Guidelines on the Use of Insecticide - Treated Mosquito Nets for the Prevention and Control of Malaria in Africa (WHO - MAL - WHO - AFRO - WHO, 1997, 88 p.) 5. Implementation Insecticide treatment of nets Logistic requirements Preparation of insecticide mixtures Insecticide treatment methods (introduction...) Dipping Spraying of nets Pre-treated nets Drying treated nets Organization of net treatment sessions Effect of washing treated-nets, care and use Safety, side effects from pyrethroid exposure Vector response to insecticides (introduction...) A) Vector behaviour B) Vector resistance to insecticides Information management (introduction...) Purpose Type of information How to collect Documentation, exchange and sharing of information Operational aspects (introduction...) Political and policy framework (introduction...) A) ITMNs and malaria control B) Insecticides C) Vector resistance D) Nets/material, insecticides: Availability, low cost Potential partners Potential users of ITMNs Institutional framework and collaboration Delivery systems (introduction...) Access to quality assumed material, affordability equity Distribution structures and systems A) Nets B) Services for insecticide-treatment of nets Promotion (introduction...) Promotional elements Promotion of events leading to net-use/providers Promotion at net-use level Messages communication channels

Guidelines on the Use of Insecticide - Treated Mosquito Nets for the Prevention and Control of Malaria in Africa (WHO - MAL - WHO - AFRO - WHO, 1997, 88 p.)

5. Implementation

Insecticide treatment of nets

Nets to be treated are those already owned/used traditionally by communities, or introduced as a public health intervention. In the former instance, the nets could be of different sizes, shapes, and fabric. An assessment of these can help to prepare the dipping mixtures more accurately so that the insecticide treatments achieve targeted dosages. Where nets are introduced, the specified standards and quality requirements can be met more easily with appropriate planning.

To correctly treat a net with an insecticide, a net of a given size/surface area is treated with an appropriate insecticide mixture (which has been prepared by mixing a specified amount of insecticide formulation, with a specified quantity of water) in order to obtain the target dosage of the insecticide.

Logistic requirements

The supply/material requirements for insecticide treatment of nets are:

· water,

· insecticide formulation,

· measuring devices for water and insecticide,

· container to dip the net(s), and to collect insecticide drips after dipping,

· rubber gloves and protective clothing including a face-mask especially when many nets are treated, when treatments are done daily or for prolonged periods, and

· spray equipment when nets are sprayed.

Preparation of insecticide mixtures

The preparation of an insecticide mixure for net treatment requires information on:

· the number of nets to be treated, and their sizes or the surface area involved;
· the amount of water to prepare the mixture (depending on how much water they absorb; and
· amount of insecticide to treat the nets.

Calculating surface area of net to be treated

The surface area is usually presented in square meters (m²). Examples of calculating this for the more commonly used rectangular, and conical designs are as follows:

Rectangular net

Hang the net up, measure the width, length, and height (in metres), and

a) Calculate the area of the top: i.e. width x length
b) Calculate the area of the sides, and ends: i.e. height x total distance around base of the net;
c) Add a) and b) calculations to get the total area of the net.

Thus total surface area (S) = sum of the surfaces of, the 2 sides, the 2 ends, and the area of top = 2 (L x h) + 2 (w x h) + 1 (L x w),

where L = length, w = width, and h = height, or perimeter x height + area of top.

For example assume, length = 1.8 m; width = 1.3 m; height = 1.5 m. Then the,

a) Area of the top = 1.3 x 1.8 = 2.3 sq m
b) Area of sides and ends = 1.5 x 2 (1.3 + 1.8)= 1.5 x 6.2 = 9.2 sq m
c) Total area of net = 2.3 + 9.2 = 11.5 sq m

Conical net

Total surface area (S) = circumference x distance up the slope x 0.5

Calculating the amount of water to prepare the mixture

This is the same as the amount of water to saturate the net, i.e. the water retention capacity of the wet fabric. This depends on the type of fabric. To determine this:

· Select about 3 nets of each type of net (i.e. with same material, size);

· Dip each net thoroughly for few minutes in a known quantity of water (Vi) in a bucket or basin;

· Remove the net from the container, wring and hold for 5-30 seconds over the bucket or basin to catch any drips;

· Repeat with each net;

· Measure the remaining water in dipping bucket (Vr);

The amount of water needed for each type of net can be determined by checking a sample, and calculating for the total number of nets to be treated.

Calculating of amount of insecticide to treat nets

The amount of insecticide to treat a net depends on the total surface area of the net, the type of fibre, and the insecticide, i.e. the type, strength, formulation, and the target dosage (TD) presented in mg or g/m²

In calculating the insecticide requirements, the active ingredient (a.i), and the commercial formulation (c.p.) are taken into account.

(a) Amount of active ingredient (a.i):

The active ingredient (a.i) in mg or g (or ml for the WP formulations) = surface area of net (m²) x target dose (mg or g a.i/m²). For example,

Insecticide	Target dosage (mg a.i./m2)	Net surface (m2)	Active ingredient for one-net (in mg)	Active ingredient for 100 nets in mg (g)
Permethrin	200	12	2400	240 000 (240)
	500	12	600	600 000 (600)
Deltamethrin	15	12	180	18 000 (18)
Lambdacyhalothrin	25	12	300	30 000 (30)

(b) Amount of commercial product (c.p.):

Commercial formulations are generally presented as:

a) percentage (%),
b) g/litre for the liquids, and
c) g/kg for powders.

The labels must be read carefully for the concentration, a) keeping in mind that some manufacturers label their products in % i.e. g/100 ml, and some in g/litre, and b) that fifty per cent (50%) is the same as 500 g/litre. Thus care is needed in relating the active ingredient (a.i) to the commercial product. For example, Permethrin, expressed as EC 50 (50%) contains 500 g a.i/litre; Deltamethrin, SC 2.5 expressed as 2.5%, contains 25 g/litre.

The amount of insecticide formulation required can be calculated as shown in the following examples:

Example 1: Assume water retention/absorbant capacity of net is 500 ml; Assume size of net to be 10 m2: Insecticide used is Permethrin EC 50, which contains 500 g in 1 litre or 500 mg in 1 ml Target dosage is 500 mg./m2; One net requires 500 mg a.i./m2; x 10 (area of net) = 5000 mg Amount of EC 50 formulation needed = 5000/500 = 10 ml

Thus a 500 ml dipping mixture that would be needed for one net (based on water retention capacity) will comprise of 10 ml of insecticide formulation, and 490 ml of water.

Example 2: Assume water retention/absorbant capacity of net is 500 ml; Assume size of net to be 10 m2: Insecticide used is Deltamethrin SC 2.5 (2.5%) which contains 2.5 g in 100 ml or 25 g in 1 litre, or 25 mg in 1 ml Target dosage = 25 mg a.i./m2; One net requires 25 mg a.i./m2; x 10 (area of net) = 250 mg Amount of EC 25 formulation needed = 250/25 = 10 ml Thus a 500 ml dipping mixture that is needed for one net will comprise of 10 ml of insecticide formulation, and 490 ml of water. The amount needed for dipping a specified number of nets may be calculated accordingly.

