Malaria is prevented through use of many tools, one being the management of larval breeding areas, also known as “larval source management” (LSM). The objective of LSM is to reduce the number of mosquito larvae and pupae so as to reduce the potential for malaria transmission.
Today, there is renewed interest in LSM, especially in areas where other interventions may not be as effective—for example where mosquitos are biting outside (versus indoors during sleeping hours when ITNs are most effective) or where insecticide resistance is growing.
Akros has contributed significantly to geo-enabling disease surveillance and response activities, including malaria interventions. Some of this work has included microplanning and delivery of health campaigns to ensure they achieve the highest coverage for impact. Through this work, Reveal, a digital global good, has been conceived and deployed across 10 countries. The robust Reveal datasets have facilitated enhanced microplanning and analysis of operational and programmatic performance to identify gaps, improve targeting and resource mobilization, and increase vector control coverage over time.
Malaria elimination requires consistent high coverage of effective malaria prevention and treatment interventions—and high coverage is challenging to achieve particularly in developing countries where highly urban or highly rural areas may not have address systems, limited maps, and challenging access due to rains, poor infrastructure, flooding, or severe events or conflict.
In order for insecticides, such as Fludora Fusion or other chemicals, to most effectively kill mosquitoes and reduce malaria burden, high coverage is required. Envu, in collaboration with Akros and the National Malaria Control Program (NMCP) in Zambia conducted an exciting rollout of geospatial planning and delivery of indoor residual spray (IRS) in Luanshya District Zambia during the 2022 spray season. The open source platform, Reveal, was used to support the planning of the campaign, including target areas, households which would be visited and sprayed, as well as the human resources and commodities required to deliver the campaign. Spray teams, including each team lead, were outfitted with the Reveal application on their smartphones or tablets. Through this application, each team was able to clearly see which settlements in Luanshya District were targeted during microplanning prior to navigating to these areas and could clearly visualize on their phone where they were in relationship to each sprayable structure and whether it had been visited or not.
No matter the health campaign or tools used to implement the campaign, “mopping-up”–that is, bringing health resources to those people that did not receive them during the primary campaign–is critical.
“Mop-up” can be necessary for a variety of reasons, but the most common causes are inclement weather that impacted the ability to achieve the desired level of coverage, people not being at home when the field teams came knocking, or field teams ending delivery too soon. Mop up campaigns can be costly, so the need for accurate, real-time spatial data to inform these mop ups and protocols to drive them is critical. Reveal, a digital Global Good that equips field teams to reach the last mile, assists in these efforts by providing digestible maps and tables to mid- and high-level managers in near real time. Managers use these maps to understand areas which were missed in order to redeploy teams to those areas that did not receive sufficient coverage before the campaign concludes. For interventions such as indoor residual spraying (IRS) for malaria and immunization campaigns, this can mean the difference between a community attaining “herd immunity” or having gaps in coverage that render the intervention less effective.
Nigeria encompasses a unique and significant role in Africa. Not only is it the continent’s most populous country, clocking in at 206 million people, but it also is also the continent’s largest economy (with a total GDP of $441 billion in 2021). However, it also maintains a less desirable superlative title, which is that it bears the highest burden of malaria deaths on the continent, and 27% of all malaria deaths worldwide in 2020. In raw numbers, this amounts to an estimated 64.5 million cases annually. As a result, the public health challenge of malaria in Nigeria is enormous, and the stakes are high. Though Nigeria’s National Malaria Elimination Program (NMEP) has risen to meet this challenge consistently throughout the years, attaining the goal of reducing malaria morbidity to less than 10% parasite prevalence and mortality attributable to malaria to less than 50 deaths per 1,000 by 2025 is far from guaranteed. One key in realizing this goal is seasonal malaria chemoprevention (SMC), which typically consists of routine administration of two antimalarial drugs to children 3 to 59 months of age during the peak months of malaria transmission. Malaria Consortium and Akros worked with the Nigeria NMEP to support the planning, tracking, and delivery of SMC in six rural health facility catchments in the Shagari local government area of Sokoto State, Nigeria in 2021.
