ASSESSMENT OF POST DISTRIBUTION OF LLIN AND

CONCURRENT EVALUATION OF IRS OPERATION AMONG THE SAMPLED AREA OF JAGDALPUR, KONDAGAON AND KANKAR

DISTRICT OF BASTAR REGION OF CHHATTISGARH STATE

DATE-16TH TO 19TH AUG 2012

By

Dr R N Sabat, Sr Regional Director,

Dr Sunil Gitte, MD(PSM), Deputy Director (Epid),

Regional Office of Health and Family Welfare and RLTRI,

Govt of India, MoHFW, Raipur, Chhattisgarh state

1

Sr no Particular Page

1 Introduction purpose of visit 2

2 Sampling and methodology 5

3 LLIN post distribution Observations

7

4 Summary and suggestions on LLIN

14

5 Concurrent IRS observations 16

6 Summary and suggestions on IRS 18

2

The major malaria intervention tools now include long-lasting insecticidal nets

(LLIN), Insecticide-treated nets (ITNs) and IRS have each been shown to be highly

effective methods of malaria vector control in their own right. A recent review of the

evidence of cost and consequences of large-scale vector control for malaria concluded

that both ITNS and IRS are highly cost-effective vector control strategies. LLIN have

been the mainstay of vector control in many countries in which the disease is endemic

and where infrastructure limits or precludes the implementation of IRS. Highly effective

LLIN and IRS campaigns that substantially reduce the size of the mosquito population

may reduce vector density further by reducing mosquito emergence. Mosquitoes that

transmit malaria are most active from dusk to dawn.

LLINs, if properly used and maintained, can act as a physical barrier to mosquitoes and

provide protection against malaria. LLINs are treated with an insecticide that is effective

for three to five years or twenty washes. This combination of an insecticide barrier and

a physical barrier (the net itself) makes LLINs much more effective than non-treated

nets. The insecticide has a repellent effect on mosquitoes and most commonly kills them

or has a knock-down effect so that the malaria parasite can no longer be transmitted

even to those not covered by mosquito nets. When used correctly, LLINs have been

shown to reduce malaria cases by approximately 50 per cent, effectively reducing all

causes of child mortality by 20 per cent.

Chhattisgarh is malaria endemic area most of the districts are under

World Bank malaria. The bastar region contributes (5 districts) about 42 % of the total

malaria cases with API ranges 10 to 48 and pf range 87% to 96%. The bastar region

contributed about 67 %( 28/42) of total reported malaria deaths in year

Introduction

3

2011epidemiological data. As per PIP 2011-12 the bastar region were proposed and

supplied LLIN in the selected district. 903040 LLIN have been received in Dec 2011 and

distribution started in 6 districts mainly in all bastar regions. The purpose visit is to

assess the IRS concurrent supervision and post distribution LLIN and put suggestion for

further improvement in the programme implementation.

4

Spray squad Interaction with ASHA during IRS

a) LLIN

1) To assess the Post distribution of LLIN among households

2) To assess the user rate in surveyed villages

3) To assess the pattern of LLIN utilization among the households

4) To assess the distribution pattern through PDS and VHNSC of LLIN

5) To assess the role of the local leaders and health workers and officials during and

after LLIN distribution.

b) IRS

1) To assess the coverage and quality of IRS in the selected villages

2) Assess the role of VHSC and staff during after IRS operations

3) To assess the logestics and PPP of Spraying squad

Objectives

5

The two teams have visited in the Jagdalpur and Kankar district separately and jointly in

the district Kondagon to assess the IRS operation and post distribution of LLIN. The

debriefing of the visit to VBD officer was done by the teams before the day of actual field

visit.

Sampling: The selection of the block and villages were done by simple random

sampling based on microplan IRS schedule and distributed plan of LLIN. Houses were

selected by stratified sampling based upon total number of houses.

