Zahedan University of Medical Sciences

Cost-effective and Sustainable Larval Source Management Solutions in Urban Setting in Chabahar, Sistan and Baluchestan, Iran: A GEF project report

June 2015

 

Authors (in alphabetical order):
Dr. M .Kiani
Dr. M. Mohamamdi
MS.F. Nikpour
Dr. A. Raeisi
Dr. M. Ranjbar
Dr. N. Sargolzaei
Dr. S.M. Tabatabaei

 

 

 

Table of Contents:
Abbreviation: 5
Acknowledgements: 5
Background: 6
Goal of the project: 7
Study area: 7
Chabahar Demographic data: 8
Review of malaria situation in Chabahar (2008-2012): 9
Chabahar meteorological situation: 10
Chabahar entomological surveys results: 10
Why Chabahar is selected as study location? 11
Why environmental management was selected? 12
Overview of the study implementation phases: 13
Preliminary studies (2010-2012): 13
LSM solutions survey 15
Objectives of LSM solutions survey: 16
Expected outputs/outcomes of LSM solutions survey: 16
Design of LSM solutions survey: 16
Method: 17
Sample Size: 17
Selection of the sample size: 17
• 23
• 23
Collection of entomological data: 23
Analysis method: 24
Results: LSM solutions efficacy: 25
Efficacy assessment of weekly and biweekly application of biological larviciding 27
Assessment of efficacy of LSM solutions in consecutive years 27
Epidemiological figure before and after interventions: 28
Results: Community Acceptance of LSM solutions: 33
Community acceptance of covering WRs with Straw Mat: 34
Community acceptance of covering WRs with Mosaic: 35
Community acceptance of Larviciding by using Bti: 36
Community collaboration during installment of coverings: 38
Durability of LSM solutions 39
LSM solutions survey challenges: Error! Bookmark not defined.
Counterparts of demonstration project: 41
Cost-effective analysis: 41
Cost effective ratio 44
Peer-to-peer education study: 46
Result of assessment of peer-to-peer education: 46
Project management: 47
Lessons learnt: 48
Achievements: 48
Recommendations: 49
Further research: 49
Annex 1: Summar report of Sero-prevelance assessment of malaria 49
Annex 2: Report of Quick pilot study 50
Annex 3: Records of Malaria Cases by clusters in the survey site (2010-2014) 53
Annex4: Template for summary report of coverage of water reservoirs with larviciding agent (Bti) 55
Annex 5: A template for reporting larviciding worker performance 55
Annex 6: Form for final delivering services covered WRs with Mosaic or Straw Mat 56
Annex 7: A template for reporting malaria cases by cluster 56
Annex8: Mat Quality Assurance Check List 57
Annex9: Entomological Evaluation of Efficacy of LSM Form for Reporting 58
Annex 10: Community acceptance questioner 58
Annex 11: Registration from for monitoring and evaluation summary results by water reservoirs. 59

 

Abbreviation:

 

BH ....................................Breeding Habitat
DDT................................. Dichlorodiphenyltrichloroethane
DDE....................................Dichlorodiphenyldichloroethylene
POPs ..................................Persistent Organic Pollutants
LSM................................... Larval Source Management
STAC.............................. ... Scientific Technical Advisory Committee
VBD ...................................Vector Borne Disease
WR..................................... Water reservoirs
UMS.....................................University of Medical Silences

 

Acknowledgements:

 

The authors gratefully acknowledge the contributions of national counterparts including all officials and malaria staff in Chabahar District Health Center , Zibashahr Health Center, and Zahedan University of Medical sciences as well as health volunteers whocontributed todesigning andimplementation of the survey.
The authors acknowledgeinvaluable technical continuations of STAC membersparticularly Dr. Imm.Kleinschmidt and Dr Joshua Otto Yukich as well as EMRO/RBM regional adviser Dr.Hoda Attah, MS.Barva Caroline (EMRO/WHO), Dr.Ibram Mnzava (WHO/HQ)and the country technical personsDr.AliAkbar Haghdoost, Dr.Reza Majdzadeh, Dr.Morteza Amlashi, Mr.Mohammad Sakeni, Mr. Khodad Gorgich, Mr.Faroogh Askani, Dr.Nazari, and Dr. Amini,

 

Background:

 

DDT was one of the first chemicals in widespread use as a pesticide. Following World War II, it was promoted as a wonder-chemical, i.e. the simple solution to pest problems. However, DDT usage was banned because of its long lasting side effects. For instance, today, nearly 40 years after DDT has been banned in the U.S., people continue to live with its long-lasting effects.
The science on human health impacts of DDT has continued to mount over the years, with recent studies showing harm at very low levels of exposure. Studies show a range of human health effects linked to DDT and its breakdown product, DDE:
• Breast & other cancers
• Male infertility
• Miscarriages & low birth weight
• Developmental delay
• Nervous system & liver damage
Stockholm Convention on Persistent Organic Pollutants banned the use of DDT and other Persistent Prganic Pollutants (POPs) for agricultural uses worldwide. However, in health areas the story is different. DDT usage is in the agenda of some countries in malaria control programme; therefor, mobilizing financial and technical support is needed towards strengthening vector control programs for transition to safer and more effective alternatives.
To address the mentioned gap in EMRO countries at the first step Vector Control Programme Needs Assessment was conducted from 2006 to 2007. Subsequently, in 2008, the Global Environment Facility (GEF) financial resources were secured for a UNEP Regional Project entitled ‘Demonstration of Sustainable Alternatives to DDT and Strengthening of National Vector Control Capabilities.
The regional project was proposed to demonstrate environmentally friendly alternative vector control solutions as contribution to a UNEP"s global DDT project, a portfolio promoting a global vector borne diseases control policy without the application of DDT through the use of sustainable, cost-effective and environment friendly alternatives.
The environmental objective of the Regional Project is to reduce the negative effects of DDT in public health and the global environment through the introduction of sustainable, cost-effective and environment friendly alternative interventions.
The development objective of the Regional Project is to reduce the reliance on DDT in case of outbreaks of vector borne diseases and to minimize the potential to revert to DDT use.
Iran project:
In line with the Regional Project a project in Iran was proposed to compare the effectiveness and cost-effectiveness of covering domestic water reservoirs with coverings versus treating water reservoirs using biological larviciding to reduce density of malaria vector larvae.

