Indoor household residual spraying program performance in Matabeleland South province, Zimbabwe: 2011 to 2012; a descriptive cross-sectional study

Introduction Matabeleland South launched the malaria pre-elimination campaign in 2012 but provincial spraying coverage has failed to attain 95% target, with some districts still encountering malaria outbreaks. A study was conducted to evaluate program performance against achieving malaria pre-elimination. Methods A descriptive cross sectional study was done in 5 districts carrying out IRS using the logical framework involving inputs, process, outputs and outcome evaluation. Health workers recruited into the study included direct program implementers, district and provincial program managers. An interviewer administered questionnaire, checklists, key informant interviewer guide and desk review of records were used to collect data. Results We enrolled 37 primary respondents and 5 key informants. Pre-elimination, Epidemic Preparedness and Response plans were absent in all districts. Shortages of inputs were reported by 97% of respondents, with districts receiving 80% of requested budget. Insecticides were procured centrally at national level. Spraying started late and districts failed to spray all targeted households by end of December. The province is using makeshift camps with inappropriate evaporation ponds where liquid DDT waste is not safely accounted for. The provincial IHRS coverage for 2011 was 84%. Challenges cited included; food shortages for spraymen, late delivery of inputs and poor state of IHRS equipment. Conclusion The province has failed to achieve Malaria pre-elimination IRS coverage targets for 2011/12 season. Financial and logistical challenges led to delays in supply of program inputs, recruitment and training of sprayers. The Province should establish camping infrastructure with standard evaporation ponds to minimise contamination of the environment.


Introduction
Malaria is a disease caused by infection of the red blood cells by a protozoan parasite plasmodium and the vector for inoculation is the female anopheles mosquito [1]. Globally, annual malaria cases range between 300-500 million episodes, leading to more than one million deaths mainly among children under the age of 5 years [2].
The greatest burden of malaria lies within the poor and vulnerable societies [2]. In 2010, World Health Organisation (WHO) estimated 216 million cases of malaria, of which 81% of cases were in Africa [3]. In Zimbabwe, over 50% of the country's population lives in malaria prone areas [4]. developed a malaria pre-elimination plan for Matabeleland South province as the malaria burden was the lowest nationally [5]. In 2006, the national malaria incidence was 109 per 1000 population while for Matabeleland South Province it was 43 per 1000 population [5]. The malaria incidence for Matabeleland South has been the lowest nationally reaching 17 per 1000 population in 2009 and in 2010 the slide positivity rate for the province was at 20.2% [5].
Vector control is one of the key strategies in malaria control [6]. Worldwide, Dichloro-Diphenyl-Trichoroethane (DDT) has been used for successful eradication of malaria [6]. Previously, DDT was banned as it tends to persist in the ecosystem leading to possible adverse effects on human health [7]. The province has been using pyretroids but with commencement of pre-elimination of malaria phase, DDT has been reintroduced [6]. The use of DDT in malaria elimination is key as long as it is used according to the WHO prescribed statutes [7].
The major objective of IRS is to kill the adult mosquito thereby reducing the mosquito density [6]. In the pre-elimination of malaria, the ideal target is to have 100% coverage of house-holds sprayed [8]. The National Malaria Control Program (NMCP) has set for the nation a target of 95% for the total household sprayed while the percentage population protected by the IRS program is pegged at  [8]. The core strategy that is employed is Indoor Residual Spraying where the target for households sprayed is 100 percent. In the 2006-7 spraying season when the pre-elimination plan was conceived, IRS failed to take off in the province, since then to date the percentage spray coverage has failed to attain at least 95 percent target set by the NMCP and a target of 100 percent set by the province [8]. During the period 2006 to 2011, the province still encountered outbreaks of malaria in Beitbridge and Mangwe districts.
We thus posed a question how the Province was performing towards achieving the malaria pre-elimination targets? We therefore conducted this study to evaluate the IRS program to determine its performance for the period 2011 to 2012, in view of achieving targets for malaria pre-elimination that had been commenced in the province. The study recommendations will be used to improve program performance and to assist the province to successfully engage into an effective malaria pre-elimination phase.

Methods
Sampling strategy: a descriptive cross sectional study was done, using the logical framework (Figure 1  Using Epi Info TM version 3.5.1, StatCal function, assuming 42,8% of the participants will report late disbursement of funds as reason for poor program performance [11], assuming that the combined provincial total population of environmental health workers and members of the district health executive are 53, with the worst acceptable rate of 10% and at 95% confidence interval, a minimum calculated sample size of 32 primary respondents was to be interviewed.