Sr No District Block Village Grass route workers interaction/

1 Jagdalpur Tokapal Chhappr-Bhanpuri

ASHA, Health supervisor, IRS squad, Villagers

Lohandiguda Aalnar ASHA, MTS,Health supervisor, IRS squad, Villagers

Sirsaguda- Gotikapara

ASHA, Health supervisor, MTS ,PDS IRS squad, Sarpanch, Villagers

2 Kondagaon Makdi Makdi-Shyampur ASHA, Health supervisor, MTS ,PDS

IRS squad, Villagers Kondagaon Bamni- Nayapara ASHA, Health supervisor, MTS ,PDS

IRS squad, Villagers Kondagaon Banyagaon-

Mararpara ASHA, Health supervisor, MTS ,PDS IRS squad, Villagers

3 Kankar Dhanelikanhar

Satlore ASHA, Health supervisor, MTS ,VHSC, IRS squad, Sarpanch,Villagers

Bagdora ASHA, Health supervisor, MTS ,VHSC, IRS squad, Villagers

IRS: Concurrent visits were made in the villages to check the IRS activities based on the

Micro plan provided by the District. Sampled selected houses of these villages were

thoroughly inspected to check the quality and coverage of spray. However, during the

concurrent visit in the village spraying operations were supervised and community

response towards the spray operations was noted on the spot. The Sarpanch and ASHAs

of the village were also interacted.

Sampling and survey design

6

LLIN: The post distribution of LLIN in the villages were assessed by selecting random

house check and perception regarding the LLIN and usage rate among the households in

selected three districts of the Baster region. The team also visited the PDS and VHSNC in

the selected locality for assess the pattern of distribution and record keeping by them.

The Sarpanch and ASHAs of the village were also interacted. The information were filled

up in the special designed proforma.

Data was retrieval and analysis was done in excel sheet

LLIN DISTRIBUTION in 2011-12 in bastar region as per PIP

Sr.no District No. of

Block

No. of

Sub

Centre

Population

Covered

LLIN

Supplied

LLIN

distributed

1 Kanker 3 69 235264 94106 94100

2 Dantewada 7 150 453303 181321 181300

3 Bijapur 4 70 193254 77301 77300

4 Bastar

including new

district

Kondagaon

9 208 907151 362861 362800

5 Bilaspur 3 77 359308 143723 143700

6 Narayanpur 2 56 108157 43263 43200

7 Extra 465

TOTAL 28 630 2256437 903040 902400

7

Table 1: showing LLIN DISTRIBUTION in the selected district Sl No

District Blocks Total populati

on

Total families

Demand of LLIN as per micro plan

Total no of LLIN received

from State

Total no LLIN

distributed

Starting date of

Distribution

Jagdalpur 367318

240900

1 Jagdalpur

Badekilepal 63056 31528 20958 20957 06/02/2012

Tokapal 80967 42928 33397 33597 16/01/2012

Lohandiguda 86383 43193 32510 32508 10/02/2012

Darbha 86353 43178 38462 34544 17/02/2012

Bastar 158224 79113 70323 68000 13/03/2012

Bakawand 143892 71945 65200 On progress

Nangur 110871 55435 62225 On progress

Kondagaon 132100

111100

2 @Kondagaon

Kondagaon 169284 84640 35000 13200 28/04/2012

Makdi 79628 39815 43951 38900 12/04/2012

Vishrampuri 84578 42288 38723 33000 26/06/2012

Pharasgaon 85602 49640 43302 26000 27/04/2012

Keshkal

Kankar 94106

94100

3 Kankar$$

Dhanelikanhar 85448 17090 34179 34179 10.02.2012

Bhanupratappur 90227 18045 36091 34621 28.02.2012

Durgukondal 59589 11918 23836 25300 14.02.2012

@Note:- 21000 supplied by DMO jagdalpur for kondagaon CHC Kondagaon 21000 + 13200 (supply by DHS) = 34200 $$-Note: - National Institute of Malaria Research, Field Unit, RLTRI Campus, Lalpur Raipur, Chhattisgarh wide letter

No./NIMR/FU/RPR/WHOPES/2011/446 March 27, 2012.With aforementioned reference NIMR have finalized the

following village in Bhanupratappur CHC/Block for the evaluation of Dawaplus 2.0 LLIN, a 3-year study (July 2012 to June

2012) supported by WHO pesticide Evaluation Scheme, Geneva.Villages:: Pharaskot, Shahkatta, Kuwapani, Pevri, Kinari ,

Vikramganj , Junwani

In year 2011-2012, LLIN were supplied from state to Jagdalpur, Kondagaon and Kankar

district to cover the unapproachable and malaria high endemic areas to reduce further

malaria morbidity and mortality. There was gap in the demand and supply of LLIN as

per microplan prepared by Jagdalpur and Kondagaon district. The LLIN supply and

demand was met at Kankar district.