 

 

 

 

Chabahar:

 

Chabahar covers an area of 24,729 km² and has been located in the extreme south-eastern end of Iran along the Gulf of Oman. Chabahar is connected to Konarak from the east, to Sarbaz and Nikshahr from the north and to Pakistan through a long border (130 km) in the east.

 

Chabahar port, the district center, with 11km² land area has been located at an altitude of 7m above sea level at 60° 37′ E and 25° 17′ N.

 

 

 

Figure1: Schematic location of Chabahar

 

Chabahar Demographic data:

 

In Chabahar district there is a population of around 2,510,000including about 206,000 who live in 477 rural foci and 45,000 in two cities that are covered by two General Hospitals, 21Urban and Rural Health Centers and 77 Health Houses .
Chabahar suburban area is expanding fast and it is a location for attracting marginalized people. The suburban area with a population of more than 25,000 is suffering from various health problems and it is a malaria prone area because of cross-border population movement with Pakistan, efficient vectors, climate condition in favor of malaria transmission as well as presence of a large number of larval breeding habitats, mainly water reservoirs. Local people in Chabahar suburban area have to use water reservoirs because they have no access to potable tap water; therefore, they have to make use of 3,048 water reservoirs as replacement which were identified as breeding places for mosquitoes in the locality.
A survey among 529 randomly selected households in suburban areas of Chabahar showed that 99.4% were Iranian, 04% Pakistani and 0.2% Afghan. Around 5% of households temporarily lived there and majority had frequent travel to Pakistan.
Chabahar suburban is underprivileged and underdeveloped areas; for instance educational level of local population is lowlife. around 31% illiterate, consisting of 45% primary and 24% secondary school education. As well as, merely 19% had access to uninterrupted electricity, 13.5% with no access to electricity, and 67.5% with an access of only for a few hours per week. In summary, around 80% have no access to air conditioning systems or equipment and as a result sleep outdoors which expose them to mosquito bites.

 

Review of malaria situation in Chabahar (2008-2012):

 

In 2008 Chabahar had one-third of malaria cases in the province with 2,069 positive cases. A significant reduction in malaria cases; same as other parts of the country; has been achieved over the recent years. However, risk of re-introduction of malaria transmission and occurring malaria outbreaks are high due to cross-border population movement within Pakistan bordering areas, unprotected houses, and poor access to electricity as well as high level of vectorial capacity.
After rapid urbanization in the last five years in Chabahar suburban areas, the proportion of urban malaria among total cases have shown an increasing trend. Following an outbreak in suburban areas %53 of total malaria cases of Chabahar district in 2010 were detected in urban area while this figure was only %20 in 2008 (Table 1).

 

 

 

 

 

 

 

Chabahar meteorological situation:

 

Chabahar is one of the nearest parts of the country to the equator and has a hot and humid climate. The average of maximum temperature (in June) over a period of 7 years is 31°c and the average of minimum temperature (in January) is 19 °c, while the average of the annual temperature is 26°c. The minimum relative humidity and average relative humidity have been reported %60 and %70 respectively. Average amount of annual precipitation is 200mm of which %64 falls in winter.

 
Chabahar entomological surveys results:
Results of preliminary entomological studies that conducted in study site (Chabahar suburban area) before interventions (2011) indicate that various species of anopheles (majority An.stephensi) with different bionomic patterns can be found.
A total of 485 mosquitoes were collected during Human Night Bite collections at study sites. It is to benoted that all collected mosquitos were of An.stephensi. Monthly density of An.stephensi based on Pyrethrum Spray Catch (881 mosquitoes) in indoor locations that were not sprayed, from March to August 2011 was varied between 0.3-19.5. In abdominal conditions, the percentage of unfed collected mosquitoes was 5.4%. 16.7% fed, 45.2% semi-gravid, 66.7% gravid. The parous rate was ranged between 0.0-0.5 (Table 2).

 

From April to September 2011, a total of 82 water reservoirs were examined using a funnel-shaped immature collection new (FCN). Of all larvae collected (10696 larvae) 59% were from genus Anopheles and 41 from sub-family Culicinae. The species composition of Anopheles was An.stephensi (99.76%) and An.culicifacies (0.21%), An.pulcherrimus 0.03% and An.dthali 0.02%.

 

Why Chabahar is selected as study location?
Controlling malaria vector in urban settings is very difficult and costly by routine controlling measures; therefore, finding an innovative, cost-effective method is a priority. In summary, Chabahar was selected because it is a good example to demonstrate an alternative solutions well as it is a top priority area for the country as a potential obstacle against elimination programme:

 
Chabahar is a good example to demonstrate an "alternative LSM solutions" because of:

• Similarity in climate
Chabahar is a Semi-arid/tropical area so there is a high similarity between Chabahar and most of malarious areas throughout the world.