Example 3: The following formula can also be used to calculate the amount of insecticide required: For example, the amount of permethrin 50% needed to give a recommended dosage of 500 mg/m2, on a net measuring 102 is: Multiply this amount by the number of nets to be dipped.

The commercial product and the water (measured previously) must be mixed thoroughly and carefully in wide, shallow containers (buckets or basins), the latter to limit side effects from insecticide inhalation on the workers. The insecticide container must be rinsed well with the water to be used for the solution to prevent waste.

To simplify the calculations in preparing dipping mixtures for collective dipping, it may be necessary to treat together: a) nets/sets of nets belonging to a family assuming these to be of comparable/similar material; and b) nets made of more or less the same fabrics and bearing in mind that cotton absorbs more (about twice) liquid than the synthetics, and that the efficacy of insecticides varies with the materials.

Charts and tables may be prepared (and made readily available) indicating the quantities of mixtures to be prepared with each insecticide according to the target dosages and water retention capacities, and on the amounts of insecticides (commercial products) for nets of different sizes.

Insecticide treatment methods

Nets can be insecticide-treated by dipping, or spraying with standard hand compression sprayers. Irrespective of method, all nets must be washed properly before being treated.

Dipping

Nets can be dipped individually or collectively in batches of ideally similar types in terms of materials. Each net is unfolded, fully submerged in the insecticide solution, and kneaded (fig. 6) until saturated with liquid. Dipped nets are wrung above the dipping container to collect the drips (fig. 7).

Fig. 6 Dipping/kneading

Fig. 7 Dipped net wrung

(a) Individual treatment (dipping) of nets:

Dipping nets one by one may lead to non uniform impregnation, unless care is taken to knead the net until it is evenly wetted. This is time consuming and less practical when large numbers of nets are to be treated in a short time.

Individual dipping is possible in plastic bags. The net is placed first in the bag, the exact amount of mixture needed to saturate the fabric is poured, and kneaded thoroughly. The net is removed and dried; wringing is not necessary.

(b) Collective dipping:

Here several nets, e.g. batches of five or tens are dipped together. In planning, an estimate must be made (e.g. through sample KAP surveys) of the numbers of nets of each type (fabric/material, size, and shape). This helps more accurate calculation of the water and insecticide requirements, and the preparation of dipping solutions to meet the target dosages. If such an assessment is not possible a compromise may be a dilution of one litre of insecticide e.g. deltamethrin SC 25, or lambdacyhalothrin CS 25 or 1 litre of permethrin EC 50, with 49 litres of water. Nets of different fabrics must be sorted out and dipped accordingly. This may necessitate dipping together the nets of individual families assuming these to be of comparable material. Dipped nets removed one by one after a few minutes are wrung thoroughly above the dipping container, and placed in an open plastic basket for some time over the decantation part to allow draining. Some families may not wish their nets to be mixed and immersed in the same dipping bath with those of others. Nets of each family may be kept separately to avoid accidental interchange.

As pointed out earlier, more absorbent material such as cotton absorbs more insecticide per square metre than with synthetic nets. However for the same insecticide effect of e.g. permethrin or lambdacyhaéothrin, a higher dose per square metre is required on cotton than on synthetic material. These differences on cotton and synthetic tends to balance out and where a mixture of light cotton and synthetics nets have to be dipped, a single mixture could be used.

A team of 2-3 trained persons assisted by a few local people can dip at least 200 nets a day.

Spraying of nets

Spraying allows collective treatment of a large number of nets in a short time. This is quick and a net could be treated in a few seconds, often less than half a minute. Spraying nets is to some extent comparable to spraying of walls where an insecticide solution is sprayed aiming at a target dosage on the net surface. Spraying nets requires more expertise and may be undertaken by those experienced in the use of spray machines and in spraying operations such as those undertaken in malaria control programmes and in agriculture.

Nets must be cleaned and ready for spraying, hung in situ over the bed (in Sichuan, China more than one million nets are sprayed annually in situ, without taking them outside)., or outdoors, away from windy places, children, food and water bodies such as rivers and streams. Sprayed nets must be kept outdoors to dry and must not be used before they are completely dry.

Achievement of good quality spraying requires, properly functioning spray machines with correct nozzles, etc. to deliver proper swath width, and flow rates, and correct spray procedures/techniques that ensure the required pressure, the distance/angle between nozzle and the surfaces sprayed, and the speed. The equipment must be checked regularly. Procurement of the same type of equipment/spare parts facilitates replacement, maintenance of equipment, and training compared to the use of different types of machines. Spray personnel must be appropriately trained including refresher training, and supervised to ensure quality of equipment and performance. Spraying nets may be relevant and/or can be easier in:

· Areas where house spraying is ongoing or has been discontinued, and where experienced staff could be trained in net treatments in a short time and with minimum inputs;

· Other areas where people are familiar with the use of insecticides and spray equipment such as in agricultural areas;

· In refugee camps, resettlement areas where treatment of tents, temporary shelters and nets are urgently needed to deal with disease outbreaks; and

· Where a large number of nets have to be treated in a very short period of time.

Pre-treated nets

Effective, permanent insecticide treatments which allow easy, safe and cheap distribution would be ideal for ITMN programmes. However net pre-treatment methods have not yet been proven to allow residual effects of insecticide treatment to cover the life of the nets. Olyset nets have not been long enough to know how long their efficacy lasts.

As re-treatment is needed eventually, pre-treatment (at factory, warehouse, shops, or otherwise) prior to transport, distribution and sales would only delay opportunities to address the re-treatment issues from the start of the programme. It is pointed out that this could be useful to start programmes until other arrangements are being made.

Drying treated nets

Treated nets may be dried, placed flat on clean non-absorbent surfaces such as plastic sheeting, (fig. 8), or spread on beds or mattresses (with bedsheets removed, and this may help kill bed bugs etc)., or hung up in the shade in the open (fig. 9).

Fig. 8 Drying treated nets flat

Fig. 9 Drying treated nets hung

In all instances, the nets should be arranged with minimum folds as possible, and turned occasionally to ensure that the insecticide is deposited evenly. Hanging nets immediately after dipping must be avoided to prevent dripping, loss of solution, and uneven spread of insecticide. The insecticide adheres better to nets dried in horizontal position; in vertical position they may dry faster as would also be when exposed to sun and wind. Long exposure to bright sunlight should be avoided as the pyrethroids can be destroyed.

Time taken to dry also depends on the fabric, the amount of insecticide absorbed, and the surface area. Cotton takes longer. Drying should be done close to the dipping sites. Nets treated should be kept clean during dipping or drying.

Organization of net treatment sessions

People must be informed in advance of the treatment schedules in their respective areas and asked to wash the nets on the day before the treatment. If several teams work in a village or an area, they must communicate their schedules with the exact locations. The locations for refilling spray tanks must be identified especially for the mobile teams.

