this publication is a ministry of health document

This publication is a Ministry of Health document.

Any part of this document may be freely reviewed, quoted, reproduced, and translated in full or in part, provided the source is acknowledged. It may not be sold or used for commercial purposes or profit.

Insecticide Resistance Management Plan – Kenya: 2020–2024

Division of National Malaria Programme Ministry of Health P.O. Box 19982 KNH Nairobi 00202, Kenya Email: [email protected] http://www.nmcp.or.ke

Indoor Residual Spraying (IRS) Implementation Strategy (2020‒2024) i

Foreword

The Ministry of Health has developed a number of strategies and guidelines to consolidate efforts by the government and stakeholders to address the challenges caused by malaria and is hereby pleased to present this Indoor Residual Spraying (IRS) Implementation Strategy (2020-2024), which was developed as an update to the IRS Business Plan 2015-2018. It is intended to contribute towards the overall goal of the new Kenya Malaria Strategy 2019-2023, which is “To reduce malaria incidence and deaths by at least 75 percent of the 2016 levels by 2023” via one of the objectives: “To protect 100 percent of the people living in malaria risk areas through access to appropriate malaria preventive interventions by 2023.” It is also aligned to the overarching Kenya Integrated Vector Control Strategy for malaria that ensures the country has a well-developed capacity and capability at all levels of the two-government system to monitor and respond to the changing eco-epidemiological landscape of malaria. It serves as a guide for the Division of the National Malaria Programme, county health management teams, and other stakeholders to implement IRS in Kenya.

One of the challenges in moving Kenya towards malaria elimination is to use the available resources optimally to have the greatest impact on the disease. More challenges after elimination will be to prevent a malaria resurgence that can have a devastating effect on populations with reduced immunity. It is my hope that this strategy will provide adequate and continuous effective malaria preventive measures for the communities at risk and I look forward to active participation by all stakeholders. In our mission to achieve a malaria-free status, I am confident of continued support by our partners, especially the United States Agency for International Development/President’s Malaria Initiative and the Global Fund to Fight AIDS, Tuberculosis and Malaria for the technical and financial assistance they have provided for the implementation of IRS in Kenya over the last several years. I look forward to other partners joining forces with the Ministry of Health to eliminate malaria to improve the socioeconomic welfare of Kenyans.

Susan N. Mochache, CBS

Principal Secretary Ministry of Health

Indoor Residual Spraying (IRS) Implementation Strategy (2020‒2024) ii

Acknowledgements

The IRS Business Plan (2015-2018) that has guided implementation of indoor residual spraying (IRS) in Kenya was updated and renamed the IRS Implementation Strategy (2020-2024). It will continue to guide the Division of National Malaria Programme (DNMP) and stakeholders on the use of IRS for malaria prevention and control in Kenya. DNMP in partnership with Abt Associates Inc., which implements the United States Agency for International Development’s (USAID’s) President’s Malaria Initiative (PMI) VectorLink Project, conducted extensive consultations with relevant organizations in developing this strategy with inputs from the Vector Control Committee of Experts, as listed in Annex A. For their commitment, I would like to extend my appreciation to all who contributed their comments, inputs, and edits to make this document complete. I would also like to single out the USAID/PMI for its continued financial and technical support for IRS in Kenya since 2008.

On behalf of the Ministry of Health, I call upon all public and private sectors and communities to re-dedicate their support for IRS in order to eliminate malaria and boost socioeconomic advances in Kenya.

Dr Patrick Amoth, EBS

Ag, Director General

Ministry of Health

Indoor Residual Spraying (IRS) Implementation Strategy (2020‒2024) iii

Table of Contents

Foreword ................................................................................................................................ i

Acknowledgements ................................................................................................................ii

Abbreviations ........................................................................................................................ vi

Executive Summary ............................................................................................................. vii

1. Introduction .................................................................................................................... 1

1.1 Global burden of malaria ....................................................................................... 1

1.2 Country profile ....................................................................................................... 1

1.3 Malaria epidemiology in Kenya.............................................................................. 1

1.3.1 Malaria parasites ......................................................................................... 2

1.3.2 Malaria vectors ............................................................................................ 2

1.4 Malaria control progress in Kenya ......................................................................... 3

1.5 Status of insecticide resistance in Kenya .............................................................. 4

1.6 Problem statement ................................................................................................ 5

1.7 Purpose of this document ...................................................................................... 5

1.8 Keeping the document relevant ............................................................................. 6

2. Indoor Residual Spraying in Kenya ................................................................................ 7

2.1 History of IRS in Kenya ......................................................................................... 7

2.2 IRS in the context of integrated vector management ............................................. 8

2.3 IRS integration with ITN deployment ..................................................................... 9

2.4 WHO insecticides recommended for IRS ............................................................ 10

2.5 PCPB insecticides registered for IRS in Kenya ................................................... 11

2.6 Human resources for IRS .................................................................................... 11

2.7 Infrastructure for IRS ........................................................................................... 12

2.8 Support for IRS ................................................................................................... 12

3. IRS Implementation Strategy ....................................................................................... 13

3.1 Goal .................................................................................................................... 13

3.2 Objectives and strategies .................................................................................... 13

3.3. IRS guiding principles ......................................................................................... 13

3.4 IRS program management .................................................................................. 14

3.5. Organization of the IRS program ......................................................................... 14

3.6 Social and behavioral change communication for IRS ......................................... 15

3.7 Collaboration, roles, and responsibilities of stakeholders .................................... 15

3.8 Insecticide resistance management .................................................................... 17

3.9 Capacity building for IRS ..................................................................................... 17

3.10 Resource mobilization ......................................................................................... 17

3.11 Stratification of malaria epidemiology in Kenya ................................................... 18

3.12 Sustainability of IRS in target counties ................................................................ 18

3.13 Moving to a new site ........................................................................................... 20

Indoor Residual Spraying (IRS) Implementation Strategy (2020‒2024) iv

4. IRS Implementation Plan ............................................................................................. 21

4.1 Pre-spray activities .............................................................................................. 21

4.1.1 Micro-planning meetings ........................................................................... 23

4.2 During spray activities ......................................................................................... 25

4.3 Post-spray activities ............................................................................................ 26

4.4 Environmental compliance in IRS ........................................................................ 27

4.5 Social and behaviour change communication ..................................................... 28

4.6 Monitoring and evaluation for IRS ....................................................................... 29

5. IRS Budget .................................................................................................................. 35

5.1 Quantification assumptions with known parameters ............................................ 35

5.2 Quantification assumptions with unknown parameters ........................................ 36

5.3 Estimated budget summary for six new counties in western Kenya ..................... 37

6. Cited References ......................................................................................................... 39

7. Suggested Reading ..................................................................................................... 42

Annexes .............................................................................................................................. 43

Annex A: CoE that Validated the IRS Strategy in October 2019 ................................... 43

Annex B: Example of IRS Timeline for One Spray Round per Year ............................. 44

Annex C: Pre-Spray Inspection Checklist for Environmental Compliance .................... 46

Annex D: Mobilizer Data Collection Form..................................................................... 49

Annex E: Spray Operator Data Collection Form ........................................................... 50

Annex F: Team Leader Data Collection Form .............................................................. 51

Annex G: Example of Spray Team Leader and IRS Supervisor’s Checklist ................. 52

Annex H: Key SBC Messages for IRS ......................................................................... 54

Annex I: List of Equipment and Supplies for IRS .......................................................... 56

Annex J: Example of Capital and Operational Budget for an IRS Program .................. 58

Indoor Residual Spraying (IRS) Implementation Strategy (2020‒2024) v

List of Figures and Tables

Figure 1: Malaria epidemiological zones in Kenya ................................................................ 2 Figure 2: Distribution of major malaria vectors in Kenya ....................................................... 3 Figure 3: Population-adjusted P. falciparum prevalence in children 2-10 years old in 2015 .. 3 Figure 4: Distribution of insecticide resistance in Anopheles tested 1994-2015 .................... 4

Table 1: IRS spray rounds in western Kenya 2008-2019 ...................................................... 7 Table 2: Application of IRS within the framework of IVM ....................................................... 9 Table 3: Pesticides registered for IRS in Kenya .................................................................. 11 Table 4; Personnel trained for IRS in Migori and Homa Bay counties from 2017-2019 ....... 12 Table 5: Roles and responsibilities at different levels of IRS operations in Kenya ............... 14 Table 6: Institutions and their anticipated roles and responsibilities in IRS ......................... 16 Table 7: IRS in phases of malaria control and elimination .................................................. 19 Table 8: Performance indicators in IRS implementation strategy ........................................ 31 Table 9: Risk assessment and mitigation measures in IRS implementation strategy .......... 34 Table 10: Example of parameters for quantification of requirements .................................. 35

Indoor Residual Spraying (IRS) Implementation Strategy (2020‒2024) vi

Abbreviations

API Annual Parasite Incidence

CHV Community Health Volunteer

CoE Committee of Experts

DNMP Division of National Malaria Programme

GR Geographical Reconnaissance

HMIS Health Management Information System

ICT Information Communication Technology

IEC Information Education and Communication

IPTp Intermittent Preventive Treatment in Pregnancy

IRM Insecticide Resistance Management

IRS Indoor Residual Spray

ITN Insecticide-Treated Net

IVM Integrated Vector Management

KAP Knowledge, Attitude and Practices

KEMRI Kenya Medical Research Institute

KMIS Kenya Malaria Indicator Survey

KMS Kenya Malaria Strategy

M&E Monitoring and Evaluation

MOH Ministry of Health

MSDS Material Safety Data Sheet

NEMA National Environmental Management Authority

PBO Piperonyl Butoxide

PCPB Pest Control Products Board

PMI US President’s Malaria Initiative

PPE Personal Protection Equipment

SBC Social and Behavior Change Communication

SEA Supplemental Environmental Assessment

TOT Training of Trainers

UNHCR United Nations High Commissioner for Refugees

USAID United States Agency for International Development

WHO World Health Organization

Indoor Residual Spraying (IRS) Implementation Strategy (2020‒2024) vii

Executive Summary

Despite being preventable and treatable, malaria continues to be a global public health problem. Kenya has its own high disease burden with about 70% of its estimated 47.6 million people at risk, mostly in the Lake and coastal regions of the country. The two malaria vector control interventions used in Kenya, long-lasting insecticidal nets and indoor residual spraying (IRS), have contributed significantly to the disease reduction. The MOH provides free treated nets through mass distribution campaigns targeting universal coverage supplemented with routine distribution to expectant mothers and infants during antenatal consultations and through Expanded Program on Immunization clinics. IRS is being deployed in high malaria endemic areas in western Kenya with the aim of reducing transmission to a low level that can be sustained by insecticide-treated nets (ITNs).

However, this progress has not been without problems. Early in this decade, widespread mosquito vector resistance to the inexpensive and user-friendly pyrethroid insecticides threatened to reverse the fragile gains made. To mitigate this threat, a 2013 policy decision to discontinue the use of pyrethroids in IRS, even though no alternative insecticides were registered for IRS in Kenya resulted in IRS being suspended for four years. IRS resumed in 2017 in Migori County and in 2018 also in Homa Bay County, with a new class of insecticide, organophosphate. The Insecticide Resistance Management Strategy recommends rotation of insecticides for IRS every two years. With two newly marketed SumiShieldR and Fludora fusionR formulations in the class neonicotinoid, the latter has been registered in Kenya and will be used for rotation with pirimiphos methyl in the strategy of insecticide resistance management.

Spraying was previously operated under the IRS Business Plan, which expired in 2018. It has been updated and re-named the IRS Implementation Strategy (2019-2024). This strategy extends beyond the life of Kenya’s core document on malaria, the Kenya Malaria Strategy (KMS) (2019-2023), so that IRS will continue to operate while the KMS is being reviewed and updated.