Last month, the World Health Organization (WHO) sent joyous shock waves through the global health community and the Global South by officially recommending that the new RTS,S/AS01 (RTS,S) malaria vaccine be adopted into widespread use among children in sub-Saharan Africa and other regions with moderate to high P. falciparum malaria incidence. Now the international community, through Gavi, the Vaccine Alliance, has just stepped forward to help finance the rollout of the world’s first malaria vaccine.
It has been true for some time that sub-Saharan Africa bears the largest malaria burden in the world, with children shouldering the largest proportion of deaths. Over 90% of global cases are on the continent, with children under the age of 5 years constituting a staggering two-thirds of all malaria deaths. This is due to a confluence of factors, not least because of the widespread prevalence of P. falciparum (the most deadly species of malaria parasite), and a very efficient mosquito that spreads it (Anopheles gambiae). The economic impact of malaria is estimated to cost Africa $12 billion every year—a figure that also factors in costs of healthcare, absenteeism, days lost in education, decreased productivity due to brain damage from cerebral malaria, and loss of investment and tourism. The introduction of an effective vaccine offers a beam of hope in the fight to mitigate the massive toll this centuries-old disease inflicts on Africa.
In recent years, countries within the Southern African Development Community (SADC) region of Africa have been making outstanding strides toward the challenging goal of malaria elimination. This commitment to elimination is the guiding mandate of Elimination 8 (E8), which focuses on the following countries: Angola, Botswana, Eswatini, Mozambique, Namibia, South Africa, Zambia, and Zimbabwe. Through E8, these ministerial bodies have resolved to coordinate their efforts to collaboratively work toward the shared regional goal of malaria elimination.
To that end, in 2017, E8 contracted with MENTOR to deliver indoor residual spray (IRS) in border districts of southern Angola. The MENTOR Initiative is a registered nonprofit organization devoted to reducing deaths and suffering from tropical diseases. In Angola, MENTOR has been a stable National Malaria Control Program (NMCP) partner supporting vector control, case management, and surveillance activities since 2004. MENTOR has established offices across Angola and has full country reach in its operations, making it the ideal partner for E8 to engage for expanded IRS interventions. Since 2017, MENTOR has implemented IRS with reported high coverage rates in all campaigns conducted. For its 2020 campaign, MENTOR aimed to improve IRS reporting systems and increase accountability to donors and NMCP. To realize this goal, they chose to pilot Reveal—a digital global good and open source spatial intelligence platform used to drive the delivery of life-saving interventions. MENTOR collaborated with Akros to configure and support the field pilot of Reveal v. 1 in Menongue District (Cuando Cubango Province).
Through Reveal, field teams and managers use detailed household and community maps, protocols, and a data-collection and dashboarding platform for decision-making support to plan, implement, and adjust interventions so they achieve the greatest impact. Akros’ partnership with MENTOR Initiative to pilot Reveal v. 1 in Menogue District to support IRS delivery first included assessment and scoping to understand three key elements: intervention and data collection and management protocols, resource availability, and the environment within which Reveal was to be implemented and sustained. Akros then conducted system configuration to align IRS standard operating procedures (SOPs) with the Reveal platform, set-up mobile application and coverage dashboards, and configured feedback loops and tasking for unique user roles. Following that, the Reveal team participated in campaign planning, including enumeration and base map preparation and work to plan and validate in-field assumptions. Finally, the Reveal team supported implementation in December 2020 and provided post-implementation support.
Zambia, along with a handful of countries within Southern and Eastern Africa, is on track to reduce malaria cases 40% by 2020. Relative to 2015, the country’s progress so far translates to as many as 700,000 cases prevented annually. Such tremendous strides speak to the success of preventative interventions, such as improved access to indoor residual spraying (IRS) and insecticide treated nets (ITNs), but the work is far from over.
