Distribution of Insecticide-Treated Bednets During a Polio Immunization Campaign --- Niger, 2005

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The West African country of Niger (2005 population: approximately 14 million) is among the poorest in the world. In 2005, malaria was reported in approximately 760,000 persons and caused 2,000 deaths; however, surveillance has been inadequate, and the true numbers likely were even higher (1). In 2004, the overall mortality rate in Niger among children aged <5 years was 259 per 1,000 live births (2). At least 8% of these deaths likely were caused by malaria, and the actual proportion might be as high as 50% (3). In addition, Niger was one of only 10 countries with poliomyelitis during the first 3 months of 2006, and the risk for polio importation from neighboring Nigeria is high. Routine polio vaccination coverage remains low in Niger; in 2003, coverage with 3 doses of oral poliovirus vaccine (OPV) was 54% (4,5). To reduce the prevalence of malaria and bolster polio eradication measures, Niger's Ministry of Health, with support from international partners,* launched a nationwide integrated health campaign in 2005. In coordination with a supplemental immunization activity (SIA) distributing OPV, long-lasting insecticide-treated bednets (ITNs)^† for malaria prevention were provided free of charge to mothers of children aged <5 years. In sub-Saharan Africa, ITNs have reduced all-cause mortality in children aged 1--59 months by 17% (6). This was the second such national campaign worldwide; the first was conducted in Togo in December 2004 (7). This report describes findings from a survey of Niger's integrated health campaign and highlights differences with the campaign in Togo.

Niger's campaign occurred in three phases. During November 12--17, 2005, in all eight regions of the country, OPV and vitamin A were distributed to children aged <5 years during a house-to-house SIA. At the same time, in a trial run, bednets were distributed to selected areas before the full-scale distribution began. The second phase of the campaign occurred during December 19--24, 2005, in seven of the eight regions of Niger. Using a house-to-house approach for optimal coverage, 3,850 Niger Red Cross volunteers and approximately 16,000 vaccinators and community health workers administered OPV to children aged <5 years. Field workers marked the thumbnails of mothers whose children had been vaccinated and provided the mothers with vouchers for a free bednet. Because of the long distances, sparsely distributed population, and bulkiness of bednet bundles, delivering them to individual households was not feasible; therefore, the nets were distributed to mothers at posts within approximately 5 km of each village. Mothers presented their vouchers and nail markings to redeem an ITN 1--5 days after their child's vaccination. The third phase of the campaign occurred during March 17--21, 2006, in the eighth region (Niamey), where eligible mothers redeemed ITN vouchers at fixed posts. At the same time, a "mop-up" campaign was conducted in the rest of the country to distribute bednets to mothers who had received vouchers but not a bednet in December. All phases of the campaign were advertised in several ways, including through national media, Niger Red Cross volunteers and local leaders, and health centers. During ITN distribution, field staff members and clinic health workers promoted bednet usage.

A cross-sectional household survey was performed 1 month after the December ITN distribution during January 23--February 17, 2006, a period of low malaria transmission during the dry season. The survey assessed delivery of services in the first seven regions (those in which the ITN distribution had occurred by the time of the survey). Using a stratified, two-stage cluster sample design, two districts were selected per region (with probability proportional to estimated population size) and eight enumeration areas per district; 16 households were randomly selected per enumeration area, plus nine additional households, for a total of 1,801 households.

Respondents in 88.7% of the 1,801 surveyed households reported that they had heard about the integrated campaign.^§ A total of 2,633 children aged <5 years were included in the survey. Respondents reported that 82.3% of the children had received >1 dose of OPV before (or independent of) the integrated campaign (Figure). During the campaign, 87.3% (95% confidence interval [CI] = 85.1%--89.5%) received OPV (range among regions: 81.8%--95.5%). In November, 83.8% (CI = 81.8%--85.8%) of children had received vitamin A. Before the campaign, 6.0% (CI = 4.1%--7.9%) of households with children aged <5 years owned an ITN. After the campaign, 69.9% (CI = 63.6--76.3%) of households with children aged <5 years owned an ITN (range among regions: 58.2%--84.4%). An equity ratio also was calculated.^¶ For households with children aged <5 years, the equity ratio for household ITN ownership was 0.36 before the campaign and 0.83 afterward.

Of the 1,601 mothers with children aged <5 years, 69.3% reported receiving an ITN during the December phase. The most common reasons cited by the remaining 30.7% for not receiving an ITN were that no more bednets were available at the post (34.2%), campaign personnel never came to the village (9.3%), or the mother did not receive the nail marking needed to receive an ITN (7.1%). When asked about the voucher and nail-marking process, 20% of all eligible mothers said they did not receive nail markings, and 31.1% said that they did not receive vouchers. Of the 68.1% who received both nail markings and vouchers, 91.1% received a campaign bednet.

