FEATURE

SATURDAY VISION
August 27, 2016

11

Why are treated mosquito nets failing to eradicate malaria?

By John Agaba, Raymond Baguma
and Carol Kasujja

mmaculate Amodings home is near

an expansive wetland in Aukot parish,
Gweri sub-county, in Soroti district. The
onset of rains brings with it a malaria
season. That is because the surrounding
swamp is a breeding ground for mosquitoes.
During the 2014 universal coverage
campaign by the Government, Amoding, a
mother of six, received two insecticide treated
mosquito nets from the village health team
members.
In August that year, Uganda concluded the
second free distribution of mosquito nets,
with support from the Global Fund, the US
Presidents Malaria Initiative, World Vision
and the UK Department for International
Development (DFID).
However, two years later, a survey by the
Infectious Diseases Research Collaboration,
whose results were released last week, found
that there was no marked difference in malaria
prevalence between 2011 and today. Yet in
between, Government has distributed over
21 million free treated mosquito nets worth
sh320b to cover the population of about 34
million people.
The survey questions whether the
distribution of treated mosquito nets is value
for money and the best way to fight the
disease.
We may have to carry out further research
to find out where the problem is, said Dr.
Agaba Katurebe, the study co-ordinator. Are
the nets not effective or people are not using
them? Or do we need another intervention?

nThe survey

Sh320b nets given

but malaria persists

Distribution of mosquito nets

Sleeping under an insecticide treated mosquito net prevents malaria

The interventions impact assessment study

focusing on the national distribution of longlasting insecticide treated mosquito nets and
indoor residual spraying was conducted
in three districts, with varied malaria
incidences.
Nagongera sub-county was selected
from Tororo district as a high burden area,
Walukuba sub-county in Jinja as a semi-high
burden, and Kihihi sub-county in Kanungu
district as a least burden area.
Research data was collected in 18 to 26
months prior to the 2014 distribution of nets
at the three sites, targeting 200 households
at each. After the distribution, additional
data was collected for comparison purposes.
We wanted to determine whether or not
at least two people per household used a
mosquito. We also wanted to determine if
there was any reduction in incidence cases
(in the areas) as result of the distributions,
he said.
But findings indicated a moderate
difference in malaria incidences (at the
three sites) before and after the distributions,
suggesting that the intervention may not be
that effective in stopping the disease, which
is a leading killer in Uganda.
Also, while the intervention hoped to cover
100%, results show that only slightly over
60% people were sleeping under a mosquito
net.

nWhy not rollout IRS?

nDo nets work?

The study also showed a falling efficacy in
the pyrethroid drug injected in the nets to
keep them potent, especially after a year and
that raised questions of resistance.
Only indoor residual spraying seemed to
post immediate effect. It reduced prevalence
from over 60% to 10% in the Tororo district
site.
However, Dr Anthony Mbonye, the acting
director general of health services, said
the seeming bed net ineffectiveness could
point to a lack of health seeking behaviour
common in the population and how the
nets were used.
But we have to provide accountability to
the public. The nets cost a lot of money. We
need to benefit a lot from them, he said.

nWhat could have happened?

Dr Myers Lugemwa, a malaria consultant,

said indoor residual spraying gave the
best immediate results, but was a lot more
expensive. It costs about $70 (about sh231,000)
to spray a household.
We have to focus on a combination of
interventions to prevent and eradicate malaria.
Spraying alone would not protect us. We also
need mosquito nets because, apart from the
insecticide they carry, they provide a physical
shield between man and the vector (female
anopheles), he said.
Meanwhile, there is a malaria resurgence in
northern Uganda, with approximately six out
of 10 people in the region carrying plasmodium
parasites.

nThe killer

In Uganda, malaria remains a leading cause of

sickness and death. According to the National
Malaria Control Programme report of 2014, at
least 9% to 14% of deaths recorded in health
facilities were due to malaria. It kills mainly
children and pregnant mothers and affects
economic production due to lost work hours
when patients and caretakers are busy tending
the sickness.
According to the 2012 Household and
Demographic Survey, households on average
spend about $10 (about 33,000) on malaria
treatment every year.
Findings have revealed the widespread misuse
and theft of the distributed mosquito nets,
implying that not all the nets may not have
reached the intended households.
According to Dr Diana Atwine, the head
of the State House Health Monitoring Unit,
health workers steal these mosquito nets and
sell them in private outlets. She said the culprit
health facilities are mainly in Mubende and
Wakiso districts.
The unit has on several occasions intercepted
cartels of health workers who collude with
in-charges of district health stores to steal
mosquito nets and sell them to neighbouring
countries, especially DR Congo.
For instance, the stores officials only deliver
half of the bales to districts and sell the

remainder, Atwine says.

