operations to comply with international and local environmental impact and mitigation measures for safe pesticide use and storage and sound effluent waste disposal. Therefore, the sites complied with the Pesticide Storage and Stock Control/User Guidelines of WHO and the Food and Agriculture Organization of the United Nations.

Human Resource Development and Management

Active IRS operations require a large number of temporary operational IRS field staff and other technical, coordination, and supervisory support staff. RTI, in collaboration with district authorities, recruited an average of 700 temporary staff in Zanzibar (Table 7) The selection process was led by local government authorities and supervised by the delegated DITT and RTI personnel (see Box 2 for the selection criteria). Broad and equal representation from the targeted communities was sought.

Mechanisms were set up to guarantee a transparent and fair process. The selected staff provided personnel details, a photograph, bank account details, and a medical certificate of good health. The respective RTI offices filed all documents and provided an identity card. The selected individuals also signed a consent form. At the IRS OS level, TVCSP opened a file for each temporary staff member that included the medical attendance form and other personal documents. All female operators were tested for pregnancy prior to enrollment, and those who tested positive were disqualified.

The RTI finance team transferred compensation for temporary staff to their personal bank accounts at fixed intervals (two weeks). From 2013, RTI introduced money transfer through mobile phones using MPesa Account, which every temporary staff was required to have and submit during the recruitment process. The MPesa transfer was quicker,

Box 2. Criteria for IRS operators’ selection

Age: 18–40 years

Sex: Either (50% or more women)

Education: Standard 7 and above and efficient in reading and writing Kiswahili

Possession of a valid personal bank account (later, an MPesa account)

Acceptance in the community

Good enough health to carry pumps and walk long distances

Experience

Physical and mental fitness

Residence in the service area


more efficient, and less cumbersome for the finance team, especially when handling large cash flows.

After staff selection, knowledgeable Vector Control Officers (VCOs) conducted staff training. A cascade training approach—i.e., training of trainers (TOT)—was used: First, site managers and supervisors were trained, and these individuals later supported the training of other supporting staff, such as cleaners and site guards. The training of spray teams was conducted at different training sites and supervised by the VCOs who had trained the site managers and team leaders

The trainings usually lasted for one week and included the use of PPE, safely handling insecticides, spraying techniques, environmental compliance, minor pump repair, completion of IRS forms, and interactions with clients.

IRS training modules and training curriculum were the main training guides used by the trainers. Site managers and team leaders focused on module number three, which provides the general principles of IRS, site/sub-site management (human and resource management), and the management of environmental compliance issues, mainly focusing on human safety and effluent waste management. The module also illustrates how to decommission sites once the operations are over.

Spray teams were trained using the module designed for spray operators. The focal points of this module include the basic principles of IRS, the use and maintenance of IRS equipment, how to conduct the spraying exercise, the management of insecticide waste, personal protection, the safety of the community and general environment during IRS, and how to record the various data generated during IRS.

Preparations for Collection, Processing, Analyzing, and Disseminating Data/Information to Stakeholders

An integral component of IRS is M&E. At the preparatory stage, M&E involved putting in place the designs and procedures for collecting, processing, analyzing, and disseminating IRS outputs and outcomes. The tools used included forms completed by spray operators and later processed electronically by data clerks.

Information, Education, and Communication (IEC) for IRS

Community sensitization and mobilization were conducted to achieve optimal IRS coverage. Interpersonal communication was the most effective way to deliver IRS-related information to the public. This communication was intended to increase IRS acceptance, curb refusals, tap into community support, and ensure that the community was protected from accidental insecticide contamination.

Varied IEC approaches were used. In the first year of TVCSP, RTI collaborated with Johns Hopkins University-Center for Communication Programs (JHU-CCP) and local government authorities under the leadership of ZAMEP. JHU-CCP was subcontracted to provide technical support for the revision of IEC printed materials and the development of media spots for IRS. IEC materials (e.g., leaflets and posters) used in previous IRS rounds were revised, and additional IEC materials were developed, such as frequently asked question (FAQ) brochures and flip charts used in trainings. Posters were also created and placed on public notice boards, streets, and markets and at HFs.


Additionally, JHU-CCP assisted in the design and production of banners to display at IRS staging sites and on vehicles used during operations.

JHU-CCP also helped in using electronic media to inform communities about IRS. Radio spots and jingles that used humor and drama to engage listeners and to detail the actions that households needed to take to prepare for the spray exercise were prepared.

Local government authorities (DMOs, district IEC persons, and village shehias) were identified to inform and support the leadership in carrying out IEC activities at the community level.

These IEC partners were selected to conduct advocacy and sensitize leaders and the community in all districts and shehias to secure acceptance, compliance, and contributions from the beneficiary communities and leaders. An IEC master training curriculum and package were developed by RTI. The selected IEC partners were trained by RTI on different participatory approaches for IEC, how to conduct trainings, how to facilitate sensitization meetings, how to monitor activities, and how to conduct effective supervision, planning of activities, and time management, among other skills. During the first year of IRS, almost 800,000 informative leaflets, brochures, and posters on IRS were developed, displayed, and/or distributed to community leaders and residents.

During the implementation, RTI played a facilitating role by providing IEC materials, megaphones, and transportation. In addition to person-to-person communication, RTI continued to use electronic media to reach out to people, including radio spots and public announcement systems, just before and during IRS implementation.

M&E

In IRS, systematic monitoring was established to follow up on inputs, processes, and outputs. Information was collected and then utilized before, during, and after spraying. More importantly, daily monitoring during the operations was important to ensure that processes and outcomes were observed and, thus, allow the timely detection of gaps and constraints so that adequate responses could be triggered (Figure 10).

Figure 10. M&E framework for IRS

Monitoring Performance Measuring Results


Additional indicators reflecting the reason for IRS refusal, community satisfaction, and net coverage were also measured.

To facilitate effective daily monitoring, RTI focal persons supervised daily monitoring and facilitated the movement of IRS information from the field to the offices of the appointed district data clerks.

The flow of information was as follows:

Spray operators collected information on households (e.g., sprayed, visited, and not reached), demographics (e.g., high-risk populations and children over five years of age), refusals and the associated reasons, and IEC sensitization. This information was, in turn, compiled by their team leaders and then forwarded to their supervisors, who compiled and sent the data to a yet higher level: the site manager. The site manager was then responsible for submitting the data to the district data unit, who entered and generated reports on a daily basis to be used for interpretation and action by the IRS technical team and district teams.

From the spray operator level to the site manager level, information was captured in hard-copy format on spray forms designed specifically for each level. Upon reaching the data management unit, the hard-copy, paper-based information was transcribed into electronic format using specially designed Excel-based IRS data templates created for each district. The information in the database reflected that collected on the ground by spray operators, team leaders, supervisors, and site managers. All hard-copy forms were filed and stored at the district data office until the end of the spray round, after which they were moved to the RTI office and shelved in a categorized manner.

The technical team monitored daily performance up to the site level in IRS districts. Among the numerous data collected, the numbers of households sprayed (and not sprayed) were assessed against the daily target. The numbers of households sprayed by spray operators per day was also captured. In addition to spray performance, information on insecticide consumption and stocks for each day was collected and monitored. Feedback on performance was periodically relayed to site managers and supervisors and DMOs so that progress could be assessed and gaps, if any, responded to in a timely manner.

In addition, vehicle and fuel usage, equipment and consumable stocks, training, quality of spraying, and compliance measures were tracked in a timely fashion.

After the completion of IRS, RTI produced summary tables and charts on progress and the results achieved for dissemination to partners and stakeholders.

Impact-related indicators measuring malaria-related prevalence, morbidity and mortality, and supportive entomological parameters were periodically collected and found to be useful in observing the effect(s) of the intervention(s).


Component 2—Environmental Compliance Strategies and Monitoring Plans

Environmental Assessment

In 2010, the Tanzania Supplemental Environmental Assessment (SEA) that was submitted to accommodate new regions in the Lake Zone also included a justification for the continuation of IRS operations in Zanzibar. From 2010 onward, in each IRS round, RTI, in collaboration with ZAMEP, prepared and sent to USAID a justification letter report to inform USAID of the status of IRS environmental compliance activities, as stipulated in the SEA and in compliance with U.S. regulation 22 CFR 216. The letter included the environmental risk mitigation actions undertaken by TVCSP and the rationale for shifting from one class of insecticide to another according to insecticide rotation management plan to mitigate the development of insecticide resistance. After USAID approval was received, RTI started the procurement process for insecticide to be used in the upcoming IRS round. This process was especially relevant when the insecticide class was changed, first in 2012, from pyrethroids to bendiocarb, and later, in 2014, from bendiocarb to pirimiphos-methyl. To comply with PMI’s Programmatic Environmental Assessment (PEA) requirements, RTI, in collaboration with ZAMEP, sought insecticide importation permits from the Zanzibar Food, Drugs and Cosmetics Board in December 2012 and again in 2013.

Insecticide Management and Environmental Management Plan (EMP)

During the 2010–2015 spray operations, TVCSP utilized a set of prepared environmental compliance guidelines and standard operating procedures (SOPs) for spray personnel as well as the EMP contained in the approved SEA for spray team training and IRS operation implementation; guidelines were updated in 2014 prior to trainings to include the community-based IRS approach. Training of personnel emphasized the use of triple-rinsing for pump cleaning at the end of each spray day, the inspection of pumps for leakage and general maintenance, and the disposal of washouts and solid waste. All spray teams were trained on all aspects of environmental compliance prior to the commencement of each spray campaign. During operations, spray teams were supervised to maintain protection and safety measures for themselves and residents, as well as for emergency preparedness in case of adverse reactions and accidental exposure to used insecticide, in accordance with the EMP and Sections 44−45 of the Tanzania Occupational Health and Safety Act, 2003. In addition, to manage insecticide stocks, a control system was instituted that included bin cards, ledgers, vouchers, and daily/weekly trackers and the marking of form number one on each household structure in which a sachet/bottle of insecticide was opened. The measures used to strictly track the movement of insecticide sachets or bottles from temporary storage facilities to the spray teams were meant to prevent pilferage and potential misuse, promote the insecticides’ safer use, and protect the environment and human health. At the end of every spray day, empty sachets/bottles were returned by spray operators, counted, and subsequently incinerated or, in the case of bottles, punctured to prevent reuse. Using the insecticide-tracking forms any observed discrepancies in sachets or bottles issued and returned on each spray day were reported and investigated.

Medical attendance forms were available for monitoring undesirable and adverse reactions to insecticides for all IRS staff.


TVCSP continued to use insecticide-tracking forms to monitor consumption and the empty sachets/bottles returned on a daily basis.

SOPs guided the disposal of solid wastes, including empty sachets/bottles, according to best management practices.

In terms of storage facilities, TVCSP allocated a main warehouse in Zanzibar’s Urban District. This warehouse served as the main distribution point to the other, smaller warehouses located in each district in Zanzibar. During the blanket IRS era, nine district warehouses that also served as IRS OSs and one zonal warehouse that also served as a district warehouse for Urban District existed. Eight additional sites were set up to serve the satellite islands in Micheweni, Central, and North A Districts. However, once the strategy shifted to targeted spraying, the number of sites was reduced to 14 overall in 2011, and even further to 9 by 2015. All sites were refurbished/renovated before the start of operations to comply with international and local environmental impact and mitigation measures for safe pesticide use and storage, and sound effluent waste disposal.

Environmental Monitoring and Inspections

Environmental monitoring and environmental compliance inspections comprising pre-spray and mid-spray inspections were conducted at all OSs in Zanzibar by the TVCSP Environmental Compliance Advisor. The purpose of the pre-spray environmental inspections was to evaluate the program’s preparedness and the compliance of operational sites before the commencement of IRS operations, whereas the mid-spray inspection was designed to assess compliance with IRS best practices and environmental provisions during IRS operations. These inspections ensured that IRS activities complied with the environmental monitoring and mitigation plans, as stipulated in IRS best practices, PMI’s SEA, U.S. 22 CFR 216 and Tanzanian regulations.

IRS Waste Disposal Arrangements

In 2013, RTI began incinerating contaminated waste using the TVCSP-procured incinerator that was commissioned for use at Kivunge Hospital, located in North A District. An initial, 600-kg stockpile that had been safely accumulated during previous rounds in the main warehouse in Urban District was transported to and incinerated in batches at the facility. The disposal process required almost one year. In the final two years of the project, all contaminated waste, except for empty insecticide bottles, was incinerated. TVCSP proposed recycling all used plastic materials associated pirimiphos methyl. The stored empty plastic bottles were separated into bottles, caps, and seals, and these materials were shredded separately and handed over to the identified plastic recycler, Express Trading Co. Ltd.

Component 3—Malaria Surveillance, Epidemic Preparedness, and Rapid Response

RTI began to support ZAMEP in establishing a malaria surveillance system in 2008 via the previous Malaria Control in Mainland Tanzania and Zanzibar project. Subsequently, via TVCSP, RTI continued to provide technical support for malaria surveillance and


response activities. The following are the activities implemented by ZAMEP with TVCSP support from the beginning of TVCSP in March 2010 through June 2016.

Malaria Early Epidemic Warning System

TVCSP, in collaboration with ZAMEP, obtained a formal agreement from the Tanzanian Meteorological Agency (TMA) in January 2012, whereby TMA would provide weekly rainfall data. TVCSP supported ZAMEP in analyzing the weekly rainfall data alongside the weekly malaria data to anticipate normal seasonal malaria transmission and forecast abnormal malaria transmission trends (Figure 11). Over the years, trends have shown that increases in malaria cases are highly seasonal: When rainfall is high, the number of malaria cases is low, presumably because mosquito breeding sites are being washed away. After the rainy season, however, water becomes stagnant and, thus, creates favorable mosquito breeding sites, ultimately leading to increased malaria transmission and, hence, an increased number of malaria cases. Figure 11 also shows that the number of malaria cases in the population aged 5 years and above is higher than that in the population below 5 years of age.

Passive Surveillance—MEEDS

TVCSP provided technical support to ZAMEP to establish MEEDS in 2008. MEEDS was introduced to provide timely malaria data to monitor the impact of Zanzibar’s malaria prevention and control efforts, and to detect sudden increases in focal malaria transmission that would warrant responsive actions. The activities supported by TVCSP since the start of the project are described below.

Production of MEEDS Weekly Report

TVCSP and ZAMEP prepared and shared weekly and quarterly reports with stakeholders from March 2010 to July 2016. Figure 12 summarizes the trends of patients tested for malaria and malaria diagnostic test positivity by age group from January 2010 to July 2016. The results in Figure 12 indicate that the malaria test positivity rate in children under five years of age was consistently two to four-fold lower than that in those above five years of age.


Figure 11. Malaria positivity and rainfall data, January 2010–July 2016*

*January to July 2016

Figure 12. MEEDS malaria testing and malaria positivity by age group, January 2010–July 2016*

*January to July 2016


Active Surveillance—MCN

In August 2012, RTI, in collaboration with ZAMEP, introduced a new surveillance tool that was developed from MEEDS and is based on individual MCN.

Individual malaria cases are initially notified by the responsible HF using the same cellular phone platform used for MEEDS. COCONUT Surveillance is a next-generation, open-source data collection tool developed by RTI’s Research Computing Division and used in Zanzibar to guide public health workers through malaria elimination protocols. District Malaria Surveillance Officers (DMSOs) then obtain detailed information about individual cases at HFs, following cases up at the household level. All household members are then tested for malaria, and if they test positive, they are treated following ZAMEP’s malaria treatment guidelines.

Figure 13 shows the trends of the proportion of cases notified and followed up. Ideally, a case is notified within 24 hours, the target being that 90% of cases are followed up within 24 hours. The data demonstrates that case notification improved over time, with an average of 60% of cases notified within 24 hours.

Figure 14 shows the numbers of household members that were tested for malaria and that tested positive for malaria. The trends indicate that more malaria cases are notified between May and July of each year following the heavy rainfall season, and that the proportion of positive household members increased over time.


Figure 13. Trends in malaria cases notified and followed up, September 2012‒July 2016

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Figure 15 shows the distribution of index (notified through MCN) and secondary cases identified through household screening and treatment in Unguja and Pemba between January 2013 and July 2016.

Figure 15. Malaria case distribution, January 2013–July 2016

Figure 16 shows that the proportion of malaria cases travelling outside Zanzibar increased from 30% in 2013 to 50% in 2015. However, most of the cases were reported from Unguja Island, and the top five travel destinations in Mainland Tanzania were Dar es Salaam, Mwanza, Morogoro, Tanga, and Mtwara. Urban District had the highest proportion of cases (70%) that travelled outside Zanzibar.

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Figure 16. Proportion of all malaria cases with a reported history of travel outside Zanzibar


Outbreak Investigation and Response Activities

TVCSP provided the following support to ZAMEP and the district response teams for outbreak investigation and response when malaria hotspots and epidemics were reported.

Malaria Surveillance Technical Documents

TVCSP provided technical support to develop the four following malaria surveillance documents:

1. SOP surveillance manual for HFs, DMSOs, and the surveillance, monitoring, and evaluation team

This manual aims to provide guidance to new health personnel on the design and implementation of the two malaria surveillance systems (MEEDS and MCN) in Zanzibar. It also describes the features of the web portal that was designed to manage the data and perform basic analyses.