The citizens and communities across Zambia rely on annual district planning to determine where, how much of, and what interventions are needed in a particular population. In answering these questions, district teams begin their microplanning processes, determining on a local level the nuances of the year’s malaria interventions. These teams must deeply understand the communities they serve. Who is at greatest risk of infection? Where do they live? What settlements ought to be targeted? And what resources are needed to bring a community out of harm’s way? Lacking this information, district teams cannot fully grasp the extent of preventable malaria cases and consequently limit their capacity to act.
Traditionally, teams of local community health workers aggregate this information on foot and process it in hard copy. This costly and time consuming work flow jeopardizes the data’s accuracy, totality, and speedy delivery to key decision makers. System bottlenecks, limited resources, or a lack of confidence in the data can then undermine the quantitative foundation of an intervention. Weary decision makers might turn instead to outdated data and an imprecise understanding of the population they aim to serve. What ought to be a concrete step in the year’s plan bends to inefficacious circumstances.
Accurate quantification of a population, and the ability to locate this population with precision, are fundamental requirements for reporting the true coverage and effectiveness of public health interventions—such as childhood immunizations, indoor residual spraying (IRS) for malaria, or mass drug administration (MDA) for neglected tropical diseases.
Public health interventions, however, often rely on field teams to locate rural villages or even homes on the ground. In areas where there are no street address systems, or where homes are not mapped, manual searches often result in groups of households being missed; thus preventing the delivery of services to those in need. When service coverage is subsequently reported as a function of the population found, the impact and effectiveness of an intervention may be overstated.
Spatial Intelligence and the Reveal Solution
The transformative field of spatial intelligence is revolutionizing digital health and public health more broadly. Artificial intelligence (AI), digital maps, and spatial modeling are powerful, burgeoning toolsets; but until more recently, they have not benefited field workers and large-scale, labor-intensive campaigns. Now, the power of these digital tools is being accessed by field workers in rural, underserved communities.
Reveal, an open-source platform and global good, uses spatial intelligence to help field workers effectively navigate and deliver life-saving interventions to people who previously would have been missed, increasing the true coverage of interventions and improving health outcomes for vulnerable populations.
Supporting an IRS Campaign in Zambia
Satellite imagery was enumerated to establish a baseline understanding of structure count and spatial distribution in several districts. These were layered with risk maps to target high-risk regions, which enabled users to identify eligible households and assign teams to priority areas.
Using Reveal’s mobile and map-based interface, field workers were able to navigate through communities, identify targeted households, and collect intervention data against eligible households in a coordinated manner within and across teams. The near real-time feedback of data, as a result of the mobile application’s offline and peer-to-peer (P2P) syncing functionality, inspired increased teamwork and cohesion as the campaign progressed and teams worked toward a common goal.
Through dashboards, map-based visualizations, and built-in feedback loops, intervention managers were able to actively monitor campaign progress toward targets, in a given spray area and as a whole, thus facilitating data-driven course correction to optimize performance and maximize impact.
With the support of Reveal, Siavonga District increased its absolute coverage of IRS from 51.5% to 75.5%, while Sinazongwe increased from 31.5% to 61.9%. These changes in coverage were possible due to a better understanding of resource needs. In other words, the use of Reveal allowed districts to better understand the size and distribution of the target population, thus impacting planning and implementation.
On a sweltering summer day in Siavonga, a lakeside jewel of Zambia’s Southern Province, I sat down with Mr. Bisael Phiri, the District Surveillance Officer for Siavonga District, to get his perspective on the malaria situation in his region and at large in Zambia. A breeze lazily floating through an open window and a small desktop fan provided the only reprieve from the oppressive heat as we got down to brass tacks about the progress made in the last few seasons of malaria interventions and how Reveal has impacted that progress.