Observations on LLIN survey

8

Table 2: showing the LLIN distribution in the selected blocks and sampled villages

Sr No District Distribution

Through User charges Distribution Priority during

distribution 1 Jagdalpur PDS 5 Targeting Priority to only BPL

2 Kondagaon PDS 10 Targeting Priority to BPL

3 Kankar VHSNC 10 Universal As per norm of NVBDCP , all population tried to cover

All the LLIN in district Jagdalpur and Kondagaon distributed through PDS while in Kankar through VHSNC. In year 2010 in Kankar they were distributed through PDS at remotest blocks. The district Kankar has taken the decision regarding distribution of LLIN through VHSNC. User charges are differing in district Jagdalpur and Kondagaon. Integration and delivery of LLINs through a single system does not achieve the desired coverage targets, and a combination of models is necessary to cover all target population based on the geographical area and its operational difficulties. PDS Vs VHSNC Sr No PDS VHSNC

1 Mechanical distribution in all surveyed

areas less involvement of the local peripheral health workers

Distribution based on the Microplan supervised by the Peripheral health workers

2 Strong network in the all places included remote area of the district

Committee headed by Sarpanch and panchyat member including mitainins and distribution depends on the supply of logestics to particular villages by district/block persons

3 Supply chain was already existed The health department has to take active lead to supply LLIN at village level

4 They have warehouse from district up to village level usually protected by the rodents and other serpentines

The quantity of LLINs was less for village. It can be adjusted in small place in gram panchyat and can be distributed immediately in village. But at Block and PHC level there is usually no proper storage facility

5 During distribution health workers role is passive in the distribution

Active role and responsibility during and after distribution by committee

6 APL and BPL was issue in the distribution and the family have no ration cards are not getting LLIN

The distribution as per NVBDCP norms and spot health educations

7 Coordination was lacking between Health department and local PDS as there is no proper supervision by health officials.

Coordination was well established between VHSNC and health department

9

Table 3: LLIN Physical verification and usage rate Sr No

District Block

Sampled village

Sampled houses

Population User of net

User Rate (%)

1

Jagd

alp

ur

Tokapal

Chhappr-Bhanpuri

10 54 36 66%

Lohandiguda

Aalnar 10 56 25 45%

SirsaGuda- Gotika para

10 47 30 64%

2

Ko

nd

ago

n

Makdi Makdi Shyampur

15 78 35 45%

Kondagaon Bamni- Nayapara

10 51 18 35%

Kondagaon Banyagaon- Mararpara

10 65 26 40%

3

Kan

kar

Dhanelikanhar

Satlore 15 80 53 66%

Bagdora 10 63 34 54%

A total of 157, persons among the 30 house were surveyed in Jagdalpur district. 85 (54.14%) persons out of 157 were users bed nets at night. The users are not aware of the specialty, durability of the LLIN and they think that the net is like ordinary net. The user rate varies from 45-66%. There is need of strong IEC after distribution by the health workers for proper utilization of net to achieve the NVBDCP objectives. Kondagaon is new district caved from Jagdalpur district in year 2011. The programme nodal officer along with MTS is looking the NVBDCP activities. LLIN is distributed through already existing PDS networking in the new district. PDS accountability is totally lacking at Makdi(Kondagaon). The distribution is not proper and records are incomplete. The involvement of the local workers was almost none existing in the selected area of the Kondagaon. The user rate among the surveyed population of the selected area of Kondagaon district was 35% to 40%. There is no IEC after distribution of LLIN in the selected area. The involvement of BMO and staff is not visible in the selected area. Priority to the BPL family. In Kankar district the LLIN distributed through VHNSC and local health workers. The LLIN distributed as per micro plan prepared by DMO. Accountability and recordkeeping during LLIN distribution was maintained properly. The monitoring and supervision is done at all level in the district but the IEC needs to improve at household level. The overall User rate among surveyed household was 54-66% in the selected area of Kankar district. The distribution was done as per NVBDCP guideline and no priority given to APL or BPL which was done at Jagdalpur and Kondagaon district.