2. National guidelines for malaria surveillance and response

These guidelines were developed to provide guidance to ZAMEP, district teams, HF staff, and the community at large for conducting malaria surveillance and response efforts.

3. Guidelines for the district malaria response team

These guidelines aim to provide guidance to the ZAMEP district teams for conducting malaria surveillance and response activities. The document describes the steps that need to be taken in the event of an outbreak as well as details the possible effect and impact of each intervention that is implemented in response to an outbreak.

4. Malaria surveillance data analysis and interpretation manual

This manual describes how to detect an abrupt increase in malaria cases and, in turn, trigger the outbreak response plan implemented by the district malaria response teams.

Establishment of DMSOs

TVCSP, in collaboration with ZAMEP, established a new health cadre in each district: the DMSO. Recruited by the district authorities, the role and responsibilities of the DMSO are to provide support for malaria surveillance and response activities, specifically following-up all malaria cases notified from HFs to the household level and testing all primary case household members for malaria infection.

To date, 20 (18 males and 2 females) DMSOs have been recruited, with each district being supported by two DMSOs. TVCSP provided the DMSOs with electronic tablet devices to collect, record, and share malaria data, and with motorcycles and fuel to facilitate prompt follow-up of all notified cases.

Additionally, TVCSP conducted several trainings and workshops to enable the DMSOs to improve their skills and capacity to conduct malaria investigation and response activities in their respective districts. Furthermore, TVCSP, in collaboration with ZAMEP, conducted quarterly feedback meetings to allow the DMSOs an opportunity to share their experiences and challenges while in the field.


Establishment of the District Malaria Response Team

In 2014, TVCSP, in collaboration ZAMEP and district authorities, created district malaria response teams for Pemba and Unguja that were primarily tasked with responding to malaria outbreaks in their respective districts upon notification. Each team comprised 10–13 members, depending on the setting of the respective district, and the membership included the DMO, DMSOs, Clinical Officer/Nurse, Health Promotion Officer, Environment Health Officer, and District Administrator, among others.

TVCSP supported ZAMEP in conducting biannual feedback meetings, and approximately 117 attendants from all 10 districts were involved in each meeting. These meetings were intended to provide an opportunity to share experiences and challenges during response activities conducted in respective districts and to review the individual roles in the response team and the monitoring of malaria trends and case detection.

Capacity Building for ZAMEP Staff

As part of the effort to build capacity and develop sustainability plans, TVCSP provided several trainings to ZAMEP staff with topics including scientific writing, data management and analysis, and data quality assessment (DQA).

Additionally, in 2016, TVCSP conducted a five-day training for eight ZAMEP staff in Pemba and Unguja on the application of the Geographical Information System (GIS). This course aimed to provide virtual learning and core training and skills development in solving real-world problems and to develop cutting-edge solutions by combining technology and programmatic skills.

Training of Health Providers on Data Transmission Using the Unstructured Supplementary Service Data (USSD) System

In 2016, a total of 167 health providers (113 from Unguja and 54 from Pemba) from private HFs were trained on malaria data transmission using the USSD system. The proportions of female participants trained were 45% and 26% in Unguja and Pemba, respectively. Using simple mobile phones, health providers are required to send each patient’s name and shehia/village to the remote server via the USSD system. Then, the patient’s details are sent to the DMSO as a Short Message Service (SMS) notification, and the DMSO must visit the patient and treat the rest of the household members. Implementing this system has been a great success for ZAMEP/Ministry of Health, and all HFs (public and private) are now reporting using it.

Conduct Outbreak Investigation and Response Activities

TVCSP, in collaboration with ZAMEP, reviewed and analyzed MEEDS weekly malaria data to detect any abrupt increase in the number of malaria cases. Shehias with 10 or more malaria cases and villages with 5 or more cases within seven days were identified, and response activities were promptly conducted. Figure 17 shows the shehia/village response activities conducted between January 2013 and June 2016.


Figure 17. Shehias where response activities were conducted between January 2013 and June 2016


IRS Sustainability and Projections for Future Needs in Zanzibar

In 2013, TVCSP provided technical support to ZAMEP to develop a Malaria Strategic Plan (MSP) for 2013 to 2018. In the MSP, ZAMEP planned to focus on capacity building for logistics officers in managing resources for IRS at the district level. In addition, the program aimed to strengthen field supervision by reducing the number of operators per team to four operators/supervisor.

Under TVCSP, SOPs were developed to enable councils to implement quality IRS. The SOPs outline the procedures to be followed for quality IRS, including the following: monitoring spray procedures in the field, monitoring the effectiveness of the spraying by conducting cone bioassays and utilizing insecticide quantification kits (IQKs), and monitoring human safety and environmental compliance. Exit strategies will be planned well in advance, as early as the start of the implementation in selected areas.

Projections for Future Needs. In Zanzibar, ZAMEP plans to maintain universal coverage via vector control and IRS. ZAMEP will continue IRS in high-risk shehias, which will be selected based on epidemiological information collected via routine surveillance systems, geographical reconnaissance, and the output of the malaria risk mapping. In addition, environmental impact assessments will be conducted before and after IRS operations to monitor the impact of the IRS intervention (i.e., coverage in the targeted areas and the quality of spraying).

IV. ACTIVITIES IN MAINLAND TANZANIA

Component 1—IRS

PMI began supporting IRS operations in Mainland Tanzania in 2007. PMI first contracted RTI to provide technical support to the NMCP in controlling malaria outbreaks in the malaria-unstable areas of Karagwe and Muleba Districts in Kagera Region. In 2009, IRS operations were scaled up in Kagera Region to cover the remaining stable and high-transmission areas in the other five districts (Biharamulo, Bukoba Rural, Chato, Misenyi, and Ngara).

In 2010, IRS operations in Kagera Region transitioned to the newly awarded TVCSP. Following the success of IRS in Kagera Region, the NMCP requested that PMI expand IRS into the remaining two regions (Mwanza and Mara) in the Lake Zone because these regions have the highest malaria prevalence in the country, as revealed by the Tanzania Human Immunodeficiency Virus/Malaria Indicator Survey 2008–2009. This scale-up included eligible household structures in rural areas, as indicated by the NMCP’s Integrated Malaria Vector Control approach in Tanzania. Municipalities and other major urban centers in these regions were excluded from IRS.

Starting in March 2010, under TVCSP, IRS operations were scaled up to cover 11 districts in Mara and Mwanza Regions (Figure 18).

In 2012, a second round of IRS was conducted in five districts in Mara Region and six districts in Mwanza Region, and a third round was conducted in five districts in Kagera Region. A targeted spray round was initiated in Muleba District in Kagera Region in 2012, and an additional blanket spray round was conducted in Karagwe


District in Kagera Region. In 2013–2014, the IRS strategy changed, shifting from blanket spraying to targeted spraying and, eventually, focal spraying. The spray target for 2014−2015 was scaled down further relative to that of 2011−2012, when TVCSP sprayed the most household structures in any given implementation year (1,224,095).

Beginning in 2007, pyrethroid insecticide (lambda-cyhalothrin) was used for IRS in Kagera Region. In the 2011–2012 IRS seasons, bendiocarb was introduced in Muleba and Karagwe Districts. However, increased insecticide resistance against pyrethroids, emerging insecticide resistance against bendiocarb in a few districts, and the short residual period of bendiocarb necessitated spraying twice a year. Therefore, NMCP decided to switch to pirimiphos-methyl for the 2013–2014 IRS operations. In these seasons, a focal spraying approach was implemented in six priority districts selected based on their high burdens of malaria transmission. In 2014–2015, RTI was mandated by NMCP to implement IRS using pirimiphos-methyl and targeting 445,796 structures in the three Lake Zone regions.

In addition to routine IRS in the mandated areas of the Lake Zone, RTI also supported spraying in two wards of Geita Town during 2011–2015 as part of a public-private partnership (PPP) among Geita Gold Mine, Geita Town Council, and USAID. For nearly four years, this PPP capitalized on collective efforts and resources to implement IRS, targeting over 20,000 structures in Geita each year. Based on the success of this experience, TVCSP recommends emulating the approach with other private sector entities in Tanzania and beyond.

Figure 18. IRS scale up in the Lake Zone, 2006–2010

IRS Performance in the Lake Zone by District (2010–2015)

Table 10 summarizes the household structures sprayed and the spray coverage by district and implementation year. Table 11 summarizes the people protected from malaria infection. Throughout the project, spray coverage consistently exceeded 90%.


Table 10. IRS Performance in the Lake Zone, 2010–2015

Region/ District

2010–2011 2011–2012 2012–2013 2013–2014 2014−2015

Kagera

Biharamulo Sprayed Visited (coverage)

38,032 40,304 (94.4%)

40,331 44,510 (91%)

— 13,548 14,768 (92%)

14,327 14,661 (93%)

— — 42,767 42,793

(93.3%)

Blanket Blanket Target Target Blanket

Bukoba R Sprayed Visited (coverage)

60,548 62,730

(96.5%)

58,925 61,312 (96%)

— 16,708 17,159 (97%)

18,235 18,303 (99%)

— — —

Blanket Blanket Target Target

Chato Sprayed Visited (coverage)

60,571 62,337 (97.2%)

58,319 61,259 (95%)

— 20,514 21,604 (95%)

20,713 20,714 (95%)

— — 53,899 54,031 (92.5%)

Blanket Blanket Target Target Target

Karagwe Sprayed Visited (coverage)

115,669 115,972 (99.7%)

109,102 117,277 (93%)

— 52,331 55,930 (94%)

30,073 30,791 (98%)

— — —


Missenyi Sprayed Visited (coverage)

37,698 40,135

(93.9%)

37,580 40,813 (92%)

— 11,319 11,595 (98%)

11,582 11,871 (98%)

— — —


Muleba Sprayed Visited (coverage)

101,394 101,491 (99.9%)

52,312 56,148 (93%)

37,874 39,946 (95%)

16,692 17,738 (94%)

16,287 17,766 (92%)

— — 81,294 81,303

(98.6%)

Blanket Target Target Target Target Target

Ngara Sprayed Visited

46,264 54,578

46,069 54,066

— 13,126 15,600

15,760 15,795

— — 37,240 37,458


Region/ District

2010–2011 2011–2012 2012–2013 2013–2014 2014−2015

(coverage) (84.8%) (85%) (84%) (98%) (98.7%)


Mara

Bunda Sprayed Visited (coverage)

45,811 51,710 (88.6%)

54,744 57,457 (95%)

— 39,519 41,731 (95%)

8,238 8,750 (94%)

— 51,673 52,397 (91%)

—


Musoma Sprayed Visited (coverage)

60,363 70,597 (85.5%)

73,157 79,401 (92%)

— 53,549 54,981 (97%)

8,861 11,430 (78%)

— — —


Rorya Sprayed Visited (coverage)

47,200 49,306 (95.7%)

70,218 74,665 (94%)

— 28,867 30,587 (94%)

— 5,443 5,443

(89%)

76,249 77,768 (92%)

77,228 79,632

(91.6%)

Blanket Blanket Target Target Blanket Blanket

Serengeti Sprayed Visited (coverage)

58,993 59,366 (99.4%)

51,761 55,614 (93%)

— 39,952 43,277 (92%)

— 8,738 8,748

(91%)

53,895 55,830 (94%)

—


Tarime Sprayed Visited (coverage)

53,136 54,838 (96.9%)

74,645 82,363 (91%)

— 42,621 43,764 (97%)

— 8,633 8,642

(95%) — —


Mwanza

Geita Sprayed Visited (coverage)

127,075 127,454 (99.7%)

123,196 130,475 (94%)

— 75,199 80,305 (94%)

— 15,831 15,955 (97%)

108,142 108,457 (97%)

—


Geita Town Sprayed Visited

— 18,206 20,193

— 20,830 22,374

— — 13,620 13,624

21,363 21,402


Region/ District

2010–2011 2011–2012 2012–2013 2013–2014 2014−2015

(coverage) (90%) (93%) (61%) (96.6%)

Kwimba Sprayed Visited (coverage)

52,718 58,180 (91.7%)

57,467 61,348 (94%)

— 39,272 40,372 (97%)

6,441 7,186 (90%)

— — —


Magu Sprayed Visited (coverage)

65,462 78,767 (83.1%)

75,218 81,228 (93%)

— 48,463 52,356 (93%)

8,301 9,468 (88%)

— — 58,324 58,374

(91.8%)


Missungwi Sprayed Visited (coverage)

38,693 43,839 (89.3%)

45,385 49,154 (92%)

— 32,184 33,243 (97%)

6,765 6,866 (99%)

— — 47,638 47,718

(92.4%)


Sengerema Sprayed Visited (coverage)

84,558 87,134 (97.0%)

86,065 91,547 (94%)

— 63,197 64,721 (98%)

12,638 12,639 (93%)

45,350 45,352 (95%)

—


Ukerewe Sprayed Visited (coverage)

50,436 52,859 (95.4%)

53,520 55,229 (97%)

— 31,255 33,300 (94%)

6,090 6,092

(96%)

36,323 36,331 (88%)

—


Total Sprayed (coverage)

1,144,621 (94.5%)

1,224,095 (93%)

659,146 (95%)

114,783 (94%)

108,173 (95%)

385,252 (92%)

419,753 (94%)


Table 11. Number of People Protected from Malaria Infection by IRS in the Lake Zone, 2010–2015

Population Protected from Malaria Infection in Mainland Tanzania

Region/ District

2010-2011 2011-2012 (Round 1)

2011-2012 (Round 2)

2012-2013 (Round 1)

2012-2013 (Round 2)

2013-2014 2014-2015

Kagera

Biharamulo 209,547 216,726 68,019 74.091 228,587

Bukoba R 267,388 266,098 75,386 82,002

Chato 337,731 343,726 110,001 113,898 292,102

Karagwe 548,773 499,687 238,788 138,079

Missenyi 157,912 162,393 49,875 52,257

Muleba 480,500 246,114 177,788 75,267 70,389 378,677

Ngara 182,148 197,951 53,488 72,248 177,058

Mara

Bunda 240,169 326,779 216,521 44,411 256,628

Musoma 303,530 386,314 268,848 39,527

Rorya 210,976 299,895 123,721 22,543 308,429 310,859

Serengeti 310,671 251,409 194,908 40,106 261,130

Tarime 301,495 380,126 214,766 42,717

Mwanza

Geita 768,234 767,511 411,836 89,280 629,427

Geita Town 100,588 108,645 40,756 120,889

Kwimba 327,420 361,534 249,173 36,015

Magu 361,239 450,899 290,974 47,115 322,093

Missungwi 243,355 282,930 200,986 41,257 279,933

Sengerema 566,089 510,762 385,344 70,313 249,673


Population Protected from Malaria Infection in Mainland Tanzania

Region/ District

2010-2011 2011-2012 (Round 1)

2011-2012 (Round 2)

2012-2013 (Round 1)

2012-2013 (Round 2)

2013-2014 2014-2015

Ukerewe 282,333 291,123 164,755 30,307 172,137

Total 6,099,510 6,342,565 177,788 3,501,301 1,032,538 1,918,180 2,110,198


Preparatory Activities for IRS Operation

Before executing IRS, a number of preparatory and foundational activities were conducted to ensure optimal quality of spraying and acceptable outcomes.

Selection of Eligible Spray Areas and Logistics Assessments

Eligible areas for IRS were selected in collaboration with NMCP according to the national strategic priorities based on logistical, epidemiological, and entomological considerations.

Prior to each IRS round, RTI conducted logistics assessments in collaboration with NMCP and relevant authorities in the operational regions and districts. These assessments involved collecting information, such as demographic statistics, administrative setups, and meteorological indicators related to IRS; maps of the area showing the main geographical features and road networks; malaria epidemiological data from all HFs in the IRS areas in the Lake Zone; and estimations of the average sprayable surfaces. The assessments were performed in stages, (i.e., data collection, analysis, forecasting, preliminary report writing, dissemination and discussion of the reports with district authorities, and the production of final reports). The collected information was used to design, budget, and implement IRS activities and perform the necessary M&E.

Insecticide Selection, Quality Assurance, and Use

From 2010 to 2012, the project utilized lambda-cyhalothrin capsulated suspension (ICON® 10 CS); in 2013, the insecticide was switched to deltamethrin (K-Othrine) in most parts of Mara and Mwanza Regions, and bendiocarb (FICAM® WP), which is a member of a new class of insecticides known as carbamates, was introduced in all districts of Kagera Region. Beginning in 2014, all districts in the Lake Zone were sprayed with pirimiphos methyl (Actellic 300 CS), an organophosphate. The classes of insecticide introduced and used over subsequent project years were chosen in conjunction with NMCP based on WHOPES approval, the insecticide registration status in the country, and the availability of entomological data. Once these insecticides reached regional warehouses, samples were collected and sent to an ISO-accredited laboratory, AgriQ Lab, for quality analysis. Samples were also sent to the Tanzania Pesticide Research Institute for quality analysis. The analysis results were used to determine whether the insecticide was suitable for IRS operations. In total, 58,441 liters of lambda-cyhalothrin, 11,117 liters of deltamethrin, 29,607 kg of bendiocarb, and 252,279 liters of pirimiphos methyl were used in the Lake Zone over the duration of the project (Table 9, Zanzibar section).