 

• Similarity in socio-economic situation of population
Low income, high rate of illiteracy, limited access to air conditioning and power, verity of nationalities...

 

• Population movement with endemic areas
Cross-border population movement with endemic countries is a common problem in most of the countries with elimination goal

 

• Urbanization
Urban malaria and other health problems among marginalized people who live in slums and suburban areas are common problems among countries and become increasingly worse.

 

• A good candidate for LSM solutions
Adulticide measures are not applicable in Chabahar city (similar to the most urban settings throughout the world) so LSM solutions are recommended.
Chabahar is a high priority area in the country because:

 

 

 

 

Overview of the study implementation phases:

The demonstration project was conducted in two phases:
1) Preliminary studies to get a clear picture of the field in order to gather needed information for designing the Larval Source Management solutions study;
2) Larval Source Management solutions survey.

 

Preliminary studies (2010-2012):

 

During period of 2010-2012 a series of preliminary demographic, entomological and epidemiological studieswere carried out to gather required information for designing LSM solutions survey and to find answers to critical queries on subjects such as applicable and appropriate LSM solutions, appropriate method of sampling, sample size, determining best period of time for implementation of pilot study given seasonality of malaria transmission, and so on.
Note:
A serological study was carried out to measure serological criteria as a possible epidemiological baseline measure; however, given low level of endemicity as well as low level of specificity of serological tests it was excluded as a parameter for effectiveness analysis (Please refer to Annex 1)
In addition, the following measures were conducted during the preliminary studies:
 Updating WRs database and allocation of a unique code to each of them;
 Mapping suburban areas and WRs;
 Determining applicable and appropriate LSM solutions to be assessed in the survey via a quick pilot study.
Based on gathered data in preliminary phase before intervention among total water reservoirs in survey site 17% of water reservoirs were covered with various coverings. This indicates that covering WRs is a common strategy for the local people. They use various materials for the purpose including (among 478 randomly selected WRs) asbestos 63%, mosaic, 26.6%, wood 6%, galvanized iron sheets 2%, and plastic sheets 1%. Asbestos is believed to be carcinogenic but the locals make use of it to cover their WRs because it is cheaper and the people in this part of the country are too poor to be able to afford a more favorite material, i.e. mosaic.

 

Quick pilot study
A sample of six common types of water reservoir coverings were constructed to assess feasibility and affordability (cost) and to get a clear estimation of needed cost and required supplies and equipment. In the end two methods were selected to be assessed in large scale in the filed: Straw Mat and Mosaic (please refer to Annex 2).
 Finalizing proposal of LSM solutions survey;
 Development of an action plan for conducting LSM solutions survey;
 Resource mobilization (Zahedan UMS, CDC/MOH, UNDP and WHO);
 Development of required templates, protocols, guidelines for LSM solutions survey;
 Development of required templates, protocols, guidelines for peer-to-peer education to enhance community acceptance and participation in LSM solutions survey;
 Field staff"s capacity building for implementation of LSM solutions survey.

 

 

 

 

 

 

 

LSM solutions survey

 

 

 

 

 

 

 

 

 

 

 

Objectives of LSM solutions survey:

 

Goal: To Demonstrate Cost-Effective and Sustainable LSM Solutions in Urban Settings
Specific objectives:
 To assess efficacy of covering breeding places with Straw Mat (made of natural materials of date tree leaves);
 To assess efficacy of covering breeding places with Mosaic (manmade materials);
 To assess efficacy of regular larviciding with Bti as a routine practice;
 To assess community acceptance regarding the selected LSM solutions;
 Cost-effective analysis of the selected LSM solutions;
 To assess sustainability of the selected LSM solutions.

 

Note:
A secondary study was planned to assess efficacy of peer-to-peer community education on malaria as an innovative approach towards increasing community knowledge on malaria and enhancement of their attitude and practice towards better implementation of the LSM solutions (please refer to the report of peer- to-peer education).

 

Expected outputs/outcomes of LSM solutions survey:

 Finding LSM environment friendly solutions that are locally tailor-made;
 To revise and standardize LSM interventions procedures in areas such as planning, implementation, and monitoring and evaluation towards strengthening national capacity on LSM implementation;
 Knowledge sharing through standardizing and documentation of all aspects of the study including cost-effective analysis of LSM measure.

Design of LSM solutions survey:
This study was developed based on cluster randomised trial design.
Three arms are defined:
 Covering water reservoirs with Mosaic (Cluster one: Mosaic);
 Covering water reservoirs with Straw Mat ( Cluster two: Straw Mat);
 Regular biological larviciding as a routine practice (Cluster three: Biological Larviciding).