Most of children and antenatal and postnatal mother’s utilization the LLIN as compare to elders and old persons in surveyed villages.

10

Table 4: LLIN distribution as per norm Sr No

District Block

Sampled village

Sampled houses

Population No of Net as per norm

No of Distributed By district authority

1

Jagd

alp

ur

Tokapal

Chhappr-Bhanpuri

10 54 22 19

Lohandiguda

Aalnar 10 56 22 16 SirsaGuda- Gotika para

10 47 19 17

2

Ko

nd

ago

n Makdi Makdi

Shyampur 15 78 31 16

Kondagaon Bamni- Nayapara

10 51 20 11

Kondagaon Banyagaon- Mararpara

10 65 26 10

3

Kan

kar

Dhanelikanhar

Satlore 15 80 32 26@ Bagdora 10 63 25 18

@ 3 family yet to get LLIN from VHSC due to non-availability of stock, provide later assured by Committee

In Kondagaon district the LLIN distributed 1 per BPL family while in Jagdalpur the

distribution was 01 LLIN per family in some area where the stock is inadequate and 2

LLIN per family where the stock is adequate as per norm. Based on ration cards number

the LLINs were distributed in Kondagaon and Jagdalpur district.

Households and LLIN coverage:

Households having at least one net before the distribution: 7 %

Households having at least one net the day of the survey: 94%

Among the surveyed houses only 6 houses were already one/more than one ordinary

net in their houses before LLIN distribution.

11

Table 5: Washing of LLIN AMONG SURVEYED POPULATION

Sr No

District Block

Sampled village

No of nets

Washing of LLIN with soap/powder

Outside shade

1

Jagd

alp

ur

Tokapal Chhappr-Bhanpuri

19 3 3

Lohandiguda

Aalnar 16 11 11 SirsaGuda- Gotika para

17 11 11

2

Ko

nd

ago

n Makdi Makdi

Shyampur 16 2 2

Kondagaon Bamni- Nayapara

11 1 1

Kondagaon Banyagaon- Mararpara

10 1 1

3

Kan

kar

Dhanelikanhar

Satlore 26@ 7 7 Bagdora 18 9 9

Households have no knowledge regarding number of washes and hanging after washing

outside or inside shade. Washing behavior of the households towards LLIN needs to

given through continuous IEC activities in the selected areas by health workers should

be done. The washing factors definitely affecting the durability and insecticidal effects

of the LLIN .Effects of IEC are no visible in the sampled villages in the 3 selected

districts. In Jagdalpur district the IEC pamphlets were distributed along with the LLIN

but none of the household read.

HOUSEHOLD Exposed to BCC: Interviewed 90 household in the sampled villages are unaware of the usage of LLIN.

Out of 90 only 2 were exposed to BCC otherwise campaign focused only on distribution

in surveyed area. None of the interviewed member and PRI/Sarpanch knows about the

washing, duration and specialty of the provided LLIN. There is lot of scope for the BCC

at household level in the surveyed district. There is need to develop strategy of BCC in

the LLIN distributed without further delay. Pamphlets were supplied in the Jagdalpur

district along with LLIN but only one interviewed person read the matter.

Involvement of VHSNC: There was involvement of Village level Committee in the LLIN distribution campaign in

the selected area of 3 districts. The active involvement was noted in the area where

LLIN distributed through VHSNC. No knowledge regarding the LLIN for no of washes

and specialty of LLIN in all surveyed districts.

12

BED NET CONDITION

The 90 sampled households had a total of 133 nets during the day of visit/survey. 133

nets (100%) were in very good condition. The condition of the nets which were

distributed was very good in the all of households (100%). The distribution of net in

Kankar district before 4 month back and at Kondagon and Jagdalpur the distribution

activities takes places recently so that the condition is good. The a bit dirty nets were

observed in some families who are sleeping on the mud floor.

