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An Observational Analysis of the Impact of IRS in the Northern and Upper East regions of Ghana: 2015 – 2017 Christelle Gogue1*, Joseph Wagman1, Kenzie Tynuv1, Jason Richardson2, Andrew Saibu3, Keziah Malm4, Yemane Yihdego5, Wahjib Mohammed4, Anthony Ofosu6, Wellbeck Akplu5, Samuel Asiedu7, Erik Fosu-Kwabi7, Lawrence Slutsker1, Molly Robertson1 1PATH, Washington, DC, USA; 2IVCC, Washington, DC, USA; 3Abt Associates, NgenIRS Project, Accra, Ghana; 4National Malaria Control Program , Accra, Ghana; 5Abt Associates, AIRS Project, Accra, Ghana; 6Ghana Health Service, Accra, Ghana; 7AGAMal Ltd, Accra, Ghana; *[email protected] Introduction Approach The prevalence of malaria in Ghana in under 5s has decreased from 27.5% We conducted a set of retrospective, observational time-series analyses on confirmed malaria cases reported in the national District Health Information Management (2011) to 20.4% (2016). The heaviest burden is in the Northern Savanah – System II (DHIMS2) from January 2015 to December 2017. The following data sets were compiled, cleaned and analyzed: Upper West, Upper East and Northern regions. With the goal of reducing the • Monthly reports from all 13 districts in Upper East Region (~3.9M confirmed cases) malaria burden by 75% by 2020, compared to a 2008 baseline, the country has • Monthly reports from 11 old and current PMI IRS districts (of 26 districts total) in Northern Region (~2.8M confirmed cases) implemented a package of malaria control activities, including vector control • District population estimates from the most recent Ghana Statistical Service 2010 Census Report, adjusted for yearly population growth estimates with indoor residual spraying (IRS). Cases were represented by suspected malaria with fevers which tested positive by RDT and/or microscopy. District confirmed-case incidence rates were stratified by district IRS status for comparative analyses. Due to financial and operational considerations, there have been shifts in active ingredients as well as geographic focus, resulting in changes in the IRS status of several districts in the north of Ghana between 2014 and 2017. These Upper East Results: Removal of IRS after 2014 campaign and reintroduction in 2017 changes provided an opportunity to conduct an observational study to better describe the public health impact of IRS with a third-generation IRS (3GIRS*) product. We compared the impact of IRS with non-IRS districts in Northern a 2014 Average Monthly Incidence 2014-2015 – UER Fig 2. Impact of the changing IRS landscape in Upper East Region from 2014 to 2017. (a) In 2014, all districts in UE were sprayed with Actellic® 300CS, while none were 1500 IRS in 2014 sprayed in 2015 or 2016. Monthly incidence of malaria cases recorded from UE in the District Health Information Management System 2 from 2014 to 2016. The 2014 Region and investigated the introduction of IRS into previously unsprayed 1000 500 IRS campaign is indicated with the blue arrow. (b) IRS was reintroduced in 3 districts of UER in 2017, Kassena, Builsa North and Builsa South. districts in Upper East and Northern Regions. 0 JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC 2014 IRS 2015 no-IRS * A 3GIRS product is one that is effective against pyrethroid-resistant mosquitos and has a minimum residual efficacy of six months. ® Average Monthly Incidence 2014-2016 – UER In Upper East, health facility-level analysis of monthly reporting trends from 2014, when Actellic 300CS was 2015 & 1500 sprayed, show a low incidence of confirmed malaria cases from June to November – 6-month post IRS 2016 1000 IRS in 2014 IRS implementation and study location 500 campaign. In 2015, from June to November – there was a 50% increase in cases and double the number of 0 JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC cases in 2016 compared to 2014. IRS operations in Upper East Region were led by the AngloGold Ashanti Malaria 2014 IRS 2015 no-IRS 2016 no IRS Control Programme Limited (AGAMal); in Northern Region, operations were led by Average Monthly Incidence 2016-2017, Kassena, Builsa b North and South With available resources, IRS was reintroduced in three districts (Kassena, Builsa North and Builsa South) in PMI/AIRS. AGAMal began activities in 2006 and the PMI/AIRS program in 2008. 1800 1600 1400 2017. Health facility-level analysis of monthly reporting trends from 2016-2017, in the three IRS districts show a 1200 IRS in 2017 1000 36% reduction (815 fewer cases per 10,000-person months) in the incidence of confirmed malaria cases in June- 800 Fig 1. Ghana IRS Districts in 2017 600 400 August 2017, 3-month post IRS campaign compared to the same period in 2016; against a 16% reduction in non- Table 1. The IRS Implementation Landscape in Upper East and Northern Regions, 2014 – 2017. 