Method:

 

 

 

Sample Size:

 

According to the design, there are 3 arms. After intervention, the most prevalence of pupae was expected to be observed in Straw Mat intervention followed by Larviciding and Mosaic intervention. It was expected to observe a difference in pupae prevalence between the Mosaic covering and larviciding as large as 10%. According to the before intervention evidence in the field, pupae was estimated to be detected in about 15% of water reservoirs treated with Larviciding. Assuming type I error as 5% and a power of 90%, the sample size was determined for each group as follow,

Selection of the sample size:

Suburban areas of Chabahar were classified into 40blocks of which 13 have been randomly selected -based on simple random sampling method- for the LSM solutions survey (Mosaic, Straw Mat and Biological Larviciding).
• Mosaic cluster (blocks number 02-04-6.1) in red colour
• Straw Mat cluster (blocks number 3.1-7.1) in green colour
• Bacillus clusters (blocks number 01-40-38-37-34) in yellow colour (please refer to figure 2 and 3)

 

Figure 2:

 

 

 

 

Figure 3:

 
Phases of implementation of LSM solutions survey:

 

 

 

LSM solutions survey was conducted in three phases:

 

 

Phase one: Before LSM interventions: Gathering baseline data: (Jan -April 2013)
Baseline survey (entomological survey) was conducted in randomly selected blocks in three clusters (Mosaic, Straw Mat and Biological Larvicide) to collect up-to-date information immediately before LSM interventions.

Phase two: Implementation of LSM interventions: Covering water reservoirs with coverings and biological larviciding (May - September 2013)
• Covering WRs with coverings. 290 water reservoirs were covered with Mosaic (2,186 m2) and 148 with Straw Mat (1,160 m2)
• Biological Larviciding,484 Water reservoirs were covered with larviciding using Bti (2,505 m2)( please refer to table 3)

 

 

 

 

 

 

 

 

 

Phase three: After LSM interventions: Assessment of efficacy, community acceptance, durability, (Aug 2013- Nov 2014):
• Assessment of durability and sustainability;
• Assessment of community acceptance;
• Entomological survey to determine larval density to assess effectiveness of interventions.
Please refer to table 4 and Table 5 to get a clear picture of the time table of main steps of two phases of the study.

Collection of entomological data:
A random sample of water reservoirs in each cluster were inspected for the presence of anopheles pupae (and larvae density) before and after the deployment of the interventions. Repeated inspections were done after the interventions and their results were treated independently.

 

 

 

 

 

 

 

 

 

For collection of larva, an innovative tool (Funnel -Shaped Net trap) has been used that screened the whole WR area even if the WR had a covering.

 

Analysis method:
The prevalence of anopheles pupae in water reservoirs was compared between three clusters, before and after the interventions. Logistic regression was used to calculate odds ratios for differences in prevalence between treatment arms of pre- and post-intervention. The Straw Mat intervention was regarded as the reference. SPSS (version 18) was used for data analysis.

 

 

 

 

 

Results: LSM solutions efficacy:

 

Presence/absence of pupae was selected as ultimate indicator for assessment of efficacy of interventions that applies for all LSM solutions. Larvae density at early stage doesn"t apply for Biological Larviciding intervention because of its mode of action; therefore, larvae density is not a good indicator for comparing LSM interventions efficacy.
Pupae were detected in 22.5%, 12.2% and 14.3% of water reservoirs before being covered with Straw Mat or Mosaic, or treated with Larviciding respectively. Before intervention, there was no significance difference in pupae prevalence among the study arms. Although pupae prevalence increased to 36.4% after covering water reservoirs with Straw Mat, the prevalence decreased to 6.3% after larviciding. No pupae were observed in Mosaic arm (Table 7).
Mosaic was the most effective method. Compared to the Straw Mat, Larviciding could significantly reduce the chance of detecting pupae in water reservoirs by 88% (P<0.001) (Table 7).

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Efficacy assessment of weekly and biweekly application of biological larviciding

 

Question 1: Is there any significant difference in efficacy between weekly treatment of WRs and biweekly method?
19 extra samples in Block 1 were selected and biweekly larvicided using biological larvicide to compare its efficacy with those larvicided weekly. Proportion of An. pupae was 0.895 in biweekly larviciding compared to 0.916 in weekly larviciding. Based on Binomial test, there was not any significant difference between the two proportions (P=0.482).
Given small size of the sample the result cannot be accepted as a policy however a survey with enough sample size is recommended.
*Binomial test was used to compare the distribution of unobserved An. pupae in biweekly larvicided HBs with 0.916 due to small sample size for biweekly investigation.

Assessment of efficacy of LSM solutions in consecutive years

 

Question 2: Is there any significant difference in efficacy of intervention in various clusters in two consecutive years?
Sustainable efficacy is subject of concern. Frequency distributions of observed pupae in water reservoirs after being covered with Mosaic, Straw Mat or treated with Larvicidingi n 2013 (the same year after intervention) and 2014 are as follows:

 

There were no pupae observed in water reservoirs covered with Mosaic in both 2013 and 2014.
The proportion of pupae decreased significantly from 43.8% in2013 to 26.8% in 2014 (OR = 0.47; 95% C.I. (0.22, 0.99)) in water reservoirs covered with Straw Mat.T his might be resulted from the breaks and cracks in Straw Mat.
The proportion of pupae increased significantly from 2.3% in2013 to 14.2% in 2014 (OR = 7.13; 95% C.I. (2.78, 18.33)) in WR streated with larviciding. Given the same batch of larvicide was used for treatment of WRs with biological larviciding; it may be due to failure in storage stability of the product. Because the product had been produced in 2013; therefore, in the following year (2014), it was more than one year old. Testing storage stability of the product in the field is recommended.

 

Epidemiological figure before and after interventions:

 

Considering that the country aims at malaria elimination, the intensified controlling measures implemented in recent years resulted in reduction in the number of local malaria cases. In Chabahar a sharp reduction in autochthonous malaria cases can be seen in the period of 2010-2014.
In 2013 and 2014, total malaria cases has a slight decreasing trend while autochthonous malaria cases trend is more significantly reducing, and this conveys the impact of the elimination programme despite the effects of cross-border population movement (Graphe1). Please refer to annex 3 for more details.