This updated IRS Implementation Strategy is a product of an extensive desk review and consultations with the DNMP, the President’s Malaria Initiative (PMI) VectorLink Project, the PMI Kenya team, and other key stakeholders and partners involved in malaria control. It is intended to support the KMS’ overall goal to “Reduce malaria incidence and deaths by at least 75 percent of the 2016 levels by 2023” and objective number 1, “To protect 100 percent of the people living in malaria risk areas through access to appropriate malaria preventive interventions by 2023.” In line with this objective, the IRS strategy aims to:

a) Strengthen capacity for IRS operations in Kenya as a contribution to universal access to malaria preventive measures to populations at risk of malaria.

b) Strengthen social and behavioral change communication (SBC) in support of IRS implementation.

c) Strengthen evidence-based decision making for IRS through entomological and epidemiological surveillance, insecticide resistance monitoring, and operations research.

The strategy highlights the strategic direction that should be taken to ensure effective and high-impact IRS interventions in populations at risk of malaria. The DNMP, the target counties, and partners are responsible for overseeing the implementation of this strategy by undertaking the following actions:

Indoor Residual Spraying (IRS) Implementation Strategy (2020‒2024) viii

Action by National Government (DNMP, Kenya Medical Research Institute):

a. Convene partners and county health team meetings to plan for IRS implementation and develop costed annual work plans.

b. Determine IRS target counties based on sound epidemiological and entomological data coupled with insecticide susceptibility status.

c. Strengthen the health management information system (HMIS) to improve reliability of the DHIS-2 platform for evidence-based decision making on IRS target counties.

d. Convene quarterly consultative meetings with the ministries of Agriculture (particularly the Pest Control Products Board) and Environment (particularly the National Environment Management Authority) to share information on regulatory legislative framework on pesticides.

e. Procure insecticide and other IRS commodities at least six months in advance of IRS campaigns.

f. In coordination with regulatory and legislative authorities, ensure proper environmental compliance and safe waste disposal management.

g. In consultation with partners, evaluate insecticide resistance profile and recommend appropriate vector control interventions.

h. In consultation with policymakers and stakeholders, encourage increased domestic financing and support for IRS and diversify the donor base to scale up the budget for malaria-endemic counties.

i. Demonstrate strong commitment at all levels of the IRS implementation strategy.

j. Identify programmatic areas for operational research by partners.

k. In liaison with the DNMP and collaboration with counties, ensure proactive rotation of IRS insecticides every two years.

l. Support establishment of an entomological and insecticide resistance surveillance database.

Action by County Governments (IRS target counties):

a. Recruit and organize training of IRS personnel and assist in the recruitment process where the implementing partners are directly involved.

b. Maintain a database of trained and skilled IRS personnel in the counties.

c. In collaboration with relevant partners on SBC, develop and use the necessary materials and community sensitization and mobilization channels to ensure compliance and support for IRS.

d. Supervise, monitor, and evaluate spray operations.

e. Establish adequate warehousing and storage facilities for insecticides and IRS commodities in target counties.

f. Ensure safety of spray personnel, the public, and the environment in accordance with the existing legislative and regulatory environmental and safety framework.

g. Organize regular community leadership meetings to promote IRS.

Action by Partners: (Development partners)

a. Sustain technical, operational, and financial support for IRS implementation in Kenya.

b. Support recruitment and training of IRS personnel and logistical planning by donor-supported implementing partners in IRS target counties.

c. Facilitate use of mobile technology in enhancing IRS operations.

Indoor Residual Spraying (IRS) Implementation Strategy (2020‒2024) ix

d. Support epidemiological surveillance by strengthening the District Health Information Management System (DHIMS-2).

e. Conduct and strengthen the country’s capacity to conduct entomological and epidemiological surveillance including insecticide resistance intensity monitoring.

f. Support operational research and scientific publications.

g. Support vector control technical meetings and sharing of information.

Indoor Residual Spraying (IRS) Implementation Strategy (2020‒2024) 1

1. Introduction

1.1 Global burden of malaria

Malaria remains a major public health problem particularly in sub-Saharan Africa, which according to the World Malaria Report [1] bears 93% of the global burden of disease, with Nigeria and the Democratic Republic of Congo accounting for 37% of the disease. The Report indicate that an estimated 228 million cases occurred in 2018 compared with 251 million cases and 231 million cases that occurred in 2010 and 2017 respectively. There are a number of challenges faced in malaria control and elimination, including: insecticide resistance, outdoor malaria transmission, residual transmission whereby malaria transmission persists despite good coverage with high-quality malaria control interventions. Compounding factors include: lack of adequate funding, anomalous climate patterns, and uncontrolled land-use change. Although Kenya is not among the top 10+1 highest malaria burden countries (Burkina Faso, Cameroon, Democratic Republic of Congo, Ghana, Mali, Mozambique, Niger, Nigeria, Uganda and Tanzania), it is nonetheless struggling to sustain the gains it has made towards its goal of eliminating malaria. Recent reforms by the Kenyan government have seen positive indications in improvement of the health care delivery system aimed at achieving universal health care and a malaria-free Kenya.

1.2 Country profile

Kenya, located in eastern Africa, lies across the Equator, bordered by Ethiopia to the north; South Sudan to the northwest; Uganda to the west; Somalia to the east; Tanzania to the south; and the Indian Ocean to the southeast. It covers an area of 582,550 km2 with a population density of 87 persons per square km. Eighty percent of the country is arid or semi-arid and 20% is arable. The 2019 national census showed the population in Kenya to be 47.6 million inhabitants with an average household size of 3.9 persons and an annual growth rate of 2.2% [2].

Kenya has two wet seasons: the long rains in March-May and the short rains in October-December. The hottest period is from February to March and the coldest is from July to August. The topography consists of lowland from sea level at the coastal region of the Indian Ocean rising through the savannah plateau to the central highlands and Mt. Kenya at an altitude of 5,197m above sea level. There are areas of high elevation in western Kenya while Lake Victoria lies at an elevation of 1,135m. The Great East African Rift Valley transverses the country from north to south, thus separating western Kenya from the eastern highlands and lowlands. The change in altitude modifies the climate, particularly temperature and rainfall, which influences malaria transmission and epidemiology. About 70% of the entire population is at risk of malaria but prevalence varies from region to region as a result of the diverse climatic and ecological conditions that range from desert to tropical to cold highlands.

1.3 Malaria epidemiology in Kenya

The epidemiology of malaria throughout the country is influenced by altitude, rainfall pattern, and temperature and is broadly classified into five zones with varying malaria prevalence rates [3], namely, western lake endemic areas (27%); coastal endemic areas (8%), western highlands epidemic areas (3%), semi-arid seasonal areas (1%), and low risk malaria areas (<1%) Figure 1.


Figure 1: Malaria epidemiological zones in Kenya

Source: KMPR 2018

1.3.1 Malaria parasites All four Plasmodium species that infect humans are found in Kenya: Plasmodium falciparum, P. malariae, P. ovale, and P. vivax. The Kenya Malaria Indicator Survey (KMIS) [4] data collected between 1980 and 2015 showed that, of all infections detected, P. falciparum, which causes the severe form of malaria, was the predominant species (92%), followed by P. malariae (6%), and P. ovale 1%; the rest were mixed infections [5].

1.3.2 Malaria vectors The major malaria vectors are Anopheles gambiae complex (An. gambiae s.s, An. merus, and An. arabiensis) and An. funestus complex [6]. The distribution of these vector species is influenced by temperature, humidity, and rainfall, which varies from region to region. An. gambiae s.s., An. arabiensis, and An. funestus co-exist in most parts of the country (Figure 2) with An. gambiae s.s. and An. funestus exhibiting more anthropophilic (preference for human blood) and endophilic (feeding and resting indoors) than An. arabiensis, which is considered exophilic and an opportunistic feeder. An. merus, which prefers brackish water habitats, is confined to the Indian Ocean coastline. Other Anopheles mosquitoes, including An. pharoensis, An. nili, An. coustani, and An. moucheti, have been implicated as secondary vectors of malaria in Kenya [7, 8].

Entomological surveys conducted in western Kenya show a re-emergence of An. funestus after a decade of decline [9]. Of the over 6,000 female mosquitoes collected in sentinel sites, the majority (93%) were found to be An. funestus followed by An. arabiensis (7%) with very few An. gambiae s.s. recorded. This resurgence may be attributed to pyrethroid resistance as a result of selection pressure exerted by scaling up of pyrethroid-based insecticide-treated nets (ITNs) and indoor residual spraying (IRS). The recent IRS intervention in Migori and Homa Bay in 2018 using an organophosphate insecticide (pirimiphos-methyl CS) has led to a reduction in the An. funestus population [10]. Impact on vector dynamics has also been observed in most of western and coastal Kenya, where An. arabiensis has replaced An.


gambiae s.s., presumably due to the former’s exophilic behavior, which makes it less likely to be affected by vector interventions targeting indoor resting mosquitos [11, 12].

Figure 2: Distribution of major malaria vectors in Kenya

Source: MOH 2016

1.4 Malaria control progress in Kenya

Kenya has made notable progress in reducing the total confirmed outpatient cases of malaria. The Kenya Health Sector Strategic Plan Report of 2016 [13] showed that malaria accounted for a declining share of outpatient diagnoses: 31% in 2012-2013, 26% in 2013-2014, 20% in 2014-2015, and 18% in 2015-2016. The test positivity rate at the health facilities remained constant, averaging 33% over the review period with monthly data for the period 2016-2018 showing varying rates of endemicity with low-risk areas reporting less than 5% continuously (Figure 3).

The gains in malaria control over the last decade are a result of scaling up of prompt diagnosis and treatment, and preventive measures using intermittent preventive treatment in pregnant women (IPTp), (sulfadoxine/pyrimethamine), vector control interventions (ITNs and IRS), and community education. Unfortunately, the gains are threatened by widespread insecticide resistance to pyrethroid used on nets, outdoor feeding of mosquitoes resulting in outdoor malaria transmission, and insufficient funding to support all counties with appropriate interventions.

The Ministry of Health (MOH) provides free ITNs to target groups through various channels including, mass distribution campaigns every three years, routine distribution to expectant mothers and infants during antenatal consultations and Expanded Program on Immunization clinics, and continuous community net distribution in replacement of torn or lost nets. However,

Figure 3: Population-adjusted P. falciparum prevalence in children 2-10 years old in 2015

Source: Kenya Ministry of Health 2016


according to the most recent KMIS [4], only 63% of all households surveyed owned at least one ITN and, of these, 40% owned at least one ITN for every two people or one net for every sleeping space (universal coverage) by 2015. And although access to ITNs improved with distribution of 37 million nets to people at risk of malaria in the target counties between 2014 and 2018, universal coverage remained low at 48% in 2017 [3]. IRS, which was suspended from 2013 through 2016, resumed in 2017 in Migori County. In 2018, it resumed in Homa Bay and continued in Migori, achieving an average coverage rate of 94% and protecting about 2 million people in the two counties. IRS was reported to have a 97% reduction on densities of indoor resting mosquitoes and to have lowered the sporozoite rate in An. funestus in these counties [3].

Larval source management has not been incorporated as a control program of the Division of National Malaria Programme (DNMP) but a few pilot research-based projects in Mbita (Homa Bay county), Malindi (Kwale), Nyabondo (Kisumu county) and in Kakamega county showed an impact on the mosquito population. However, no studies were done on the impact on malaria incidence. Starting in 2020, the Kenya Government will pilot larval source management in eight endemic Lake counties: Migori, Homa Bay, Siaya, Kisumu, Kakamega, Vihiga, Busia, and Bungoma.