Insecticide Resistance Mitigation Management Plan

To mitigate the vector resistance to pyrethroid insecticides, TVCSP, in collaboration with NMCP, embarked on developing an insecticide resistance management plan in the second year of the project. The interim plan adopted in 2012 recommended replacing pyrethroids with carbamates for IRS according to a rotational strategy for at least two years until new formulations became available. Therefore, carbamates were used for IRS in 2012–2013. Because of carbamates’ short residual period (two months as per the IQK data collected in Karagwe and Muleba Districts), it was necessary to conduct two IRS rounds each year to protect communities throughout the transmission seasons. Some resistance and high levels of tolerance to carbamates were recorded in some parts of the country, including Muleba, Kondoa,


Kyela, and Arumeru Districts. Thus, monitoring vectors for their susceptibility to a range of insecticides was intensified. Given the above considerations and the availability of a new product on the market, NMCP selected pirimiphos-methyl for the 2014 IRS operations in the Lake Zone; this insecticide has a reported residual effect of up to nine months. Pirimiphos-methyl was also used for subsequent spraying in 2015.

IRS Logistical Arrangements

Establishment of DITTs

In Mainland Tanzania, the basic IRS management and implementation unit was the DITT. Between 2010 and 2013, a total of 18 DITTs (one in each district) were established. In 2014, because of the scale down, only six DITTs were established in the implementing districts, and in 2015, only seven DITTs were operational. Each DITT was chaired by a DMO and included five main staff positions: (1) malaria integrated management of childhood illnesses focal person (IRS coordinator), (2) vector control staff, (3) M&E staff, (4) logistic officer/storekeeper, and (5) health education focal persons. RTI provided support to the DITT through initial training and by seconding one or two consultants during the operations for further on-the-job training and mentoring of the district team. An overall RTI supervisor from the RTI zonal or regional office was appointed for each district.

Offices for the seven DITTs were provided by the health authorities in close proximity to the district temporary IRS warehouse. The program refurbished and equipped the offices with computers, supplies, and communication equipment (modems). The malaria focal persons for the respective districts were responsible for day-to-day office management.

Implementation teams (sub-units) for advocacy and health education, vector control, and M&E met daily during the IRS operations, and the DITTs met weekly.

Transportation and Storage of IRS Commodities

Four logistics levels were operational under this project: (1) the zonal warehouse located in Mwanza, (2) regional warehouses located in Kagera and Mara Regions, (3) district temporary storage facilities during IRS operations, and (4) temporary IRS OSs.

The storage of other IRS materials was organized according to the established four levels:

1. The zonal warehouse, which was the highest level, received supplies from domestic and international suppliers and served the regions of Mwanza, Kagera, and Mara.

From the zonal level, supplies were distributed to regional warehouses in Mara and Kagera one month before IRS.

From the regional warehouses, supplies were distributed to the districts stores in operation regions of Mwanza, Kagera, and Mara.

Two weeks before IRS operations, supplies were transported from the district stores to the temporary IRS sites stores, where IRS activities were conducted on a day-to-day basis.

Throughout IRS operations, distribution was guided by the quantification needs at each level.


RTI contracted private vendors to ship insecticides and equipment directly from Dar es Salaam port to the zonal warehouse in Mwanza. From there, the IRS commodities were moved to regional and respective district warehouses as per quantification needs.

Procurement of Equipment, Insecticides, and Services

Procurement of pumps, PPE, and other IRS supplies was done directly by RTI in accordance with USAID regulations. During the peak TVCSP period in 2012, a total of 600 vehicles and nine water craft were used to transport spray operators and commodities and for supervision. The procurement of transport services was arranged in the respective districts in collaboration with district health authorities.

Organization of Spray Sites

The general TVCSP IRS design was based on the OS. Each site had an operation target, which ranged from 5,000 to 10,000 household structures. The OS received adequate infrastructure for effluent waste disposal, sanitary accommodations for operators, and storage facilities. The OS effort was led by a site manager supported by an average of four spray teams (range two–eight persons per team) and four–eight site attendants, depending on the size of the site. The time of operation per site, number of operation days, and allocated resources (e.g., human resources, insecticide, equipment, and consumables) were calculated based on targets. TVCSP decided to select an average duration of operation of approximately 17 days per site. Each IRS team had eight operators; with an average of 41 spray operators per site. Each team was headed by a team leader. The team leaders and spray operators were selected from the targeted communities. The OS manager was assisted by support staff who maintained spray equipment, washed suits, cleaned the site, fetched water, and handled security. A rate of 10 sprayed household structures per operator per day was used to calculate the daily workload and to develop the spray schedule. An average of 30 liters of water per each operator per day was calculated. In the predominantly rural areas, water was provided by OS staff fetching water from the nearest source. Figure 19 provides an indication of the site distribution across the regions of the Lake Zone where IRS was being implemented.


Figure 19. IRS OSs location in the Lake Zone

IRS delivery evolved through continuous improvement based on TVCSP’s experiences and lessons learned from each subsequent IRS round. To further improve the efficiency of IRS implementation approaches, RTI, through the DITT and communities, piloted a community-based IRS (CBIRS) approach in Rorya District in 2013.

The CBIRS approach is highly decentralized, with a village at the center of operations. Pre-requisites for CBIRS include the following:

The district should include villages that have clear boundaries and a well-known number of structures to be sprayed.

Most of the villages should have ideal storage space for insecticides and other IRS field requirements (e.g., office space, a dispensary or health center, and storage space).

Spray operators can cycle or walk from the storage facility and reach the targeted household structures for spraying.

Enough space is available for the fabrication of effluent waste disposal structures.

The district and village government and the community at large are willing to support CBIRS.

The objectives of the CBIRS approach are to (1) reduce the organizational complexity of IRS, (2) increase the level of community participation and ownership, (3) reduce the costs of IRS implementation, (4) achieve an acceptable level of IRS quality, and (5) comply with environmental protection requirements and regulations.


The community-based sites were supported by the existing permanent OSs, which had larger storage facilities and permanent soak pits. These OSs were managed by site managers who were tasked with coordinating a number of community-based sites (ranging from three to five). CBIRS site stores were stocked with minimal amounts of insecticide, with regular supplies of replenishments provided from the parent permanent/standard site. Spray operators at each site were recruited (with recruitment managed by the village government) from the villages within the catchment area of the community-based sites. The spray operators were men and women trusted by the community in which they worked and who had good knowledge of the area. The local recruitment ensured that spray operators worked within walking distance from their homes within their assigned site. Where necessary, spray operators used bicycles to reach the respective sites.

Each CBIRS site was supervised by a team leader who, at the end of each day, was responsible for collecting data forms, which were delivered to the site manager for forwarding to the district level for data entry. This community-based approach not only increased the community’s ownership of IRS operations but also shortened the spray cycles to between 7 to 15 days, decreasing the probability for disruptions to the campaign (e.g., rain and flooding). Unlike the centralized approach, CBIRS also eliminated the need for transporting spray operators from one community to another, reducing the cost of vehicle transportation for spray operators

Following the success of this approach in Rorya, TVCSP expanded CBIRS to five districts out of the seven targeted for IRS in 2015. In fact, out of a total of 198 sites in the Lake Zone, 184 (93%) were CBIRS sites.

Human Resource Development and Management

Active IRS operations require a large number of temporary operational IRS field staff and other technical, coordination, and supervisory support staff. RTI, in collaboration with district authorities, recruited an average of 5,000 temporary staff in Mainland Tanzania (Table 8). The selection process was led by local government authorities and supervised by the delegated DITT and RTI personnel (see Box 2 for the selection criteria). Broad and equal representation from targeted communities was sought.

Mechanisms were set up to guarantee a transparent and fair process. The selected staff provided personnel details, a photograph, bank account details, and a medical certificate of good health. The respective RTI offices filed all documents and provided an identity card. The selected individuals also signed a consent form. At the IRS OS level, TVCSP opened a file for each temporary staff member to include a medical attendance form and other personal documents. All female operators were tested for pregnancy prior to enrollment, and those who tested positive were disqualified.

The RTI finance team transferred compensation for temporary staff to their personal bank accounts at fixed intervals (two weeks). From 2013, RTI introduced money transfer through mobile phones using MPesa accounts, which every temporary staff was required to have and submit during recruitment process. The MPesa transfer was quicker, more efficient, and less cumbersome for the finance team, especially when they were dealing with large cash flows.

After staff selection, knowledgeable VCOs conducted staff training. The cascade training approach—i.e., TOT—was used, starting with site managers and supervisors, who later supported the training of other supporting staff, such as


cleaners and site guards. The training of spray teams was conducted at different training sites and supervised by the VCOs who had trained the site managers and team leaders

The trainings usually lasted for one week and included the use of PPE, the safe handling of insecticides, spraying techniques, environmental compliance, minor pump repair, the completion of IRS forms, and interactions with clients.

IRS training modules and training curriculum were the main training guides used by trainers. Site managers and team leaders focused on module number three, which provides the general principles of IRS, site/sub-site management (human and resource management), and managing environmental compliance issues, mainly focusing on human safety and effluent waste management. The module also illustrates how to decommission a site once the operation is over.

Spray teams were trained using the module designed for spray operators. The focal points in this module include the basic principles of IRS, the use and maintenance of IRS equipment, how to conduct the spraying exercise, the management of insecticide waste, personal protection, the safety of the community and general environment during IRS, and how to record the various data generated during IRS.

IRS Capacity Building for VCOs

In October 2012, RTI, in collaboration with NMCP, the Centre for Educational Development in Health, Arusha, The Nelson Mandela African Institute of Science and Technology, and Muheza Vector Control Training Institute, conducted a National IRS Core Facilitator Training course. Participants included Regional and District Malaria Focal Persons, two NMCP representatives, one representative from the MoH Vector Control Unit, and one VCO from the Tanzania People’s Defence Force. Over a period of two weeks, the training extensively covered IRS management and other supportive aspects of IEC, logistics planning and management, M&E, and environmental compliance at all levels. The training consisted of 14 modules, which were developed prior the training and updated as per changes in IRS implementation design or the insecticide used for spraying. The final set of modules was handed over to the NMCP for adaptation and to serve as a useful reference for further capacity building of districts and communities implementing IRS in the future.

Preparations for Collection, Processing, Analyzing, and Disseminating Data/Information to Stakeholders

An integral component of IRS is M&E. At the preparatory stage, M&E involved putting in place the designs and procedures for collecting, processing, analyzing, and disseminating IRS outputs and outcomes. Tools used included forms completed by spray operators and later processed electronically by data clerks.

IEC for IRS

Community sensitization and mobilization were conducted to achieve optimal IRS coverage. Interpersonal communication was the most effective way to deliver IRS-related information to the public. This communication was targeted at increasing IRS acceptance, curbing refusals, tapping community support, and ensuring that the community was protected from accidental insecticide contamination.

Varied IEC approaches were used. In the first year of TVCSP, RTI collaborated with three main partners: JHU-CCP, local government authorities, and community-based


organizations (CBOs). JHU-CCP was subcontracted to provide technical support in the revision of IEC printed materials and development of media spots for IRS. IEC materials (e.g., leaflets and posters) used in previous IRS rounds were revised, and additional IEC materials were developed, such as FAQ brochures and flip charts used in trainings. Posters were also developed and placed on public notice boards and at streets, markets, and HFs. JHU-CCP also assisted in the design and production of banners to display at IRS staging sites and on vehicles used during operations.

JHU-CCP also helped in using the electronic media platform to inform communities about IRS. Three radio spots and one jingle that used humor and drama to engage listeners and to detail the actions that households need to take to prepare for the spray exercise were prepared. These radio spots aired on local FM radio stations. JHU-CCP also organized radio discussions on local radio stations; they arranged for IRS experts and people whose households were sprayed previously to discuss their experiences with IRS on the air and took calls from audience members. These call-in discussions were aired twice a week before and during spray operations.

Local government authorities (DMOs, district IEC persons, malaria focal persons, ward leaders, and village and hamlet leaders) were identified to inform and support the leadership at the community level in carrying out IEC activities.

Additionally, a total of 26 nongovernmental organizations (NGOs)/CBOs/faith-based organizations and six local health authorities were contracted out by RTI to provide thorough interpersonal communication information and education to the communities. These IEC partners were selected to carry out advocacy and sensitization of leaders and the community in all districts and wards to secure acceptance, compliance, and contributions from the beneficiary community and leaders. An IEC master training curriculum and package were developed by RTI. The selected IEC partners were trained by RTI on different participatory approaches of IEC/BCC, how to conduct trainings, how to facilitate sensitization meetings, how to monitor activities, and how to conduct effective supervision, activity planning, and time management, among others. During the first year of IRS, almost 800,000 informative leaflets, brochures, and posters on IRS were developed, displayed, and/or distributed to community leaders and residents.

Beginning in year 2 of the project, TVCSP introduced some tangible changes in the IEC design. The cascade of events to reach the households was modified to simplify and shorten the messaging. The aim was to maximize the use of interpersonal communication to reach the communities with IRS messaging. The main IEC-delivering partners shifted from local authorities, NGOs, and CBOs to the more CBIRS Site IEC Mobilizers, a cadre newly created to facilitate the linkage between IRS operating site and the served community. The establishment of this new cadre aimed to make the process less top-down and to deliver IEC in a more community-based way. The new design was also cheaper and less cumbersome in terms of management. It maintained, and in some cases improved upon, the previously reached high levels of IRS coverage. The SIMs were selected from their respective communities. One SIM was allocated to each average-sized IRS OSs. In few cases, two SIMs were allocated to serve exceptionally large IRS sites. The majority of SIMs were selected from among the CCAs previously trained on community health matters under the auspices of the USAID-funded Communication and Malaria Initiative in Tanzania (COMMIT) project implemented by the JHU Center for Communication


Programs (CCP). SIMs were given a one-week training course covering general knowledge of IRS, communication skills, and use of IEC materials. During the implementation, RTI facilitated their tasks by providing IEC materials, megaphones, and transportation. In addition to person-to-person communication, RTI continued to use the electronic media platforms to reach out to the people including radio spots and public announcement systems just before and during IRS implementation.

Over the subsequent spray rounds, TVCSP primarily used the SIMs and electronic platform to inform and educate communities on IRS as it proved to generate optimal acceptance of IRS at most cost-effective benefit.

M&E

In IRS, systematic monitoring was established to follow up on inputs, processes, and outputs. Information was collected and then utilized before, during, and after spraying. More importantly, daily monitoring during the operations was important to ensure processes and outcomes were monitored, thereby allowing timely detection of gaps and constraints in order to trigger adequate responses

Additional indicators to measure the reason for IRS refusal, community satisfaction, and net coverage were also measured.

To facilitate effective daily monitoring, RTI focal persons supervised daily monitoring and facilitated the movement of IRS information from the field to the offices of appointed district data clerks.

The flow of information was as follows:

Spray operators collected information on households (e.g., sprayed, visited, and not reached), demographics (e.g., high-risk populations, children over five years of age), refusals and the associated reasons, and IEC sensitization. This information, in turn, was compiled by their team leaders, which was then forwarded to their supervisors, who compiled and sent the data to a higher level—the site manager. The site manager was then responsible for submitting the data to the district data unit, who then entered and generated reports on a daily basis to be used for interpretation and action by the IRS technical team, along with the district teams.

From the level of spray operators to site managers, the information was captured in hard copy format on spray forms designed specifically for each level. Upon reaching the data management unit, the hard copy, paper-based information was transcribed into electronic format on specially designed Excel-based IRS data templates, created for each district. The information on the database reflected the information collected on the ground by spray operators, team leaders, supervisors, and site managers. All hard copy forms were filed and stored at the district data office until the end of the spray round, after which they were moved to RTI office and shelved in a categorized manner.

The technical team monitored daily performance up to the site level in IRS districts. Among the numerous information collected, the number of households sprayed (and not sprayed) against the daily target was assessed. Number of households that spray operators were spraying per day was also captured. In addition to spray performance, information on insecticide consumption and stock for each day was also captured and monitored.


Feedback on performances was periodically relayed to site managers and supervisors, as well as DMOs, to assess progress and respond to gaps, if any, in a timely manner.

In addition, vehicle and fuel usage, equipment and consumable stock, training, quality of spraying, and compliance measures were also tracked on a timely basis.

After the completion of IRS, RTI produced summary tables, charts, and for dissemination to partners and stakeholders on progress and results achieved. Impact-related indicators measuring malaria-related prevalence, morbidity and mortality, as well as supportive entomological parameters, were periodically collected and found useful in observing the effect of the intervention(s).

Component 2—Environmental Compliance Strategies and Monitoring Plans

Environmental Assessment

RTI, in collaboration with NMCP, revised the Kagera Region SEA to accommodate the new IRS regions of Mara and Mwanza in fulfillment of 22 CFR 216. The SEA was approved by USAID in July 2010 before the start IRS operations in the two new regions. The SEA was valid for a five-year period through March 2015.

