Insecticide-treated bed nets (ITNs) are a form of personal protection that has been shown to reduce illness, severe disease, and death due to malaria in endemic regions. Long-lasting insecticide-treated nets (LLINs) have been developed commercially that maintain effective levels of insecticide for at least 3 to 5 years, even after repeated washing. So the choice for public health planners and for people themselves, is to either treat (and re-treat) their existing bed nets with a suitable insecticide which will provide protection for 4 to 8 months or to buy ready made LLINs which last much longer.
How Do ITNs protect people?
Bed nets form a protective barrier around people sleeping under them. However, bed nets treated with an insecticide are much more protective than untreated nets. The mode of action is excito-repellent.
The insecticides that are used for treating bed nets kill mosquitoes, as well as other insects. (Note: There is no ‘instant’ drop dead action on vectors, similar to IRS, the lifespan of the mosquito is affected when it is exposed to the insecticide) The insecticides also repel mosquitoes, reducing the number that enter the house and attempt to feed on people inside. In addition, if high community coverage is achieved, the numbers of mosquitoes, as well as their length of life will be reduced. When this happens, all members of the community are protected, regardless of whether or not they are using a bed net. To achieve such effects, more than half of the people in a community must use an ITN. (Source : http://www.cdc.gov)
“Strategies for delivering insecticide-treated nets at scale for malaria control: a systematic review” An article published in the Bulletin of the WHO in 2012 , accessible on https://www.who.int/bulletin/volumes/90/9/11-094771/en/
Gorakhpur and Siddharth Nagar districts in Eastern Uttar Pradesh, bordering Nepal, are endemic for Acute Encephalitis Syndrome (AES) with frequent outbreaks over the years and considerable morbidity. Tata Trusts in partnership with Government of Uttar Pradesh (GoUP) and now supported by BPCL, has launched a Community based Health Promotion Program in the AES prone Gorakhpur region. The aim of the Project is to establish ‘Model Blocks’ in the two adjacent districts of Siddharth Nagar and Gorakhpur, to strengthen primary healthcare delivery combining an innovative community mobilization approach with early identification and prompt referral of illnesses being the keystone.
A multi-sectoral involvement is being focused on for health promotion in selected Blocks, with emphasis on Swacch Bharat Abhiyan strategies of long term improvement in hygiene and sanitation and healthy living conditions.
Acute Encephalitis Syndrome (AES) being multifactorial in its causation, with mosquito borne diseases being a part of the differential diagnoses, emphasis is also being laid by the Project on facilitating vector control measures as a component of Primary Prevention. Hence in the selected Blocks, to further strengthen the partnership with the community and the Govt, the Project is endeavouring to facilitate execution of vector control measures which mainly include source reduction (environmental, biological and chemical methods as larvicidal measures) and anti-mosquito measures (personal protection, encouraging use of bed nets).
No community based project to mitigate the influence of vectors would be complete without exploring various community level aspects of Vector Control as beautifully illustrated in a 1997 WHO publication by Rozendaal (Vector control. Methods for use by individuals and communities) available at https://www.who.int/whopes/resources/vector_rozendaal/en/ . Hence after discussions with the principal Stakeholders it was decided to undertake a ‘proof of concept’ community driven bednet treatment campaign in four villages in Eastern Uttar Pradesh. Usually, it is teams of Govt healthcare personnel who go from village to village and provide services for treatment of bednets. However, in the current iteration of the Project Prayaas which has its foundations in community mobilization for health promotion , it was decided to involve the village folk at the household level, to literally take their health in their own hands, i.e to treat their own bednets under supervision of the Project personnel, with all due precautions incorporated.
Globally, ITNs have evolved as one of the potent weapons to fight with mosquito borne diseases and have been widely adopted. It is known that, in addition to providing personal protection, ITNs also have the potential to produce a ‘Mass Effect’ if comprehensive coverage of ITNs is achieved at the community level. It also provides partial protection to other family members in the same House Hold, even if others are not using such a net. It is noted that use of mosquito nets is a common practice in the region due to the nuisance of mosquitos, and that is why there is widespread acceptability for these nets.
In India, the National Vector Borne Disease Control Program of the Govt of India has recommended usage of ITNs in endemic areas for protection from vectors. ( Please access the NVBDCP document on ITNs here https://nvbdcp.gov.in/WriteReadData/l892s/Guidelines-for-ITNS-LLINS.pdf )
Objectives for the ‘proof of concept’ ITN campaign in the Gorakhpur region in end April 2019
(a) To execute a pilot initiative regarding ITN at community level as per standard WHO and NVBDCP guidelines.