1.5 Status of insecticide resistance in Kenya

Resistance to pyrethroids used on ITNs and previously for IRS is widespread in Kenya [14]. Increasing insecticide resistance in An. funestus and An. arabiensis was reported in 14 entomological monitoring sites in western Kenya in 2017 in the two IRS-targeted counties (Migori and Homa Bay) and in non-IRS sites in Bungoma and Siaya counties. Resistance to pyrethroids (alpha-cypermethrin, permethrin, and deltamethrin) was observed in all sites in An. arabiensis and An. funestus but both species were susceptible to organophosphates (pirimiphos-methyl). Susceptibility to pyrethroids was restored in An. funestus and An. arabiensis mosquitoes collected from Bungoma and Siaya counties after exposing them to the synergist, piperonyl butoxide (PBO) thus indicating metabolic resistance. The distribution of resistance to the four classes of insecticides that have been used for IRS in Kenya as recorded over the years is shown in Figure 4.

Figure 4: Distribution of insecticide resistance in Anopheles tested 1994-2015

Source: Ondeto et al. 2017


1.6 Problem statement

When applied properly and at high coverage of over 85% of the target structures, IRS is a powerful malaria vector control intervention that rapidly reduces vector transmission capacity and malaria incidence, after which the low-level transmission can be controlled by use of effective ITNs and appropriate case management. This IRS Implementation Strategy as well as the overarching Integrated Vector Control Strategy [15], the Insecticide Resistance Management Plan [16], and the Kenya Malaria Strategy [17] are being implemented to ensure sustainability of vector control interventions. The MOH has put in place measures to re-orient and focus on harnessing resources for malaria vector control. However, the MOH faces challenges in vector control interventions such as: i) inadequate human and infrastructure resources at various administrative levels to plan, implement, and supervise IRS operations, ii) inadequate intra- and inter-sectoral collaboration for vector control, iii) development of insecticide resistance to pyrethroids, and iv) insufficient funding for IRS, and consequent overreliance on external support. This strategy will address these challenges through capacity strengthening of planning, implementation, and supervision of IRS in Kenya as part of the broader objective of protecting 100 percent of the population at risk of malaria by 2023.

1.7 Purpose of this document

This IRS Implementation Strategy is a product of the review and update of the IRS Business Plan (2015-2018), extensive desk review, and consultations with DNMP, the U.S. President’s Malaria Initiative (PMI), the PMI VectorLink project, and other key stakeholders involved in malaria control (Annex A). It is intended to contribute to the overall goal of the new KMS 2019-2023 to “Reduce malaria incidence and deaths by at least 75 percent of the 2016 levels by 2023” via the objective “To protect 100 percent of the people living in malaria risk areas through access to appropriate malaria preventive interventions by 2023.” The IRS Implementation Strategy is also aligned with strategies and targets of the Kenya Health Sector Strategic and Investment Plan [13], the Kenya Insecticide Resistance Management Plan [16], the Kenya Integrated Vector Control Strategy [15], the Kenya Malaria Monitoring and Evaluation Plan [18], the Kenya Malaria Communication Strategy [19], the Global Technical Strategy for Malaria [20], the WHO Framework for Malaria Elimination [21], the WHO Operational Manual for IRS [22], the U.S. PMI Technical Guidance [23], the U.S. PMI Best Management Practices for IRS [24], and other local and international guidelines. The document was developed to serve the following purposes:

• For use by the MOH and county health management teams, as well as stakeholders such as prisons, military camps, mining settlements, refugee camps, farm estates, educational institutions, and other parties interested in protecting their communities, under guidance by the MOH.

• To inform policymakers and decision makers on IRS scope, scalability, and commitment by the Kenyan government and partners to eliminate malaria.

• For use by research and training institutions as a reference document in capacity building on malaria vector control.

• For use by the government to solicit and negotiate for in-kind, financial, and technical support for IRS from partners and communities.

It should be noted, however, that the document is a comprehensive tool for implementing IRS in Kenya. Other local and international resource materials by researchers, development partners, and United Nations bodies, some of which appear in the Reference Section, can serve as resource materials for detailed knowledge on IRS and vector control interventions in general.


1.8 Keeping the document relevant

As malaria transmission continues to decline in Kenya, stratification of malaria epidemiology using both parasitological and entomological data will be important for addressing potential disease hotspots and outbreaks. The stratification will show high malaria transmission foci, which will allow for targeted IRS application and hence rational use of resources. In addition, with the threat of insecticide resistance, routine monitoring for effectiveness of IRS will be undertaken. To remain current and relevant, this IRS Implementation Strategy will be updated, particularly on insecticide and target site selection, to reflect the emerging trends in malaria eco-epidemiology and vector control approaches. For instance, new vector control products and paradigms are being researched and brought to market faster than in any other period since the malaria eradication campaign of the 1960s due to the global urgency to eliminate malaria. For this reason, the DNMP will continue to examine new information and adapt or integrate new approaches with the existing tools to rationalize and maximize the impact of these interventions. To determine the impact of this IRS Implementation Strategy on capacity building and devolution of IRS to county and sub-county levels, an external review process will be undertaken at mid-term in 2022 and end of term in 2024 to address the changing malaria landscape.


2. Indoor Residual Spraying in Kenya

2.1 History of IRS in Kenya

With an effective insecticide, IRS remains a proven vector control method for reducing malaria transmission and the most effective method for obtaining a rapid, large-scale impact. IRS is the application of residual insecticides on surfaces of human dwellings where mosquitoes rest before and after biting in order to kill them, normally within 24 hours. It interrupts malaria transmission by reducing the lifespan of the female mosquito before it can feed again and lay eggs. However, IRS is a labor-intensive and expensive undertaking compared with distribution of ITNs and, therefore, its use should be guided by evidence derived from epidemiology of malaria and entomological indices on susceptibility, density, and behavior of mosquitoes; capacity to operationalize IRS; and effective supervision and monitoring and evaluation (M&E) of the program.

The El Niño-related epidemics in the Kenyan highlands and the semi-arid lowlands of northern Kenya that resulted in high mortality triggered the use of IRS in Gucha, Kisii, Nandi, and Uasin Gishu districts in 1999. In 2002, IRS was extended to 16 epidemic-prone districts to prevent epidemics. In 2008, IRS continued in these epidemic-prone districts with spraying in two (Nandi South and Nandi North), taken up by USAID/PMI. For the first time, a malaria-endemic district of Kisumu (Rachuonyo) was also taken up by PMI and included in a survey on comparison of bed nets in combination with blanket IRS coverage. The Kenya Malaria Program Review of 2009 recommended use of IRS in malaria-endemic areas but the then Division of Malaria Control (DOMC) continued focalized IRS in 12 high-risk epidemic-prone districts in the highlands in 2011. From 2008 to 2012, with PMI support IRS was implemented in Nandi, Rachuonyo, Homa Bay, Migori, and Nyando Greater districts (Table 1). No IRS activity was undertaken between 2013 and 2016 due to the transition to a non-pyrethroid insecticide, a policy change informed by the emergence of pyrethroid insecticide resistance throughout much of western Kenya. This change required the registration of alternative insecticides that were not available at the time. In 2014, pirimiphos-methyl, an organophosphate, was registered for IRS.

Table 1: IRS spray rounds in western Kenya 2008-2019

Year

Target county/Greater

district

Sub-county/ District

Insecticide class

No. structures sprayed

% coverage

Population protected

1999 4 epidemic-prone districts

pyrethroids NA NA NA





2008 Nandi North 1 pyrethroids 764,050

96

3,061,967 Nandi South 1 pyrethroids

Rachuonyo 1 pyrethroids

2009 Rachuonyo 1 pyrethroids 764,050

95

3,061,967 Nandi North 1 pyrethroids

Nandi South 1 pyrethroids

2010

Rachuonyo 3 pyrethroids 134,716 99 536,723

Migori 5 pyrethroids 231,994 96 866,515

Kisumu 3 pyrethroids 136,997 97 489,487

2011






Year

Target county/Greater

district

Sub-county/ District

Insecticide class

No. structures sprayed

% coverage

Population protected

2012 Homa Bay 5 pyrethroids 200,099 97 739,817



2013 No IRS conducted

Widespread pyrethroid resistance = As a resistance management strategy, the National Malaria Control Program policy changed to non-pyrethroids insecticides

2014

2015

2016

2017 Migori 6 organophosphates

221,029 98 906,388

2018

Migori 6 organophosphates

217,100 93 906,388

Homa Bay 8 organophosphates

271,223 95 1,166,260

2019


217,100 94 906,388


271,223 92 1,166,260

2020


ongoing ongoing ongoing


ongoing ongoing ongoing

IRS has made an impact on malaria in Kenya. During the period 2005-2012, there was a drastic reduction in the disease burden in the epidemic-prone sub-counties and no major malaria outbreak was reported. Similarly, in high burden malaria sub-counties, IRS significantly altered the disease burden and entomological indices. During the period following the 2012 IRS spray round, malaria test positive rates for patients reporting with fever at health facilities reduced to as low as 15% in the IRS sub-counties compared with 32% in the non-IRS sub-counties. Indoor vector densities were suppressed to below 2 mosquitoes per house in all the sub-counties where IRS was implemented compared with densities of 10 vectors per house in the non-IRS sub-counties (Health Facility Based Malaria Surveillance Bulletin Dec 2013). Introduction of the long-lasting organophosphate pirimiphos-methyl 300CS in 2017 has resulted in further reduction of vector density and sporozoite rates. Data from a baseline survey conducted in 2016, before the resumption of IRS, showed that sporozoite rates ranged from 4.1 to 5.7%; after IRS in 2017, the sporozoite rate in the unsprayed areas was 3.2%, and no sporozoites were detected in the sprayed sites in Migori County. The duration of effectiveness as estimated by wall cone bioassays ranged from 6 to 11 months. IRS has continued in Migori and Homa Bay counties from 2018 to 2020. Discussions are ongoing between the DNMP and partners to scale up IRS to other endemic areas in the Lake region while planning an exit strategy for those counties already receiving IRS.

2.2 IRS in the context of integrated vector management

Kenya adopted an integrated vector management (IVM) approach for malaria control in 2009 [25]. This IRS Implementation Strategy will operate under the auspices of IVM on the basis of sound local evidence on disease eco-epidemiology. WHO defines IVM as “a rational decision making process for the optimal use of resources for vector control.” IVM is the recommended approach that ensures cost-effectiveness and sustainability of vector control [26]. The five key principles of IVM as described by WHO are; i) advocacy, social mobilization, and legislation, ii) integrated approaches, iii) evidence-based decision making, iv) cross-sector collaboration, and v) capacity building. These principles formed the framework for developing this IRS


Implementation Strategy, as adapted from the WHO 2015 Operational Manual for IRS [22] https://apps.who.int/iris/bitstream/handle/10665/177242/9789241508940_eng.pdf?sequence=1 and as described in Table 2.

Table 2: Application of IRS within the framework of IVM

IVM principles Scope Application to IRS Advocacy, social mobilization, and legislation

IRS principles embedded in development policies of all relevant agencies, organizations, and civil society

• Ensure IRS advocacy/communication targets policymakers, implementers, communities, and other stakeholders including donors.

• Ensure up-to-date national insecticide legislation and regulations by the Pest Control Products Board.

Cross-sector collaboration

Functional collaboration within and between public and private sectors Effective channels of communication among policymakers, vector-borne disease control programs, communities, and partners

• Establish a mechanism for consultations, joint planning, and implementation of IRS by stakeholders, with clearly defined roles and responsibilities.