RTI, in collaboration with NMCP, also conducted a Preliminary Environmental Assessment (PEA) for the new IRS regions from August 17 to September 7, 2010, thus fulfilling the Tanzania environmental requirements (EMA Act No. 20: 2004). The PEA report was submitted to the National Environment Management Council on September 17, 2010, for review, but the program was given conditional approval to proceed with the spray operation. During the course of TVCSP, RTI, in collaboration with NMCP, prepared and sent USAID justification letter reports and waivers to inform USAID about the status of environmental management for the 2013–2015 IRS seasons. This was concurrent with the change in IRS strategy from blanket to targeted and the change in the class of insecticide for application on treated walls. The letter reports were sought to obtain a waiver for the procurement of bendiocarb (2013) and pirimiphos methyl (2014 and 2015). The letter report delineated the environmental risk mitigation actions proposed to be undertaken by TVCSP in the yearly IRS campaigns to satisfy US 22CFR216 and the Tanzania Environmental Management Act of 2004 requirements. This waiver also included the IRS activities undertaken in Kagera Region, which were already covered by the 2010 SEA. The implementation approach was changed from centralized IRS in standard sites to CBIRS in Muleba and Chato Districts of Kagera Region.

Insecticide Management and EMP

During the 2010–2015 spray seasons, TVCSP utilized a set of prepared environmental compliance guidelines and SOPs for spray operators and pump technicians and the EMP contained in the approved SEA for the training of spray teams and implementation of the program. The guidelines were updated in 2014 prior to the commencement of the training to include the community-based approach. The training emphasized the use of triple-rinsing for pump cleaning at the end of the spray day, inspection of pumps for leakage and their general maintenance, and disposal of washouts and solid waste. All spray teams were trained on all aspects of environmental compliance prior to the commencement of each spray campaign. During operations, spray teams were supervised to maintain protection and safety


measures for themselves and for residents, as well as emergency preparedness in case of insecticide adverse reactions and accidental exposure to insecticide in accordance with the EMP and Sections 44−45 of the Tanzania Occupational Health and Safety Act, 2003. In addition, to manage insecticide stocks, a control system was instituted that included bin cards, ledgers, issues vouchers, and daily/weekly trackers, and the form number was marked on each household structure in which a sachet/bottle of insecticide was opened. Measures for strictly tracking the movement of insecticide sachets or bottles from the temporary storage facilities to the spray teams were meant to prevent pilferage and potential misuse, promote the safer use of pesticide, and protect the environment and human health. At the end of every spray day, empty sachets/bottles were returned by spray operators, counted, and subsequently incinerated or, for bottles, punctured to prevent reuse. All observed discrepancies were reported and investigated.

Medical attendance forms were available for monitoring undesirable and adverse reactions to insecticides for all IRS staff. TVCSP continued to use insecticide-tracking forms to monitor consumption and empty sachets/bottles returned on a daily basis.

SOPs guided the disposal of solid wastes, including empty sachets/bottles, according to best management practices.

In terms of storage facilities, TVCSP allocated a main warehouse at the zonal level in Mwanza, followed by regional warehouses in each of the remaining regions (Mara and Kagera). District-level warehouses were rented temporarily during IRS operations, and temporary sites were also established at the ward level (173‒200 in total), depending on the scale of operations in each project year. Effluent waste disposal structures and temporary storage and sanitation facilities were also repaired/refurbished in preparation for IRS operations.

Environmental Monitoring and Inspections

Environmental monitoring and environmental compliance inspections comprising pre-spray and mid-spray inspections were carried out in all OSs in Kagera, Mara, and Mwanza regions by the TVCSP Environmental Compliance Advisor. The purpose of the pre-spray environmental inspections was to evaluate the program’s preparedness and the compliance of OSs before the commencement of the spraying activities, whereas the mid-spray inspection was designed to assess compliance with IRS best practices and environmental provisions during field implementation. The inspections ensured that IRS activities complied with the environmental monitoring and mitigation plans, as stipulated in countries’ SEAs, Tanzanian regulations, IRS best practices, and, more widely, 22 CFR 216 and international regulations.

IRS Waste Disposal Arrangements

In 2013, RTI began incinerating contaminated waste using the TVCSP procured incinerator that was commissioned for use at the Nyanguge Health Centre, which is located 33 km from Mwanza City. An initial stockpile of 15 tons that was safely accumulated from previous rounds was incinerated at the facility in batches. Waste accumulated in the regional warehouses was transported to the zonal warehouse to await disposal. The disposal process took almost one year. In the final two years of the project, all contaminated waste, with the exception of empty insecticide bottles, was incinerated. TVCSP proposed to recycle all used pirimiphos methyl plastic bottles through a recycling company (Express Trading Co. Ltd); the empty bottles were shredded at Kasamwa warehouse in Geita and handed over to the recycler. In


total, the plastic waste disposed of consisted of 496 sacks of shredding, which weighed 24,896 kg

Effluent waste in the Lake Zone was disposed of in properly designed soak pits for treating insecticide-contaminated waste.

Component 3—Sustained Entomologic Monitoring System on the Mainland

Entomological monitoring was critical as it formed the basis for evaluating effectiveness of IRS operations implemented under the TVCSP. TVCSP and NMCP implemented this activity in collaboration with the National Institute for Medical Research (NIMR). The objective was to determine whether vector interventions, such as IRS, were properly applied, forming a basis for evaluating effectiveness of IRS operations and its impact on malaria. Additionally, TVCSP aimed also to support NIMR to continue longitudinal entomological monitoring which had been previously established in Kagera under RTI’s Malaria control in Mainland Tanzania and Zanzibar project with joint support from CDC, and to scale up in other IRS regions in Mwanza and Mara. The following are the specific entomological monitoring activities that were supported during this project life cycle:

Support for Operation and Maintenance of Entomological Laboratory

TVCSP supported NIMR-Mwanza to establish and maintain an entomological laboratory in Mwanza, which is serving a zonal laboratory for the Lake Zone regions. As part of this maintenance effort, the TVCSP supported NIMR to recruit and fund salaries for two additional laboratory technicians provide technical assistance (TA) in entomological activities in the laboratory. TVCSP also supported procurement of reagents and equipment for PCR and enzyme-linked immunosorbent assay (ELISA) testing of mosquito samples.

Additionally, TVCSP supported to train two entomologists, Juma Mcha from ZAMEP and Chacha Mero from NIMR. The training was conducted in Durban, South Africa, in March 2011. The training curriculum covered basic principles on insectary management, laboratory techniques for mosquito rearing, colony maintenance, conducting cone bioassays, and susceptibility testing, according to WHO protocols. The two entomologists provided oversight and TA to all entomological activities at the specified organization.

Support Longitudinal Entomological Monitoring in the Lake Zone

TVCSP supported NIMR to establish longitudinal entomological monitoring activities in Mara and Mwanza following IRS expansion in these two regions. TVCSP supported expansion of sentinel sites for longitudinal entomological monitoring from three sites (Chato, Karagwe and Muleba Districts in Kagera) to seven sites, including Serengeti and Tarime Districts of Mara Region and Sengerema and Ukerewe Districts. The project also supported training of community mosquito collectors and district VCOs (DVCOs) from each respective sentinel districts that were randomly selected. Community mosquito collectors and DVCOs were trained on basic entomological techniques, including different mosquito collection methods, such as CDC light traps, pyrethrum spray catch, and pit traps.

NIMR has been conducting entomological monitoring concurrently with IRS operations, and separate quarterly and quarterly reports were submitted and annexed in the TVCSP quarterly and quarterly reports. The following are the


summarized results of the analysis conducted on the mosquitoes collected in Kagera, Mwanza, and Mara Regions.

Many more mosquitoes with positive sporozoites were collected indoors using the CDC light trap technique than using the pyrethrum spray catch and pit-trap collection techniques.

Using PCR-based approaches, predominant malaria vector species were found to be: (1) An. arabiensis, (2) An. gambiae s.s., and (3) An. funestus complex.

ELISA results revealed that sporozoite infection rates ranged from 0% to 5.2%, indicating that the mosquito infection rate is very low.

Cone Bioassays Surveys in the Lake Zone

NIMR-Mwanza conducted cone bioassays in all seven sentinel sites in Mara, Mwanza, and Kagera to determine the insecticide decay rate on sprayed wall surfaces. NIMR used the mosquito An. gambiae s.s. (i.e., a susceptible mosquito strain) for cone bioassays on IRS-treated surfaces.

According to the standards recommended by WHO (i.e., insecticidal residual effect ≥80 in 24h % mortality), the findings of the cone bioassays (regardless of wall type [cement, wood, or mud] in a given household structure) indicated the following:

Lambda-cyhalothrin (ICON®10CS) insecticide was effective in killing susceptible malaria mosquitoes up to the 25th week post-IRS.

Bendiocarb (FICAM VC®) insecticide was effective up to the 12th week post-IRS.

Pirimiphos methyl (Actellic® 300CS) showed effectiveness up to the 21st week post-IRS.

The three insecticides were used for IRS during this project lifecycle (see also Component 1, IRS)

National Survey of Malaria Vector Resistance to Insecticides

TVCSP also supported NIMR in conducting annual nationwide monitoring of insecticide resistance among local malaria vector populations. This activity was implemented by NIMR-Amani Centre. Over the course of the project, TVCSP supported these activities in 14 already established national sentinel districts (Moshi, Handeni, Kyela, Kilombero, Muheza, Ilala, Mvomero, Arusha, Babati, Lushoto, Muleba, Magu, Dodoma, and Uyui). TVCSP supported the establishment of 12 more sentinel districts (Ngara, Bariadi, Tarime, Arumeru, Moshi Rural, Bagamoyo, Manyoni, Iringa Rural, Masasi, Nkasi, Kigoma Rural, and Ruangwa). These sites were added to cover all 25 regions of Mainland Tanzania, resulting in a total of 26 sentinel sites operational for a national survey to monitor mosquito insecticide resistance. NIMR conducted resistance monitoring in 14 sites alternating yearly.

Each year, TVCSP supported all preparatory activities, which included the following:

Procurement of laboratory equipment, reagents, and supplies (e.g., WHO testing kits, impregnated paper, and PCR reagents);

Training for a total of 14 field teams, which included research scientists and laboratory technicians; and


Training for mosquito collectors to improve their skills in mosquito collection.

Mosquito larvae were collected from 14 sentinel districts and reared to adults which were then tested with insecticides. Adult mosquitoes (two–five days old) were exposed to insecticides using the standard WHO susceptibility testing technique to check for resistance. Annually, the key findings from the survey were disseminated at the stakeholders meeting, which was chaired by the NMCP. The reports were prepared and annexed to the quarterly and annual reports for TVCSP for submission to USAID and shared with NMCP. The summary results of the key insecticide used for IRS in Lake Zone were as follows:

Pirimiphos methyl resistance was reported to show resistance in three sentinel districts: Geita, Muleba, and Arumeru.

Pyrethroid resistance was reported in 11 out 21 sentinel districts.

Bendiocarb resistance was reported in two districts: Mbozi and Ngara.

Component 4—SNP2

In Year 4, USAID requested RTI to support the NMCP and stakeholders with the SNP2 as part of a “keep-up strategy” to maintain the high access to LLINs, following the mass campaign and SNP1 implemented in 2011. SNP2 was implemented in 19 districts across 3 regions in Tanzania’s Southern Zone—Linda, Mtwara and Ruvuma—to expand universal access and maintain appropriate LLIN use and ownership among at least 80% of the population by distributing LLINs through schools.

TVCSP subcontracted the Tanzania Red Cross Society (TRCS) to provide technical assistance to the NMCP to implement the SNP2. TVCSP and TRCS partnered with JHU-CCP, which led the IEC/BCC component of the SNP2; John Snow Inc. (JSI), which procured and stored the LLINs; and Population Services International (PSI), which supported complementary advocacy activities.

NMCP’s NETCELL, a unit responsible for coordinating all aspects related to LLINs in the country, established the SNP Task Force that specifically coordinates all activities related to LLIN distribution through schools. The taskforce includes Tanzanian government entities and various nongovernmental organization and institutions: NMCP (chair), Ministry of Health and Social Welfare–School Health Program (MoHSW/SHP), Swiss Tropical and Public Health Institute-NETCELL project (Swiss TPH/NETCELL), USAID/PMI, CDC/PMI, WHO, JHU-CCP, U.S. Peace Corps, Mennonite Economic Development Associates (MEDA,) RTI, TRCS, PSI, JSI, Ministry of Education and Vocational Training (MoEVT), and the Prime Minister’s Office Regional Authority and Local Government (PMORALG). Several SNP Task Force meetings were conducted chaired by NMCP for planning, implementation, and M&E of SNP2.

Through the SNP2, TVCSP, in collaboration with TRCS, distributed LLINs free of charge to all school children enrolled in Standards 1, 3, 5, and 7 in primary schools and Forms 2 and 4 in secondary schools in Lindi, Mtwara, and Ruvuma regions. For Lindi Region only, Standards 2 and 4 were included to enhance the “keep-up” strategy in the region. Going forward, as students progress through the school system, they will receive a new LLIN for their household every other year. A detailed technical report about SNP2 implementation was prepared and submitted separately during the Year 4 implementation period to USAID.


Prior to the LLIN issuance under the SNP2, TVCSP conducted and accomplished several preparatory and logistic activities, including the following:

Logistics Assessment

In collaboration with TRCS, RTI undertook a logistic assessment, including identifying storage facilities at the district level, and verifying the availability and condition of the roads. This information facilitated the logistics plans before LLIN distribution was implemented — starting from the Medical Stores Department warehouse in Dar es Salaam to the districts and finally to each participating school. As part of the process, TRCS — through its Logistics Unit — identified through a competitive bidding process the transport company that would transport the LLINs from the Medical Stores Department warehouse to all the identified warehouses at district level. For safety and security purposes, the LLINs were covered with an insurance policy, which covered the SNP2 in the event of unforeseen adverse circumstances.

Advocacy Meetings

RTI and TRCS, in collaboration with NMCP, conducted advocacy meetings to solicit and reach an agreement for support and cooperation from regional/district administrations and community leadership. A total of 401 (337 male and 64 female) participants from the regional and district authorities actively participated in advocacy meetings conducted in Lindi, Mtwara, and Ruvuma Regions. In addition to USAID funding to TRCS, advocacy meetings were also financially supported by PSI.

Training

Training was conducted at various levels using a cascade approach. The training objective was to equip participants with knowledge about use of LLINs and the need for continuous distribution of nets throughout schools, including apprising them about the technical improvements to SNP2. Participants were trained in the systematic approach to managing the LLIN distribution process, changes in the data collection forms, student/pupil enumeration, recording LLIN issuance data, summarizing data, and delivering data to implementing partners. This training was a one-day orientation, during which, sessions for TOTs were conducted first; then, TOT teams trained implementers during the training of implementers (TOI).

The TOT targeted district malaria focal persons, District School Health Coordinators (DSHCs) for health and education, and the ward education coordinators (WECs). Participants in the TOIs included head teachers and school health teachers. Table 12 shows the number of people trained in all three regions.

Table 12. Training Prior to LLIN Distributions for ToTs and ToIs Conducted in May 2014, by Gender and Region

Participating Cadre

Lindi Mtwara Ruvuma All regions

Male Female Male Female Male Female Male Female Total

TOT (WECs DMFPs, and DSHCs)

108 32 135 36 145 31 388 99 487

TOI (teachers) 734 337 1,072 493 1,168 692 2,974 1,522 4,496

Total 842 369 1,207 529 1,313 723 3,362 1,621 4,983


Community Sensitization Activities

The community sensitization activities were coordinated by JHU-CCP. The WEOs/Village Executive Officers, CCAs, U.S. Peace Corps Volunteers, and CCA village counterparts were trained to support implementation of IEC/BCC activities. The IEC/BCC materials and radio spots were revised from the previous campaign (SNP1) to strengthen the community aspect of the LLIN distribution. These spots provided details on the importance of using LLINs and emphasized that the pupils who received LLINs served as conduits for channeling the nets to the community. The radio spots and program were broadcasted in Ruvuma, Lindi, and Mtwara through Jogoo FM, Pride FM, Newala FM, and the Tanzania Broadcasting Corporation. A detailed report about the IEC/BCC activities was submitted separately under a separate PMI/JHU-CCP agreement.

LLIN Net Issuance at Schools

Overall, RTI and TRCS, in collaboration with NMCP, issued a total of 464,893 (98%) LLINs to students out of 474,094 students who were registered at schools to receive a LLIN (i.e. corresponding to 98% coverage). In addition, a total of 24,206 (96%) school teachers received nets out of 25,269 schools teachers registered. Table 13 shows the summary of LLINs issued to students and teachers in all districts of Lindi, Mtwara, and Ruvuma regions. The registration and issuance booklets were used to track the registration of students and teachers and the issuance of LLINs. Recipients’ names were first registered into the registration and issuance booklets; on the day of issuance, each registrant signed against his or her name after receiving an LLIN (Figure 20). Students who were absent did not sign the booklet and, thus, did not receive an LLIN. Figure 21 shows schoolchildren from Lindi who received LLINs.