The number of nets to be treated should be determined as far as possible, and the water and insecticide requirements estimated correctly. Buffer stocks of insecticides and solutions must be ensured to avoid interruption due to their shortage. Having to wait a long time to get the nets retreated can discourage people and eventually compromise the programme.

As already pointed out, the dipping must be done outdoors in large shallow containers to protect the dippers from inhaling insecticide fumes. This is particularly important when large numbers of nets are to be treated continuously over a period of time, or daily. Care is needed to prevent insecticide splashing on skin, and nasal irritation of the dippers. The dippers must be interchanged periodically to avoid over exposure of any one individual to insecticide fumes. During net dipping, use of strong rubber gloves are recommended to avoid risk of skin irritation. Goggles or other eye protection are also recommended for those who work close to the dipping container, to avoid risks of splashes in the eye.

Spraying nets against the wind must be avoided to prevent any insecticide falling on people spraying. People, especially children, and also food must be kept at a distance to avoid contamination.

Spillage and waste of insecticides or water must be avoided when preparing the mixtures. After the treatment, the equipment used must be cleaned, but never in rivers, streams, or ponds as pyrethroids are toxic to fish. Surplus insecticide, waste packaging and contaminated material should be disposed of e.g. in pit latrines, or buried far away from human settlements, water sources (wells, rivers, streams and fish ponds). Empty insecticide boxes, contaminated containers must be destroyed to prevent their use for other purposes. Adequate care must be taken to avoid environment contamination throughout the work.

Net owners, other members of the community should be invited to observe, and where appropriate to participate in net-treatment so that they may recognize and appreciate the importance and implications of the activity. The community health workers (CHW) and other health providers in the village/community must be active partners, properly motivated to participate in the (re)treatment, and in the support of the overall programme.

People must be advised to keep and use treated nets away from fire places and lamps to prevent fire hazards, informed that such risks are higher where people cook and sleep in the same room. They must also be advised to prevent children putting treated nets in their mouth.

The community must be informed of the potential risks and effects of insecticide contamination, and be taught measures to be taken if contamination occurs. The need to seek prompt medical assistance and to refer to a physician if any signs of such effects are detected or suspected must be emphasized.

Effect of washing treated-nets, care and use

The effectiveness of treated nets can be reduced with treatment with an inadequate dose, and from loss or reduced dosages insecticide from washing treated nets. The treatment efficacy is considered to be more dependent on the amount of washing than on the time after the treatment.

Thus people should be, a) advised to get nets (re)treated on time, b) to wash the nets before the insecticide treatment, but discouraged from doing so after the treatment, c) informed of the consequences of frequent washing of treated nets, and d) advised to retreat the nets which have been washed more than twice to sustain efficacy, through appropriate information, education and communication (IEC) messages, and opportunities to get the required net (re)treatments must be provided.

When in use, nets should be hung down to cover the entire bed, and tucked under the mattresses or sleeping mats etc.. During daytime, they should be tied up, out of the way to avoid being damaged.

The insecticidal effect on a treated net at a given time may be checked, to provide guidance for re-treatment of nets in operational use, through “bio assay tests”. Here a sample of anophelines (susceptible to the insecticide under consideration) is allowed to contact insecticide on treated net for a standard time (e.g. 3 minutes) by confining the mosquitoes in the WHO bioassay cones attached to the net. Subsequent observations are made on, the percentage knocked down after one hour, and the mortality after 24 hours. Generally nets freshly treated with the recommended dose of an insecticide is expected to give almost a 100% mortality. After a period of use, and in particular after washing, the mortality tends to decline. From an operational context, the efficacy of the pyrethroids in treated nets is expected to last 6-12 months depending on the insecticide, but less with nets washed frequently. In general, nets may be treated at 6 monthly intervals, depending on the transmission pattern; with timing of treatments planned immediately prior to the transmission season.

Safety, side effects from pyrethroid exposure

Reports on side effects from pyrethroid use are related to the workers who spend long hours mainly in net-dipping (often compelled to inhale solvent vapour), and the ITMN users. The former in particular are reported to suffer from non specific symptoms of mild intoxication such as headaches which have been transient. Exposure to skin especially the mucous membrane have caused paraesthesia (tingling, burning sensations) caused by temporary transient effects on sensory nerves. Such symptoms are common with the alpha cyano compounds (deltamethrin and lambdacyhalothrin etc.) and are rare with permethrin. Deltamethrin is reported with more severe side effects on polyethylene nets.

Other reports include painful irritation caused when emulsions splash in the eyes, tingling sensation when droplets fall on the skin, facial swellings of those handling freshly dipped, dried ITMNs, and nasal irritation and sneezing (lasting a few days to 2 weeks) of those sleeping under freshly treated nets. Closer monitoring with documentation and dissemination of information on related observations and experience are needed, especially for the alphacyano compounds.

The side effects could have operational consequences in discouraging people from the use of ITMNs, and/or prompt them to wash the nets soon after treatment. Appropriate IEC messages should be developed and delivered to convey to the public, the potential side effects and the conditions under which they may occur, the precautionary possibilities and actions to be taken if side effects are encountered or suspected.

Vector response to insecticides

Vector response to insecticides in terms of behaviour and insecticide susceptibility is an important determinant of the efficacy of ITMNs. If and how ITMNs impact on the vector and/or malaria must be known or ascertained when planning, and monitoring the implementation.

A) Vector behaviour

Insecticide use can lead to changes in the vector behaviour such as resting, biting sites and times, sometimes causing shifts in peak biting periods.

The vectors' behavioural responses to pyrethroids can have significant epidemiological implications. The behavioural response depends on the type of insecticide, dosage/formulation, and the inert material/solvent used in the formulations. The pyrethroids can cause deterrent, irritant, killing, and knock down effects, or feeding inhibition on the vectors. Deterrence may prevent entry and favour mosquito exit from houses; thus providing personal protection to people indoors. Where such mosquitos are not killed outdoors, adequate impact on transmission and community level protection may not occur unless a good level of ITMN coverage is achieved to effect mass killing of the vector populations.

Different mosquito species e.g. Culex quinquefasciatus and Anopheles gambiae have responded differently with permethrin-treated nets. Such information is important in planning ITMN programmes in urban areas, and other situations where protection from nuisance insects has been a strong motivation for ITMN use.

The choice between insecticides with high deterrency or high killing effect may depend on the targeted objective of the intervention, whether personal protection, or mass protection of a community. The insecticide/vector interaction however is not very clear at present, and the relevant information is inadequate. More information is needed: a) on the effects, advantages and disadvantages in relation to the deterrent/repellent, irritant, knock down and killing effect of different insecticides, and dosages including sub-lethal dosages, and at different periods after the insecticide treatments, and b) on their impact in relation to personal and community level protection, and transmission. The relevant information is necessary for the selection of insecticides, and in preparing IEC messages to convey to the people the expectations from insecticides used in net-treatment. Some of the information can be collected with monitoring during operational implementations; others through relevant operational research.