• Establish partnership with the ministries of Agriculture and Environment for supervision, pesticide management, and climate change.

Capacity building Essential physical infrastructure, financial resources, and adequate human resources developed at all levels to plan and manage malaria vectors

• Identify skills, competencies, and staffing levels for effective IRS operations.

• Train and decentralize human resources to county level.

• Mobilize relevant cross-sectoral capacities.

• Establish requisite infrastructure for IRS.

Evidence-based decision making

Strategies and interventions adapted to local ecology, epidemiology, and resources, guided by routine M&E and operational research

• Clarify information needs, indicators, and data collection methods.

• Establish entomological and epidemiological monitoring plans for targeting, and M&E.

• Select insecticide based on local knowledge on vector ecology, susceptibility/resistance.

• Ensure timeliness and completeness of data; manage and use evidence to decide on IRS target sites.

Integrated approach Rational use of available resources, including appropriate integration of ITNs and other vector control approaches

• Ensure residents of the IRS counties continue to use other personal protection methods such as ITNs after each spray round.

• Ensure adequate and evidence-based guidance on combination of IRS with other appropriate interventions.

Adapted from WHO 2015 [22]

2.3 IRS integration with ITN deployment

IRS and ITNs are the major malaria vector control interventions in Kenya. Does scaling up of malaria control by combining ITNs and IRS enhance protection of the population? There is no firm methodology for determining the circumstances under which a combination of the two

https://apps.who.int/iris/bitstream/handle/10665/177242/9789241508940_eng.pdf?sequence=1



interventions (or what levels of combination) will have benefits, or the extent of such benefits. However, there may be incremental benefits such as, i) where ITNs are failing due to extensive holes and pyrethroid resistance, ii) where using a non-pyrethroid IRS with ITNs may restore susceptibility to pyrethroids in the vector or prevent emergence of resistance in the first place, and iii) slowing down the emergence of resistance when a non-pyrethroid insecticide is used in IRS [27].

Results from a literature search and multi-country household survey showed a reduced risk of infection in those protected by both interventions compared with either intervention alone. A prospective cohort study conducted in western Kenya in 2008 comparing parasitemia incidence in Rachuonyo sub-county where only ITNs were used, with Nyando sub-county where IRS in addition to ITNs was used showed convincing evidence of the benefits of combined intervention [28]. However, ITN ownership and use was low and the true level of these findings and the cost-effectiveness of combining these two proven tools in an area of high malaria transmission remains unclear and so should be a pressing research question locally and internationally.

As a general guidance by WHO, deployment of IRS should not be done to compensate for poor coverage of ITNs. However, IRS may be combined with ITNs as part of insecticide resistance management strategy taking into consideration not to use the same chemical in both interventions [29]. Evidence is needed to determine the effectiveness of IRS and ITNs interventions in different eco-epidemiological settings. This of course requires a reliable health management information system combined with reliable vector surveillance system.

Based on the WHO recommendations, therefore, the following will generally guide the joint deployment of IRS and ITNs in Kenya:

• In areas of high endemic transmission in western Kenya to reduce local transmission and disease burden to a level low enough that universal coverage with an effective ITN will sustain the reduced transmission.

• Use of IRS as an insecticide resistance management strategy to preserve the effectiveness of nets.

2.4 WHO insecticides recommended for IRS

WHO promotes judicious use of effective insecticides recommended for IRS by the WHO Prequalification Team of Vector Control Products. For several decades, WHO recommended only four classes of insecticides for use in vector control: pyrethroids, organochlorines, carbamates, and organophosphates. This has largely constrained options for countries such as Kenya that banned the use of DDT and had not registered carbamates for public health use. In response to the threat posed by insecticide resistance, the Innovative Vector Control Consortium has catalyzed the development of nine novel insecticide classes that have demonstrated long-lasting insecticidal activity and are at different stages of evaluation; three of which have demonstrated entomological efficacy (www.IVCC.com). Two new products, which include a neonicotinoid insecticide, are now pre-qualified and recommended for use in IRS programs: SumiShieldR 50WG by Sumitomo Co. Ltd. (active ingredient is clothianidin) and FludoraR Fusion WP by Bayer Co. Ltd. (active ingredient is a mixture of clothianidin and deltamethrin). These two formulations present additional tools and flexibility in managing insecticide resistance. FludoraR Fusion was recently registered by the Pest Control Products Board of Kenya for IRS, Chlorfenapyr 240 SC, a halogenated pyrrole, is another active ingredient that has been incorporated to one LLIN product (Interceptor G2) and is undergoing further trials for use in IRS [30], but the slow-acting chemical requires different testing procedures and has not yet been recommended through the WHO pre-qualification process. Whether this Interceptor G2 product that has the same active ingredient in both ITN and IRS will be suitable for resistance management is yet to be clarified by WHO. As of January 2020, 25 insecticides were listed by the Pre-qualification Team for use in IRS [31].

http://www.ivcc.com/


2.5 PCPB insecticides registered for IRS in Kenya

The use of public health insecticides must be fully regulated to ensure adequate protection of human and environmental health. The Ministry of Agriculture through the PCPB regulates the registration, importation, and use of public health pesticides in Kenya; among these are insecticides for IRS as listed in Table 3. SumiShieldR product which has clothianidin as an active ingredient is currently under review by PCPB.

Table 3: Pesticides registered for IRS in Kenya

Product name Registration No.

Active ingredient Class Registrant/Local Agent

Fludora fusion 56.25 WP

PCPB (CR) 1927

Clothianidin 500g/kg + Deltamethrin 62.5g/kg

Neonicotinoid Bayer, E.A Ltd

Pirimiphos-methyl 300CS

PCPB (CR) 1233

Pirimiphos-methyl 300g/L

Organophosphate Syngenta, E.A. Ltd

Fendona 50WP PCPB (CR) 0747

Alpha-cypermethrin 50g/kg

Pyrethroid BASF, Germany

Fendona 60 SC PCPB (CR) 0166

Alpha-cypermethrin 60g/L

Pyrethroid BASF, Germany

K-Othrine 250WG

PCPB (CR) 0681

Deltamethrin 25% w/w

Pyrethroid Bayer, E.A Ltd

Icon 10 CS PCPB (CR) 0678

Lambdacyhalothrin 100g/L

Pyrethroid Syngenta, E.A Ltd

Mokrid 10 EC PCPB (CR) 0763 p(i)

Alpha-cypermethrin 10g/L

Pyrethroid Rallis Ltd, India

Pali 5% WP PCPB (CR) 0863

Deltamethrin 5% w/w/

Pyrethroid Kapi Ltd

Vectron 20 WP PCPB (CR) 1191

Etofenprox 200g/kg Pyrethroid Sumitomo, Corporation

Pali WDG PCPB (CR) 1022

Deltamethrin 25% w/w

Pyrethroid Kapi Ltd

Culexon 10 WP PCPB (CR) 1239-pi

Lambdacyhalothrin 100g/kg

Pyrethroid Willowood Africa Ltd

Ascon 10 WP PCPB (CR) 1239

Lambdacyhalothrin 100g/kg

Pyrethroid Willwood Africa Ltd

Talstar 10 WP PCPB (CR) 0802

Bifenthrin 10% w/w Pyrethroid FMC Corporation, USA

Source: www.pcpb.go.ke/publichealthproducts.php accessed on 9 March 2020

2.6 Human resources for IRS

The DNMP with technical and financial support from PMI, Global Fund, UNHCR and others have built the capacity of IRS personnel through training at each spray round, which has improved the quality of IRS operations, environmental safety, and coordination and supervision of activities. Since 2017, when IRS resumed in Kenya, various categories of seasonal workers for IRS operations have been trained and re-trained in Homa Bay and Migori counties (Table 4). As more counties are targeted for IRS, more personnel will be recruited and trained by DNMP, donors, the Kenya Medical Research Institute (KEMRI), County Health Teams and other partners to develop skills and competencies that will enable efficient IRS operations. Opportunities for tapping into existing human resource assets within the DNMP, the MOH, and other public agencies such as the ministries of Agriculture and Environment, will be pursued to strengthen skills in entomology, epidemiology, procurement and logistics management, data management, and program M&E.

http://www.pcpb.go.ke/publichealthproducts.php%20accessed%20on%209%20March%202020


Table 4; Personnel trained for IRS in Migori and Homa Bay counties from 2017-2019

Area of training

2017 2018 2019

Total Migori Migori

Homa Bay Migori

Homa Bay

ToT for sprayers 70 286 298 260 399 1313

Spray operators 1031 1306 1084 1471 2735 7627

Data entry clerks 30 33 41 41 56 201

Logistics 59 60 82 60 276 537

IEC mobilizers 795 1117 1619 1267 1715 6513

Public health training 2159 2741 2984 2595 68 10547

Data collection 1986 2339 199 2533 2136 9193

PPE washers 74 1203 74 1264 330 2945

Financial training 3 7 254 84 186 534

Storekeepers 30 60 247 60 276 673

Security 56 56 82 56 259 509

Environmental compliance training

2296 450 245 2931 2527 8449

mHealth 48 289 257 330 441 1365

Total 8637 9947 7466 12622 11404 50,076*

Note: ToT=training of trainers; IEC=information, education and communication; PPE=personal protective equipment *Some of these figures are duplicated since refresher trainings are conducted each spray round for some workers who were previously trained.

2.7 Infrastructure for IRS

With funding from PMI, the DNMP has built infrastructure capacity and improved storage facilities for insecticides and equipment and ensured environmental and human safety in liquid and solid waste disposal. Other donors including Global Fund, WHO, UNHCR and Department for International Development have also been involved in strengthening capacity for IRS. Eighteen entomological monitoring sentinel sites across the country have been strengthened to collect reliable data on vector density, resting behavior, species composition, larval habitats, infection rate, blood feeding index, and insecticide susceptibility. An insectary at KEMRI-Kisumu supports insecticide susceptibility and net durability tests and a full range of entomological evaluations and assists the coordination of assessments of sentinel sites. Warehouses for storage of insecticides, spray pumps, and PPE have been established in every IRS county while soak pits and wash areas have been constructed and refurbished in each operational site during spray operations. The counties have been instrumental in providing for the storage facilities and providing suitable sites within health facility compounds for construction of soak pits and washing slabs. PMI has supported rehabilitation of these facilities to reduce costs and enhance sustainability.

2.8 Support for IRS

The MOH has a number of key partners that support malaria prevention and control. The Kenyan government has supported IRS through in-kind contributions over the years; technical and financial support has been provided by the U.S. government through PMI, and by the Global Fund, Department for International Development, UNHCR and WHO. USAID/PMI is the main funder of IRS, technical and financial assistance to the tune of US$8,214,000 in fiscal year 2019. UNHCR provides technical and financial support in refugee camps such as the Kakuma camp in northern Kenya. The DNMP through its IRS strategy will encourage sharing of resources and expertise to ensure efficiency, compliance with safety, and impact on malaria transmission.


3. IRS Implementation Strategy

3.1 Goal

The main goal of this IRS Implementation Strategy is to strengthen capacity for evidence-based IRS operations in high malaria burden and epidemic-prone counties to protect 100% of the population at risk of malaria in Kenya.

3.2 Objectives and strategies

Objective 1: To strengthen capacity for evidence-based IRS operations in high malaria burden and epidemic-prone counties to protect 100% of the populations at risk of malaria by 2024.

Strategies:

a) Strengthen human and infrastructure capacity to plan, implement, and supervise IRS operations in target counties.

b) Adhere to best management practices in IRS to safeguard human and environmental health.

Objective 2: To strengthen social and behavioral change communication in support of IRS implementation.