Figure 20. Copy of a registration and issuing booklet

Figure 21. School children who received LLINs in Lindi

Picture removed to protect named individuals

bethcedoz

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Table 13. Summary of LLINs Issued to Teachers and Students at Schools of Lindi, Mtwara, and Ruvuma Regions, August 2014

Region/District

# of Nets Receive

d by School

# of Students Registere

d

# of Nets Issued to Students

# of Teachers

Registered

# of Nets Issued to Teachers

Total # Registered

Total # of Nets

Issued

# of Nets Remaining

% of Nets Issued vs. Registered

% of Nets Issued vs. Quantified

% of Nets Remainin

g

LINDI

Kilwa 38,684 36,303 35,702 1,226 1,206 37,529 36,908 1,776 98% 95% 5%

Lindi District 37,815 33,164 32,451 1,218 1,195 34,382 33,646 4,169 98% 89% 11%

Lindi Municipal 12,672 12,202 11,901 619 619 12,821 12,520 152 98% 99% 1%

Liwale 20,844 19,867 19,807 654 653 20,521 20,460 384 100% 98% 2%

Nachingwea 31,088 30,602 29,660 1,222 1,112 31,824 30,772 316 97% 99% 1%

Ruangwa 23,055 20,573 20,194 886 868 21,459 21,062 1,993 98% 91% 9%

Total 164,158 152,711 149,715 5,825 5,653 158,536 155,368 8,790 98% 95% 5%

MTWARA

Masasi DC 33,173 29,965 28,932 1,588 1,501 31,553 30,433 2,740 96% 92% 8%

Masasi TC 10,934 10,421 10,095 714 664 11,135 10,759 175 97% 98% 2%

Mtwara District 28,881 28,202 26,896 1,360 1,266 29,562 28,162 719 95% 98% 2%

Mtwara Municipal 14,394 13,357 13,244 1,112 1,050 14,469 14,294 100 99% 99% 1%

Nanyumbu 20,943 18,749 18,681 885 878 19,634 19,559 1,384 100% 93% 7%

Newala 24,821 22,706 22,314 1,419 1,322 24,125 23,636 1,185 98% 95% 5%

Tandahimba 28,135 27,957 26,310 1,485 1,317 29,442 27,627 508 94% 98% 2%

Total 161,281 151,357 146,472 8,563 7,998 159,920 154,470 6,811 97% 96% 4%


Region/District

# of Nets Receive

d by School

# of Students Registere

d

# of Nets Issued to Students

# of Teachers

Registered

# of Nets Issued to Teachers

Total # Registered

Total # of Nets

Issued

# of Nets Remaining

% of Nets Issued vs. Registered

% of Nets Issued vs. Quantified

% of Nets Remainin

g

RUVUMA

Mbinga 45,600 42,688 42,380 2,601 2,550 45,289 44,930 670 99% 99% 1%

Namtumbo 28,009 26,279 26,133 1,561 1,483 27,840 27,616 393 99% 99% 1%

Nyasa 20,322 19,397 19,281 964 943 20,361 20,224 98 99% 100% 0%

Songea District 23,716 21,958 21,525 1,647 1,584 23,605 23,109 607 98% 97% 3%

Songea Municipal 32,128 28,727 28,689 2,365 2,365 31,092 31,054 1,074 100% 97% 3%

Tunduru 32,561 30,977 30,698 1,743 1,630 32,720 32,328 233 99% 99% 1%

Total 182,336 170,026 168,706 10,881 10,555 180,907 179,261 3,075 99% 98% 2%

Grand Total 507,775 474,094 464,893 25,269 24,206 499,363 489,099 18,676 98% 96% 4%


Component 5—Malaria Surveillance, Epidemic Detection, and Response

In Year 2 (2011–2012), PMI requested TVCSP to support the NMCP to set up a malaria surveillance system for the timely detection of malaria epidemics, akin to the MEEDS that had been established on Zanzibar. MEEDS is in line with the NMCP’s MSP of 2014–2020, specifically the objective to “design and support the implementation of a comprehensive malaria surveillance and response system for epidemic-prone districts to ensure that 80% of malaria epidemics are responded within two weeks from the onset by 2020.”

In Mainland Tanzania, malaria is a core disease under the MoH’s IDSR. In support of integrated reporting through the District Health Information System 2 (DHIS2), streamlining mHealth systems, and reducing double-reporting burden on HF workers; TVCSP worked with the NMCP and the MoH’s Epidemiology Unit to develop three additional data points as an annex to the weekly routine IDSR reporting.

The following are the malaria parameters included as a one-page annex, as defined in the updated Tanzania IDSR guidelines of 2012:

1. Total number tested with RDT/microscopy

2. Total number tested positive with RDT/microscopy

3. Total clinical malaria cases

MoH’s Epidemiology, ICT, and mHealth units, in collaboration with partners, including NMCP, RTI, the CDC Foundation, and the University of Dar es Salaam (UDSM), established an electronic system of reporting the IDSR diseases (eIDSR) from HFs using mobile phone technology. The CDC Foundation, through funding support from PEPFAR, provided technical support to UDSM to develop a system for strengthening eIDSR reporting based on USSD, which is commonly used in mobile money transfer (e.g. m-Pesa and Tigo-Pesa).

At the HF level, only those who were registered could use the system to submit the report by dialing *152* 05#. This code was pre-paid; thus, the user did not incur any charges. The report submitted was viewable in DHIS2 and accessible by officials at the district, regional, and national levels.

MEEDS Reporting within IDSR System

Over the course of the project, TVCSP, in collaboration with NMCP, supported the following activities:

eIDSR Reporting Booklets

In collaboration with NMCP, TVCSP supported the MoH–Epidemiology Unit to revise and update reporting forms and develop eIDSR reporting booklets. Figure 22 shows the updated malaria section included in the eIDSR reporting booklets.

TVCSP also supported the printing and distribution of eIDSR booklets in all HFs implemented eIDSR every year.


Figure 22. Updated malaria section in the weekly IDSR forms

Malaria Case Definitions MALARIA RELATED CONDITION

AGE CASE DEFINITION CARDINAL SIGNS EPIDEMIC ACTION/ THRESHOLD

Suspected Malaria All ages This is a patient suspected of having malariaFever, headache, joint pains, malaise, vomiting/diarrhea, body ache, poor appetite, body weakness, pallor, enlarged spleen

Not applicable

Malaria Tested All ages A patient suspected of having malaria tested with either mRDT or microscopy

Not applicable

Confirmed Malaria (tested positive)

All ages A suspected malaria case in which malaria parasites have been demonstrated by microscopy or a rapid diagnostic test

Number of cases for the period clearly exceeds cases of previous year/season

Clinical Malaria (not tested

All ages A suspected malaria cases that did not receive a diagnostic test for malaria but were nevertheless treated as malaria

Not applicable


Development of job-aids. In collaboration with NMCP, TVCSP developed a supervision checklist and posters illustrating the step-by-step process of sending weekly and immediate reports from HFs. The eIDSR user manual and posters provide guidance to users at the district and regional levels on how to log into the eIDSR and analyze the data from their respective districts and regions. We also developed summary forms, and weekly recording sheets (Figure 23). Meetings were held in the respective regions to train HF, district, and regional staff on the use of these tools.

Figure 23. Materials and tools developed to facilitate eIDSR implementation at the HF, district, and regional levels

Poster showing step-by-step instructions for generating weekly reports, displayed at HF level

Poster showing step-by-step instructions for reporting immediately notifiable diseases, displayed at HF level

Poster showing how to create reports for eIDSR in the DHIS at the district and regional levels

User manual for eIDSR in the DHIS for the district and regional levels


HF supervision checklist for the district, regional, and national levels

Summary form showing the HFs’ annual reports to be displayed at the district and regional levels

Development of malaria surveillance and response guidelines. These guidelines will assist so to equip national, regional, district and HF level on how to detect, investigate and respond once malaria epidemic has been detected.

Pilot and roll-out of eIDSR.

- In partnership with MoH’s Epidemiology Unit, ICT and mHealth units, NMCP, CDC foundation and UDSM, TVCSP launched a pilot eIDSR system in 67 HFs in Temeke District of Dar es Salaam region in November 2013. Following operational success and lesson learned from this pilot, multi-phase roll out began in January 2014 to other regions.

- As of June 2016, the eIDSR has been rolled-out in a total of eight regions (i.e. Kagera, Dar es Salaam, Mara, Mwanza, Geita, Manyara, Dodoma, and Singida) and a total of 2,194 HFs were implementing eIDSR (see Table 14 and Figure 24).

- Over the course of the TVCSP, MoH received support from the World Bank for further eIDSR roll out in Arusha and Kilimanjaro regions (701 HFs).

- As of June 30, 2016, a total of 2,895 HFs in Mainland Tanzania had implemented eIDSR.


Figure 24. Map showing regions implementing eIDSR

Training for eIDSR. The training for eIDSR was conducted as part of the eIDSR roll-out efforts; therefore, all regions implementing eIDSR were trained. Prior to the training, TVCSP, in collaboration with NMCP, supported all preparatory activities including printing of all training manuals, IDSR Guidelines, and eIDSR reporting booklets.

The training was conducted for five days to empower and equip participants with a better understanding of IDSR priority diseases, conditions, and events; case definitions; detection; and identifying, recording, and reporting cases. The training also aimed to orient participants on eIDSR reporting forms, as well as the hands-on submission of immediate and weekly reports using mobile phones to enhance the timely sharing of information to foster rapid responses to disease outbreaks and other public health emergencies in the country. Furthermore, participants were trained on the use of the existing DHIS2 to access data and reports. Trainings involved HF staff who are responsible for daily data capturing and reporting on IDSR diseases. At the regional and district levels, HMIS, IDSR, and malaria focal person(s) were involved. Overall, a total of 151 health workers (103 male and 48 female) were trained at the regional and district levels, and a total of 2,304 health workers (1,188 male and 1,116 female) from HFs were trained in all eight regions (Table 14).


Table 14. Health Workers Trained and HFs Reporting using eIDSR, November 2013‒July 2016

Region

Number of Facilities

Implementing eIDSR

HFs Workers District/Regional Health

Workers Trained

Male Female Total Male Female Total

Mwanza 357 200 159 359 13 10 23

Mara 271 161 125 286 17 7 24

Geita 143 96 48 144 13 5 18

Dar Es Salaam 369 185 235 420 6 2 8

Manyara 181 122 86 208 16 2 18

Singida 214 104 122 226 11 5 16

Dodoma 372 178 194 372 13 7 20

Kagera 287 142 147 289 14 10 24

Total 2,194 1,188 1,116 2,304 103 48 151

Setting malaria epidemic threshold for detecting malaria epidemics. TVCSP supported NMCP to develop a threshold that has been set within DHIS2 in the eIDSR system. The epidemic threshold for malaria was set for the confirmed malaria cases based on the three-week rolling average as recommended by WHO for settings without historical data. The malaria threshold was set at two-fold increase of confirmed malaria cases in the current week compared to the average of malaria cases in the previous 3 weeks. Alerts were sent automatically via SMS at the district, regional, and national levels when thresholds were exceed. No districts reported any alert, with no HFs exceeding set thresholds. There is a need to review historical data that are available so far to calibrate the epidemic thresholds.

Support for malaria data analysis, interpretation and sharing. Over the course of the project, TVCSP supported NMCP to develop an eIDSR Dashboard to show the following key indicators:

Trends of HF submitting reports including timeliness of reporting (reports received on time every Monday 3:30pm of the reporting week.

Number of clinical and confirmed/positive malaria cases) as well as proportion of confirmed malaria cases/malaria positivity rate

Number and proportion of malaria cases tested

Malaria epidemic thresholds

Analysis was undertaken through this dashboard and used to share information of eIDSR results monthly, quarterly and annually.

Table 15 and Figure 25 show summary results of malaria data extracted from the eIDSR Dashboard since the beginning of the eIDSR in November 2013 to June 30, 2016. During this period, there was a progressive scale up from 67 HFs in 2013 to over 2,194 HFs in June 2016.


Table 15 shows overall summary of reports and malaria cases reported in 2013–2016. Overall, the reporting rate is 40% and reports received on time (by Monday 3:30pm) are about 12%. The findings over these reports showed that out of 5,420,106 (90%) people tested, a total of 1,822,392 (34%) tested positive for malaria.

Figures 26 and 27 shows trends of malaria reporting, testing and cases (clinical and confirmed) in HFs reporting through eIDSR from November/December 2013 to June 2016.

Table 15. Summary Results of eIDSR Reports and Malaria Data, November 2013–July 2016

Region Reports

Received (%)

Reports Received on

Time (Monday)

Number of People Tested

Number Malaria positive Cases

Number of Clinical Malaria Cases

Dar es Salaam 8,834 (33%) 3,506 (13%) 1,930,075 (95%) 381,074 (20%) 105,153

Dodoma 5,313 (29%) 1,596 (8%) 260,839 (90%) 52,318 (20%) 27,062

Geita 4,660 (40%) 1,047 (9%) 474,919 (89%) 218,639 (46%) 54,303

Kagera 18,783 (49%) 6,874 (18%) 1,511,386 (92%) 658,633 (44%) 127,743

Manyara 4,041 (40%) 387 (4%) 115,414 (88%) 14,463 (13%) 14,616

Mara 7,696 (41%) 1,903 (10%) 510,595 (84%) 236,275 (46%) 94,443

Mwanza 9,344 (36%) 2,768 (11%) 622,400 (79%) 268,241 (43%) 163,291

Singida 6,350 (58%) 1,585 (14%) 240,120 (92%) 45,409 (19%) 19,469

Total 65,329 (41%) 19,666 (12%) 5,665,748 (90%) 1,875,052 (34%) 606,080

Supportive supervision. Over the course of the project, TVCSP supported NMCP and the MoH’s epidemiology unit to conduct several supportive supervision visits in regions implementing eIDSR. The main objective of the visits were to support HFs to improve the reporting rates of eIDSR, identifying challenges encountered when sending reports, and recommending ways to improve the reporting rate. During the supportive supervision visits, the supervisory team also conducted DQAs to verify that the data that is being reported in the system matches with the data found in HMIS registers and eIDSR forms. Supportive supervision visits at regional, districts and HF levels allowed identification of challenges and their resolution in situ. For instance, low reporting rates were due to several reasons, including:

Some facilities had new untrained staff replacing trained staff that were transferred or left their positions. Therefore, district / regional personnel were empowered to orient new staff and assist them to submit their eIDSR reports.

In a first instance, only one mobile service provider (i.e. Vodacom) was used to submit eIDSR reports, and some facilities were located in areas where the Vodacom network was not stable or very limited. Subsequently. Two other mobile network providers, Tigo and Airtel, were also linked to


eIDSR servers, allowing for better coverage for electronic reporting by HFs.

Going forward, supportive supervision visits will be intensified to ensure that the reporting rate and data quality is reaching the target of 90% as per NMCP’s Strategic Plan of 2014–2020. As part of the supportive supervision, TVCSP in collaboration with NMCP and MoH conducted several training workshops to the regional and district personnel to assist them to improve their skills on supervision, data quality verification, analysis, Interpretation and use.

Other Surveillance Activities: Operational Research

Over the course of TVCSP, PMI supported operational research; for malaria surveillance there were two main operational researches conducted which included;

Monitoring Parasitemia Prevalence among Pregnant Women and Children in 54 RCH Sites in the Lake Zone

This activity was conducted as operational research beginning from December 2012 to November 2013. The main objective was to pilot a system to monitor longitudinal trends in malaria parasitemia prevalence among two sentinel populations following ongoing, multiple malaria vector control and case management interventions. The two sentinel populations include (1) infants attending RCH clinic for measles vaccinations (usually 9–12 months of age) and (2) pregnant women attending RCH clinics for their first prenatal care visit for a particular pregnancy. The research was conducted in 54 selected HFs of Kagera, Mara, and Mwanza regions. The final technical report was completed and annexed to the TVCSP quarterly report of July 2014. The key findings were disseminated to NMCP’s surveillance, M&E networking group and a manuscript was accepted for publication in Malaria journal (see Component 9). The findings from the report showed that over a period of one year, a proportion of 86.7% and 74.7% reports were received for pregnant women and infants, respectively. A total of 44,898 pregnant women attended their first ANC visit, and 31,868 infants attended for measles vaccination, with 44.7% and 42.7% tested with mRDT, respectively.

The overall prevalence of malaria parasitemia among pregnant women and infants was 12.7% (95% confidence interval [CI] 11.5-12.8) and 10.8% (95% CI 9.3-11.0), respectively (Table 16). Therefore, routine screening of these accessible populations may offer a practical strategy for routine continuous surveillance for tracking malaria control progress over time. Given the low test rate, it is recommended that increased efforts are needed to examine and address barriers hindering the high test rate.