200 0 IRS districts (335 fewer cases per 10,000-person months). Jul-16 Jul-17 Jan-16 Jan-17 Jun-16 Jun-17 Oct-16 Apr-16 Apr-17 Feb-16 Sep-16 Feb-17 Dec-16 Aug-16 Aug-17 Nov-16 Mar-17 2017 Mar-16 May-17 Region District 2014 2015 2016 2017 May-16 Builsa p x x p Bolgatanga p x x x Kassena Nankana p x x p Talensi Nabdam p x x x Northern Region Results: IRS vs. Non-IRS incidence and expansion in 2017 UPPER EAST Bawku West p x x x a Bongo p x x x Average Monthly Incidence 2015-2017 - NR Fig 3. Impact of the changing IRS landscape in Northern Region from 2015 to 2017. (a) In 2015 and 2016, the districts shown in green were sprayed with Bawku Municipal p x x x 1000 Actellic® 300CS, while districts in blue received no IRS. In 2017, IRS operations expanded to include 2 additional districts in Northern Region. (b) Monthly Garu Tempane p x x x 900 800 incidence of confirmed malaria cases recorded from Northern in the District Health Information Management System 2 from 2015 to 2017. (c) Monthly Chereponi x x x x 700 incidence of confirmed malaria case in Gushiegu and Karaga, where IRS was introduced in 2017. Saboba x x x x 600 500 IRS IRS IRS Gushiegu x x x p 400 Karaga x x x p 300 In Northern Region of Ghana, district-level analysis of monthly reporting trends from 2015 to 2017 Savelugu Nanton p x x x 200 ® NORTHERN* 100 show that over these 3 years, districts where Actellic 300CS was sprayed had ~4,200 fewer cases Bunkpurugu-Yunyoo p p p p 0 Jul Jul Jul Jan Jan Jan Jun Jun Jun Oct Oct Oct Apr Apr Apr Feb Sep Feb Sep Feb Sep Dec Dec Dec Aug Aug Aug Nov Nov Nov Mar Mar Mar May May East Mamprusi p p p p May per 10,000 person-months at risk than in the districts with no IRS in the 6 months that followed Kumbungu x p p p 2015 2016 2017 No IRS IRS spraying. West Mamprusi p p p p Mamprugu Moaduri p p p b Average Monthly Incidence 2016-2017 - Gushiegu and Karaga districts 500 In 2017, IRS was expanded to 2 additional districts in the eastern part of Northern Region, Gushiegu and Karaga. The P (pirimiphos-methyl), an organo-phosphate 400 IRS in 2017 300 comparison of the confirmed malaria incidence in these districts from 2016 (no IRS) to 2017, shows a very small reduction Upper East Region – In 2014, IRS was implemented in all districts of Upper East 200 in cases 6-months post spray in 2017 (~306 less confirmed malaria cases per 10,000 person-months from June to 100 Region. However, operations were suspended in 2015 and 2016, but reintroduced 0 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec November). The reduction in these two new cannot be attributed to IRS, since malaria incidence varies from year to year. in selected districts in 2017. 2016 2017 Northern Region – In 2015 and 2016, 5 of 26 districts benefitted from IRS. In 2017, Conclusion operations were expanded to 2 additional districts of the region. These preliminary analyses show clear correlations in time and space with the indoor residual spraying of a 3GIRS product and reduced incidence of *Only 11 of 26 districts in the Northern Region are included in this analysis. These 11 districts are in the north-eastern confirmed malaria cases from routine surveillance systems in the north of Ghana, where pyrethroid resistance is widely reported. Additional analyses are part of the region and have been sprayed at some point in earlier years (2008-2014) before the switch to 3GIRS products. underway to further disaggregate epidemiological surveillance data to sub-district levels and align results with entomological surveillance and expanded ecological **One district was split into 2 districts: West Mamprusi became West Mamprusi and Mamprugu Moaduri datasets to allow for more robust conclusions. Project Partners *The NgenIRS (Next Generation IRS) project is a partnership, led by IVCC, that includes the US President’s Malaria Initiative, Abt Associates, and PATH. NgenIRS works in close collaboration with leading insecticide manufacturers, national malaria control programs, the Global Fund, and other stakeholders to save lives and protect health by reducing transmission of malaria through affordable indoor residual spraying of long lasting, non- pyrethroid insecticides. It is funded by UNITAID. For more information please visit http://www.ivcc.com/ngenirs or email David McGuire ([email protected])..
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