B) Vector resistance to insecticides

Vector susceptibility is basic for the efficacy of insecticides. The eventual development of insect/vector resistance to insecticides is inevitable if the insect populations concerned are continually exposed to insecticides, irrespective of the purpose for which they are used. The types of resistance/resistance spectra depend on the mechanism(s) prevalent in the insect population and are being selected. A number of resistance mechanisms are known in insects/mosquitos; some conferring broad multiple resistance and which also involve the different pyrethroids. At present the insecticides for net-treatment are limited to the pyrethroids and a pseudopyrethroid, etofenprox. Anopheles strains which are resistant to one of these compounds are often cross resistant to others also. Despite limited monitoring and reporting, such resistances are already encountered in a number of malaria vectors including some populations of An. gambiae in Africa. The operational implications of these resistances are not yet known, or investigated; but the findings may alert potential threats to the continued use of the pyrethroid group of insecticides and the sustainability of the ITMN strategy.

The use of the pyrethroid insecticides is also spreading fast, in public health (house spraying, ITMNs, space spraying) in addition to their already extensive use in agriculture and in household pesticides. Insecticide resistance related information is thus necessary to guide planning, implementation and evaluation of insecticide uses. It is therefore necessary that the insecticide susceptibility or resistance status of the vectors be assessed, with the practical implications of resistances already encountered (especially at high levels) in different representative situations investigated.

(i) Assessment of insecticide susceptibility status

At present, monitoring coverage, and information base on susceptibility or resistance status is limited and patchy. Monitoring must be undertaken/improved for the insecticides in use, and for the potential alternatives. These must be focused in representative areas where:

· Insecticide use has been ongoing for a known period of time, or is planned for bednet treatment and for other malaria/vector control interventions and public health purposes;

· resistance and multiple resistance (especially involving the pyrethroids) are reported or suspected; and

· considerable amounts of insecticides have been in use for a known period of time:

- for agriculture,
- in indoor residual spraying,
- for treatment of bednets and other material, and
- as domestic insecticides.

In each of the above areas, the monitoring should cover diverse epidemiological situations, and vectors with different breeding, resting and feeding habits which are likely to influence their exposures to insecticide selection pressures. The monitoring may be supported by networking activities.

As pyrethroid resistance levels vary with mosquito age; tests are needed on adults collected directly from the field, as well as on adults emerged from the field collected larvae.

The WHO test procedure for the use of “discriminating dosages” must be used in the monitoring, as is also the standard formats (WHO/CTD/VBC/Resis.1a.97 (adult), WHO/CTD/VBC/Resis.1b.97 (larva), WHO/CTD/VBC/Resis.1c.97 (pesticide use) developed to record and report relevant data. These will enable collation and comparison of data from different sources based on standardized test procedures and collection of information, to facilitate exchange, use and extrapolate experience.

(ii) Practical implication of resistance, and other investigations

It is emphasized that the WHO test alone is not the criterion to establish whether an insecticide in use is effective or not under field operational use. The results do not simulate or represent the actual insect response under the field operational use of the insecticide concerned. Resistance detected during these tests however is a strong indication that mosquito populations are responding to selection, thus signaling the need for further monitoring and field observations in order to guide the planning of insecticide uses. The information also provides opportunities to examine the resistance spectra. When investigating reports of resistance, the operational elements of the programme, and the entomological and disease impact indicators must be examined critically in order to determine the conditions and levels at which resistance can lead to control failures.

Information on resistance must be collected and correctly documented, and disseminated and exchanged, as for all other important aspects of the programme.

Some nuisance insects may be more tolerant and/or have already developed resistance to pyrethroids. Others may rapidly develop resistance. Whether such occurrence could compromise compliance of the people whose motivation to use ITMNs is primarily linked to the protection from nuisance insects, needs to be examined. Appropriate action, and IEC messages must address this issue.

Information management

ITMN implementation related information must be readily available, ideally as part of the information management systems already available, or being developed for malaria control. Linkages must be established with other relevant information systems, within and outside the health system including NGOs who may contribute to the implementation.

Purpose

The use of information must be directed to:

· Convince the macro-economic level policy and decision makers including financial bodies and other support agencies, and the implementers concerning specific requirements, including support;

· Select and prioritize targets for ITMNs;

· Select materials (nets, insecticides, spray equipment);

· Guide net (re)treatment;

· Identify the types and contents of IEC messages, and assess communication skills and success of community mobilization and intersectoral actions;

· Identify gaps, shortcomings;

· Identify training and research needs, and evaluate their performance and achievements;

· Examine the relevance and/or effectiveness of the ITMN strategy, the processes and activities, of the insecticides used, and the use of ITMNs by the community;

· Provide information for programme adjustments.

Type of information

The information needs could be general, or target-oriented. The types of information that may be required are listed in Annex 4. It is to be noted that most of this information need not be collected exclusively for the ITMN programmes. Many could be accessed from what is already available and through other sources as listed in Annex 5.

How to collect

There is no single method to collect information. Examples for planning are:

¨ List the minimum data/information that is required, for what and at each level of implementation;

¨ Clarify from where, by whom, how and when to collect;

¨ Establish processes to collect, and identify the channels to obtain the information with minimum efforts and inputs;

¨ Develop suitable data collection formats;

¨ Train the data collectors and users of information;

¨ Make the best use of the existing information systems, adapting them to ITMN programme needs.

Documentation, exchange and sharing of information

As indicated earlier, experience gained in ITMN implementation is limited, and the programmes are to be progressively expanded, benefiting from experience. Existing information and that collected during the implementation must be made widely available. Mechanisms must be established providing for opportunities to promote reporting, publishing and dissemination of information and experience. These should be in relation to the operational aspects and related research undertaken in different epidemiological situations and institutional arrangements. Information updating, rapid transfer, exchange and sharing within and outside the country must be promoted.

An updated inventory may be maintained of all ongoing ITMN related activities (operational and research) in the country indicating, for example, their location, coverage, time frames, and expenditures. The experience gained and achievements made in each of these activities must be periodically updated in qualitative and quantitative terms. Suitable formats must be developed and used to guide and standardize the information gathered and reported on activities from different sources. Information exchange within and among the countries may necessitate periodical meetings of relevant personnel in workshops and seminars, regular communication through newsletters, and through national, regional networking programmes (which may be established) involving relevant scientists and institutes.

Operational aspects

The end-point determinant of the effectiveness of an ITMN programme is the use of ITMNs by those at risk of contracting malaria. Others' inputs must lead to this end in order to ensure:

Figure

ITMN programmes require that the potential ITMN-users have access to nets, and have opportunities to get them treated on time with correct amounts of insecticides. Appropriate insecticides must be selected and good quality procurements made at low cost. They must be stocked and delivered to treatment levels. The efficacy and retention of insecticides on treated nets must be assured. Nets must be used properly (to prevent mosquitos from entering the nets in use) and at least during periods of peak vector biting and disease transmission. People must know the conditions for using them to get optimal benefits. The costs must be met and operations sustained, thus requiring appropriate support. These actions, especially on a large-scale, have a number of technical, socio-cultural, operational and managerial implications. Policy, institutional and collaborative arrangements may be involved.