Table 16. Summary of HF Reports, Attendance, Testing, and Malaria Positivity by Region, December 2012–November 2013

Characteristic Pregnant Women Infants Aged 9−12 Months

Kagera Mara Mwanza Total Kagera Mara Mwanza Total

# HFs 18 14 22 54 18 14 22 54

# reports expected

198 154 242 594 198 154 242 594


Characteristic Pregnant Women Infants Aged 9−12 Months

Kagera Mara Mwanza Total Kagera Mara Mwanza Total

# reports received 171 150 194 515 153 146 145 444

% reports received

86.4% 97.4% 80.2% 86.7% 77.3% 94.8% 59.9% 74.7%

# participants attended clinic

15,551 8,307 21,040 44,898 11,861 7,256 12,751 31,868

# tested 8,276 6,404 5,410 20,090 5,265 5,371 2,966 13,602

% participants tested

53.2% 77.1% 25.7% 44.7% 44.4% 74.0% 23.3% 42.7%

# positive 1,141 757 645 2,543 700 402 371 1,473

Malaria positivity (%)

13.8% 11.8% 11.9% 12.7% 13.3% 7.5% 12.5% 10.8%

Investigating the Prevalence of SP-resistant Malaria Parasites in the General Population

This activity was conducted as operational research was implemented in Year 5, quarter three. The main objective of the study was to investigate for prevalence of SP-resistant malaria parasites in the general population in Lake Zone (Mwanza, Geita, Mara, and Kagera regions) and Southern Zone (Lindi, Mtwara, and Ruvuma regions) of Tanzania.

This surveillance activity was designed to be a cross-sectional HF-based survey and was conducted in 14 selected HFs. The study participants included people testing positive for malaria parasites. The study involved training for HF staff (i.e. clinicians and laboratory technicians) to provide them with knowledge on how to collect samples, and store and transport them to RTI offices for eventual shipment to the University of North Carolina (UNC) reference laboratory in the U.S. for analysis. The training for HFs in the Lake Zone took place on April 21–29, 2015, and in Southern Zone on May 12–15, 2015. In the Lake Zone a total of 16 health staff (8 laboratory technicians and 8 clinicians) were trained. In Southern Zone, a total of 12 health staff (6 laboratory technicians and 6 clinicians) were trained.

Dried blood spot (DBS) samples were collected from consenting patients presenting to the outpatient department who had positive rapid diagnostic tests for malaria. Patients with recent exposure to SP or related drugs were excluded. The DBS were sent to UNC for further analysis to determine the frequencies of SP-resistant mutations in circulating P. falciparum populations.

A total of 1,750 DBS samples were collected from the 14 HFs (117 to 160 samples per HF). The final technical report was prepared and annexed to the TVCSP quarterly report of June 30, 2016. The results showed that the dhps540 mutation was prevalent, ranging from 55% to 98.4%. Additionally, the prevalence of the dhps581 mutation ranged from 0% to 2.4%, except at Kayanga HF (Kagera Region), where this mutation was found at a rate of 24.9%. The dhfr164 mutation was detected at a low frequency in only one HF (Kayanga: 0.06%).


Figure 25. Reports received from HFs implementing eIDSR, November 2013–July 2016


Figure 26. Malaria testing and cases trends in HFs implementing eIDSR, November 2013–July 2016


Figure 27. Trends of confirmed malaria cases and clinical malaria cases in the eIDSR, November 2013–July 2016


Component 6—RSS

During Year 4, PMI awarded TVCSP additional funds to implement RSS in Mainland Tanzania as a pilot activity. The main objective of RSS was to support NMCP to improve the quality and use of malaria data collected in the HMIS. This initiative constitutes an important milestone towards achievement of the NMCP’s objective to improve accuracy, completeness, and timeliness of malaria indicators within the country’s HMIS to reach 90% by 2020. This activity was implemented in collaboration with the M&E department-HMIS unit of the MoH.

The RSS activity was conducted in three phases: (1) planning; (2) implementation; and (3) evaluation.

Planning Phase

The planning phase was completed in the first quarter of TVCSP’s Year 5, and the detailed comprehensive report was annexed to the first quarterly report of Year 5. Activities conducted during the planning phase included the following:

First stakeholders meeting. In collaboration with NMCP, TVCSP conducted a first stakeholders meeting on May 7, 2014, to inform stakeholders of the goals and plans for improving malaria data quality and use. The stakeholders discussed in groups to identify main issues regarding malaria data quality and these issues were divided into five domains including; (1) data collection tools and malaria parameters; (2) data transmission; (3) data analysis, visualization and use; (4) data quality checking; and (5) organizational / behavioral factors. Participants felt next steps should include conducting further assessment of HMIS malaria data quality and use at select facilities, districts, and regions in Tanzania using an adapted version of the Performance of Routine Information System Management tool; a second stakeholders meeting would review those findings and identify actionable recommendations to improve the HMIS.

Situational analysis. TVCSP conducted a situational analysis to assess the quality of malaria data, identify gaps in the existing information system that are contributing to poor data quality, and highlight how data were being used for decision-making. This analysis was conducted in two phases: (1) desk review; and (2) field-based data collection. Overall, the findings suggested that data quality was very poor. Data from 93% of the 60 HFs had inconsistencies when comparing HMIS data sources (i.e. in the registers, tally sheets, summary forms and DHIS2) in key malaria indictors. Issues related to data collection tools not being available and not being completed were seen both at the facility level (in the registers, tally sheets, and summary forms) and at the district level (in the summary forms and data entered into the DHIS2). The main challenges appeared to be behavioral and organizational, relating to how staff value and use data in their everyday work.

Second stakeholders meeting. TVCSP, in collaboration with NMCP and University of California San Francisco, convened a second stakeholders meeting held on November 19 to 21, 2014, in Morogoro, Tanzania. The main objectives were to discuss findings from the field-based assessment, identify and prioritize which problems to address first, and develop the pilot’s implementation plan.


The meeting was attended by partners from the Government of Tanzania, including MoH, NMCP, regional medical officers, and DMOs, HMIS and malaria focal person(s), and clinicians from HFs. Also attending were representatives from private sector and civil society entities engaged in strengthening malaria and routine health information, particularly data quality and use.

Following the meeting, three areas of priorities for improving malaria data quality and use were recommended for implementation as part of the second phase. The priority areas included the following:

Introduce data quality and use as part of the permanent agenda item in the HFs, Central Health Management Team (CHMT), and Regional Health Management Team (RHMT) meetings

Establish and strengthen data analysis and routine monthly meetings for data discussion at HFs (guidelines on data use), including training

Support CHMTs to conduct regular, comprehensive, and effective supportive supervision, including DQAs

Implementation

In order to scale up malaria data quality improvement as per the above-mentioned priorities, TVCSP, in collaboration with NMCP, developed a training guide to support regions, districts, and HFs to improve malaria data quality and use. The guide is intended to build capacity of the regional and district personnel (1) to improve their skills for malaria data quality verification, analysis, interpretation and use; (2) to identify important issues related to data quality, sorting, and processing of data from HF to higher levels; and (3) to improve skills and prepare plans for effective supportive supervision, monitoring and DQA.

The training was initiated in Pwani Region in September 2015 and involved regional and district health personnel from all seven districts (Kibaha District Council, Kibaha Town Council, Bagamoyo, Mafia, Kisarawe, Rufiji, and Mkuranga district councils). Overall, a total of 47 health workers (32 male and 15 female) were trained, including regional and districts medical officers, HMIS, malaria, laboratory, pharmacy focal person(s).

Along with the guide, the project developed a data quality audit tool which was incorporated in a general malaria supervision tool; the tool has now been adopted by the NMCP and is being rolled out in all regions to be used by RHMTs/CHMTs for supervision at regional, district and health facility level.

Evaluation phase

This will be conducted through guidance from PMI/USAID. It is not part of the scope of the TVCSP.

IRS Sustainability and Projections for Future Needs in Mainland Tanzania

In 2013, TVCSP provided technical support to NMCP to develop a National MSP for 2014 to 2020. In the MSP, NMCP plans to build the capacity of local government authorities and the private sector to plan, manage, implement, and evaluate IRS. The


major focus for IRS will be to build implementation capacity at the council level. The capacity-building plan will target council staff to enable them to plan, manage, implement, monitor, and evaluate IRS interventions in their respective councils. This process will involve a broad partnership comprising players from local governments, civil society, and the private sector. SOPs will be applied for the IRS implementing councils to ensure quality IRS application. The selection of the councils to be targeted will be based on the recent updated epidemiological profile of malaria in the country.

Under TVCSP, IRS was implemented in selected areas in 18 districts in the three Lake Zone regions (Kagera, Mara, and Mwanza). As per the 2014‒2020 MSP, IRS operations will be scaled up in selected focal areas in 43 districts, based on the following criteria: (1) identified holo- and hyper-endemicity areas with perennial transmission and resilient to changes; (2) moderate- and high-prevalence areas with seasonal transmission; (3) areas with high levels of insecticide resistance (especially pyrethroids); (4) areas with increased risk of epidemics; and (5) focal areas in the Lake Zone where IRS has historically been implemented. Using the malaria risk map, it has become possible to locate the target areas more accurately so that IRS operations can be more focused and effective. The proposed IRS scale-up entails a geographical expansion, with an increase in target areas. However, the total number of households sprayed will remain similar to the current levels (i.e., approximately 14% of households in Mainland Tanzania).

The focus of implementation will be on ensuring optimum coverage, in space (i.e. in terms of household structures sprayed) and frequency of spray rounds (i.e. in accordance with the residual effect of the insecticide used). To preserve optimal protection of LLINs, which are currently treated with pyrethroids, the NMCP recommends the exclusive use of insecticides with different mode of action to that of pyrethroids for IRS, such as organophosphate and carbamates.

Under TVCSP, SOPs were developed to enable councils to implement quality IRS The SOPs outline the procedures to be followed for quality IRS, including the following: monitoring spray procedures in the field, monitoring the effectiveness of the spraying by conducting cone bioassays and utilizing IQKs, and monitoring human safety and environmental compliance. Exit strategies should be planned well in advance, as early as the start of the implementation in selected areas.

Projections for future needs. In the 2014‒2020 MSP, Mainland Tanzania aims to consolidate and expand IRS in epidemiologically and operationally suitable areas, with the goal of covering at least 20% of household structures in Tanzania by 2020. The prerequisite for such strategy will be to develop criteria for identifying areas that are epidemiologically and operationally suitable for IRS. Currently, the evidence regarding the added value of combining the use of LLINs and IRS is inconclusive, particularly when coverage and use of either strategy is high. However, conditions exist under which a combined approach involving both LLINs and IRS is deemed beneficial, particularly in focal areas with seasonal malaria transmission, epidemic-prone areas to pre-empt malaria outbreaks, and areas with high levels of insecticide resistance. Mapping the local transmission patterns and potential will allow more targeted and focal spraying in these areas. Because pyrethroids are currently the


only option for LLINs, other classes of insecticides are recommended for IRS. Under TVCSP, a total of 18 districts were covered by IRS, targeting approximately 12% of households in mainland Tanzania. NMCP aims to increase the number of households targeted for IRS to 43 districts, corresponding to 20% of households in Mainland Tanzania.

V. OTHER ACTIVITIES

Component 7—Capacity Building and Sustainability

Over the course of TVCSP’s implementation, the project focused on capacity development both at national district levels as well as HFs.

Human Resource Development

Training and mentoring activities for individuals and groups from the national to district level was ongoing throughout TVCSP implementation and has been detailed in respective components mentioned above.

Additionally, TVCSP established national IRS core facilitators and organized a training conducted at the Nelson Mandela Institute of Science and Technology in Arusha, Tanzania, September 10–22, 2012. A total of 25 people (19 men and 6 women)—including malaria focal persons from districts and regions of Mwanza, Mara and Kagera, MoH’s Vector Unit and NMCP—were trained.

The main objective of this training was to impart knowledge and skills to all participants working in the planning and execution of technical trainings, spray operations, development and review of tools for M&E and quality assurance of IRS implementation in Tanzania. This training offered participants hands-on experience in practical exercises, case studies, and field experience reflections. At the end of the course, the participants acquired IRS certificates, and they are considered certified IRS-champions from the central and local government, capable of supporting the entire IRS process (e.g., planning, implementation, and evaluation) anywhere in the country.

Organizational/Institutional Development for IRS Implementation

TVCSP has been continuously supporting NMCP’s development and procedures at all levels and in all sectors to enhance their capacities and sustainability. TVCSP supported NMCP and ZAMEP to develop several policy and strategy documents including the following:

Comprehensive Training Package for IRS; the package includes strategy, curriculum, trainer’s guide, thematic sourcebooks, and teaching aids.

National Malaria Surveillance and Response Guidelines and a district handbook for surveillance and response, detailing step-by-step actions to be taken at the district level when notified by HFs of abnormal increase in malaria cases (see also Surveillance Section above).

National malaria vector control guidelines

Insecticide resistance management (IRM ) plan detailed appropriate management of vector resistance for IRS insecticides


In addition, every year as part of the sustainability plan prior to IRS operations taking place, the Memorandum of Understanding (MOU) between RTI and district authorities was reviewed and updated to ensure greater responsibilities were transferred to the district authorities in order to increase local ownership.

Component 8—M&E

Performance Monitoring Plan (PMP)

The project’s performance in terms of inputs, processes, outputs, outcomes, and impact were measured using the set of indicators developed and outlined in the PMP, and approved by USAID following TVCSP award. Using the annual work plan, the project’s performance was closely monitored to determine milestones and challenges. Annually, a PMP summary report was prepared and annexed to the TVCSP annual report.

Build Capacity: Strengthen M&E and Data Management System

TVCSP implemented several activities to support and strengthen M&E and data management systems at ZAMEP and NMCP. Activities conducted included the following:

RTI supported ZAMEP in using a GIS mapping application by providing on-the-job training to one staff member.

RTI assisted NMCP and ZAMEP to strengthen capacity in data management including data analysis and improving skills in data quality verification at all levels (from HF to district level)

RTI conducted a Scientific Technical Writing Workshop for 19 ZAMEP staff in September 2013. The objectives of the workshop aimed to enable ZAMEP staff to undertake basic data analysis and interpretation using MS Excel. The workshop also provided skills training in writing technical reports and abstracts and preparing MS PowerPoint presentations. Many presentations resulted in abstracts submitted for presentation at the NIMR Annual Joint Scientific Conference (AJSC).

DQA

TMEMS in accordance with USAID’s mandate conducted a DQA every year on either one of on three core IRS indicators on which TVCSP reports to USAID. The three core indicators are (1) number of household structures sprayed with United States Government (USG) funds; (2) number of household structures targeted for spraying with USG funds; (3) number of people trained with USG funds to deliver IRS. The main objective of this exercise was to ensure that the quality of data reported by RTI met the required data quality standards. Following this exercise reports from the TMEMS show that TVCSP has adhered to high standards in the five key elements of data quality (validity, integrity, precision, reliability and timeliness) throughout the project implementation.

Component 9—Cross-Cutting Activities

Cross-cutting Issues—Gender

Throughout the implementation of TVCSP, there were ongoing efforts to increase the percentage of women’s involvement to meet the USAID target of 50%–50%. Overall


figures show that an average of 27% of spray operators involved in IRS operations were female.

Knowledge Management and Communication

Conferences and Other Forums

TVCSP, in collaboration with ZAMEP, NMCP, PMI and other stakeholder staff participated and made presentations at different conferences and fora in and outside of the country (Table 17 and Appendix 1). The presentations focused on TVCSP performance and achievements, lessons learned, best practices, as well as sharing the latest epidemiological and programmatic data on malaria and its prevention and control in Mainland Tanzania and Zanzibar.

TVCSP supported each year ZAMEP and NMCP in commemorating World Malaria Day on April 25, being able to inform in-country stakeholders and communities about TVCSP activities and achievements.

Table 17. Number and Type of Presentations Delivered at Key Scientific Conferences

Presentation Type

Name of Conference

Year

Total 2010 2011 2012 2013 2014 2015

Oral NIMR AJSC, Tanzania 23 23

American Society of Tropical Medicine and Hygiene (ASTMH) Annual Meeting, USA 1 10 4 15

Multilateral Initiative on Malaria (MIM), South Africa 8 8

Poster American Public Health Association, USA 1 1

ASTMH Annual Meeting, USA 1 1 3 2 4 4 15

MIM, South Africa 4 4

Total 1 1 4 15 37 8 66

Publications

Several manuscripts authored by TVCSP staff were accepted and published in the peer-reviewed scientific and medical literature, including the following:

1. Alidina Z, Colaco R, Ali AS, Mcha JH, Mwalimu CD, Thawer NG, et al. Taking local ownership: government and household contribution to IRS in Zanzibar and mainland Tanzania. Int. Health. 2016;8:299–306.

2. Cook J, Xu W, Msellem M, Vonk M, Bergström B, Gosling R, et al. Mass screening and treatment on the basis of results of a Plasmodium falciparum-specific rapid diagnostic test did not reduce malaria incidence in Zanzibar. J. Infect. Dis. 2015;211:1476–83.

3. Haji KA, Thawer NG, Khatib BO, Mcha JH, Rashid A, Ali AS, et al. Efficacy, persistence and vector susceptibility to pirimiphos-methyl (Actellic 300CS) insecticide for IRS in Zanzibar. Parasit. Vectors. 2015;8:628.