 

Graph 1: Trend of malaria cases in Chabahar district 2010-2014.

 

Comparing malaria situation in rural and urban areas, the indicated reduction of autochthonous malaria cases in urban areas is much more significant compared with rural areas (Table 8, Graph 2 and 3).

 

This may indicate effects of LSM intervention in urban settings. It should be noted that all WRs in suburban areas that were not selected in the study areas were covered by biological larviciding as a routine practice.

 

Graph 2: Trend of malaria cases in Chabahar district by urban and rural settings, 2010-2014.

 

Graph 3: Trend of autochthonous malaria cases in urban and rural settings of Chabahar district 2010-2014.

 

In table 9the trend of malaria cases by clusters before and after interventions can be found. Given the border of clusters is very close to each other and considering population movement, the epidemiological indicator cannot be reliable to assess the interventions efficacy.

 

The trend of autochthonous malaria cases before and after interventions in three study clusters can be found in Graph 4.

 

Graph 4: Trend of autochthonous malaria cases in three clusters of the study 2010-2014.

 

The trend of total malaria cases before and after interventions in three clusters of the study can be found in Graph5.

 

 

 

Graph 5: Trend of malaria cases in three clusters of the study Chabahar district 2010-2014.

 

It should be noted that based on a preliminary study that was conducted before LSM interventions among local population in selected blocks, out of the total of 526 households under GEF project (Straw Mat group with 90 households, cement & Mosaic group with 213 households, and Larvicide group with 223 households) 470 households (89.4%) did not have any history of malaria but 10.6% had a past malaria history. The number of cases in these households varied from 1 to 5.
In summary, epidemiological indicators is not reliable criteria given study design and low burden of the disease although reduction of autochthonous malaria cases in study arms is promising.

 
Results: Community Acceptance of LSM solutions:
An evaluation was conducted on social acceptance and people"s opinion about advantages and disadvantages of the intervention through a questionnaire. The evaluation was carried out twice; once, at least one month, and then at least 8 months after the intervention.

 

Community acceptance of covering WRs with Straw Mat:
In summary, community acceptance of users of WRs covered with Straw Mat was very poor. In a survey that was conducted after 8 months among 10% of randomly selected households the majority of them were not happy with the intervention.
Lack of people acceptance was caused the less number of WRs covered with mats than what it had already planned. The reasons for the lack of community acceptance were that mats did not have enough strength and durability as well as its negative effects on the taste and odor of water. Details of received feedback from the users of WRs with Straw Mat are as follows:

 

Answers of users of WRs covered by Straw mat regarding advantage and disadvantage of Straw mat.
What is the advantage of covering WR with Straw mat?
• Reduction in fly density and in malaria and diarrheal diseases: 76.3%;
• Ineffective: 18.3%;
• No comment: 5.4%.

 

What is the advantage of covering WR with Straw mat?
• Early destruction of Straw Mat and water contamination: 34.5%;
• Possibility of reptiles and animals falling into water reservoir: 23%;
• Unpleasant changes in smell and taste of water: 5.5%;
• No comment: 47 %.

 

 

 

Community acceptance of covering WRs with Mosaic:
In summary, community acceptance of users of WRs covered with Mosaic was very good. In a survey that was conducted after 8 months among 10% randomly selected households, all of them were happy with the intervention.

 

Answers of users of WRs covered by Mosaic regarding advantage and disadvantage of Mosaic.
What is the advantage of covering WR with Mosaic?
• Reduction in fly density and in malaria and diarrheal diseases, keeping water safe, prevention of insects and other animals entrance: 98.2%;
• No comment: 1.8%.

What is the disadvantage of covering WR with Mosaic?
• No comment: 100%.

 

 

 

Community acceptance of Larviciding by using Bti:

 

In summary, community acceptance of users of WRs covered with Larviciding (with Bti) was good. In a survey that was conducted after 8 months among 10% randomly selected households, the majority of them were happy with the intervention. Some people were not happy and changes in the taste of water after application of larvicide (Bti) mentioned as a reason. Given there is no negative effects of application of a small dose of Bti on water taste and health system has not received any similar complains after more than a decade using Bti, local health staff believed that the local people are not happy that their water reservoirs are not covered with Mosaic same as their neighbours in Mosaic cluster. Mosaic is a valuable asset compared with continuous larviciding by Bti and our local staff had to deal with frequent request of almost all households in other clusters to provide them with service of covering WR with Mosaic.

 

Answers of users of WRs treated with Bti regarding advantage and disadvantage of larviciding.
What is the advantage of treatment of WR with Bti?

• Reduction in fly density and in malaria cases: 79.8%;
• Ineffective: 0.4%;
• No comment: 19.8%.

What is the disadvantage of treatment of WR with Bti?
• Changes in smell, color and taste of water and also alga growth: 35%;
• No comment: 65%.

 

 

 

Overall satisfaction (defined as not expressing any disadvantages) in the three groups is shown in Graphs 6 and 7.

 

Graph 6: overall satisfaction with the three interventions at least 1 month after the interventions.

 

 

 

Graph 7: Overall satisfaction with the three interventions at least 8 months after the interventions.