Recently, officials from the unit carried out
a sting operation in which they arrested a
suspect who would buy the mosquito nets
from Mubende, transport them to a location
in Makindye and repackage them for resale in
Kasese and eastern DR Congo.
It was the Government strategy to give free
bed nets to new mothers. But Atwine says
there are widespread incidents of midwives at
health centres who refuse to give the nets to
the mothers. During an operation in health
centres across the country, we found many nets
lying idle in stores at health facilities. And these
stores do not lock, so you can imagine what
goes on, she says.
In Soroti, where the national distribution
exercise began in 2013, George Michael
Egunyu, the district chairperson, notes that
some homesteads use the mosquito nets as
ropes to tether goats. While in the low-lying
areas bordering Lake Kyoga, the nets are used
to catch fish.

nAre they used?

According to the health minister, Dr Jane Ruth

Aceng, more households own mosquito nets,
with the national bed net coverage standing at
about 92%.
In the rural areas of Uganda, mosquito net
ownership has increased from 14% in 2006, to
92% in 2015. This is compared to urban areas
where bed net use is at 84%. Also, over 70%
of women and children in Uganda sleep under
mosquito nets compared to 10% women and
children a decade ago.
However, a post-distribution indicator survey
reveals that owning a mosquito net and using
it are different. Mbonye says they realised that
some people do not use the nets.
The survey, whose findings were released
in 2015, shows that rural households are more
likely to own and use bed nets compared to
households in urban areas.
The survey shows that districts with the
highest level of using mosquito nets are in
Karamoja and northeastern Uganda regions.
They include Abim, Amudat, Kaabong,
Kotido, Moroto, Nakapiripirit, Napak, Amuria,
Bukedea, Katakwi, Kumi, Ngora, Soroti,
Kaberamaido and Serere.

DISTRICT
Mayuge
Kaliro
Bugiri
Serere
Soroti
Busia
Sironko
Kaberamaido
Bukedea
Bukwo
Bulambuli
Kapchorwa
Katakwi
Kumi
Kween
Manafwa
Nakapiripirit
Ngora
Pallisa
Amuria
Bududa
Amudat
Mbale
Budaka
Kibuku
Namutumba
Tororo
Namayingo
Luuka
Iganga
Buyende
Jinja
Kamuli
Buikwe
Buvuma
Mukono
Kayunga
Butaleja
Rakai
Lwengo
Kiboga
Kyankwanzi
Mityana
Luwero
Mpigi
Sembabule
Nakasongola
Gomba
Lyantonde
Mubende
Kalungu
Masaka
Nakaseke
Butambala
Kalangala
Bukomansimbi
Rubirizi
Bushenyi

NETS
225,750
120,650
175,900
129,590
213,877
208,139
180,402
136,570
129,182
54,600
110,428
65,888
113,000
159,669
64,630
266,406
101,259
96,081
260,092
181,355
99,494
59,925
345,878
139,553
135,895
166,111
339,907
145,773
166,914
345,120
197,480
301,107
306,715
276,370
75,117
368,309
243,187
163,920
325,200
176,786
96,685
142,400
203,921
289,894
150,816
156,200
113,832
96,720
64,085
421,714
111,977
172,315
126,004
63,700
39,866
91,801
86,570
161,622

DISTRICT
Mitooma
Sheema
Mbarara
Buhweju
Isingiro
Kabarole
Bundibujyo
Ntoroko
Kyegegwa
Kyenjojo
Kamwenge
Kiruhura
Ibanda
Buliisa
Kanungu
Rukungiri
Kabale
Kisoro
Ntungamo
Kasese
Hoima
Masindi
Kiryandongo
Kibaale
Apac
Oyam
Kole
Amolatar
Lira
Dokolo
Kaabong
Kotido
Moroto
Napak
Abim
Otuke
Kitgum
Gulu
Alebtong
Agago
Nwoya
Lamwo
Pader
Amuru
Nebbi
Zombo
Maracha
Koboko
Yumbe
Moyo
Adjumani
Arua
Mulago Kampala
Kampala
Wakiso Urban
Wakiso Rural

NETS
131,320
140,862
312,804
74,427
288,074
312,249
181,367
52,338
164,841
265,445
263,988
219,387
160,489
83,768
160,677
228,320
345,809
171,208
326,084
493,500
386,298
178,813
163,107
473,463
248,823
262,858
150,951
91,518
298,817
123,943
216,803
137,652
73,627
128,908
102,042
72,356
145,319
313,801
154,190
154,410
89,589
95,461
123,588
185,760
306,373
150,679
133,598
133,588
209,882
92,062
114,840
548,505
28,668
775,059
340,723
722,395

ToTal

22,267,777

However, Richard Walyomu, a public health

expert at Kampala Capital City Authority, reasons
that the perceived low use of mosquito nets among
the educated and wealthy is because they prefer to
buy their own bed nets. He says the health ministry
distributed white mosquito nets in urban areas,
especially Kampala, to cater for the urban tastes.

nMore nets

Next month, the health ministry will embark on

a third nationwide distribution of nets and about
25 million are available. This will be the third
exercise that the ministry will be carrying out in
the country. But if the nets have not delivered
the result we wanted, is it any more feasible for
Government to spend more money when the
strategy is deemed ineffective?