Annex 1 lists the activities necessary to sustain large-scale implementation. For each activity area, indications are given as to who may be responsible and at what level. The probable processes or mechanisms, and the needs and conditions of support to be met are indicated but are neither prescriptive nor comprehensive. They may be considered in overall programme planning, and in planning participation and support to specific activity areas. The format may be adapted to local circumstances, and can include resources, training, and research issues.

Political and policy framework

Political commitment, policies or legislation are involved in some aspects of programme implementation.

A) ITMNs and malaria control

“Selective and sustainable preventive measures including vector control” is one of the four technical measures of the GMCS. ITMNs is a vector control option involving personal protection and insecticides; the concept and the objectives of ITMN implementation in Africa are in keeping with those of the GMCS. In the commitments for intensified malaria control by the African Ministers of Health, “the use of insecticide-impregnated bednets and other materials (ITMNs)” is recognized as one of the three key elements to be addressed (AFR/RC45/R4: Resolutions of the Regional Committee for Africa, Regional Programme on malaria control, 1995). A national policy specifying “ITMNs as an integral component of National Malaria Control Programmes (NMCPs)” could help ensuring that ITMN implementation is in keeping with the NMCP's strategies and objectives.

B) Insecticides

National policies and legislation in relation to the selection, importation, and use of insecticides are needed to ensure efficacy, quality, safety of insecticides, and in the long-term, vector resistance management. The specific issues are:

(i) Mechanism for registration of pesticides

This can regulate pesticide imports/use in the country. The registration must be based on adequate evaluation data which can be obtained through WHO/CTD, supplemented where possible by data from evaluations undertaken in the country itself. Where registration mechanisms do not yet exist in the country, the insecticides considered should be registered, at least in a neighbouring country, but in the long-term the countries should have their own pesticide registration mechanisms so that the insecticides used are registered in the country of use. WHO/CTD may be consulted for further information on registration requirements and procedures.

(ii) Specifications

The insecticides imported and used must conform to WHO specifications for public health. When procuring insecticides, reports of conformity of the selected insecticides to WHO specifications must be requested and examined by an independent authority or institution before the insecticides concerned leave the place/country of origin.

C) Vector resistance

The current trends in pyrethroid resistance development and the possible implication are discussed above.

These highlight the urgent need for new insecticide groups which do not fall within the resistance spectra conferred by the resistant mechanisms in the vectors. At the same time, precautionary measures must be taken to delay or avoid pyrethroid resistance in the malaria vectors. A recommendation related to the latter reads that, “Synthetic pyrethroids should not be used for indoor residual spraying in areas targeted for insecticide-treated bednet use if physiological resistance is to be prevented or delayed ......” (WHO Technical Report Series 857). A policy in this connection may help to ensure that the recommendation is followed.

D) Nets/material, insecticides: Availability, low cost

National governments can facilitate the availability of appropriate materials at low cost through a policy directed at:

· Tax/import duty exemption for nets, netting, and insecticide formulations designed for net treatments

· Promotion of local manufacture of nets, netting, other material by removal (or reduction) of import duty/taxation on raw material, removal of other regulatory measures, and providing subsidies and other concessions to business and consumers;

· Establishment of an efficient procurement system at national level to enable speedy procurement of quality assured materials at lesser costs. The ITMN related procurement systems may be incorporated in the systems which may already exist or may be established for other aspects of the health system's activities.

Potential partners

In addition to the ITMN users, others expected to participate in ITMN activities are:

· Health services/malaria control programmes (NMCPs);

· National level macro-economic policy and decision makers;

· Non-health public (government) sectors/agencies;

· Academic and research institutes;

· NGOs within (national, district, and community levels) and outside the country;

· Local community groups;

· Private/commercial sector;

· Support agencies, both domestic (DSAs) and external (ESAs), and the proposed networking programmes.

The expected roles/responsibilities of each are listed in Annex 6.

Potential users of ITMNs

Irrespective of the targets which may be established at national or local levels, there will in fact be other users of ITMNs in a large-scale ITMN programme which is adequately established and properly functional. The potential users are likely to be those already listed under target groups, and in addition the following:

· People accustomed to using nets and who will continue to buy/use them on their own initiative; and who may seek access to insecticide-treatment facilities and opportunities;

· People who may be motivated to use ITMNs as a consequence of IEC and other promotional activities of the programme.

Institutional framework and collaboration

The implementation may entail the participation of many actors within and outside the health services, the private sector, the communities, and other support agencies (though not all in the same location or activity area at a given time). Some inputs may be on an ad hoc basis, limited in space and/or time. The expertise needs and responsibilities will vary at different levels of management and implementation. Such diverse inputs/activities must be coordinated and linked at each level:

· to ensure adherence to specifications, standards and the national malaria control programme's objectives and targets,

· for optimal utilization of resources, sharing of inputs avoiding wasteful duplication, and

· for overall effectiveness and sustenance of delivery services.

The necessary linkages and coordination among these must be formalized through appropriate institutional and collaborative arrangements. These may necessitate adjustments to the administrative/institutional structures of the Ministries of Health and NMCPs. Equally important are issues of decentralization, managerial flexibility, intersectoral/agency collaboration, and community mobilization.

Fig. 10 provides an example of a possible framework covering the institutional and collaborative links among different partners, in particular with malaria control/health services at each level of management and implementation. The format in Annex 7 listing the tasks and the expected possible actors of an ITMN programme may be considered in planning collaborative/partnership linkages. Which activities need collaboration, who will collaborate at what level, and how the collaboration should function depends on local circumstances. Therefore not all the actors are expected to be present all the time at all levels for a given activity.

Some activities which may need continued collaboration and interaction may be effected through committees representing relevant expertise. Other time-limited activities may often require major managerial and policy-related decisions and may be implemented by specific task forces. In order to ensure interest, efficiency and sustainability, making the best use of partners' expertise, skills and potential, it is important that the “right persons” are involved in a given functional body, committee or task force.

Collaboration at national level is needed, for example in establishing policies, regulatory measures, procurement systems, pesticide registration mechanisms, and for import duty exemptions. These are of a limited time frame and may be effected through task forces. Decision making and ensuring concurrence on service delivery concepts (e.g. to make use of the resources/facilities of other sectors/agencies) by higher level management, including those from other relevant ministries/sectors, the private sector, etc. are also time limited and may be effected through task forces. Committees may contribute to subsequent implementation and monitoring which will be continuous. Continued collaboration at national level is also expected on information management, training, operational research, and the assessment of needs at country level. A suitable coordinating structure at national/central level could be “A National Committee for Malaria Control (NCMC)” which may already exist or is likely to be established to deal with the overall malaria control issues. The partnerships involved in such a body are indicated in fig. 10. Members of this body with relevant expertise may be co-opted for specific tasks involving ITMN implementation.

District level collaboration will occur in a number of areas. The structure concerned may be comparable to that at central level, “District Coordinating Committee for Malaria Control (DCMC)”. Similarly, activities at community/peripheral level could be coordinated through community-based committees for malaria control (CBCMC). Fig. 10 indicates the possible linkages and roles and responsibilities at each level. These may be adapted to national and local needs.