4. Kabula B, Tungu P, Malima R, Rowland M, Minja J, Wililo R, et al. Distribution and spread of pyrethroid and DDT resistance among the Anopheles gambiae complex in Tanzania. Med. Vet. Entomol. 2014;28:244–52.

5. Kabula B, Kisinza W, Tungu P, Ndege C, Batengana B, Kollo D, et al. Co-occurrence and distribution of East (L1014S) and West (L1014F) African knock-down resistance in Anopheles gambiae sensu lato population of Tanzania. Trop. Med. Int. Health TM IH. 2014;19:331–41.

6. Lalji S, Ngondi JM, Thawer NG, Tembo A, Mandike R, Mohamed A, et al. School Distribution as Keep-Up Strategy to Maintain Universal Coverage of LLINs: Implementation and Results of a Program in Southern Tanzania. Glob. Health Sci. Pract. 2016;4:251–63.

7. Mutagahywa J, Ijumba JN, Pratap HB, Molteni F, Mugarula FE, Magesa SM, et al. The impact of different sprayable surfaces on the effectiveness of IRS using a micro encapsulated formulation of lambda-cyhalothrin against Anopheles gambiae s.s. Parasit. Vectors. 2015;8:203.

8. Thawer NG, Ngondi JM, Mugalura FE, Emmanuel I, Mwalimu CD, Morou E, et al. Use of insecticide quantification kits to investigate the quality of spraying and decay rate of bendiocarb on different wall surfaces in Kagera region, Tanzania. Parasit. Vectors. 2015;8:242.

9. West PA, Protopopoff N, Wright A, Kivaju Z, Tigererwa R, Mosha FW, et al. IRS in combination with insecticide-treated nets compared to insecticide-treated nets alone for protection against malaria: a cluster randomised trial in Tanzania. PLoS Med. 2014;11:e1001630.

10. Willilo RA, Molteni F, Mandike R, Mugalura FE, Mutafungwa A, Thadeo A, et al. Pregnant women and infants as sentinel populations to monitor prevalence of malaria: results of pilot study in Lake Zone of Tanzania. Malar. J. 2016;15:392.

Summary of research findings

Table 18 summarizes the key research findings from various studies undertaken during the course of TVCSP.


Table 18. Summary of Key Research Findings

Title of study Aim and Methods Key Findings Conclusions

Taking local ownership: government and household contribution to IRS in Zanzibar and Mainland Tanzania

This study explored the in-kind contributions of local governments and households towards the cost of IRS operations in Tanzania.

Data were collected through interviews with local government officials and technical teams involved in the TVCSP project. Household contributions were based on the provision of water for IRS operations. Government contributions included government-provided warehouse and office space, vehicles, and staff labor. In-kind contributions were aggregated at the district, regional, and national levels. Calculations were based on the proportion of total costs of IRS operations incurred from 2010 to 2012.

On average, in-kind contributions covered 5.5% of the total costs for Zanzibar and 2.9% for Mainland Tanzania. The proportion of the government’s in-kind contributions was higher in Zanzibar than Mainland Tanzania (86% vs. 50%), whereas household contributions were higher in Mainland Tanzania than in Zanzibar (50% vs. 14%).

Government involvement, particularly through budgetary allocations and increased in-kind contributions, must be encouraged for malaria control efforts to be locally owned, managed, and sustained.

MSAT on the basis of results of a Plasmodium falciparum-specific rapid diagnostic test did not reduce malaria incidence in Zanzibar

Mass screening and treatment (MSAT) may help reduce the reservoir of infection; however, it is unclear whether RDTs detect a sufficient proportion of low-density infections to influence subsequent transmission.

Two rounds of MSAT using Plasmodium falciparum-specific RDTs were conducted in five hot spots (population, 12,000) in Zanzibar in 2012. In parallel, blood samples were collected on filter paper for PCR analysis. Data on confirmed malarial parasite infections from HFs in intervention and hot spot control areas were monitored as a proxy for malaria transmission.

Approximately 64% of the study population (7859) were screened at least once. The P. falciparum prevalence, as measured by RDT, was 0.2% (95% CI, 0.1%-0.3%) in both rounds, compared with the PCR-measured prevalences (for all species) of 2.5% (95% CI, 2.1%‒2.9%) and 3.8% (95% CI, 3.2%‒4.4%) in rounds 1 and 2, respectively. Two fifths (40%) of the infections detected by PCR included non-falciparum species. Treatment of RDT-positive individuals (4% of the PCR-detected parasite carriers) did not reduce subsequent malaria incidence compared with control areas.

Highly sensitive point-of-care diagnostic tools for the detection of all human malaria species are needed to make MSAT an effective strategy in settings where malaria elimination programs are in the pre-elimination phase.



Efficacy, persistence and vector susceptibility to pirimiphos-methyl (Actellic 300CS) insecticide for IRS in Zanzibar

This study investigated the residual efficacy of pirimiphos methyl (Actellic 300CS) sprayed on common surfaces of human dwellings in Zanzibar.

The residual activity of Actellic 300CS was determined over 9 months through bioassay tests that measured the mortality of female Anopheles mosquitoes when exposed to sprayed surfaces. The wall surfaces included; mud wall, oil or water painted walls, lime washed wall, un-plastered cement block wall and stone blocks. Insecticide susceptibility testing was done to investigate the resistance status of local malaria vectors against Actellic 300CS using standard WHO protocol; anopheline species were identified using PCR methods.

Baseline tests conducted one-day post-IRS revealed 100% mortality on all sprayed surfaces. The residual efficacy of Actellic 300CS was maintained on all sprayed surfaces for up to 8 months post-IRS. Only oil paint surfaces retained the recommended residual efficacy beyond 9 months post-IRS, with mortality maintained at ≥97 %. Results of susceptibility tests showed that malaria vectors in Zanzibar were fully (100%) susceptible to Actellic 300CS. The predominant mosquito vector species was An. arabiensis (76.0%) in Pemba and An. gambiae (83.5%) in Unguja.

Actellic 300CS is a highly effective and appropriate insecticide for IRS use in Zanzibar: compared to other insecticides commonly used for IRS, it showed prolonged residual activity, allowing to effectively protect communities with a single annual spray round and thereby potentially reducing overall programmatic costs. Actellic 300CS may prove to be a useful alternative in insecticide resistance management plans.



Distribution and spread of pyrethroid and DDT resistance among the Anopheles gambiae complex in Tanzania

A national survey was carried out in Tanzania in 2011 to monitor the susceptibility of malaria vectors to pyrethroid, organophosphate, carbamate and DDT insecticides, and compare these findings with those identified in 2004 and 2010. Standard WHO methods were used to detect knock-down and mortality rates in wild-caught female Anopheles gambiae s.l. (Diptera: Culicidae) collected from 14 sentinel districts. Diagnostic doses of the pyrethroids deltamethrin, lambdacyhalothrin and permethrin, the carbamate propoxur, the organophosphate fenitrothion and the organochlorine DDT were used.

Anopheles gambiae s.l. populations were resistant to permethrin in Muleba (where a mortality rate of 11% [95% CI 6-19%] was recorded), Muheza (mortality rate of 75%, 95% CI 66-83%), Moshi and Arumeru (mortality rates of 74% in both). Similarly, resistance was reported to lambdacyhalothrin in Muleba, Muheza, Moshi and Arumeru (mortality rates of 31-82%), and to deltamethrin in Muleba, Moshi and Muheza (mortality rates of 28-75%). Resistance to DDT was reported in Muleba. No resistance to the carbamate propoxur or the organophosphate fenitrothion was observed.

Anopheles gambiae s.l. is becoming resistant to pyrethoids and DDT in several parts of Tanzania, a likely result of the scaling up of vector control efforts in the country. Resistance may impair the effectiveness of these interventions in the future and, therefore, demands close monitoring and the adoption of a resistance management strategy.

Co-occurrence and distribution of East (L1014S) and West (L1014F) African knock-down resistance in Anopheles gambiae sensu lato population of Tanzania

The study investigated the presence and distribution of knock-down resistance (kdr) mutations in Anopheles gambiae s.l. in Tanzania.

Indoor-resting Anopheles mosquitoes were collected from 10 sites and tested for insecticide resistance using the standard WHO protocol. PCR-based molecular diagnostics were used to genotype mosquitoes and detect kdr mutations.

Sampled An. gambiae were resistant to lambdacyhalothrin in Muheza, Arumeru, and Muleba. Out of 350 An. gambiae s.l. genotyped, 35% were An. gambiae s.s., and 65% were An. arabiensis. L1014S and L1014F mutations were detected in both An. gambiae s.s. and An. arabiensis. L1014S point mutation was found at an allelic frequency of 4‒33%, whereas L1014F was observed at an allelic frequency of 6‒41%. The L1014S mutation was strongly associated with An. gambiae s.s. (χ(2) = 23.41; P < 0.0001), and L1014F was associated with An. arabiensis (χ(2) = 11.21; P = 0.0008). The occurrence of the L1014S allele was significantly associated with lambdacyhalothrin resistance in mosquitoes (Fisher exact P < 0.001).

The observed co-occurrence of the L1014S and L1014F mutations coupled with reports of insecticide resistance in this country suggest that pyrethroid resistance is becoming a widespread phenomenon among Tanzania’s malaria vector populations. The presence of the L1014F mutation in these East African mosquito populations indicates the spreading of this gene across Africa. The potential operational implications of these findings for malaria control require further exploration.



School distribution as keep-up strategy to maintain universal coverage of LLINs: Implementation and results of a program in southern Tanzania

This study documented the design, implementation, monitoring, and outputs of the SNP2 undertaken in 2014. SNP2 was conducted in all schools in Lindi, Mtwara, and Ruvuma Regions, targeting students in primary (Standards 1, 3, 5, and 7) and secondary (Forms 2 and 4) schools and all teachers. In Lindi Region, two additional classes (Standards 2 and 4) were targeted. LLIN distribution data were managed using an Android software application called SchoolNet.

SNP2 included 2,337 schools, 473,700 students, and 25,269 teachers. A total of 5,070 people were trained in LLIN distribution (487 trainers and 4,583 distributors), and 4,392 (434 ward and 3,958 village) community change agents undertook sensitization and mobilization. A total of 507,775 LLINs were distributed to schools, with 464,510 (97.9% of those registered) students and 24,206 (95.8% of those registered) schoolteachers receiving LLINs.

LLIN ownership and use are expected to have increased, potentially further reducing the burden of malaria in the Southern Zone of Tanzania.

The impact of different sprayable surfaces on the effectiveness of IRS using a micro encapsulated formulation of lambda-cyhalothrin against Anopheles gambiae s.s.

The study investigated the residual efficacy of micro-encapsulated lambda-cyhalothrin sprayed on common surfaces of human dwellings and domestic animal shelters in Zanzibar and Mainland Tanzania.

An experimental hut was constructed with different types of materials simulating common sprayable surfaces in Zanzibar and Mainland Tanzania. Surfaces included cement plastered wall, mud-daub, whitewash, wood, palm-thatch, galvanized iron-sheets, burnt bricks, limestone, and oil paint. The WHO procedure for IRS was used to spray lambda-cyhalothrin on the surfaces at a dose of 20‒25 mg/m2. The residual efficacy of the insecticide was monitored through cone bioassays using laboratory-reared mosquitoes (Kisumu strain (R-70) of An. gambiae s.s.). The cone bioassays were performed every fortnight for a period of 152 days. The WHOPES threshold (80% mortality) was used as the cut-off point for acceptable residual efficacy.

A total of 5,800 mosquitoes were subjected to contact cone bioassay to test residual efficacy of lambda-cyhalothrin. There was a statistically significant variation in residual efficacy between the different types of wall surfaces (r = 0.24; p < 0.001). Residual efficacy decreased with increasing pH of the substrate (r = -0.5; p < 0.001). As per WHO threshold, shorter residual efficacy (42-56 days) was found in wall substrates made of cement, limestone, mud-daub, oil paint and white wash. Burnt bricks retained the residual efficacy up to 134 days while galvanized iron sheets, palm thatch and wood retained the recommended residual efficacy beyond 152 days.

The study revealed a wide variation in residual efficacy of micro encapsulated formulation of lambda-cyhalothrin across the different types of wall surfaces studied. In areas where malaria transmission is bimodal and wall surfaces with short residual efficacy comprise > 20% of sprayable structures, two rounds of IRS using lambda-cyhalothrin should be considered. Further studies are required to investigate the impact of sprayable surfaces on residual efficacy of other insecticides commonly used for IRS in Zanzibar and Mainland Tanzania.

Use of IQK to investigate the quality of spraying and decay rate of bendiocarb on different wall surfaces in Kagera region, Tanzania

This study used the IQK to investigate the intra-operational IRS coverage and quality of spraying, and decay rate of bendiocarb on different wall surfaces in Kagera region.

To assess intra-operational IRS coverage and quality of spraying, 104 household structures were randomly selected out of 161,414 sprayed household structures. A total of 509 samples (218 in Muleba and 291 in Karagwe) were obtained by scraping the samples from wall

Of the 509 samples, 89.5% met the WHO recommended concentration (between 100-400 mg/m2) for IRS target dosage. The proportion of samples meeting WHO standards varied between Karagwe (84.3%) and Muleba (96.3%) (p < 0.001). Assessment of quality of spraying at household structure level revealed that Muleba (84.8%) had a significantly higher proportion of households that met the expected target

IQK is an important tool for assessing IRS coverage and quality of spraying. The study found adequate coverage of IRS; residual life of bendiocarb was observed to be three months. Results suggest that in order to maintain the recommended concentrations with bendiocarb



surfaces. To investigate insecticide decay rate, 66 household structures (36 in Muleba and 30 in Karagwe) were selected and samples were collected monthly for a period of five months. Laboratory testing of insecticide concentration was done using the IQK.

dosage (100-400 mg/m2) compared to Karagwe (68.9%) (p < 0.001). The quality of spraying varied across different wall substrates in both districts. Evaluation of bendiocarb decay showed that the proportion of household structures with recommended concentration declined from 96.9%, 93.5% and 76.2% at months one, two, and three post IRS, respectively (p-trend = 0.03). The rate of decay increased in the fourth and fifth month post spraying with only 55.9% and 26.3% household structures meeting the WHO recommendations, respectively.

effective for malaria control, a second spray cycle should be carried out after three months.

IRS in combination with insecticide-treated nets compared to insecticide-treated nets alone for protection against malaria: a cluster randomised trial in Tanzania

A cluster randomised controlled trial was conducted to investigate whether IRS in combination with LLINs provides added personal protection from malaria infection compared to ITNs alone.

In northwest Tanzania, 50 clusters (village areas) were randomly allocated to LLINs and IRS, or LLINs only. Dwellings in the LLIN+IRS arm were sprayed with two rounds of bendiocarb in 2012.

The P. falciparum prevalence rate (PfPR) in children 0.5-14 years old (primary outcome) and anemia in children <5 years old (secondary outcome) were compared between study arms using three cross-sectional household surveys in 2012. Entomological inoculation rate (secondary outcome) was compared between study arms. IRS coverage was approximately 90%. LLIN use ranged from 36% to 50%. In an intention-to-treat analysis, mean PfPR was 13% in the LLIN+IRS arm and 26% in the LLIN only arm, odds ratio = 0.43 (95% CI 0.19-0.97, n = 13,146). The strongest effect was observed in the peak transmission season, 6 months after the first IRS round. Subgroup analysis showed that ITN users were additionally protected if their household structures were sprayed. Mean monthly entomological inoculation rate was non-significantly lower in the LLIN+IRS arm than in the LLIN only arm, rate ratio = 0.17 (95% CI 0.03-1.08).

This study found significant added protection from combining IRS and LLINs compared to LLINs alone. The effect is likely to be attributable to IRS providing added protection to LLIN users as well as compensating for inadequate LLIN use. Policy makers should consider deploying IRS in combination with LLINs to control transmission if local LLIN strategies on their own are insufficiently effective. Given the uncertain generalizability of these findings, it would be prudent for malaria control programs to evaluate the cost-effectiveness of deploying LLIN+IRS versus LLINs only prior to programmatic operationalization.



Pregnant women and infants as sentinel populations to monitor prevalence of malaria: results of pilot study in Lake Zone of Tanzania

This pilot study explored the feasibility and utility of tracking the prevalence of malaria infection in pregnant women attending their first antenatal clinic (ANC) visit and infants presenting at 9‒12 months of age for measles vaccination.

Pregnant women attending their first ANC and infants 9‒12 months old presenting for measles vaccination at a non-probability sample of 54 HFs in Tanzania's Lake Zone (Mara, Mwanza, and Kagera Regions) were screened for malaria infection using an RDT from December 2012 to November 2013, regardless of symptoms. Participants who tested positive were treated for malaria per national guidelines. Data were collected monthly.