Results
We interviewed 37 primary respondents, 68% were males and 32% females. Sixty-eight percent were direct program implementers from the environmental health department. The median age in service for the primary respondents was 5.5 (Q1=1, Q3=10.5) years. We also recruited 5 key informants into the study, all were males and their median age in service was 14 (Q1= 11; Q3= 24) years.
All 5 districts had plans for IHRS but without specific plans for the malaria pre-elimination. Surveillance and malaria trends analysis using available data was being done, however all the districts had no copies of the emergency preparedness plans. There were no Information Education and Counselling (IEC) materials with preelimination of malaria. Community and stakeholder sensitization meetings were cascaded from provincial, district and then to ward level.
The province was allocated 65% of the fuel they requested and thus there was not enough fuel for total coverage and incidentals such as call backs. There were 10 functional motorcycles from a request of 20. The province had 100 spray pumps and 62% were functional while spray-pump spares were not available. There were no chairs and torches for use in the camps. There were no respirators and belts for the spraymen however the rest of the protective clothing was supplied though not in adequate quantities. There were 32 four-man tents, 30% of them were worn out. The districts received funds that were less than their budgeted requests. Beitbridge  Table   1). Data is captured, analyzed and reported to the province by data managers that are stationed in IRS camps, it was 100% complete. A total of 8 different forms that include daily spraymen log books are were inspected and they were completely filled. The province expects 3 reports from the districts and these were sent on time and this includes the final IHRS reports.
Mangwe district managed to spray all the 7 wards, while Gwanda, Bulilima and Matobo managed to spray all the designated 8 wards.
In Beitbridge, they sprayed 11 out of the 15 targeted wards.
However, not all households were sprayed even in those districts where all wards were covered ( Table 1). The provincial IHRS coverage for 2011 was 84%, which is below the set target of 95%.
The main challenges reported by the primary respondents why the IHRS is not attaining its targets were; delays in starting spraying (67%), food shortages for spraymen (60%) and failing to complete spraying (41%). All key informants blamed late delivery of inputs Page number not for citation purposes 5 and poor state of IHRS equipment for not meeting targets. In the field that 3 teams relied on one motor-cycle for warning. This affects information dissemination as door-to-door warning was not feasible. Motorcycles were made available by the districts but they were not serviced and could not be used by the IHRS teams.
All the key informants and 92% of primary respondents stated that there were problems in sourcing spares for the spray pumps and thus they could not service their pumps in the camps. There has been a shift from using the Hudson pump to the Micronair. The Hudson pump had spares that were easily accessible but the new Micronair pumps have no spares available. DDT is reported to have bigger granules and they block the pores of the strainers for the Micronair pumps, thus more blockages and broken down pumps are being experienced by the sprayers.
Community mobilization was reportedly being done mainly by the environmental health department (62%), while 27% of primary respondents said it was inter-departmental. Only 8% said the Health Promotion department was responsible for community mobilization.
In the field, program implementers reported that the acceptance of DDT was poor. Some villagers refused for DDT to be sprayed on their walls as it leave them dirty with "whitish" stains. Some were afraid of the harmful effects of DDT.
The province has no specific camp sites built for IHRS and are using makeshift camps at the chosen rural health centres. There should be evaporation ponds that are fenced off and with floors made of impervious surfaces. Currently they are using makeshift evaporation ponds that liquid DDT waste seeps on to the ground while some of it is kept in plastic containers and the plans for its disposal are not clear. Solid DDT waste is kept under lock and key at the camp sites while awaiting collection for incineration.
All key informants were knowledgeable on malaria pre-elimination phases, plans and program re-orientation. They were all trained in program re-orientation, program targets and implementation including monitoring and evaluation of the malaria pre-elimination.
Primary respondents were divided into direct program implementers (Environmental Health Officers, technicians, field orderlies) and nondirect program implementers, the District Health Executive members) and their knowledge was assessed ( Table 2). Generally direct program implementers knew more that indirect program implementers but the knowledge trend was not statistically significant (p-value=0.4) ( Table 2). Primary respondents knowledge among direct and indirect program implementers was aggregated, tallied and measured against a Likert scale from very poor (1) to excellent knowledge (4). 28/29 direct program implementers and 5/8 indirect program implementers had knowledge >2 Likert score respectively. Sensitization workshops, intensified health education in the clinics and sending posters into the community were mentioned by both key informants and primary respondents as possible ways of educating the community and health workers on malaria preelimination. This should include the use of DDT and its advantages.
All 5 key informants alluded to improved community participation, 4/5 was advocating for more resources from treasury and 3/5 needs to see program re-orientation as possible strategies that will enable the possible implementation of the malaria pre-elimination plan. In a study done in Swaziland by Hlongwana et.al, they found out that there is need for improving the availability of information through the preferred community channels, as well as professional health routes [14]. Community mobilization is not well co-ordinated in the spraying districts. The Provincial Health Promotion Office should be on the forefront to coordinate awareness campaigns but they cite financial challenges as they are not given a budget by the NMCP. This then leaves the Environmental Health department to do health education and promotion. Apart from stakeholder sensitizations that are taking place, there should be efforts thus to improve the way program messages are conveyed to the community so as to improve on overall acceptance of the program.

Discussion
Public officials need to mobilize funding and advocacy to assure political commitment and continuous funding [9]. There is also need for non-governmental organizations working with the Global Fund The province with the support of the NMCP has to commit resources in construction of malaria spraying camps that will have proper infrastructure which will contain fenced off evaporation ponds where DDT (both solid and liquid waste) will be opened, diluted and washed without seeping to contaminate the environment. Safety of use among spray operators, transportation, storage use and disposal of DDT has to be put in place by a country. Monitoring and evaluation is necessary for measuring the overall success of the IRS program using DDT [10].

Conclusion
We can conclude that Matebeleland South Province has failed to achieve Malaria pre-elimination IRS coverage set targets in the