 

Community collaboration during installment of coverings:
Lower level of community acceptance of Straw Mat coverings resulted in lower level of relevant households collaboration during covering WRs with Straw mat (Graph 8) and difference of cooperation of households in Mosaic cluster was significant compared with Straw mat .

 

Graph 8: Percent of households cooperated during covering instulation in the Straw Mat and Mosaic groups
Based on χ2 test there was a significant difference between people cooperation in the Straw Mat and Mosaic groups (P< 0.001).

 
Community collaboration during maintenance of installed coverings
After installation of water reservoirs coverings, the households were asked to keep the provided hatches closed. During field visits by health staff, it was observed that many of the users of WRs covered with Straw Mat kept installed hatches of WRs opened. This wrong behavior may result in breeding mosquitos and transforming WRs to active and secure breeding places. In addition, they can turn into a convenient shelter for adult mosquitos to rest. Consequently, a survey was conducted among 10% of randomly selected households in Block 7/1 to assess the volume of the problem of keeping hatch of water reservoir opened, to find how much this is common among users and also the reason behind it, in order to design appropriate mitigating actions. The survey result showed that 73%of Water reservoirs hatches were left open or it was not standardized to prevent entrance of the mosquito. Face to face education conducted and local people were asked to keep the hatch door closed and they were informed about consequences of left the hatch door open.
After remediation measure all coverings were checked out and observed. It was found out that 100% of the Straw Mat coverings hatches and 99% of the Mosaic coverings hatches were closed except for the water refilling/replacing time.

Durability of LSM solutions

 

In summary, durability of covered WRs with Straw Mat was very poor. All coverings were evaluated and inspected for insects entryways and probable damages after one month. As seen in Graph 9 during the first evaluation (at least 1 month after intervention) in Straw Mat group some breaks and cracks were found which could let insects in.

 

Graph9: Percentage of observed insects entryways in the Straw Mat and the Mosaic groups, one month after the intervention.
During the second evaluation (at least 8 months after the intervention) insects entryways were detected in 64% in the Straw Mat Group due to breaks and cracks, left-open hatches, and covering removal. But we observed the insect entryways were observed only in 4.9% in the cement & Mosaic group due to left-open hatches (Graph 10 and 11).

 

Graph 310: Percentage of observed insect entryways in the Straw Mat and the Mosaic groups at least 8 months after the intervention.
Based on χ2 test there was a significant difference between observed insectsentryways in the Straw Mat and the Mosaic groups (P< 0.001).

 

Graph 11: Comparison of Insects Entryways in Groups of Straw Mat and Mosaic after One and Eight Months
Lessons learnt:
In evaluation of the cement covered water reservoirs, it was noticed that some of the roofs had cracks in the cornerstone places. The reason was specified through the expert surveys which were done by the construction unit of Chabahar"s Health Center. The reason was specified and the defects were eliminated by changing the ratio of the used materials.
At the start of the project, some of the cornerstones which were used in water reservoirs coverings were tar-covered in order to prevent their corrosion. However, it caused changes in the taste and smell of water.
The expert surveys revealed the solution and suitable rustproof material replaced tar.

 

Counterparts of demonstration project:
The overall responsibility of implementation of the pilot phase of the project lies with the National Malaria Control Program, CDC-MOHME. Deputy for Health Affairs of Zahedan University of Medical Sciences was responsible for implementation of the activities in Chabahar and reporting. The UNDP country office of Iran in line with goals of SSF GF malaria project and its mandate to battle malaria as a development barrier contributed financially and technically, along with those provided by other contributing parties for implementation of LSM solutions (covering water reservoirs). WHO contributed to technical support and covering cost of preliminary studies as well cost of technical measures of the project. Institute Pasture of Iran, School of Public Health of Tehran University contributed technically to the implementation of entomological and serological surveys.

Cost-effective analysis:
As described above, this study was not designed to measure effectiveness in terms of cases because the country is at elimination stage; therefore, epidemiological variables changes are not significant. Hence, an intermediate outcome indicator (the proportion of breeding sites which no longer have pupae) has been selected as the basis for analyzing the effectiveness. As a result the cost of the intervention per water reservoir in a period of 1-10 years is estimated to get a figure of cost-effective analysis.
This analysis is done based on the assumptions that the efficacy of Larviciding and Mosaic is the same; it is followed by the fact that considering two long transmission seasons 10 months of Larviciding per year is required, and also the fact that durability of Mosaic has been estimated more than 10 years based on local experience.
It should be noted that Straw Mat was excluded from cost-effective analysis because of its low efficacy and low level of community acceptance. The estimated cost of covering water reservoirs with Straw Mat is 14.83 USD per sqm.
Costs of Mosaic for year one is estimated as 25.3 USD per sqm and Larviciding 9.6 USD per sqm for the same period. Costs of Mosaic are reduced significantly because of low cost of maintenance after installation of the coverings of WRs while the cost of Larviciding will be increasing significantly. The cost of Larviciding is almost the same for the following years as well as the inflation has a major effect on components of Larviciding costs (Graph 12).

 

Graph 12: Cost Comparison of per Square-Meter of Larviciding and Mosaic Interventions
In summary, yearly costs of Mosaic after 2.5 years would be equal to costs of Larviciding for the same period. However, after 2.5 years as the time passes by Larviciding yearly costs go up as opposed to the trend of yearly costs of Mosaic which is substantially lower (Graph 13).