Fig. 10: Institutional/Collaborative Framework for ITMN Implementation (Collaborative linkages with Malaria Control Services)

NCMC = National coordinating committee for malaria control
DCMD = District coordinating committee for malaria control
CBCMC = Community-based committee for malaria control

Examples of interagency/intersectoral collaboration for ITMN programmes are: The Malaria control services and other implementers collaborating: a) with Ministries of Education to incorporate educational messages in schools, universities and other relevant educational curricula, and b) with decision makers concerned with communication and media in support of development and delivery of IEC messages. The malaria control services and other relevant persons may interact/collaborate with macro-economic and policy makers, with the customs and immigration authorities concerning the establishment of policies, import duty exemptions for materials, and the establishment of procurement systems, and with finance authorities to seek financial commitments, and to promote local production of nets/netting. The NGOs and other local level community organizations may collaborate on financial/logistic matters, including management of cost-recovery systems/revolving funds. Collaboration within country and at international level can support resource mobilization, speedy procurement, and information exchange. Continuing collaboration is expected among malaria control services and other sectors and agencies, the private or commercial sector, NGOs and other community organizations on service delivery issues; malaria control services and academia and researchers on monitoring of insecticide resistance, training, operational research, quality control on insecticide treated nets/biological efficacy and information exchange. Continued collaboration is also needed among WHO, WHO collaborating centres, and the proposed networking programmes for exchange and sharing of information/experience, technical inputs, insecticide resistance monitoring, procurement, and with donor communities for financial, logistic and other support.

Delivery systems

The ITMN delivery services are expected to ensure wider net ownership and insecticide-treatment of the nets on time, and to provide relevant information to encourage proper use of ITMNs. The specific issues to be addressed include:

¨ Quality assurance of products delivered;

¨ Gaining access to other formal and non-formal public and the private sector and community-based structures and processes in support of ITMN delivery;

¨ Access to populations at highest risk of contracting malaria, focusing on those who may live in less accessible areas, and/or cannot afford the services.

There are different delivery, quality assurance and regulation, and promotional needs and approaches for the nets, and the net-treatment. The methods according to which nets are distributed, insecticide-treated and re-treated may vary depending on local circumstances. Reliable channels that can get the nets and insecticide to the target population on a sustainable basis are critical for the success of the programme.

ITMN service delivery is likely to be more realistic and promising where potential delivery systems exist or can be accessed within the operational areas; such situations are referred above. The availability of, or the potential to access such services in ITMNs activities must be considered in immediate and medium-term planning. All such structures/bodies in the target areas should be listed, earmarked and explored for partnership potentials in the delivery services. This will entail collaborative planning.

Access to quality assumed material, affordability equity

Key elements in ensuring that nets are accepted and used on a sustainable basis are the quality and cost of the nets provided.

The cost of the nets should be set so that they are affordable to all members of the target population. Experience has shown that this may require the costs to be heavily subsidized. Setting a price for nets should be based on two principles:

1) Every member of the target group(s) should be able to afford and have an opportunity to obtain the required nets; and get them treated with insecticides.

2) The price should not be so low that people would rather buy new nets than maintaining the existing ones.

There are two important factors that determine the quality and durability of nets: first, the strength of the fiber and second the quality of sewing/construction of the nets. The general rule is that net purchases should not be made on price alone. Better quality costs more in terms of the initial investment but in the end will cost less because high quality nets will last longer. A good quality net that is taken care of should last about 5 years.

Ensuring availability of the best quality nets at the lowest possible cost may require one or more of the following strategies:

· Bulk procurement: The country's overall import needs for nets, material and insecticides may be planned, assessed, coordinated with orders for bulk procurement made jointly by all concerned at the central, district and peripheral levels. These may include health sector/malaria control programme personnel, NGOs, the private sector and donor communities. Estimates may be made for specified periods, at least a year and preferably more often:

· Tax exemptions on imports;

· Efficient import clearance processes: at ports of entry to avoid unnecessary payments of demurrage etc.;

· Sales price control system: Mechanisms may be established for the control of net sale prices. The prices may be stipulated after making the necessary allowances for transport/distribution, for sustenance of cost-recovery systems, and marginal profits to business (when the latter is involved);

· Taking appropriate measures to encourage and ensure quality assurance of commercially marketed nets and netting;

· Access to temporary transport/distribution services through other sectors or partner's facilities;

· Inputs from the macro-economic policy and decision making levels in support of policies and legislation recommended under political and policy framework).

The economic feasibility and/or affordability at the ITMN user's, provider's and programme implementer's levels will determine net ownership, the ability to pay for insecticides and net (re)treatment, and sustained support of the providers. Plans must be made to ensure that those at highest risk who cannot afford can also have access to ITMNs. The prospects of providing all or some of the services free of charge or subsidized, at least initially, must be explored. People who already spend on other anti-mosquito methods, or those who are accustomed to using nets and can afford should be motivated to pay for the services. The benefits of ITMNs should be clearly demonstrated.

Payments (whether in full or subsidized) for nets and/or insecticide-treatment may be effected through revolving-funds, preferably through local community groups. The decisions on the level of payments, the amount and types may be made by the communities concerned. Women who look after the nets at home, women or women's organizations participating in other community-based decision making enterprises can play an important role in the decisions concerning the payments for nets and treatments at the household and community levels. The timing of net-treatment can affect affordability. For example, money could be scarce during periods of rain (favouring malaria transmission) when the ITMNs are most needed. Ways of sharing and spreading costs need to be explored with the communities themselves making decisions on the most appropriate forms of payments. Options may include extended payments such as pre-payments, hire purchases, credit schemes, salary deductions for employees or through saving schemes, and village development funds. Communities' decisions on the level of subsidy also affect the service delivery outside the targets.

Seed money will invariably be needed to start such programmes, i.e. cost-recovery systems. Subsequent use of sales income for running costs, to buy replacements, to give services free to the most deserving, and for the insecticides for net-treatment are options to be examined. Temporary subsidies have been used along with promotional messages to stimulate a general level of demand. While distribution free of charge is considered advantageous, most equitable, and avoids problems of handling money, the possibility depends on national resources, the potential donors, and more importantly their continuity.

At the programme/providers level long-term commitment must be ensured and support prospects planned including for donations. Lack of provisions for insecticide-(re)treatment, or net replenishment will compromise the programme. Communities paying for the nets, ideally also for insecticide treatment, and with financial management of procurement/sales handled through community-based cost-recovery systems/revolving funds are thus considered to be more sustainable. Here external inputs/initial investments could contribute favourably to start the programme through capacity building/training and managerial aspects, seed money and logistics support and technical inputs. Support and guidance must be given to establish and manage cost-recovery systems. To avoid breakdown of programmes initiated well with free supplies and external funding, it is important that the sustainability issues are clarified at the planning itself. Projections are also needed on the responsibilities, including of the promoters and the community.

