Insecticide-treated nets (ITNs) are a highly effective means of malaria prevention and form a cornerstone of the global malaria control strategy. Use of ITNs reduces the incidence of clinical malaria by 50% and reduces all-cause child mortality by almost 20%.1
ITN use during pregnancy has also been shown to reduce the prevalence of low birth weight deliveries and miscarriages/stillbirths.2
At high levels of coverage, community-wide benefits of ITN use have been demonstrated that extend beyond the personal protection afforded by sleeping under an ITN through a mass effect on the Anopheles
Recent years have seen accelerated malaria control efforts and establishment of revised consensus targets of ≥ 80% ITN use by pregnant women and young children by 2010.6–8
In addition, new Roll Back Malaria universal coverage targets aim to protect the entire population at risk by 2010 through an approach that includes household ownership of one long-lasting insecticidal net (LLIN) for every two inhabitants.9
Ongoing monitoring and evaluation of national malaria control operations has shown that ITN coverage is increasing in many countries, and some are well on the way to achieving these revised targets.10–12
The introduction of LLINs that retain insecticidal activity for 3–5 years, along with free distribution, has contributed greatly to recent increases in ITN coverage. In many countries, LLIN coverage has increased through a combination of delivery systems including routine public health services (antenatal clinics, routine vaccination visits), subsidized social marketing, and integrated mass campaigns.11,13,14
In particular, integrated campaigns that deliver LLINs in conjunction with vaccination, de-worming and other health interventions have achieved rapid increases in LLIN coverage and improved the equity of net ownership.11,15,16
The cost-effectiveness of integrated delivery versus social marketing has been assessed and compared.17,18
Despite debate on both sides.19–21
it has been suggested that these strategies are complementary and may serve to increase overall community-wide coverage.14
Madagascar is located off of the eastern coast of Africa and has a population of approximately 19 million persons. Administratively, the country is divided into 22 regions and 111 districts. In Madagascar, malaria is a major public health problem responsible for more than one million clinical cases per year.22
Malaria is endemic in 90% of Madagascar. However, its entire population is considered to be at risk. There are four distinct malaria epidemiologic zones with stable, perennial transmission on the eastern and western coasts, and unstable, seasonal transmission in the central highlands and in the southern region. The ITN distribution strategy in Madagascar differs by geographic region. The highly endemic eastern coast is the highest priority area and was the first targeted for ITN distribution, with distribution later expanding to the western coast and recently to the southern region. Indoor residual spraying has been the main vector control intervention in the epidemic-prone central highlands as outlined in the national malaria control strategy, and, until the present time, this area has not been targeted for generalized ITN distribution.
ITNs have been available in Madagascar since 2001 through commercial social marketing channels,23
and routine distribution commenced in 10 districts in 2005.24
According to the 2003–2004 Demographic and Health Survey, ownership of any type of bed net (treated or untreated) ranged from 11% to 34% in the central and southern provinces and from 62% to 82% in the eastern and western provinces.25
In October 2007, the Government of Madagascar, in conjunction with international partners, launched a national campaign directed to 2.8 million children less than five years of age for measles vaccination, mebendazole, and vitamin A in all 111 districts nationwide, and integrated the distribution of LLINs in the 59 districts in the western and southern regions of the country, which had not previously benefited from large-scale LLIN distribution. The campaign was led by the Madagascar Ministry of Health and Family Planning as a collaborative effort among the American Red Cross; the Canadian International Development Agency; the Canadian Red Cross; the Global Fund to Fight AIDS, Tuberculosis and Malaria; the International Federation of Red Cross and Red Crescent Societies; the Madagascar Red Cross; Malaria No More; the Measles Initiative; Population Services International; the President's Malaria Initiative; Roll Back Malaria; Sumitomo Chemical; the United National International Children's Fund; the United Nations Foundation; the U.S. Agency for International Development; the U.S. Centers for Disease Control and Prevention; Vestergaard Frandsen; the World Health Organization; and other organizations.
More than 1.5 million Olyset and Permanet LLINs were distributed by the Ministry of Health and the Madagascar Red Cross at fixed and mobile distribution points, comprising health centers and other community landmarks, at the fokontany (smallest administrative unit) level. The distribution strategy was one LLIN per eligible child up to a maximum of two LLINs per household. LLINs were also provided to pregnant women at distribution points in roughly half of the 59 districts. The 32 districts along the eastern coast of Madagascar, which are routinely targeted for ITN distribution, and 20 districts in the central highlands, did not receive free LLINs as part of the integrated measles/malaria campaign. A social mobilization campaign was conducted by the Ministry of Health and the Madagascar Red Cross one week before the campaign to sensitize the local population on the location and timing of the campaign. In addition, for one week post-campaign the Madagascar Red Cross conducted hang-up activities in the communities to sensitize the local population on the proper way to hang and use nets.
To evaluate the impact of the integrated campaign on LLIN ownership and use, a cross-sectional national household survey was conducted six months post-campaign during the rainy season. Because of its programmatic importance to the national malaria control strategy, and to understand the current status of malaria control efforts in Madagascar, we present estimates of LLIN ownership and use for the malaria-endemic area of Madagascar (91 of 111 districts). However, because of differences in LLIN distribution methods and timelines in other parts of the country, the main focus of this report is on post-campaign LLIN ownership, equity of LLIN ownership, and use of LLINs in the 59 districts where LLIN distribution was integrated during the October 2007 campaign.