Overall, 89.9 and 78.1% of expected monthly reports on malaria infection prevalence were received for pregnant women and infants, respectively. Among 51,467 pregnant women and 35,155 infants attending routine preventive HF visits, 41.2 and 37.3 % were tested with RDT, respectively. Malaria infection prevalence was 12.8 % [95 % CI 11.3-14.3] among pregnant women and 11.0 % (95 % CI 9.5-12.5) among infants, and varied by month. There was good correlation of malaria prevalence among pregnant women and infants at the HF level (Spearman rho = 0.6; p < 0.001). This approach is estimated to cost $1.28 for every person tested, with the RDT accounting for 72% of the cost.

Malaria infection was common and well correlated among pregnant women and infants attending routine health services. Routine screening of these readily accessible populations may offer a practical strategy for continuously tracking malaria trends, particularly seasonal variation. The positivity rates among afebrile individuals presenting for routine care offer an advantage because they are unaffected by the prevalence of other causes of febrile illness, which could influence the positivity rates among febrile patients presenting to outpatient clinics. The data presented here suggest that in addition to contributing to clinical management, ongoing screening of pregnant women could be used for routine surveillance and the detection of hotspots.

Pilot of community based IRS in Geita, Chato and Rorya districts of Tanzania

Mainland Tanzania has implemented IRS using different operational designs, starting with highly centralized (2007‒2009) and medium-decentralized (2010‒2013) designs. These two approaches were perceived to be complex to manage and expensive. We report a pilot of CBIRS, which is less complex, relatively inexpensive, and more community owned.

CRIRS was organized and implemented at the village level and included the following: the recruitment of spray operators by village governments, the use of bicycles by spray operators for transportation, the provision of consent by the village government to implement IRS, and the construction of effluent waste disposal structures using local materials.

To evaluate the CBIRS pilot, focus group discussion were

The evaluation suggested that the objectives of CBIRS were attained. CBIRS reduced the implementation costs, increased community participation and ownership, reduced the organizational complexity of IRS, achieved acceptable quality and quantity of IRS, and maintained compliance with environmental protection requirements. The evaluation revealed the following aspects that need improvement: The training of team leaders was inadequate to cover their important roles in CBIRS. The village mobilizer and sub-site supervisor were redundant. Effluent disposal sites were unnecessarily large compared to the small number of spray teams involved in CBIRS. The installation of two soak-pits was

CBIRS is a beneficial approach to reduce the cost and complexity of implementing IRS in Tanzania. However, modifications are needed to achieve the following: reduce redundant staff (e.g., the village mobilizer and sub-site supervisor), simplify the fabrication of effluent waste disposal structures, and increase the level of team leaders’ training.



undertaken with RITTS and DITTS, site managers, sub-site supervisors, team leaders, village mobilizers, site-based mobilizers, spray operators, and community leaders. The evaluation also reviewed the IRS implementation guide, IRS performance report, IEC meeting minutes, and supervisors’ report and undertook an inspection of the constructed sub-sites for compliance to environmental requirements.

unnecessary because one pit can accommodate the small amounts of effluent waste generated by a small team.

Surveillance for sulfadoxine-pyrimethamine (SP) resistant malaria parasites in the Lake and Southern Zones, Tanzania using pooling and next-generation sequencing

This study investigated the prevalence of molecular markers of SP resistance in malaria parasites in the Lake and Southern Zones of Tanzania. A cross-sectional survey was conducted in 14 HFs in seven regions of Mainland Tanzania from April to June 2015. A total of 1,750 DBS samples were collected (117‒160 samples per facility) from consenting patients presenting to the OPD who had positive RDTs for malaria. Patients with recent exposure to SP or related drugs were excluded. DNA was extracted from the DBS, pooled by HF, and analyzed by Illumina MiSeq deep sequencing to yield estimates of the mutated parasite allele prevalence at each locus of interest.

The dhps540 mutation was prevalent across all 14 sites, ranging from 55% to 98.4%, with higher prevalence observed in the Lake Zone than in the Southern Zone. The prevalence of the dhps581 mutation ranged from 0 to 2.4%, with the exception of Kayanga HF (Kagera Region, Lake Zone), where 24.9% of the sequences were mutated. The dhfr164 mutation was detected only at Kayanga HF (0.06%).

Although the quintuple mutant was highly prevalent, dhps581 remains geographically restricted, suggesting that IPTp-SP may remain effective in most of Tanzania. However, additional surveillance, particularly in and around Tanga Region, is warranted. In addition, a better understanding of the effect of the dhps581 mutant on the efficacy of IPTp-SP is needed.


Component 10—Management

Program Planning and Reports

Throughout TVCSP’s period of performance, RTI prepared and submitted to USAID for approval monthly summary reports, quarterly technical and financial reports, as well as annual reports. In addition, separate technical reports, including an End of Spray Round Performance Report after every spray round, were regularly prepared and submitted to USAID for approval; ad hoc reports included a report on Comprehensive Malaria Surveillance for Mainland Tanzania; RSS: Improving Malaria Data Quality and Use; and SNP Performance. These reports were also shared with NMCP and ZAMEP.

Support Provision of Short-term TA (STTA)

TVCSP STTA trips were made to provide RTI headquarter technical assistance to the project and to share TVCSP knowledge and experiences outside the country by project staff. Table 19 shows the total number of international trips approved at the beginning of the award in comparison with those that were taken during TVCSP implementation. Detailed purposes of trips have been elaborated in quarterly and annual reports submitted to USAID.

Table 19. STTA Trips Approved in the Original CA

From To

# of Trips Approved for Project Duration

# of Trips Taken During

Project Implementation

USA Tanzania 70 46

Regional Tanzania 35 35

Tanzania USA 6 16

Tanzania Kenya 5 7

Tanzania South Africa

7 11

Tanzania Ghana 2 2

Tanzania Switzerland 3 3

Total 128 120

Fiscal Report

Table 20 shows the project’s estimated financial status at the end of the performance period. The Vector Control program allocated funding to components based on the annual targets for households sprayed, resources required in the annual work plans, and close out costs.


Table 20. Funding Provided for Each Program Component

Component Funding

IRS 36,823,093

Environmental Compliance 3,359,555

Entomological Monitoring 1,860,854

Capacity Building 27,327,506

Surveillance 12,564,777

Cross Cutting 1,863,291

M&E 2,777,957

Routine Systems Strengthening 129,098

SNP 2,102,879

Wall Lining Study 177,818

Total 88,986,828

VI. CHALLENGES AND RECOMMENDATIONS

Challenges Faced

Insecticide resistance. Beginning in 2007, pyrethroid insecticide (lambda-cyhalothrin) was used for IRS in Kagera Region. In the 2011–2012 IRS seasons, bendiocarb was introduced in Muleba and Karagwe Districts. However, increased resistance to pyrethroids, emerging resistance to bendiocarb in a few districts, and the short residual period of bendiocarb necessitated spraying twice a year. Therefore, NMCP decided to switch to pirimiphos-methyl for the 2013–2014 IRS operations. Resistance can impair the effectiveness of IRS interventions and, therefore, requires close monitoring and the adoption of a resistance management strategy.

Financial implications. As the program transitioned from blanket to targeted to focal spraying, the cost per household/number of persons protected sprayed increased. Additionally, the use of insecticides with short residual efficacies necessitated more than one spray round, increasing the operational costs. These factors must be taken into consideration when planning IRS in any context.

Gender targets. The project had a goal of achieving participation by women at a rate of 50% for the project, especially in terms of spray operators. However, our achievement stalled out at 27%.

Recommendations for Future Implementation

Comprehensive vector control approaches. One study that RTI conducted found that significant added protection was achieved by combining IRS and ITNs compared to ITNs alone. This effect is likely attributable to IRS providing added protection to ITN users and compensating for inadequate ITN use. Policy-makers should consider deploying IRS in combination with ITNs to control transmission if local ITN strategies are insufficiently effective on their own.

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CBIRS. To reduce the complexity and cost of IRS and improve its sustainability, IRS operation modalities, such as CBIRS, which was previously piloted by TVCSP, should be considered for large-scale implementation in future IRS operations.

PPPs. In addition to routine IRS in the mandated areas of the Lake Zone, RTI also supported spraying in two wards of Geita Town during 2011–2015 as part of a PPP among Geita Gold Mine, Geita Town Council, and PMI/USAID. For nearly four years, this PPP capitalized on collective efforts and resources to implement IRS, targeting over 20,000 structures in Geita each year. Based on the success of this experience, TVCSP recommends emulating this approach with other private sector entities in Tanzania and beyond.

Use of electronic banking platforms for spray operations. Beginning in 2013, RTI introduced money transfer through mobile phones using MPesa accounts, which every temporary staff was required to have and submit during the recruitment process. The MPesa transfer was quicker, more efficient, and less cumbersome for the finance team, especially when dealing with large cash flows.


Annex 1. List of topics presented at scientific conferences

Year Title Type Venue Country

2010

Establishment of population malaria surveillance in Kagera region, Tanzania, by routine testing for parasitemia at time of measles vaccination and first antenatal care attendance to evaluate impact of malaria intervention Poster ASTMH USA

2011 Is Active Malaria Case Detection in Asymptomatic Populations Able to Reduce Focal and Seasonal Malaria Transmission in Zanzibar? Poster ASTMH USA

2012

Examination of Surveillance Data Milestones as Zanzibar Transitions to the Malaria Pre-elimination Phase, 2008-2012 Poster ASTMH USA

Representativeness, completeness, timeliness, and accuracy of Zanzibar’s Malaria Epidemic Early Detection System (MEEDS), 2008–2011 Poster ASTMH USA

Shifting from Blanket to Targeted IRS for Malaria Control in Zanzibar: a Novel Approach for Integrated Management of Malaria Vectors Poster ASTMH USA

Shrinking the Malaria Map in Muleba District, North Western Tanzania: monitoring the impact of malaria prevention interventions scale-up through hospital admissions Oral ASTMH USA

2013

Taking local ownership: Government and household contributions for malaria control in Zanzibar and Mainland Tanzania

Poster ASTMH USA

Oral MIM South Africa

Pregnant Women and Infants as Sentinel Populations to Monitor Prevalence of Malaria Parasitemia and Track Impact of Intervention Scale-up in Tanzania Poster ASTMH USA

Monitoring Malaria Parasitemia Prevalence among Pregnant Women at Reproductive and Child Health Clinics in the Lake Zone, Tanzania Poster APHA USA

Novel surveillance systems for malaria in pre-elimination settings of Zanzibar Poster MIM South Africa



The impact of spray-able surfaces on the effectiveness of IRS using lambda-cyhalothrin against malaria vectors in Zanzibar and Mainland Tanzania Poster MIM South Africa

Co-occurrence and distribution of East (L1014S) and West (L1014F) African Knockdown Resistance Mutations in Anopheles gambiae sensu lato population in Tanzania

Poster MIM South Africa

Oral MIM South Africa

Spatial-temporal relationship between climatic factors, malaria transmission and their impact on interventions in Zanzibar Poster MIM South Africa

Decentralization and Capacity building in national indoor residual spraying (IRS) programme: The Tanzanian experience Oral MIM South Africa

Evaluation of response activities following increased seasonal malaria transmission in Zanzibar, 2013 Oral MIM South Africa

Detection of increased seasonal malaria cases and response activities in Zanzibar, 2013 Oral MIM South Africa

Fit for purpose: Novel surveillance systems for Malaria in pre-elimination settings of Zanzibar Oral MIM South Africa

Where do we go from here: Lessons learnt from 2013 response activities and way forward Oral MIM South Africa

Mass screening and treatment (MSAT) of malaria cases in hotspots following increased seasonal transmission of malaria in 2013 Oral MIM South Africa

2014

Trend of confirmed malaria cases by use of microscopy and MRDT technique in Mara, Tanzania for the period of 2012 to 2013 Oral AJSC Tanzania

Comparison of malaria prevalence among Pregnant Women and General Population in Kagera, Tanzania Oral AJSC Tanzania

Evaluation of response activities following increased seasonal transmission of malaria in Zanzibar, 2013 Oral AJSC Tanzania



Comparative analysis of IRS waste load disposal using commercial incineration facilities and TVCSP owned facility Oral AJSC Tanzania

Shifting from Blanket to Targeted Indoor Residual Spraying for Malaria Control in Zanzibar: a Novel Approach for Integrated Management of Malaria Vectors Oral AJSC Tanzania

Data for the Decision Making targeting IRS operation in the Lake zone for year 2014 Oral AJSC Tanzania

Piloting of Electronic- Integrated Diseases Surveillance and Response Oral AJSC Tanzania

Evaluation of IRS operations in the Lake Zone in 2013 Oral AJSC Tanzania

The impact of different spray-able surfaces on the effectiveness of IRS using a micro encapsulated formulation of lambda cyhalothrin against Anopheles gambiae ss Oral AJSC Tanzania

Novel surveillance systems for Malaria in pre-elimination settings of Zanzibar Oral AJSC Tanzania

Oral ASTMH USA

Use of Insecticide Quantification Kits (IQK) to investigate the quality of spraying and decay rate of Bendiocarb on different wall surfaces in Kagera, Tanzania Oral AJSC Tanzania

Taking local ownership: Government and household contributions for malaria control in Zanzibar and Mainland Tanzania Oral AJSC Tanzania

Decentralization and Capacity building in national indoor residual spraying (IRS) programme: The Tanzanian experience Oral AJSC Tanzania

Community based Indoor Residual Spraying in Tanzania: Findings and recommendations from pilot testing Oral AJSC Tanzania

Pregnant women and infants as sentinel populations to monitor prevalence of malaria parasitemia and track impact of intervention scale-up Oral AJSC Tanzania

Fit for purpose: Novel surveillance systems for Malaria in pre-elimination settings of Zanzibar Oral AJSC Tanzania

Detection of increased seasonal malaria cases and response activities in Zanzibar, 2013 Oral AJSC Tanzania



Efficacy and persistence of pirimiphos-methyl for IRS in Zanzibar Oral AJSC Tanzania

Entomological surveying and larviciding for effective malaria control: findings from seven shehias in Unguja, Zanzibar Oral AJSC Tanzania

Mass screening and treatment (MSAT) of malaria cases in hotspots following increased seasonal transmission of malaria in 2013 Oral AJSC Tanzania

Focal Mass drug administration in malaria hotspots following increased seasonal transmission of malaria in 2013: Zanzibar experience Oral AJSC Tanzania

Where do we go from here: Lessons learnt from 2013 response activities and way forward Oral AJSC Tanzania

Trends of malaria positivity in Zanzibar in 2012 Oral AJSC Tanzania

Clustering and risk factors for malaria in elimination settings: the role of travel in influencing malaria epidemiology in Zanzibar Oral ASTMH USA

Indoor residual spraying in Zanzibar: from blanket spraying, to targeted and focal spraying Oral ASTMH USA

What needs to be done differently: strategies for accelerating malaria elimination in Zanzibar Oral ASTMH USA

Examination of 2006-2013 Malaria Incidences in Relation to the Scaling of Preventative Control Interventions in Muleba District in North-West Tanzania Oral ASTMH USA

Improving Malaria surveillance through use of mobile technology in Mainland Tanzania: findings from a pilot study Oral ASTMH USA

Malaria reporting through electronic Integrated Diseases Surveillance and Response (eIDSR) in Kagera region of Tanzania Poster ASTMH USA

Active case detection in malaria elimination settings: timeliness of malaria case notification in Zanzibar Poster ASTMH USA

Factors affecting insecticide treated net use among children under age of five years in Mainland Tanzania Poster ASTMH USA



Pilot of community based indoor residual spraying (CBIRS) in Geita, Chato and Rorya districts of Tanzania Poster ASTMH USA

Indoor Residual Spraying (IRS): Lessons from the Tanzania Vector Control Scaling-Up Project (TVCSP): Magesa et al Oral ASTMH USA

Lessons from the Innovative Community Based Indoor Residual Spraying in Tanzania: Mutagahywa et al Oral ASTMH USA

Capacity Building and Decentralization of Indoor Residual Spraying (IRS) Operation Mainland Tanzania ‘’Eight Years Experience ’’ 2006 – 2013: Mwalimu et al Oral ASTMH USA

Strengthening surveillance for informing malaria control decision making in the Lake Zone, Tanzania: Ngondi J et al Oral ASTMH USA

2015

Risk factors associated with malaria epidemiology in Zanzibar: a pre-elimination setting Oral ASTMH USA

Improving malaria data quality and use in health management information system, Tanzania Oral ASTMH USA

Design, monitoring and implementation of the second round of School Net Distribution to maintain access to long-lasting insecticidal nets in Southern Tanzania Poster ASTMH USA

Seven year trends of Malaria in Zanzibar, 2008-2014: a pre-elimination setting Poster ASTMH USA

Towards malaria elimination in Zanzibar: Development of early epidemic detection thresholds in an increasingly low transmission setting. Oral ASTMH USA

Efficacy and persistence of pirimiphos-methyl (Actellic 300CS) for IRS in Zanzibar Poster ASTMH USA

Entomological surveillance system in Zanzibar: Contributions to malaria elimination efforts on the islands Oral ASTMH USA

Patterns of malaria among people travelling outside Zanzibar: results of malaria case notification and household testing in a pre-elimination setting Poster ASTMH USA