Strategies:

a) Mobilize communities and stakeholders to sustain vector control interventions.

b) Promote local and international partnerships towards resource mobilization for IRS.

Objective 3: To strengthen evidence-based decision making for IRS through entomological and epidemiological surveillance, insecticide resistance monitoring, and operational research.

Strategies:

a) Reinforce malaria epidemiology stratification for rationale decision making on determination of IRS target counties and exit strategy.

b) Strengthen routine entomological surveillance including insecticide resistance susceptibility monitoring.

3.3. IRS guiding principles

a) The national and county governments and partners shall provide adequate resources for IRS and insecticide resistance monitoring in targeted counties.

b) The MOH shall recommend to the Ministry of Agriculture new products for IRS for timely registration on the basis of sufficient local and international evidence of efficacy, cost-effectiveness, safety, and conformity with WHO specifications and recommendations.

c) The MOH in collaboration with the Ministry of Agriculture and the National Environmental Management Authority (NEMA) shall ensure that disposal of pesticide wastes and expired insecticides will be conducted in accordance with the requirements of WHO/Food and Agriculture Organization guidelines.

d) The DNMP and counties shall use equipment for IRS application and PPE that conforms to WHO specifications and guidelines.


e) The DNMP shall oversee evidence-based high-quality IRS operations in targeted high malaria burden and epidemic-prone counties.

f) The MOH and counties shall promote social and behavior change communication (SBC) and partnerships between public and private sectors and beneficiary communities in support for IRS.

g) The MOH, Ministry of Interior, and target counties shall provide storage facilities and sites for setting up environmentally compliant facilities.

3.4 IRS program management

Kenya’s recent political reforms arising from the new Constitution in 2010 established a devolved system of government with 47 counties and the national government. This has contributed to greater investment and strengthened accountability and public service delivery at the local level as per the Kenya Health Policy [32]. The health system was also devolved but the DNMP, based at the national level, works closely with counties, PMI, the Global Fund, and other partners to ensure coordination of IRS. IRS requires detailed and well-synchronized planning with well-trained and motivated personnel to execute high-quality and safe spray operations. Capacities at the national and county levels to supervise IRS are well established. The Vector Control Committee of Experts (CoE) established at the national level is responsible for organizing regular formal and informal consultative meetings with key stakeholders to discuss issues on vector control, and provide feedback, strategic orientation, decision making, technical support, and resource mobilization. However, this level of strategic planning, implementation, and supervision is inadequate at the county and sub-county levels. The DNMP will strengthen county capacity for delivering, monitoring, and evaluating IRS interventions. These are vital areas for support given the changing epidemiology of malaria in Kenya, which will increasingly call for responsive malaria control tailored to the sub-county level.

3.5. Organization of the IRS program

The IRS program is planned and implemented by the national and county health management teams down to wards and community levels (Table 5). At each level, skilled personnel are involved in implementation of the program as follows:

Table 5: Roles and responsibilities at different levels of IRS operations in Kenya

Level/Entity Roles and responsibilities

National / DNMP leaders

• Do policy formulation, enforcement, review, quality control/assurance, and resource mobilization.

• Determine the target counties for IRS.

• Oversee implementation of IRS in target counties.

• Identify IRS capacity needs and technical advisory services.

• Provide mentorship and support M&E of IRS program.

• Centralize procurement of insecticides and supplies.

• Ensure multi-sectoral cooperation with other sectors, agencies, and partners.

• Support operations research and collaboration with relevant research institutes and universities.

• IRS planning, formulation of guidelines, and setting standards and policies.

County / County health management teams

• Provide coordination and guidance in IRS implementation activities.

• Produce and implement annual IRS operational plans and reports.

• Identify human resource needs and report them to national level.

• Supervise and monitor the spraying program in sub-counties.

• Manage finances and personnel for IRS.

• Collate and verify county IRS reports for submission to national level.


Level/Entity Roles and responsibilities

Sub-county / Sub-county health management teams

• Conduct weekly supervisory visits of spraying operations.

• Coordinate stakeholders in resource mobilization.

• Ensure proper utilization of resources including transport, insecticide, and logistics.

• Collect, compile, and submit weekly reports to county coordinator.

• Conduct ToTs for IRS supervisors.

• Budget and resources mobilization at the sub-county level.

Community / Community leadership

• Community leaders are in charge of CHVs and assist in recruitment of local spray operators and mobilizers.

• Community health committees facilitate community mobilization and local resource mobilization for IRS.

• Community meetings mobilize beneficiaries to accept their houses to be sprayed.

Field supervisors

• Supervise spray teams consisting spray operators.

• Ensure adequacy of daily insecticides and other commodities to spray teams.

• Collect, compile, and submit daily reports from the team leaders.

Team leaders • Supervise a team of six spray operators.

• Ensure adequacy and accountability of daily insecticides and other commodities.

• Collect, compile, and submit daily reports to supervisor.

• Support health education and social mobilization of communities.

Community mobilizers

• Conduct mobilization of spray operations.

• Provide key messages to households for IRS before, during, and after spraying.

• Promote use of ITNs after the spray round.

Spray operators

• Spray targeted structures.

• Provide information on malaria vector control to the communities.

• Record target structures and size of households sprayed.

• Record insecticide consumption per structure sprayed.

• Adhere to environmental compliance and safety procedures as trained.

Note: CHV=community health volunteer

3.6 Social and behavioral change communication for IRS

Advocacy is necessary to ensure awareness and involvement of communities and those beyond the health sector and partners to secure support for IRS. Kenya has a combination of well-designed and targeted tools and messages on malaria prevention and control that are widely disseminated through multiple channels, including CHVs, focus group discussions, and mass media. The SBC department of the DNMP is responsible for community awareness and mobilization while its CoE plays a key role in reviewing IRS IEC materials and dissemination strategies.

3.7 Collaboration, roles, and responsibilities of stakeholders

Responsibility for malaria prevention should not be the MOH’s alone—non-health activities also contribute directly or indirectly to the proliferation of mosquito populations. For instance, farmers who have opened marshland ecosystems to rice and vegetable cultivation create an ecosystem favorable to the breeding of Anopheles mosquitoes, as have traders in parts of western Kenya who have abandoned their brick-making pits. Use of insecticides for crop protection in agriculture increases the chances of mosquitoes developing resistance. While these development activities improve food security and economic welfare, they also end up expanding malaria transmission—which in turn could have negative repercussions on


socioeconomic development. As such, the interrelationship between, for example, health, veterinary, environment, public works, and agriculture on vector control and pesticide use is important. The MOH, ministries of Agriculture and Environment, and other stakeholders should ensure that the continued vector/pest susceptibility to insecticides is preserved. In particular, there should be collaboration with the Ministry of Agriculture, which is responsible for pesticide use and management. Table 6 shows how the MOH should collaborate with stakeholders and the roles each should play in the IRS implementation strategy.

Table 6: Institutions and their anticipated roles and responsibilities in IRS

Sector/Department Role and responsibilities in IRS implementation strategy

Ministry of Health Policy guidance, enforcement, supervision, M&E,

coordination of multi-sectoral collaboration, advocacy for

malaria elimination

Ministry of Agriculture Ensure judicious use of pesticides in crops and animal

protection, and advocate for integrated pest management

Ministry of Housing Enforce environmental impact assessment compliance in

housing, roads, dams, and other infrastructure construction

Ministry of Environment and

Natural Resources

Enforce climate change mitigation and environmental impact

assessment compliance related to vector borne diseases

Ministry of Education Create awareness on malaria control and prevention

Ministry of Finance Mobilize resources for IRS activities

Ministry of Interior Provide security and storage facilities for IRS commodities

County governments Provide linkage, resources, and buy-in for IRS activities in

target counties

Kenya Bureau of Standards Ensure compliance with national and international standards

and quality of vector control products and tools imported into

the country

Pest Control Products Board

(PCPB)

Ensure timely legislation and registration of public health

pesticides for vector control

Kenya Medical Supply Authority Ensure procurement, storage, and equitable distribution of

vector control products and tools

National Environmental

Management Authority

Enforce environmental impact assessment compliance

related to vector-borne diseases and pesticide safety

Kenya Meteorological Department Provide climate data for forecasting and prediction and early

warning system for malaria

USAID/PMI, Global Fund, UK

Department for International

Development, WHO, etc.

Support technical and financial requirements for IRS and

insecticide resistance management

Private sector and insecticide

manufacturers

Collaborate and support vector control interventions

Tertiary institutions: KEMRI,

International Centre of Insect

Physiology and Ecology, University

of Nairobi, Maseno University, etc.

Conduct operational research and training in vector control

and insecticide resistance monitoring

Local NGOs: farmers

cooperatives, faith-based and civil

societies

Promote community participation in vector control

Targeted communities Collaborate with spray teams for maximum compliance

Electronic, social, and print media Do mass communication and awareness on malaria

interventions, and prevention


3.8 Insecticide resistance management

Rotation of IRS insecticides with different modes of action every two years is currently the best option for resistance management [33]. The Kenya Insecticide Resistance Management Plan [16] recommends that IRS should be conducted with one class of insecticide for two consecutive years before moving to a new class. However, Kenya has only two classes of insecticides (pyrethroids and organophosphates) registered for IRS use since carbamates and DDT are not registered, and this limits the potential for resistance management. However, the newly registered neonicotinoid class of insecticide adds on to the arsenals available for resistance management. Carbamates (bendiocarb and propoxur) have been approved for IRS but PCPB declined to register this class for public health due to potential toxicity to humans. Many African countries have used these chemicals for resistance management, and it is therefore recommended that the DNMP provide sufficient evidence and re-negotiate for their registration in Kenya. Also as a resistance management strategy, the DNMP plans to introduce next-generation LLINs with a synergist-PBO, and any other WHO-recommended vector control intervention.

3.9 Capacity building for IRS

IRS requires detailed and well-synchronized planning with well-trained and motivated personnel to execute high-quality and safe spray operations. The DNMP and donors should work closely with the counties to plan, budget, and implement IRS. Building a critical mass of IRS personnel is essential for long-term vigilance of malaria towards elimination. Decentralized IRS capacities have enabled appropriate decision making at the county level, which is critical in reducing the lag time between early detection of a malaria outbreak and the deployment of interventions. As the country moves towards elimination, it is necessary to ensure that malaria-endemic counties are adequately prepared, as part of epidemic prevention and response strategy.

In this IRS strategy, the DNMP will consolidate a database of the local capacity in each county that has undergone IRS. In the eight Lake region counties that still have a high malaria burden and the epidemic-prone areas in the western highlands, the DNMP will work closely with PMI and other partners to consolidate skills and competencies that can effectively carry out IRS operations. Timeliness and completeness of epidemiologic and entomologic data collection and reporting in the established sentinel sites will enable county health teams to plan, budget, and implement IRS when and where appropriate.

3.10 Resource mobilization

Consistent and responsive donor support has been key to IRS intervention in Kenya with PMI supporting substantial funding for IRS. Lack of a requisite national budget for IRS has led to scale-down of interventions and lack of long-term planning with this intervention. Therefore, retaining the traditional donors (PMI and Global Fund), increasing domestic funding, and attracting new donors should be stepped up if IRS coverage is to be sustained. The Kenyan government should allocate resources on a shared basis, for example, 30% from the government and 70% from donors. This will ensure sustainability in case donors withdraw their support, increased coverage, and self-reliance.