Mr. Phiri has been working in public health for several years, and is a big picture thinker when it comes to tackling malaria in Zambia. His motivations to work in this field are straightforward, “I know the kind of impact that good health can have on people’s lives. I wanted to do this work to help change the environment so it doesn’t constitute a danger to the public.” His work is based in one of the select districts of Southern Province that utilizes Reveal for their indoor residual spraying (IRS), mass drug administration (MDA), and reactive IRS malaria interventions through a PATH MACEPA and Akros-implemented program. Reveal is a powerful, open-source platform that aids in household-level intervention management and data authenticity by using spatial intelligence and smart planning tools. Mr. Phiri stresses that learning how to use this technology is self-explanatory and that the dashboards, which are tailored to his administrative level, greatly assist his day-to-day responsibilities. In his own words, “the dashboard is important to view on a daily basis because it identifies the status of various teams and shows us where we need to go and where the problem areas are. When we have this information, we can change our strategy based on how well our teams are performing, and change targets midway if need be. For instance, if I didn’t receive updated data from a certain district, I would not know that there’s an issue there. Now because I have these data, I would be able to make a quick plan for how best to move forward with that district.”
Beyond program planning, Mr. Phiri’s work is strengthened by the hard proof the platform provides that work is being done where it is supposed to be done.
Deep in Zambia’s Southern Province, in a town a three-hour drive away from the district’s largest city and economic hub (Siavonga), lies Manchamvwa Health Facility. This clinic serves as the focal point for the health needs of hundreds of people who live in the surrounding villages, and as such, is often overwhelmed with the many health needs of its patients. Malaria season in particular tends to put a great strain on the facility, with peak periods in previous years seeing anywhere from 100 to 200 cases per month.
Over the last couple of years, the Government of the Republic of Zambia (GRZ), with the assistance of Akros and PATH’s Bill and Melinda Gates Foundation-funded Malaria Control and Elimination Partnership in Africa (MACEPA), have been working with the National Malaria Elimination Program district staff to overcome these numbers and improve the health of the local community by using geospatial technology to optimize indoor residual spraying (IRS) campaigns. Recently, the two organizations teamed up again to be the first to ever use Reveal’s spatial intelligence approach to maximize reach and ensure accountability in a mass drug administration (MDA) campaign that distributed antimalarials to the doorstep of each community member in three districts of Southern Province.
The recent history of malaria in Southern Province is one of resounding progress thus far. Due to its proximity to Lake Kariba’s glistening, still water, it is unfortunately a heavily malaria-burdened region by nature. But malaria in this region is highly seasonal, linked to the annual arrival of rainfall from December to April, leaving ample overgrowth and standing water—prime mosquito-breeding real estate. This seasonality provides an attractive window through which most interventions have taken aim. The result has been an impressive decrease in prevalence of malaria parasitaemia among children less than five years of age, from 15.5% in 2006, to 5.5% in 2010, and 0.0% in 2018.1,2 Trends like these make Southern Province appealing as a prime candidate for malaria elimination. However, despite overall improvement in the province’s malaria burden at large, districts directly adjacent to the lake are still at higher risk, as malaria cases have shown to be persistently high in some health facilities despite ongoing interventions.
To propel Southern Province closer to elimination, in 2014 MACEPA supported the national program with a malaria MDA research study in the Southern Province districts lining Lake Kariba, an area with an estimated population of 300,000 people. The rapid malaria reduction in the study area resulted in Zambia adding MDA to its arsenal of interventions in 2017. The country’s experience of malaria MDA—two rounds with one month in between doses—has shown it to be an effective intervention in areas with a strong foundation of vector control, case management, and surveillance. Recognizing that MDA campaigns are most effective when every household and individual in the targeted region are reached, MACEPA engaged Akros for its technical expertise in introducing Reveal as a novel approach to maximize the impact of MDA for malaria control and elimination in this area.