 

Graph 13: Cumulative Cost Comparison of per Square-Meter of Larviciding and Mosaic Interventions

 

After 10 years the cumulative costs of larviciding would be 122 USD per sqm. However, for Mosaic it is equal to 30.5 USD per sqm (only 24% of Larviciding costs), (Graph 14).

 

Graph 14: Total 10-Year Cost Comparison of per Square-Meter of Larviciding and Mosaic Intervention

 

Cost effective ratio

 

To have an estimation of cost-effective ratio, cost per pupae averted is calculated.
The results are in line with the previous cost analysis although given higher efficacy of Mosaic compared with Larviciding (with Bti), the costs per outcome ratio of larviciding is much higher than Mosaic and for a period of ten years costs of Mosaic is only about 20% of Larviciding (Table 10, Graph 15).

 

 

 

 

 

Graph 15: Cost-Effective (CE) Ratio Comparison of Larviciding and Mosaic Interventions

 

The above graph shows an analysis of cos-effective ratio though 10 years. Having compared it with the ‘Cost Comparison of per Square-Meter of Larviciding and Mosaic Interventions" graph (see above), it can be concluded that the slope is clearly steeper. The steeper slope utterly states the higher costs of Larviciding intervention in comparison to Mosaic intervention, i.e. Mosaic intervention on the long term is much more economical.

Peer-to-peer education study:

 

In the context of GEF alternative solution survey in Iran, community collaboration was a vital factor and prerequisite of successful implementation of the survey. Given local condition and in consultation with local health staff, peer-to-peer education in collaboration with volunteers from local population was selected as an appropriate method to promote community collaboration/participation for LSM solutions.
Accordingly, active face to face community education sessions focusing on personal protection and LSM solutions were conducted in three rounds; before, during and after implementation of LSM solutions in the selected sites.
To record the efficacy of peer-to-peer education on enhancement of knowledge, attitude and practice of local people regarding malaria and LSM solutions two KAP studies were conducted, before and after peer-to- peer educations. 150 households were studied in the KAP survey before the interventions.

 

Result of assessment of peer-to-peer education:

 

 

 

* Knowledge, attitude, and action scores ranged between 0 and 100.
The average score of knowledge was 44.7 and 44.2 before and after the intervention respectively. The difference was not significantly different (P=0.642). These mean knowledge scores were far less than the possible maximum score of knowledge (100).
Mean of attitude score was significantly higher after the intervention (P<0.001). It was 62.3 before the intervention and increased to 82.1 after the intervention.
Although mean of action score was 37.9 after the intervention compared to 35.7 as the baseline, the difference was not significant (P=0.270). Generally, most of action scores were much lower than the maximum score (100).

 

Project management:

 

A strong mechanism has been developed to have all the stakeholders to be effectively involved throughout the study course. For instance regular biweekly 51 meetings (sometimes weekly) were conducted at district level with presence of Chabahar District Health Center relevant staff and authorities to monitor the project progress and take prompt remedial decisions. 16 joint sessions were conducted with presence of provincial and district health canter staff and authorities during 2013-2014. Technical discussion of the study"s various aspects and logistical, managerial and administrative support facilitated the implementation of the project.
During 2013-2014 five joint sessions with presence of district, provincial and national levels counterparts were conducted with the same purpose, and monitoring of the study progress, reviewing the achievements and bottlenecks, and technical support were parts of it.

 

Lessons learnt:
The importance of continuous supervision and monitoring of all aspects of the study is crucial. While there was a sophisticated system of monitoring, supervision and quality control of interventions, around 25% of the collected data through the entomological evaluations of WRs was not according to the developed protocols. Therefore, these data could not be counted in the study because refilling water reservoirs had happened in less than 4 days.

 

Achievements:
1. Strengthening capacity of the health system for designing, planning, implementation and monitoring and evaluation of LSM solutions;
2. Strengthening capacity of the health system for peer-to-peer education;
3. Strengthening capacity of the health system for designing, implementation and reporting of applicable research;
4. Strengthening capacity of the health system for inter-sectoral collaboration and advocacy for community participation and collaboration in line with multi-sectoral approaches.;
5. Strengthening the health system capacity for larviciding through revising/developing national protocols and standards; Some of which are listed here:
• A training package for peer-to-peer education (flip chart) was developed;
• A package for training volunteers was developed;
• Criteria for selection of local volunteers to handle peer- to-peer education on malaria was developed;
• A questionnaire and relevant protocols for assessment of communities acceptance and satisfaction with LSM interventions were developed;
• National template for determining larval density and its protocols and the relevant action plan was revised;
• A checklist for assessment of Environmental Management (EM) interventions was developed;
• A standard protocol for implementation of EM was prepared;
• A protocol for assessment of durability of EM was developed;
• M&E tools and checklists with relevant guidelines were prepared.
Please refer to annex 4 to annex 11 for more details.

 

Recommendations:
During the process, the mat-weaving workers and the cement water reservoirs contractor frequently faced locked doors. |To solve the problem, it was decided to continue the coverage of water reservoirs and in case of confronting such a problem, it had to be reported to the Chabahar Health Centre as it could be solved through local dignitaries, city council and county council.

Further research:

 

• Further research is recommended to extend the CE analysis of the study of intermediate outcomes (larvae density) to health outcomes by modelling.
• More studies on innovative LSM solutions in urban settings is suggested. In Chabahar the required infrastructure and system is in place and this makes further researches more feasible and efficient.