Private sector support also is needed. Malaria is a major threat to private sector profitability because it leads to absenteeism and reduced workforce output, thereby significantly raising the cost of labor. Opportunities will be explored to enhance private sector input and public-private partnerships for IRS and other malaria control activities [34]. Modalities will be established to facilitate and acknowledge private sector ‘corporate social responsibility’ initiatives in malaria control. In particular, mining companies, farm estates, and hotels will be encouraged to work closely with the MOH to adopt vector control interventions, including IRS operations, to cover their staff. It is recommended in this document as a measure to expand on donor base that the DNMP take the initiative to encourage some of these private sectors


to participate in malaria control using the example of Ghana mining industry that contributes to malaria control in that country.

3.11 Stratification of malaria epidemiology in Kenya

Accurate stratification of malaria transmission intensity is essential for effective targeting of interventions. The first malaria risk map of P. falciparum prevalence was developed in 2009; in it, 16 districts around the Lake region were singled out to receive special interventions to significantly reduce their endemicity [35]. The map was updated in 2012 for the first comprehensive malaria epidemiology and control profile [36] and used to stratify counties into levels of malaria endemicity. This began regular updates of malaria risk by the DNMP.

Although health facilities nationwide collect routine malaria data that are fed into the DHIS-2 on a monthly basis, reliable micro-stratification maps are not updated regularly for counties and sub-counties. This is partly because data are incomplete and unreliable. Reasons for this include lack of resources, unavailability of appropriate reporting tools, nationwide health workers strikes in 2016 and 2019, and a system overburdened by data elements and indicators, and demands for disaggregated data that slow its operation [18]. In addition, the DHIS-2 platform rarely receives data from the private health sector. This poses a challenge in selecting sites for IRS and in measuring the impact of the intervention. As Kenya progresses towards elimination, finer-scale mapping is required and stratification done at sub-county and ward levels, so that operational decisions and planning can be done quickly. The stratification maps should be revised and updated frequently, preferably at the end of each malaria transmission season.

As such, the DNMP should ensure that reliable records of annual parasite incidence (API) from routine surveillance are regularly mapped to guide a targeted malaria response. It is recommended that the DNMP and partners should conduct point-parasite prevalence surveys during or just after the peak transmission season or before and after IRS campaigns to obtain reliable data that can be used to measure trends of malaria transmission in sub-counties and IRS impact on health facility malaria cases. This will fine-tune malaria stratification as well as add value to the three yearly Malaria Indicator Surveys. The WHO framework for malaria elimination [21] has classified stratification on the basis of local malaria transmission as follows:

a) High transmission - characterized by annual parasite incidence of about ≥450 cases per 1,000 population and a P. falciparum prevalence rate of ≥ 35%.

b) Moderate transmission - areas with API of 250-450 cases per 1,000 population and P. falciparum rate of 10-35%.

c) Low transmission - areas with API of 100-250 cases per 1,000 and P. falciparum rate of 1-10%.

d) Very low transmission - areas with API of <100 cases per 1,000 population and P. falciparum rate of >0 but <1%.

3.12 Sustainability of IRS in target counties

Without any supporting evidence—the global malaria elimination framework does not recommend a firm IRS exit date [21]. The previous Kenya IRS Business Plan 2015-2018 specified that IRS should be conducted in a county for three consecutive years, and then move to another county. The expectation was that, within this time, IRS will have reduced transmission to a level that does not require this relatively expensive and labor-intensive intervention, and IRS should move to other, equally deserving counties.

However, a variety of factors can affect this three-year target. The decision to withdraw, or not, needs to be informed by an understanding of epidemiological and entomological data, topographical features, land-use changes especially in wetlands, and a sustainable source of IRS support. For example, ecological features within a county could mean that hotspots of


malaria transmission remain and require IRS, even as other areas in the same county are weaned off IRS after three years. Or, IRS may be so effective that it can be withdrawn from an entire county in less than three years. Another important consideration is administrative boundaries of counties earmarked for IRS exit because of the free flow of vectors and people across borders. Premature withdrawal of IRS can result in resurgence of malaria transmission to pre-existing levels, with severe consequences for the community. Financial constraints and political disturbances also can affect IRS scheduling. These are issues with which the DNMP and partners are grappling.

The current framework for malaria elimination [21] does not provide an absolute API or parasite prevalence threshold above which IRS should be implemented and below which it should be halted. The discussion to halt IRS in a particular area and transition to a surveillance-driven program depends on whether IRS is intended to reduce transmission and to what level or if it is meant to eliminate malaria. In Kenya, it might be necessary to optimize the health delivery system and the quality, completeness, and timeliness of epidemiological and entomological data to inform when the transmission and disease burden have drastically reduced rather than to specify a three-year exit plan. In this regard, regularly updated API and P. falciparum prevalence data would greatly assist the DNMP to stratify malaria by sub-counties and wards and determine thresholds for which IRS should be targeted or scaled down. This micro-stratification has not been reliable as discussed in Section 3.11 and therefore, making evidence-based decisions on when to exit remains a challenge. Micro-stratification should be done and mapped by sub-counties and IRS to continue until such a time that the API and prevalence declines to a given cut-off threshold of low transmission with an API of 100-250 cases per 1,000 and P. falciparum rate of 1-10% [21]. Guidelines are given by WHO [22] on API and parasite prevalence that could be used as cut-off for different phases of malaria control and elimination (Table 7). However, due to the 4-6 months advanced planning process required for IRS, the DNMP and partners may have to rely on counties that have persistently high cut-off thresholds for six consecutive prior months to continue or receive IRS.

Table 7: IRS in phases of malaria control and elimination

Phase Activities Transmission IRS operations

Preparatory • Survey (geographical reconnaissance [GR], mapping, epidemiological, entomological)

API >5/1,000 PP> 1%

Pilot IRS operations in selected areas

• Planning, organization, legislation, training, and public education

Attack • Surveillance and repeated surveys with generalized attack operations in all malaria areas

API >5/1,000 PP> 1%

Total coverage IRS of all malaria risk areas for 3–5 years

• Evaluation of operations

• Update GR and mapping

Consolidation • Surveillance for 3 years API <5/1,000 PP <1%

Targeted IRS operations

• Update GR and mapping

Maintenance • Surveillance Sporadic cases Focalized IRS operations

• Update of GR and mapping

Source: WHO 2015

The overall aim of Kenya’s exit strategy is to reduce the malaria burden in a county to the point where the transmission cycle is broken but to leave the county well prepared for a resurgence of malaria due to climate and ecological factors and human movements that favor transmission. However, financial constraints or political disturbances could force an earlier


withdrawal. In preparing a sustainability strategy, the DNMP and counties should recognize that malaria can rebound to pre-IRS levels and therefore must take the following measures:

a) As malaria incidence falls towards elimination, improved entomological and disease surveillance system should be put in place to identify non-receptive and receptive areas (transmission hotspots).

b) Ensure universal coverage and use of ITNs and introduce next-generation nets (PBO, etc.) as a measure of insecticide resistance management.

c) Introduce supplementary vector control interventions such as larval source management in situations where larval habitats are few, fixed, and findable or personal protection with repellents as per the principles of the Integrated Vector Control Strategy.

d) Equip entomological surveillance sites with adequate tools and skilled human resources to inform on vector bionomics. Where possible, train and use community-based entomological surveillance strategies, including vector densities, biting rates, and resting behavior.

e) Strengthen epidemiological surveillance and quality data collection, analysis, and timely reporting into the DHIS-2 platform.

f) Provide clear SBC messaging on malaria awareness and prevention.

g) Strengthen malaria case detection and response system.

h) Closely monitor stocks of artemisinin-based combination therapy and rapid diagnostic test kits.

i) Incorporate malaria vaccines, if and when they become available.

3.13 Moving to a new site

In moving to a new area, the choice of IRS intervention should be based on a thorough understanding of the vector bionomics and eco-epidemiology of malaria. It is also important to conduct GR to gather information on the vector species, density, distribution, resting and feeding behavior, susceptibility to insecticides, and ecological requirements and to monitor longitudinally to follow any changes that might affect the efficacy of the intervention. In view of the limited funding for IRS, the selection of counties/sub-counties to do implementation is informed by technical and programmatic feasibility of maximizing the benefits of IRS through rational use of vector control interventions. Epidemiological data collected routinely in health facilities will be aggregated by wards and used to determine the counties/sub-counties with the highest transmission rates that warrant IRS intervention. The current prevalence trends indicate eight counties in western Kenya comprising 20% of the entire Kenya population are at highest risk of malaria. In 2020, two counties, Homa Bay and Migori are currently receiving IRS. Kisumu, Siaya, Vihiga, Kakamega, Bungoma and Busia would also benefit with IRS if resources were available. In case IRS moves to any of these six counties, community perception/acceptability studies will be conducted using knowledge, attitude and practices (KAP) surveys.


4. IRS Implementation Plan

The IRS Implementation Strategy will be operationalized and managed by the DNMP and counties in collaboration with donors and other relevant public and private sectors and beneficiary communities at the national, county, sub-county, and community levels of the health system. This chapter draws heavily from the WHO and PMI manuals and guidelines for IRS [22:24]. The timeline of IRS implementation from pre-spray, to spraying and post-spray is shown in Annex B. The activities to be implemented are grouped under the three objectives and their respective strategies.

4.1 Pre-spray activities

IRS macro-planning meetings: IRS is a resource-intensive and time-sensitive intervention where timing and synchronization of activities are key to success. Effective planning and implementation are crucial to deliver high-quality spraying and make a positive impact on vector population and malaria transmission. Logistical support and well-trained and motivated personnel are also key to successful IRS. In addition, active and effective collaboration with local leadership and the community ensures high compliance and wider coverage. All these activities must be supported through extensive consultations between the DNMP, the counties, donors, and other stakeholders. The race to the starting line should start at least six months before the onset of the rainy season to: determine target counties; select insecticide; procure equipment, supplies, and vehicles; develop and disseminate SBC messages; and conduct a pre-spray environmental assessment (Annex B). An environmental assessment also need to be done well in advance of the spray operations. The DNMP, donors, and other partners in conjunction with county health committees will develop a spraying plan and budgets to guide the spray operations.

Pre-spray environmental compliance assessment: The DNMP, counties, and the project environmental compliance officer should ensure the operational sites selected meet minimum requirements for liquid waste disposal in soak pits or evaporation tank as well as storage facilities. An assessment should be conducted to determine the siting of washing areas, soak pits that need construction or refurbishment, and suitably located storage facilities. The facilities for insecticide storage should have the following features: i) double locks and a full-time guard, ii) a roof that is well maintained with no leakage, iii) prominently displayed storage signage and warning notices, and iv) insecticide packages shelved in wooden pallets that are raised off the floor, with space between that is big enough for ease of inspection and airflow. The facility should have a trained warehouse manager or storekeeper who should maintain a daily accounting of records of stocks received, held, and issued with appropriate documentation procedures. A pre-spray Environmental Compliance checklist is shown in Annex C.

Determination of IRS target counties: It is important that the DNMP identify the target counties for each spray round and agree with partners on whether the spraying will be blanket or focal. There are two broad strategic approaches to determining IRS sites and each imposes slightly different operational requirements:

Objective 1: To strengthen capacity for IRS operations in Kenya as a contribution towards universal access to malaria preventive measures to the populations at risk.

Strategies:

a) Strengthen human and infrastructure capacity to plan, implement, and supervise IRS operations in target counties

b) Adhere to best management practices in IRS in order to safeguard human and environmental health


• IRS should be deployed with the intention of quickly 'knocking down' transmission to a lower level as well as to depress the overall vector capacity in the area, if possible. This approach should be supported by evidence from epidemiological and entomological data. It is appropriate for western Kenya, where the malaria burden is the highest in the country.