Cost-effectiveness is important to sustain implementation. Information and experience on cost-effectiveness of ITMNs are extremely limited. Information on these aspects from different epidemiological situations and conditions of use is essential. To enable such assessments in the medium and long-term, it is necessary that relevant information (on inputs, and the outcome achievements) which enables cost-effectiveness assessments, is collected and documented. The information to be gathered must be detailed.

Distribution structures and systems

A) Nets

Net usage varies within and among communities and countries. Nets are already sold commercially in many places and are being used by some people and communities.

They are thus a familiar household personal protection item for some, while others may not recognize the potential benefits of ITMN uses. Sometimes, the people who use nets or would like to use these may not always have adequate access to the nets and/or in particular nets of quality recommended for ITMNs.

When nets are available through regular commercial channels the retail prices are often too high for families to afford enough nets for everyone in the household. The purchase of a net or nets often represents a major investment; a choice has to be made between a net that should last for five years or some more immediate need. For this reason special attention may be necessary to create opportunities outside commercial channels to reach/access the most direct and immediate targets of ITMNs at affordable prices. The distribution of nets may require close cooperation of many agencies and sectors and the community.

During distribution and insecticide-treatment, it is often necessary to make use of staff, transport and facilities of other health and non health government sectors, and the private sector to get the work done.

The delivery services may include mobile services to reach the target areas and populations when the net-treatment is scheduled. The activities can be coordinated by a core staff expected from the local (district, peripheral) health services, and others such as school teachers, leaders of community organizations. The delivery services with prospects to incorporate ITMNs (some successfully utilized in the Western Pacific Region) may be:

· The existing formal health structures/networks (e.g. district health systems including PHC systems, MCH clinics covering antenatal care, nutritional and vaccination programmes, sick child initiative, home package intervention, etc.). These programmes generally draw-in, or could reach-out to the risk groups such as children, pregnant women;

· Non-health government sectors, e.g. education in particular schools and universities, the irrigation and agricultural extension networks/services, the water sector whose network of services often pervade even the peripheral communities, and the school children;

· Other health and development based systems, schools, community-based programmes, e.g. village based structures, women's and church/religious groups, NGOs;

· Development projects, in particular the major large-scale ones such as irrigation, agriculture, and industrial establishments and armed forces with well structured, organized distribution or delivery services and where the populations are easily accessible to allow a high coverage;

· Local commercial outlets.

Reach of scattered rural settlements/populations is often more difficult. Prospects of involving local traders, hawkers who reach these may be explored; house-to-house service through health services is time consuming, logistically demanding and unrealistic.

In planning the introduction of nets to a community, it is important that as far as possible the local needs and preferences are taken into account. Estimates may be taken on the sizes and shapes of nets, sleeping arrangements, perceptions and preferences for colours e.g. through sample surveys. While nets already owned and in use are to be insecticide-treated irrespective of the type and quality assurance, the IEC messages must be directed to create demand for the most suitable nets.

Nets must be stored securely with careful records maintained at each level, and stage of distribution. Precautions must be taken to protect nets from being eaten/damaged by termites and other insects, and from theft.

B) Services for insecticide-treatment of nets

Insecticides are moderately hazardous, necessitating special safety requirements in their use. In addition, the issues of efficacy and vector resistance management necessitates continued regulatory/control measures in terms of registration, stringent quality control in imports, distribution, and precautions in handling, net treatment and use. Net-treatment is a recurrent expense. A treatment lasting 6-12 months is reported to cost US$ 0.25 to 0.50 depending on the nature, quantities and costs of procurement. Insecticides may be seen more as a public health product in personal protection. Options so far considered for insecticide-treatment of nets are:

(i) Communal (re)treatment services

This involves the coordinated treatment of nets in a community at once, a practice in most net projects including in China. The approach is useful when a high coverage of a population in an area is required, for instance in order to coincide with transmission seasons. It also enables making use of the existing forms of insecticide packaging, supervision of treatments to ensure proper dosing, and quality assurance checks. This is an easy method and appropriate to initiate the insecticide distribution for this purpose, and may be the most cost-effective approach in terms of cost per net treated. The programmes can be organized through existing health services' structures such as malaria control, PHC systems, MCH, health centres, hospitals and clinics, through mobile arrangements, and properly managed/functioning community-based structures.

(ii) Net (re)treatment and demonstration centres

These may be more or less permanent net-treatment and demonstration centres which can serve a given catchment area, or a target population. The centres can also provide opportunities for the use of existing insecticide packaging systems.

The system allows timing of collective treatment to coincide with the transmission seasons. These and related centres can also provide individual treatment services adapted to peoples' convenience. For example, people may bring their nets at their own convenience or when they can afford to pay. The nets left behind for treatment and drying may be collected later.

These systems require premises, staff, subsidies for service related costs, for advertising/publicity and for other operational maintenance. The centres can serve as training and demonstration sites. These may be coordinated or operated through local community organizations such as women's groups, village health or bednet committees and managed through cost-recovery systems, revolving funds.

(iii) Mobile facilities

The facilities of the communal and demonstration sites (discussed above) may be extended to include mobile teams in order:

· To reach target populations especially in remote areas;

· To achieve high coverage in population groups such as in schools, hospitals, army camps/regimented groups, and development/industrial projects; and

· To achieve high coverage of a population or area within a limited/short time e.g. to cover a transmission period.

Permanent or semi-permanent staff trained and skilled on relevant techniques are required in all systems. The systems must be self-sustaining, but seed money must be provided to start cost-recovery/revolving-fund systems.

To ensure and facilitate proper net-treatment, charts/tables must be prepared and made readily available to the users with information on the water, insecticide, and dilution requirements for different insecticides and formulations, and the categories of nets (sizes, shapes, fibre) available locally.

Net treatment must be guided and supervised through the relevant malaria control and other appropriate services.

(iv) Do-it yourself

This involves a system to allow people to dip their own nets at home with insecticide in single dose sachets, for each category of nets. The insecticides will be added to water during washings. The need for special staff, training on treatment, and spillage and adulteration can be avoided. Where such a distribution system seems affordable, appropriate kits may be made available (if relevant marketed) through licensed pharmacies as a standard medical commodity, or through other suitable arrangements. It is necessary to ensure that the insecticides taken home for the treatment are water-based formulations in sealed packages and confined to one or two single net dosages. Quality assurance may be difficult but the need is less. The packaging system at present is costly and should be made affordable.

(v) Pre-treated nets

Some pre-treated types of nets are available. Their introduction is considered relevant to start a programme until other arrangements are made for the net-treatment. It is also useful to gain time to demonstrate the efficacy of ITMNs, and to convince people of the benefits of ITMNs. However as retreatment is needed in the long-term, this approach may only postpone the development of local capacities for insecticide-treatment of nets.

The expectations of the overall delivery processes are to focus initially on defined subgroups, and for promoting a gradual increase in coverage over a wide area depending on the local circumstances including the strategy objectives at local level. More exploratory work is needed to examine and improve the delivery processes for nets and insecticide-treatment, especially the latter.