The team inspecting the condition of bed net at Kondagaon District

13

HUNG UP PERCENTAGE OF LLINS IN SURVEYED AREA OF BASTAR

The 72 %( 96/133) of the Long Lasting Insecticide treated nets (LLIN) were found hung

during the time of the survey. Only 1 LLINs was missing during the time of the survey as

family gifted other relatives. The reason of hang-up was the high density of mosquito in

rainy season as told by many respondents.

Hang-up of bed net at Sarpanch house of village Saltori (Kankar District)

Hang-up of bed net in one surveyed household

14

There was significant gap in the demand and supply of LLIN in district

Kondagaon and Jagdalpur while in Kankar district supplied as per demand

generated based on microplan.

LLIN distribution in Jagdalpur and Kondagaon through PDS while in Kankar

distributed through VHSNC.

Record keeping is not properly maintained by PDS at Kondagaon and one

surveyed village of Jagdalpur district while record was very good maintained at

Kankar VHSNC and health workers. Based on the ration cards LLIN distributed to

BPL families in mostly Kondagon and Jagdalpur. Team recommended that all

household should be distributed LLIN as per NVBDCP GOI guidelines without

disparity like APL, BPL, cardholders or without cardholders.

The team had a discussion with local village heads and beneficiaries who did not

receive the LLIN .it seem that the distribution was improper because of logestics

challenges. So, it recommends a mop-up session planned where by the deficiency

could be covered.

The user rate of LLIN was (35 to 45%) in the Kondagon district, 45-66% in

Jagdalpur and above 54-66% in Kankar surveyed areas. Priority was given to

children’s and women are sleeping under LLIN in majority of the households in

the surveyed areas.

Post distribution BCC activities were not up-to mark in all selected villages of 3

districts. On spot education were given to the LLIN owners in Kankar district.

Household had no knowledge regarding no of washes, durability and specialty of

the LLIN in all surveyed areas of 3 districts. Nirma, surf excel and local soap were

used in the washing of the nets and dried outside shade in many sampled places.

Conclusions and suggestions on LLIN distribution

15

Hang up percentage LLIN of the surveyed area was 72% and mostly nets are

clean and in good condition.

Only 2 out of 494 person among the net user experienced mild irritation and

burning sensations over exposed parts especially face relived after 2 to 3 days.

Involvement of village level leaders in the distribution of LLIN was noted in the

surveyed sampled areas but part of team in the distribution actively in Kankar

district.

District VBD officers should planned LQAS with the help of VBD consultants in

the bastar region in available resource for assess further improvement in the

programme activities.

16

Table 1 : showing the room coverage of IRS in the survey area of bastar region.

Sr No

District Block Sampled village

Sampled houses

Population Total no of rooms

No of rooms

covered

Coverage (%)

1

Jagd

alp

ur

Tokapal Chhappr-Bhanpuri

24 79 70 33 47%

Lohandiguda Alnar 18 87 109 57 52%

Sirsaguda- Gotika para

23 115 95 64 67%

2

Ko

nd

ago

n Kondagaon Bamni-

Nayapara 20 93 79 48 61%

Banyagaon-Mararpara

26 181 145 101 69%

3

Kan

kar

Dhanelikanhar

Satlore 18 92 146 125 85%

Bagdora 15 73 144 128 88%

In all surveyed district, Synthetic Pyrethroid insecticidal were used in first and

second round.

a) Concurrent supervision: (1 village of each district was taken for concurrent

supervision)

Date of spray, advance notification, scheduling, and spray crew: Advance

notification of spray operation was observed upto grassroots level.

Announcement of the IRS was done in all surveyed villages the spraying

schedule. The community was sensitized regarding IRS and cooperation was

sought to make the first round spray programme successful. The spray squad

team constitutes as per guidelines and tensile wall writing was properly

maintained in many places. Some discrepancies mentioned in the tensile wall

writing were also noted in surveyed places. Sarpanch of the surveyed villages

were aware of the IRS squad in the villages and they put signature after

completion of operation.

Most of the households were not aware of the exact day before

operation. Active involvement of PRI members were not observed in all surveyed

villages.