• Use of IRS to prevent unstable transmission that is prone to epidemic outbreaks, as in highlands areas. This approach requires credible epidemic prediction and preparedness capacities. The experiences and lessons learned in scaling up IRS in western Kenya enable the country to consolidate its personnel competencies and skills, infrastructure, institutional arrangements, and policies that are critical to cost-effective IRS in these epidemic-prone areas. It also requires building a credible and reliable HMIS system in conjunction with weather forecasting that gives sufficient lead time to epidemic prediction and prompt response.

The following considerations will also be taken into account when determining the spray counties: ease of physical access, security of spray personnel, and sleeping habits of the target community.

Geographical reconnaissance: Before implementing IRS in a new area, it is important to conduct GR to provide the following information that will assist in developing an IRS operational plan:

• Map of the target area with boundaries and important ecological features.

• Distances and accessibility to the area and available routes within the area.

• Total number of structures to be sprayed, types of structures, average area of sprayable surfaces.

• Total population to be protected and their social factors such as sleeping habits.

The GR information should be obtained from the latest National Census report, and population projections from an annual growth rate or a demographic survey of the target areas. This information should be verified every 2-3 years to guide IRS decisions.

Blanket or focal spraying: The IRS program should aim for 100% coverage of all eligible structures in the target area (entire county) while focal spraying is guided by precise local entomological, epidemiological, and ecological malaria hotspots in a target county (sub-county or ward or village). Blanket spraying will be deployed in endemic counties around the Lake region.

Number of spray rounds: The number of spray rounds per year will be based on local evidence, and which decisions will change over time as the local eco-epidemiology of malaria changes. Issues for consideration will include seasonality of malaria transmission as well as the length of residual effectiveness of the insecticide used. On this basis, it is essential that IRS operations are monitored to assess the residual efficacy to establish the actual field performance on the targeted surface types. Given the length of the rainy seasons in the Lake endemic region, a minimum residual efficacy length of 6-8 months is required. Timing of IRS is also critical to the success of the operation. The optimal timing is just before the wet season begins, to ensure the greatest killing effect of the insecticide coincides with periods of highest malaria transmission risk. When using insecticides with longer residual effect (6-9 months), spraying will be done once a year around January/February, before the long rainy season in March-May. For insecticides with residual duration of less than six months, it is recommended that spraying be done twice a year, 1-2 months before the long rains (March-May) and again before the short rains (October-December).

Selection of insecticide: There are several considerations for selecting an IRS insecticide from among the recommended and registered products, namely: mode of action (for resistance management), cost-effectiveness, safety, residual efficacy period (in relation to the


duration of transmission season), toxicity to untargeted organisms, acceptability by residents, and country registration. The MOH in consultations with the ministries of Agriculture and Environment will be responsible for determining the insecticide to use for each spray round based on vector susceptibility tests and the requirements for insecticide resistance management. The insecticide selected must be recommended by WHO for IRS and duly registered for that purpose in Kenya. There are four classes of insecticides recommended by WHO for IRS: pyrethroids, carbamates, organophosphates, and most recently, a neonicotinoid (clothianidin). DDT, which is in the organochlorine class, and bendiocarb and propoxur in the carbamate class are not permitted for use in Kenya, and so, in practice, only three classes (pyrethroids, organophosphates, and clothianidin) are available. It should be noted, however, that pyrethroids are not recommended for IRS where there is extensive use of ITNs and where there is extensive resistance to pyrethroids that precludes their use in Kenya. New insecticide formulations with longer residual efficacy being developed by manufacturers and recommended by WHO will be fast-tracked by the MOH for registration by PCPB to be availed as alternatives for use in IRS.

Quantification of insecticide, equipment, supplies, and budgeting: Population figures from targeted counties have been used to estimate the number of households and sprayable structures, which in turn determines the quantity of insecticide to use and other logistics of the IRS campaign. In Kenya, the average structure has a sprayable surface area of about 92m2

[37]. Using this information, the total sprayable surface area for the target county can be estimated and used to calculate units of insecticides required, cost per structure, and human resource needs and number of equipment and supplies.

Procurement of insecticide and equipment: The insecticide and other IRS commodities for each spray round will be quantified and procured in accordance with Kenya’s and donor’s procurement laws and regulations. Each year, a commodity gap analysis is conducted to plan on the amounts required vis a vis the available and projected funds by the government and partners. These procurements will be split into international procurement of insecticides, spray pumps, and personal protective equipment (PPE) while local procurement will include transport services, printed materials, stationery, materials for the renovation of operations sites, and food for spray operators’ training and breakfast. International procurements should be done at least six months in advance of the IRS campaign. Once the DNMP and counties have developed their requirements, the MOH submits the procurement plan to the Kenya Medical Supplies Authority and the required commodities are procured through open tenders from local and internationally recognized/ certified manufacturers and/ or their certified and authorized local agents while adhering to the Kenyan government and partner’s laws and regulations. The successful bidder is awarded the tender after technical and financial evaluation of the products.

4.1.1 Micro-planning meetings Detailed planning meetings between the implementing partners, county health management teams, and local leadership are held at the county level to discuss and reach agreement on the following issues:

• Criteria for selection and recruitment of spray operators and mobilizers

• IEC/community mobilization plan for IRS and mobilization strategy

• Involvement of community leaders

• Identification of operations sites and storage space for IRS materials at the operations sites

• Role of county/sub-county in the provision of IRS operational site offices and stores

• Role of local leaders in supervision of IRS activities during the IRS operations

• IRS operation walk to work strategy


• Mobile money payment system

• Field simulation trainings of spray operators

• Participation at weekly meetings at the sub-county level.

Insecticide transportation: Shipping the insecticide from the port of entry to the central warehouse, and then to the counties and operations sites, must be done in accordance with Best Management Practices in IRS [24] and NEMA regulations. The following should be taken into account when transporting insecticides: i) insecticide loading and containment, ii) insecticide transport route planning, iii) selection of vehicle to be used, iv) driver’s training and appropriate response in case of an accident and spillage.

Recruitment of spray teams: The required numbers of spray personnel (spray operators, community mobilizers, data clerks, storekeepers, washers) will be recruited from local communities where IRS is targeted to cut down on transportation costs. The DNMP will collaborate closely with counties and community leadership, as well as with other relevant social/community governance structures, to recruit IRS seasonal workers. Area chiefs, sub-county health management teams, and CHVs will be responsible for recruitment but guided by selection criteria agreed upon during micro-planning. A spray operator is preferably a CHV, resident of the IRS site, age 18-40 years, physically fit, and able to read and write; a gender balanced team is ideal. Spray operators should undergo pre- and post-spray medical examination in line with the requirements of the insecticide to be used for IRS. All female spray operators will undergo a pregnancy test before and every 30 days for the duration of the spray operations and, if they are found to be pregnant, they will be assigned roles such as mobilization, where they will not come into contact with insecticide.

Training: Before each round of IRS, TOT and re-fresher trainings will be conducted for seasonal workers: spray operators, mobilizers, team leaders and washers. The training will take place at least 1-2 weeks before spraying begins. Cascade training will be carried out, starting with the TOT, at national, county, and sub-county levels, followed by training of spray operators and mobilizers at the community level. All spray operators will be trained for a period of not less than five days using the Standard Curriculum on IRS for Malaria Control [38] with focus on the following key areas:

• Introduction to malaria control

• IRS planning and logistics management

• Definition of an eligible spray structure

• Spray techniques and processes

• Environmental compliance and personal safety

• Advocacy and community mobilization

• M&E data collection and reporting (using the Performance Monitoring Tracker)

• Supervision of IRS activities (mHealth)

• IRS walk to work strategy

• Insecticide application techniques, training wall, and pump maintenance

• Incident reporting

Training of supervisors and team leaders will be conducted as TOT and refresher training on the use, operation, maintenance, calibration, and repair of the sprayer pump and supportive supervision. The spray operators will be trained on maintenance and handling of spray pumps and proper use of PPE. Selected health facilities will be equipped to serve as operations sites


in the counties as well as reference points on insecticide poisoning. Health workers at these facilities will receive training on the management of insecticide poisoning.

In addition, capacity to conduct routine entomological and epidemiological surveys will be strengthened through training and provision of basic equipment and supplies to counties through KEMRI.

IEC campaign: For the spray program to be successful, the community will be informed in advance of the procedures and benefits of the program. CHVs and IRS mobilizers will explain to the community the benefits, the mode of action of the insecticide, and the duration of effectiveness in killing mosquitoes on the sprayed surfaces. They will also be informed that the insecticide is not hazardous to humans or their animals provided precautions outlined by the mobilizers and spray operators are followed. The community receiving IRS will also be urged to continue using ITNs for malaria prevention. Different channels of communication, including interpersonal communication, mass media, radio talk shows, banners, brochures, and posters, will be used to disseminate spray campaign information on malaria prevention.

4.2 During spray activities

Launch of IRS: For effective implementation of IRS, the spray operation should be completed before the onset of the rains in March for a single round and before October for the second round, if applicable. A day or two before the start of IRS, the operation should be launched officially by the local leadership and invited prominent personalities, with fanfares, parades, and other entertainment to raise awareness among targeted communities. M&E should start immediately after the launch and be conducted at various times during the campaign to ensure its effectiveness and efficiency, identify strengths and weaknesses, and help make the necessary adjustments or modifications in the plan. Process indicators must be monitored, such as insecticide dispatch and return, spray quality, cleaning of equipment, and proper wearing of PPE.

Community mobilization for IRS: The success of an IRS campaign depends largely on community compliance. Door-to-door advocacy and community mobilization activities should be implemented to raise community awareness on the importance of IRS as a malaria intervention strategy (Annex D). This encourages commitment and strong participation of the community to support IRS in the long term. The purpose of community mobilization is to achieve 100% of the targeted structures with IRS. The spray operator should ensure that all households mobilized are sprayed effectively and data collected on assigned forms for daily performance tracking (Annex E).

Supervision of spray teams and spray operations: The aim of supervision is to ensure high quality IRS and high coverage of insecticide spray in terms of time and space with minimum hazardous effects to humans and the environment. Supervisors should regularly visit households being sprayed and conduct supervision using standard forms or e-applications and checklists to ensure uniformity, accuracy, completeness, and timeliness of reporting. Team leaders and supervisors should ensure that each structure is adequately prepared for spraying, that spray operators wear PPE properly and adhere to the IRS handbook, and that effective supervision and monitoring of the spray teams is conducted (Annex F). As the IRS operation is implemented, the DNMP and county supervisors must ensure high-quality spray operations, structure coverage, insecticide and other commodity use, and strict adherence to environmental compliance and best management practices. Daily submissions of key operations data should be sent to supervisors through a Performance Monitoring Tracker and meetings held to discuss challenges and how to mitigate them. An example of a supervision checklist as illustrated in WHO Manual for IRS [22] is shown in Annex G.

Mid-spray environmental compliance safety monitoring: In accordance with the WHO health and safety regulations, all persons working in IRS must be adequately protected against potential harm due to exposure from insecticides and it is therefore mandatory for them to


wear appropriate PPE/clothing as per the safety instructions on the product label or material safety data sheet (MSDS). Specific PPE consisting of a helmet, face shield, face masks/ visors, long-sleeve overall, rubber or neoprene gloves, and gumboots [22] should be worn by spray operators and washers. All PPE including gumboots should be washed and changed daily. Household members will be given adequate safety advice before and after insecticide application in their houses for their personal safety as per the PMI BMPs [24] and safety aspects highlighted in Annex H.

Effluent waste disposal during spray activities: Consideration of locations for wash areas, progressive rinsing, soak pits, and evaporation tanks will depend on topography, soil type, ground water, and proximity to rivers, lakes, and sensitive areas such as schools. It is ideal to choose sites close to storage facilities where the sites can be easily be protected and monitored.

