By Jeanne d’Arc Munezero
Malaria has a considerable impact on developing countries’ populations’ health. To bridge the gap, endemic districts have become the target of a national drive for malaria vector control using Indoor Residual Spraying (IRS).
According to the World Health Organization, the life-threatening disease kills roughly 600,000 people globally each year, mostly children who are vulnerable. It sickens more than 200 million people.
Further, in 2015, malaria was the leading cause of death among children under five mostly in the Southern and Eastern Provinces.
Dr Emmanuel Hakizimana, the Director of Vector Control at Rwanda Biomedical Centre (RBC) says that, although various interventions to control malaria have been implemented, malaria is still prevalent in the country.
“The RBC/Malaria program has monitored parasite resistance to antimalarial drugs since 2001 and mosquito resistance to insecticides since 2011,” he points out.
Between 2008-2009, the disease caused 30 percent of outpatient visits and 20 percent of hospital admissions.
Chantal Mukeshimana, is a Community Health Worker in Nyagitabire cell, Gahini sector, Kayonza district. She says that because of swampy areas, malaria infection is still a concern for many residents, even though they sleep under mosquito bed nets.
“Symptoms range from fever, intense headaches to vomiting and body-shaking chills,” she notes.
Various interventions such as mosquito nets, diagnosis, treatment, and increased access to community-based health insurance have been implemented; however, a critical gap remains.
To bridge the gap, endemic districts have become the target of a national drive for malaria vector control using indoor residual spraying (IRS).
IRS is a proven core vector control intervention that reduces malaria transmission.
It involves the application of a residual insecticide to housing structures’ internal walls, structures and ceilings.
When a vector comes into contact with a sprayed surface, it absorbs a lethal dose of insecticide. This reduces its lifespan vector density and longevity and, therefore, malaria transmission.
RBC says the selection of districts/sectors for IRS must take into account the relationship between the vector, humans and the environment.
In addition, it must consider the level of disease transmission in the area under consideration.
Following the choice of target sectors, collaboration and coordination between stakeholders is initiated.
It involves a one-day microplanning meeting with districts and sector authorities to discuss and develop an IRS operational plan.
Further, recruitment and training of IEC mobilizers and spray operators (SOPs) occurs in the same villages/districts targeted for spraying.
For one to qualify as an SOP they must have worked as Community Health Workers (CHW’s).
Once selected and medically screened, they receive a week of training specific to their roles.
Esther Mutesi an experienced SOP in Akamuyezi cell, Kayonza district says that they’re trained on how to wear personal protection gear, mix insecticide, fill and pressurize the spray tank. In addition, they gather data from each household/spray location.
During the exercise, SOPS are transported by a project vehicle to the spraying area. They move from structure to structure on foot, carrying their equipment.
They work in teams of four, with one team leader. Who submits the team’s data collection cards at the end of each day?
“We spray 10 households a day.” Mutesi explains, “We do not spray inside structures for pregnant women, newborns, the sick, or the elderly. We also record data pertaining to rooms per structure covered as well as population covered, insecticide used and problems encountered.”
Data is collected in SOPs regarding the number of people in a house, its location, its sector, and its district. Indicting and confirming the date and month of spraying, they leave a form for the household.
Before the exercise is conducted, village and cell IEC mobilizers inform communities about upcoming spray operations.
A vehicle with loud speakers travels around community streets, informing residents to prepare for spraying.
Households are given a three-day notice to prepare to move their belongings out of the house before actual spraying can begin.
Jean Marie Uramahoro a resident of Mwibiza cell, Rukara sector in Eastern Province says, “Prior to spraying, we move all items from the house including food.”
According to her, “We follow their instructions, spray, and remain outside for 6 hours before cleaning and entering the house.”
Pest control sprays generally take between 5 – 6 hours to dry which is why this is the time recommended for inhabitants to stay away. In Rwanda, IRS takes place bimonthly in selected areas normally in April and October.
In 2013, over 121,154 structures were sprayed in Gisagara, Bugesera, and Nyagatare. It was carried out by 1,605 SOP’s in 20 days.
Dr. Hakizimana notes that effective IRS operation requires effective insecticides, high quality of application on surface walls, and insecticides applied before malaria transmission peaks.
When making a selection of areas for the IRS, Dr. Hakizimana notes among other issues, the burden of malaria, the susceptibility of insecticides in terms of choosing an effective insecticide and the biting behaviour of mosquitoes inside and outside homes.
The cost depends on the number of structures/households per district. The average cost of a structure is US$ 18 or around RWF 19,997. Approximately US$ 14.26 or RWF 16.226 is spent on insecticide (81.1 percent of the structure’s cost). The cost of spraying per sprayed structure is around US$ 3.71 or RWF 3,771, which is 18.9 per cent,” Dr. Hakizimana affirms.
Since 2007 when IRS was introduced, Rwanda has seen a significant decrease in malaria cases.
RBC says infection rates have dropped from 409 cases per 1,000 people in 2016 to just 76 cases per 1,000 people in 2022. Malaria deaths fell by more than 89 percent over the same period.
The number of uncomplicated cases decreased from 3.9 million to less than a million from 2018 to 2022. In contrast, deaths decreased to 264 in 2018.
“We noticed that since the program started, any mosquito that lands on the wall dies,” Uramahoro commented. Neither her three children nor her two dependents have suffered from malaria since last year.
“During excessive rainy seasons, we did not have many mosquitoes in the house. Now it’s over, they’ve departed. Only minor mosquitoes and insects still roam. Spraying has demonstrated significant and sustained reductions in house mosquito infestation,” she adds.
Grace Umuraza, a resident of Kigabiro sector, Rwamagana district says mosquitoes, other insects, and bugs invade her house. You couldn’t sleep because of the buzzing.
“After the first spraying in 2019, my children now sleep comfortably. Spray repels mosquitoes and bed bugs,” she notes.
On the other hand, the program also faces criticism. Households claim that insecticides cannot work in areas with mobile populations, or where households migrate seasonally.
“There are homes where residents are not mobilized, and some deliberately close their homes. They fear and dislike spraying insecticides,” Mutesi adds.
Some homes are left unsprayed because people move to graze cattle, harvest and for other seasonal activities.
“Sometimes, households are unreceptive or unwilling to cooperate with the program” Umuhoza admits.
The high reliance on external funds currently PMI and Global Funds is also a daring issue, according to Dr. Hakizimana. He adds, “For instance, the Rwanda government supports 3 districts while external donors cover 9 districts. If the financial partner withdraws, malaria transmission could occur due to IRS termination.”
This story was first published in Panorama Tv