 
Annex 1: Summary report of Sero-prevelance assessment of malaria
Title: Sero-prevalence assessment of malaria in target population in Chabahar City Iran before using non-chemical intervention
Prior to applying a new intervention in the elimination program in a given area, assessing malaria transmission intensity and the prevalence of asymptomatic parasite carriers are highly needed. Serology is applied to detect anti-malarial antibodies, as a unique measurement of past infection and to help delineate temporal and spatial trends in transmission. Also the absence of antibody responses in certain age groups has been used as evidence of the cessation of transmission. Therefore, prevalence of antibodies against malaria parasites has been explored as a means of assessing malaria transmission intensity. In 2011, the Iranian Ministry of Health and the National Malaria Program decided to test non-chemical intervention as a new vector control in addition to the current tools in Chabahar city of Sistan and Baluchestan province as one of the main malaria endemic areas of Iran since 2012. Consequently a population-based seroprevalence study is highly needed in order to determine transmission status in this malaria hypoendemic region prior to using non-chemical intervention. Therefore, the main objective of this study is to provide base line data on the real malaria situation in Chabahar city at the population level prior to non-chemical intervention by using serologic markers.

 

In this study, a total 774 consenting individuals from 32 clusters from Chabahar city provided blood samples for microscopy, PCR and serological testing. In each cluster 24 subjects (6 from each age group) were being selected from both sexes in four different age groups (>5; 5-15; 16-45 and <45 years of old). None of the examined blood subsets collected was positive for P. vivax and/or P. falciparum parasites by using light microscopy and nested-PCR assays. Cloning and sub-cloning of PvMSP-119, PvAMA-1, GST-PfMSP-119 and PfAMA-1 were carried out and all recombinant proteins were used as antigen to test the presence of anti-PvMSP-119, -PvAMA-1, -PfMSP-119 and -PfAMA-1IgG by ELISA. The overall prevalence of antibodies against blood stage antigens were 0.9% (7/774) for anti-PvMSP-119/AMA-1 , and 1.5% for anti-PfMSP-119/AMA-1 in the examined samples. All IgG PvMSP-119-AMA-1 or PfMSP-119/AMA-1-specific antibodies in positive sera had also positive IgG1 and IgG3 subclasses antibodies to all recombinant antigens. In conclusion, the present results showed that the risks of P. falciparum and P. vivax transmission in Chabahar city are very low with evidence of limited recent transmission. It seems that Chabahar city has a biologically feasible for the elimination of P. falciparum very soon. Therefore, based on our preliminary results, transmission of P. falciparum but not P. vivax parasites was stopped in the study area in this malaria hypoendemic region prior to using non-chemical intervention.

 

 

 

Annex 2: Report of Quick pilot study

 

Selection of LSM solutions survey for a pilot study:
To select the most applicable LSM solutions survey and to get a figure of needed resources, 7 methods for covering water reservoirs were selected based on expert opinions and previous experience of local people. These are 1) Straw Mat, 2) Mosaic &cement, 3) Foam & Aluminum, 4) Asbestos sheets, 5) Composite slab, 6) Tarpaulin, 7) Foam.
Two samples of each of the above mentioned covering methods was constructed in the study area and in the end based on Focus Group Discussion with presence of a vast range of experts and representatives from the local staff and by using a score table two interventions were selected for the pilot study including Straw Mat and Mosaic & cement.

 

Annex 3: Records of Malaria Cases by clusters in the survey site (2010-2014)

 

 

 

Annex4: Template for summary report of coverage of water reservoirs with larviciding agent (Bti)

 

Annex 5: A template for reporting larviciding worker performance

 

 

 

Annex 6: Form for final delivering services covered WRs with Mosaic or Straw Mat

 

Annex 7: A template for reporting malaria cases by cluster

 

 

 

Annex8: Mat Quality Assurance Check List

 

 

 

 

 

 

 

Annex9: Entomological Evaluation of Efficacy of LSM Form for Reporting

 

Annex 10: Community acceptance questioner

 

Annex 11: Registration from for monitoring and evaluation summary results by water reservoirs.

 

 

 

 

 

 

Why environmental management was selected?

• Water reservoirs are a common type of larval breeding places in undeveloped areas. It is a common problem not only relevant to malaria but also to other VBDs (Vector Borne Disease);
• LSM is recommended for controlling urban malaria;
• Knowledge gap due to limited number of conducted research on LSM;
• Role of LSM is becoming more prominent in VBD control program compared with Adulticide measures (given insecticide resistance, vector behavior and operational problems);
• Routine larviciding is costly.
• Covering water reservoirs is a positive action towards reduction/prevention of contamination of water with dangerous pathogens.
A microbiological test conducted in 5 randomly selected water reservoirs without coverings. The results indicate that %85 of the water reservoirs were contaminated with different types of coliform bacteria and one of the water reservoirs was contaminated by E.coli, which belongs to coliforms.

Chabahar has a potential to become a big obstacle to achievement of malaria elimination goal and it is the last urban area with local malaria transmission in the country.

 

Goal of the project:
To Demonstrate Cost-effective, Sustainable and Alternative LSM solutions in Urban Setting

Study area:

The project site was in Chabahar suburban area in the south of Sistan and Baluchestan province. Chabahar is one of the major malaria affected areas of the country. Most local malaria cases in Iran occur in Sistan and Baluchistan province in districts close to the borders with Pakistan, particularly in Saravan, Sarbaz and Chabahar districts. Most parts of the province are suffering from the development and economic deprivation as underlying factors for continuing malaria transmission.