Observations on Indoor Residual Spray

17

Discharge rates of nozzles, condition of pumps: Discharge rate of nozzles not

measured on day of visit. The condition of stirrup pumps were presently in good

condition and nozzles were replaced of some of spray squad in Jagdalpur district.

Preparation of suspension and supervision for technique, speed, coverage,

safety, etc.

Preparation of suspension in right quantity and proportion by visited spray

teams was observed by the visiting team in selected villages except Sirsaguda

village of Lohandiguda block. Protective equipment’s of spray workers were

inadequate and poor quality and no replenish after damage.

Supervision of the IRS activities by health supervisors were seen in the all

selected villages. There was interaction between Spray team and mitanin

regarding IRS at village level but active involvement was not seen in all surveyed

area.

b) Consecutive supervision: (1 village of each district was taken for

consecutive supervision)

Evidence of spray deposits: Cattle shades were not covered in Kankar

district, while mix dwelling were also covered in all selected village.

Uniformity of spray: uniformity of the spray was seen in all selected

sampled villages while some of the indoor houses patchy spraying.

Coverage: The IRS coverage of rooms in the survey area of the Jagdalpur

ranges from 47 to 67% and at Kondagaon 61 to 69%. Coverage was

highest in the district Kankar i.e 88%. Mainly the kitchen and worship

rooms are not spray in the district Kondagaon and Jagdalpur. While cattle

shed are not sprayed in the district Kankar. The spray operation was done

as per IRS micro plan in all surveyed villages. Most preferred spraying

sites were outdoors rather than indoors. The spray operation started in

the morning and continuous upto evening. Many of the working

household went outside for agriculture or nonagriculture working,

children’s or old age persons were present during spraying and some of

the rooms were locked.

18

Mopping up of operations to spray unsprayed houses: The Mopping

up of operation to spray up sprayed houses was not seen in the surveyed

houses in selected districts.

Strengthening the IEC activities to sensitize the community regarding

Indoor residual spray through involving local panchyat members and

local health leaders.

Intimation slips should be distributed to each household covered under

spray to inform them about actual date of spray with an intention to

improve coverage. Consecutive and concurrent supervision to improve

the present coverage and spot feedback is given

The house numbering system noted in the houses after spraying was not

proper due to which the IRS spray team are getting less wages

Ex: In one big house it was observed that 4 families were staying having 4

ration cards and 4 separate kitchen and entrance but the IRS team instead

of giving 4 numbers mentioned as it is only one house.

All the dwellings, viz. human dwellings, mixed dwellings, cattlesheds,

temporary sheds and other structures should be sprayed.

Conclusions and suggestions of Indoor Residual Spray

19

Bastar, Kondagaon and Kankar

1 Dr Basak, DMO,jadalpur

2 Dr D.K. Ramteke ,DMO,Kankar

3 Mr K.Nagurajw, VBD Consultant, Kankar

4 Mr Anil, I/C AMO, jadalpur

5 G.S Thakur, Malaria Inspector

6 Barish Kumar Shory, Malaria Technical Supervisor

7 R.P.Sharma, MPW, Banyagaon Village

8 J.M Baghel, MPW(F),

9 Rajendra Yadhav, MPW(M),Bagdora PHC

10 B. Kuldeep, Sector supervisor, Bagdora SHC

11 Smt Somavati Darro, Mitanin,Satlora

12 Smt bati Bai, Satlora village

13 PDS staff of Kondagaon and Jagdalpur

14 Smt Jamuna Bhagel ,Sarpanch, Village Sirsaguda, Jadalpur

15 Mr. Sukhram Netam, Sarpanch, village Bagdora, Kankar district.

16 PRI members of Kankar, Kondagaon and Jagdalpur

17 ASHAs of selected villages of Jagdalpur and Kondagaon

18 Spray Squad of selected villages of Kondagaon,Jagdalpur and

Kankar

Interacted staff, PRI members and Others

20

Record kept by PDS at Makdi, Record kept by VHNSC/HW,

Kondagaon District Kankar District

Record kept by PDS at

IRS wall tensil Marking Kankar district IRS wall tensil Marking Jagdalpur

dist.

21