After the campaign, bednet usage was low; respondents in 20.3% of all households reported they had hung an ITN the preceding night. Of the children included in the survey, 15.4% (range among regions: 8.3%--38.5%) were reported to have slept under an ITN the preceding night. In households with an ITN, 21.8% of children slept under it the preceeding night.

Reported by: I Ousmane, MD, S Issifi, Niger Ministry of Health; M Lama, MD, Regional Office for Africa, World Health Organization. J Roy, MD, S Hoyer, MD, J Haskew, International Federation of Red Cross and Red Crescent Societies. J Vanden Eng, MS, W Hawley, PhD, A Wolkon, MPH, Div of Parasitic Diseases, National Center for Zoonotic, Vector-Borne, and Enteric Diseases (proposed); M Watkins, MPH, Global Immunization Div, National Center for Immunization and Respiratory Diseases (proposed); N Hochberg, MD, M Eliades, MD, EIS officers, CDC.

Editorial Note:

The national ITN integrated health campaign in Togo and district-level campaigns in Ghana, Mozambique, Tanzania, and Zambia have demonstrated that integrating ITN distribution with an immunization activity can improve ITN ownership rapidly and equitably and help bring African nations closer to achieving the objectives of Roll Back Malaria** and United Nations Millennium Development Goals (8).^†† Survey results indicate that the integrated campaign in Niger rapidly increased ITN ownership. Approximately 2 million ITNs, at a cost of $4.16 per net, were distributed free of charge, with a resultant increased equity in ITN ownership among poorer and wealthier persons.

Although Niger's campaign reached 2 million persons, Togo's OPV coverage and ITN distribution among eligible children was higher: 93.7% (CI = 91.4%--96.1%) for OPV and 90.8% (CI = 88.1%--93.4%) for ITNs (7). Certain geographic and demographic differences might help explain the disparity. Niger is approximately 22 times the size of Togo, and 80% of the terrain is desert, which makes travel difficult (9). Furthermore, the widely dispersed, often migrant population of Niger is twice as large as that of Togo; because of food shortages, migration likely increased during the period before the campaign (9). Because of these factors, estimating initial ITN needs and resupplying fixed posts was difficult. These logistical factors might explain the reason some mothers did not receive ITNs even though their children had been vaccinated. In addition, culture and religion might have been a barrier; in some areas of Niger, women need permission from their husbands to leave the house.

Differences between the campaign protocols might also have contributed to increased coverage in Togo. In addition to providing OPV vaccination and ITNs, Togo's campaign included measles vaccination and mebendazole deworming treatment, which might have encouraged participation (Table). In Togo, ITNs were directly distributed to participants at the time of vaccination. Niger used a more complicated voucher and nail-marking system, possibly decreasing ITN distribution; 31.9% of eligible mothers did not receive vouchers, nail markings, or either. The Niger strategy involved marking thumbnails of all mothers (and vaccinating their children) and providing vouchers, which had to be retained and redeemed at a later date by the mothers. Such difficulties in the voucher strategy need to be weighed against the possible benefits; for example, providing vouchers for ITNs during vaccinations might encourage vaccination program participation.

Although the distribution campaign increased ITN ownership in households with children aged <5 years from 6% to nearly 70% by the end of the campaign, bednet usage was low. Low usage was not completely unexpected, because the survey was conducted during the dry season, which has few mosquitoes and low, although ongoing, malaria transmission. Nonetheless, bednet usage was higher in Togo (43.5%) than in Niger (15.4%) during the dry season (7,8). Unlike in Togo, which has a dry season of approximately 4 months, Niger's dry season lasts approximately 8 months (October--May), and this survey was conducted midway through the dry season. A follow-up survey during the rainy season might indicate higher usage rates, as was the case in Togo (V. Takpa, Togo Ministry of Health, unpublished data, 2005). In addition, community outreach is advisable to encourage increased bednet usage before the rainy season (June--September).

Integrating free ITN distribution with an immunization campaign seems an effective way for Niger to increase ITN ownership rapidly without decreasing OPV coverage. Because of the similarities between the malaria and immunization programs in terms of target groups, field staff, and logistical requirements, coordination between these programs can minimize the costs and maximize the benefits of service delivery (10). The population of Niger is sparsely distributed and difficult to reach; therefore, a house-to-house approach was needed to ensure high OPV coverage. Field staff should consider whether OPV could be administered at posts in more densely populated areas or whether house-to-house bednet distribution (rather than at fixed posts) is feasible. Future investigations will focus on how such campaigns can increase bednet usage in addition to ownership. Although these concerns should be addressed, the successful integration of ITN distribution with an immunization campaign in Niger suggests that such national campaigns are feasible in other large African nations.

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