(b) Forge partnership with community to encourage continued use of bed nets as personal protective measures and build community capacity to treat nets in future iterations of the campaign.
(c) Build capacity of ASHAs and community volunteers as Resource Persons to plan and execute ITN campaign at the village level.
Technical training for the Prayaas team
Once finalised, field teams from two Blocks received orientation at Gorakhpur on the plan of insecticide treatment of bed nets and the rationale of the campaign. The orientation session was anchored by the Project Mentor . The content of the training was as follows:
(a) Appropriate use of bed nets
(b) Benefits of ITN
(c) Process of treating net along with demonstration with the use of standees
(d) Precautions to be taken while treating the net
(e) Precautions to handle Deltamethrin at personal level, field level
(f) Precautionary measures to be informed to community regarding use and upkeep of treated net
Communicating, forging partnerships with the community:
In the Project Action Plan for the ITN campaign it was decided that there would be community level meetings and interactions with key stakeholders which would address the following points:
(a) Use of bed nets is the best strategy at the individual level, to prevent vector borne diseases, such as malaria , to an extent.
(b) Treated bed nets are more effective in comparison with untreated bed nets.
(c) Process of treating bed nets is simple; it can be treated by anyone in a village under adequate guidance and supervision.
(d) The plan was to launch a campaign to treat bed nets of all households from 24th April to 30th April 2019 in the first phase, with a repeat round four months later depending on the situation.
(e) The Project Prayaas team would provide technical guidance as well as tubs, mugs, insecticide to treat bed nets. However, household members themselves would be required to treat bed nets available in their household.
Accordingly, the Project team started conducting meetings at the community level to spread information about the campaign, in the selected villages of the two Blocks.
Key stakeholders such as Gram Pradhans, Anganwadi workers, ANMs and ASHAs were informed about the plan. Hamlet level meetings were organized to make people aware about the campaign.
Communicating the microplan & schedule:
To make sure that the community knew the exact plan of action, pamphlets were printed and field staff members, along with ASHAs undertook house to house visits to distribute pamphlets. Wall paintings were also done through village volunteers.
Intensive mobilisation phase
Once the community received information about the campaign and the microplan was finalised, shared with all households, streetplays and rallies were organized for intensive mobilisation just a week before. It was done with the purpose of strengthening awareness activities done earlier.
Community level pre campaign demonstration:
Community level demonstrations were organized in several hamlets, to illustrate to the community the easy process and reassure them that it could be done at their doorstep, by them using the material provided by the Project Prayaas teams. These demonstrations helped to develop concept clarity in the villagers, which helped the teams to a great extent while executing the actual campaign.
Coverage of households
The campaign was successfully implemented by the able young Dr Sandeep Chavan, Project Leader of the Tata Trusts, in the selected villages and 86% coverage of households was achieved. Over the campaign period , 5,131 bednets were treated and 46.14 Litres of Deltamethrin was utilized.
Inter sectoral collaboration
It was a unique experience in this region in recent times to execute this ITN campaign. Uniqueness of the campaign was in its execution at the doorstep of a household through active community participation. The ASHA, AWW and Gram Pradhan were involved in implementation of this campaign. Full support of the NVBDCP Dept and participation of the DMOs and Medical Superintendents ensured the success of the campaign.
Orientation Workshop for District level Vector Borne Disease Control Personnel at Lucknow, Uttar Pradesh on 04 Jun 2019 After successful execution of the ‘proof of concept’ community driven insecticide treatment of bed nets (ITN) campaign in the Project Blocks, the Project Prayaas team was invited to share the execution plan and experiences with personnel of high risk districts of UP.
In addition to sharing experiences related to the ITN Campaign, the opportunity was utilised to review existing vector control national guidelines and to understand community based preventive measures for scrub typhus. You can access the Operational Guidelines for Integrated Vector Management here https://nvbdcp.gov.in/WriteReadData/l892s/IVM10_March_2016.pdf
Along with the Technical Advisors of the Tata Trusts, Dr. Sita Rama Budaraju and Col (Dr) MP Cariappa, domain experts from the Armed Forces Medical Services – Col (Dr) Rahul Ray (Director-Health, Central India ) and Lt Col (Dr) Shruti Vashishtha (Public Health Instructor) were resource persons for the workshop.
The various presentations can be accessed here