Promotion

The success of the programmes depends on the ITMN net uses, and the continued efficacy and sustainability of events leading to this. Thus all concerned, the net users, and the providers (the implementing partners including potential donors) who are expected to sustain the chain of events must be promoted to carry out their expected roles.

Promotional elements

The overall and major ITMN promotional elements may involve:

· Providing resources (human, logistic and financial);

· Creating supporting/facilitating environments through appropriate policy, institutional or administrative and collaborative arrangements;

· Developing skills;

· Providing appropriate IEC to:

- convince,

- create awareness and sensitivity, and

- influence perceptions, practices, attitudes, and behaviours, for motivating positive actions.

Annex 1 on activities expected, related support needs and conditions to be met provides leads to the promotional requirements and elements.

Promotion of events leading to net-use/providers

Large-scale implementation requires major decisions/action some with policy implications which are beyond the scope of the health sector/malaria control programme management. The promotional targets here are the macro-economic level decision makers. They must be sensitized and convinced of the need and the type of support expected from them. Relevant information must be provided for this purpose. The potential donors must be sensitized to the need and type of support by projecting the disease burden and the potential role of ITMNs. They must be made aware of the need to meet the specifications and standards, and the technical, logistic and procedural requirements to be met in their inputs, and which are also conducive to sustainability. At the peripheral level, the community organizations who manage net distributions, insecticide-treatment of nets and revolving funds need information, training and skills. Their contributions must be appreciated/recognized. Thus the promotional needs and approaches depend on the level of contribution expected. Table 1 gives more examples in this connection, as to who should be promoted, to do what, and how to promote.

Table 1: Examples of promotional events leading to ITMN use

Who should be promoted	To do what	How to promote
Policy, decision makers, financing bodies	establish policies, clarify institutional, collaborating frameworks	demonstrate benefits of ITMNs, provide information to convince of needs for support and of conditions to be met for delivery
Malaria control programme staff	ensure overall planning, coordination of implementation, training, monitoring, evaluation and guidance	provide guidance, train/develop skills, create opportunities, provide resources
Decision makers, relevant staff of other sectors (public/private)	incorporate ITMN delivery within their networks of delivery services	convince of the need/importance, provide inputs and guidance, appreciate/recognize contributions, partnerships in planning
Community-based bodies, e.g. village communities, NGOs	treat nets with insecticides, convince people to buy nets, get them treated with insecticides and use ITMNs properly, manage cost-recovery, revolving funds	train/provide skills, enable access to insecticides, help establish/manage cost-recovery systems, provide seed money, guidance, recognize contributions
Private/commercial sector	participate in ITMN delivery, reduce costs	convince potential actors of the value of their contributions, recognize/acknowledge and give visibility to contributions

Promotion at net-use level

A high rate of ITMN use by those at risk of contracting malaria is expected. Research, KAP surveys, field experience, and hearsay point to wide variations among and within countries and communities on the perceptions and beliefs concerning mosquitos, (a nuisance or transmitter of malaria), on attitudes and reasons for using nets and other domestic anti-mosquito measures, and on the understanding of the role of ITMNs. These influence net procurement, insecticide-treatment, net-use, coverage and effectiveness of the strategy. These must be taken into consideration in planning promotional activities such as the development and dissemination of IEC messages used as vehicles to influence changes in behaviours, attitudes and practices. The potential net-users must be aware of the benefits of the ITMNs, the need and conditions for insecticide treatment, and proper use of ITMNs. They need access to good quality nets, and opportunities to get insecticide-treatment.

Promotional needs at net-user level being net ownership, insecticide-treatment of nets, and their use, the promotional requirements are to:

· meet the costs of nets and/or insecticides,

· to create a new behaviour to use nets,

· to get net (re)treatment on time,

· wash nets before treatments, limit washing after treatment, and get them retreated if they are washed too often;

· convince that those at the highest risk of contracting malaria (under 5 years, pregnant women) be given priority access/opportunities for ITMN uses.

Table 2 provides an example for promoting these.

Table 2: Examples of promotion of net-use level

Current status	Expectations/desired	Promotional elements
accustomed to use net (cultural habit) already buy/own nets	purchase right type of nets, get nets insecticide-treated on time, make proper use of ITMNs	insecticide-treatment opportunities/facilities, education on optimal conditions of ITMN use; information on sources, cost, standards, specifications
no habit of using nets	change in behaviour to use nets; buying right type of nets, getting nets insecticide-treated on time, proper use of ITMNs	information, IEC on role of ITMNs, and conditions for proper use, access to good quality nets and treatment facilities, information on sources, cost
at malaria risk, likes to use ITMNs but cannot afford	access to ITMNs at subsidized cost or free of charge (selective basis)	mechanisms to provide free of charge or at affordable prices, revolving funds, cost-recovery systems, other free of charge services
can afford, not convinced of benefits of nets/ITMN, spends on coils, sprays and even nets	to be convinced and ready to use ITMNs, buying nets, paying for insecticide treatments, motivated to use ITMNs	IEC messages, comparative benefits and costing with other antimosquito measures, access to good quality nets, treatment facilities and informed of conditions for use, standards, specifications
can afford to pay for insecticide treatment of nets	paying for insecticide (re)treatments, convinced of benefits of ITMNs	insecticide-treatment facilities, cost-recovery systems, information on treatment, sites/cost
cannot afford to pay for insecticide treatments	opportunities provided for insecticide treatments	subsidies, cost-recovery systems, support (domestic, external)

Messages communication channels

The types and choice of promotional messages should be guided by the current situation, and the expected outcome after promotional activities. For example, the outcome expected at user-level is improved net ownership, insecticide-treatment and proper use of ITMNs and those which influence communities' access to nets, and the insecticide-treatment facilities.

Where nuisance reduction has been a motivation to use nets, it is important that the potential role of ITMNs in malaria prevention is conveyed emphatically as the knowledge is vital for sustainability.

Other important messages to be conveyed include that:

· Children under 5 years and pregnant women are at highest risk of contracting malaria and that proper use of ITMNs can help prevent this risk;

· Nets must be washed before the insecticide-treatment, but that too much washing should be avoided after insecticide-treatment, giving reasons (e.g. that washing reduces the insecticidal efficacy); and that treated nets washed too often must be retreated;

· ITMNs uses can have a number of benefits compared to other household anti-mosquito measures and specifying what they are;

· ITMNs can be used without beds and even outdoors, explain how;

· Mosquitos of a given type transmit malaria and the proper use of ITMNs reduces risks of contracting the disease;

· Importance of using the right type of nets/material, and information on them.

Different communication approaches are expected. Social marketing with an overview on the perceptions, behaviours, and the perceived and actual needs of the target populations will provide leads to the types of audience, choice of messages, communication and delivery approaches. Their uses will be determined by the local circumstances, resources available or can be accessed with minimum inputs. A combination of methods (radio, posters, role plays, interpersonal communications, etc.) are expected to be used. Promotion of the younger generation, school children will not only be a highly effective route to transmit messages, access people, and stimulate actions, but a long-term investment for the future.