Monitoring and reporting of IRS: With a dedicated database, all data will be entered on a daily basis during the campaign by a team of trained data entry clerks and M&E assistants. IRS-specific data collection tools will be used by trained field personnel to gather the information for the database.

4.3 Post-spray activities

Decommissioning of operation sites: After the IRS round, a clean-up exercise should be conducted to collect and dispose of all solid wastes accumulated during the spray round in accordance with international standards to avoid environmental contamination. Soak pits should be covered to prevent access to contaminated material by humans, and birds, bees, and other animals. The used insecticide bottles are to be punched to prevent re-use and are recycled. Boxes, insecticide sachets, and used PPE are incinerated. The storekeeper is responsible for maintaining an accurate record of all IRS wastes using the forms provided for stock management. An inventory of all equipment, insecticide, and PPE will be categorized and entered into a computer spreadsheet. Broken pumps should be repaired before storage.

Post-spray environmental compliance audit: Periodic audits to monitor compliance shall be conducted to ensure that IRS operations adhere to NEMA regulations and requirements at all times. Reconciliation of the insecticide used and remaining, as well as assessment of damaged PPE will be done before storage. Soak pits and wash areas must be covered and solid waste accounted for and weighed before disposal. Adequate and safe storage facilities shall be provided to ensure careful management of IRS commodities and minimize pilferage.

Stakeholders’ evaluation meetings: A stakeholders’ meeting should be held soon after the spray round to assess its achievements and shortcomings, community compliance, lessons learned, and to give feedback to the DNMP and county health management teams and donors. The proportion of structures in targeted counties protected by IRS, the population protected in those structures, the number of people trained in IRS, and the amount of insecticide used will be recorded. An end of spray report will be written and submitted to the DNMP and donors.

Assessing quality of spraying and residual efficacy: The DNMP jointly with partners and research institutions will assess quality of spraying, which will be conducted in randomly selected structures within two weeks after the spray round using standard WHO cone bioassays. In addition, the rate of decay of the insecticides on sprayed wall surfaces will be conducted using cone bioassays monthly thereafter until the effectiveness of the insecticide reaches ≤80% mortality for two consecutive months [39]. The An. gambiae s.s. Kisumu or other susceptible strain should be used.

Evaluating IRS operational performance: The program’s operational performance will emphasize accuracy of data entry and validation processes, streamline and standardize data flow, minimize errors and facilitate timely reporting, ensure IRS data security and storage, and document lessons learned and good practices observed. Quantitative data will be measured


by calculating the proportion of sprayed structures and population protected (disaggregated as male, female, pregnant women, children under 5 years) against the targets. A post-spray data quality assessment will be done by an external consultant appointed by the Vector Control CoE to determine the overall performance and impact of the spray round. Annual review and joint planning meetings of all participating counties and sub-counties and all other stakeholders will be held to share lessons learned and plan for future spray rounds.

4.4 Environmental compliance in IRS

WHO and PMI have developed policies and guidelines for judicious use of pesticides and safeguards that help ensure human and environmental health [22; 24]. Community and spray personnel awareness on these safety measures and mitigation measures is paramount to an effective and efficient spray round.

Environmental assessment: A pre-spray season environmental assessment should be conducted to assess the operations sites, soak pits, storage facilities, and those that require refurbishments or new construction. A post-season environmental assessment should also be conducted to make sure all operational sites have been decommissioned and all supplies/equipment entered into the inventory and returned to the warehouse/store and disposal of wastes conducted in accordance with the Best Management Practices Manual and NEMA requirements. Disposal certifications should be obtained. The IRS manager through the project’s environmental compliance officer should ensure that all mitigation measures stipulated in the Environmental Mitigation and Monitoring Plan for the operational sites, such as adequate warehouse, storage, soak pits, and wash areas are compliant with Best Management Practices.

Safety of household residents: Prior to the spray operation, household members will be advised to remove from the house all movable items and cover unmovable ones, and stay out of the house for at least two hours after spraying. They also will be advised what to do post-spraying: two and a half hours after spraying, the windows and doors should be opened to air out the structure, after which the floor should be swept. The resident should be advised to report any sign of adverse health effect to the spray team leader or the nearest health facility.

Environmental safety: Washers should use a progressive rinse process when cleaning pumps and re-use the wastewater the following day to mix insecticide. The wastewater from cleaning the PPE and outside of the spray pumps is disposed of in soak pits or evaporation tanks. Trucks designed to prevent widespread spillage in case of an accident are recommended to transport insecticides. Drivers of these vehicles should be trained on the three “C’s—control, contain, and clean—for handling insecticides and spill responses. Transportation of insecticide across lakes and rivers should be carefully planned and the condition of the boat, boat speed, and route should be taken into account before using water transport.

Solid wastes disposal: Solid wastes including packaging materials, empty containers/sachets/bottles, used masks, worn-out PPE (e.g. gloves and overalls), damaged IRS materials (e.g., buckets and basins), and expired insecticides shall be disposed in an environmentally sound manner in an incinerator that meets international standards to avoid environmental contamination. PMI is currently using a NEMA-certified recycling plant at VINTZ Plastics Ltd, Nairobi, for empty insecticide bottles that are recycled into plastic sheets for construction. Other less bulky wastes and empty boxes are incinerated at Kamongi Waste Paper Ltd, the Environmental & Combustion Consultants Ltd, and at KEMRI.

Proper insecticide and commodities storage, tracking, and inventory: Strict management of storage facilities is essential to ensure adequate and safe storage of insecticides and IRS equipment and to minimize pilferage. Warehousing capacity will be established in the counties for the IRS supplies and equipment to facilitate logistics management. Pesticide storage and


inventory practices will be established. These facilities will be fenced off and located away from riverine areas, schools, water wells, and animal sheds.

Quality assurance of insecticide and commodities: Quality assurance testing of insecticides should be conducted when importing the insecticide to ensure that the batches of insecticides and other commodities conform to the required specifications available in http://www.who.int/whopes/quality/en/.

Insecticide poisoning and first-aid measures: Failure to correctly use PPE during spraying may result in undesired exposure to insecticide or to poisoning which also depend on the active ingredient of the chemical used. The common signs and symptoms of insecticide poisoning are skin and eye irritation; digestive, nervous, and respiratory system problems; and general weakness. Local health facilities will be provided with training on these side effects and how to manage poisoning with the recommended antidotes. All the storage facilities and vehicles used for IRS should be equipped with the MSDS for the insecticide being used.

4.5 Social and behaviour change communication

Community engagement in vector control: The success of IRS relies heavily on SBC to enhance commitment, support, and buy-in from target communities and other stakeholders. Lessons learned from the current IRS operations will be used to inform the advocacy and communication efforts linked to the scale-up of IRS implementation. The key indicators of SBC will be aligned with; i) attitude of the community towards IRS, ii) community acceptance or reasons for not accepting the spraying, and iii) reasons for locked rooms or re-plastering the sprayed rooms. Gathering this information through a KAP survey can help guide the development of educational messages to improve program performance.

In consultation with the DNMP, a variety of SBC messaging using multidisciplinary channels will be used to enhance coverage and compliance by:

• Promoting acceptance and appropriate use of vector control tools.

• Empowering communities to strengthen self-monitoring and decision making about malaria.

• Encouraging appropriate health-seeking behavior.

• Advocacy for community and local political support for IRS.

• Sensitization and education through print and mass media and public events.

• Social mobilization through the use of local community networks (e.g., youth groups, women groups, community health volunteer networks, faith-based organizations, school children) and use of local leaders to galvanize household support for IRS.

• Other activities (e.g., school health education, branded communication platform) to increase visibility of IRS campaign activities with guidance of the SBC CoE.

The CHVs, community mobilizers, and spray operators will explain to the community the procedures and benefits of the program by addressing the following key messages before, during, and after spraying (Annex H).

Objective 2: To strengthen SBC in support of IRS implementation.

Strategies:

a) Mobilize communities to sustain vector control interventions

b) Promote local and international partnerships for IRS resource mobilization

http://www.who.int/whopes/quality/en/


Stakeholders’ sensitization for IRS: The MOH through the DNMP will provide leadership for, and coordinate advocacy and communication on IRS by targeting the following groups:

• Policy and decision makers in the public sector: Solicit support for IRS recurrent annual budget allocation. Communication will be well tailored and will cover the benefits of IRS in malaria control and present proposals for funding requirements.

• Donors, stakeholders, and private sector and developmental partners: Communicate the need to support the national strategy and goals for malaria control and the role of IRS toward achieving the goals.

• Communities and general public: Conducted through various public news media, public forums with communities, as well as visits of trained CHVs to individual households. The goal will be to promote buy-in from the targeted community and maximize participation and acceptance rate.

• Private sector: It is important to note that advocacy for buy-in by other public sectors and development partners will largely depend on the government’s efforts to demonstrate strong commitment to eliminate malaria in Kenya. Demonstration of best practices in IRS and success stories that showcase the achievements and impact of IRS program on malaria morbidity will encourage the buy-in of potential donors because partners like to be associated with successful programs. The government must also demonstrate transparency and accountability in resource mobilization and expenditure for malaria control. Other incentives for stakeholders to buy in are Malaria-free Kenya, a healthier workforce leading to higher productivity of the institutions, and alleviation of poverty, a United Nations Sustainable Development Goal.

4.6 Monitoring and evaluation for IRS

Assessing the impact of IRS intervention will largely be determined through entomological and epidemiological surveillance indicators and linking these datasets to make informed decisions. Details of parameters and frequency of M&E is described in other documents as highlighted below:

Epidemiological surveillance: Since 2010, PMI and Global Fund have provided support to strengthen routine malaria-specific reporting on the DHIS-2 that is linked from national to county and sub-county health facility levels. This platform is meant to ensure that malaria indicators are reported on a monthly basis to monitor health facilities’ disease epidemiology. It is therefore critical that the DNMP streamline routine collection of epidemiological indicators (parasite prevalence, parasite incidence, and anemia) to ensure consistency, completeness, and accuracy in reporting. The HMIS is currently being strengthened with support from partners, to fine-tune decisions on target sites and impact of interventions.

Entomological monitoring: Entomological monitoring will be conducted in established sentinel sites to assess the indicators on malaria vector density, vector species, vector resting,

Objective 3: To strengthen evidence-based decision-making for IRS through entomological and epidemiological surveillance, insecticide resistance monitoring, and operational research.

Strategies:

a) Reinforce malaria epidemiology stratification for determination of IRS target counties and exit strategy

b) Strengthen entomological surveillance including insecticide resistance susceptibility monitoring


sporozoite rates, human-vector contact, blood meal index, and entomological inoculation rate. The DNMP has developed a Malaria Vector Surveillance Operational Guideline that will guide entomological monitoring.

Insecticide susceptibility testing: Insecticide susceptibility tests will be conducted in sentinel sites once a year using WHO tube tests with insecticide impregnated papers [39 and the CDC Bottle bioassay [40]. More sentinel sites should be established for nationwide coverage and representation of varying transmission levels. Resistance to an insecticide will first be suspected when the mortality of the mosquitoes tested in bioassays falls below 98%. Mortality below 90% confirms phenotypic resistance. If phenotypic resistance is confirmed, an alternative insecticide is indicated for use in IRS. Furthermore, analysis of metabolic mechanisms of resistance will be conducted in the laboratory. This will provide an understanding of the intensity and mechanism of resistance and guide the selection of an insecticide with a different mode of action in management of resistance.

As an insecticide resistance management strategy, the program should not wait for resistance to be detected but rather, should proactively rotate insecticides with different modes of action every two years. As such, the recommended rotation plan of insecticides during the period of this strategy is to continue with pirimiphos-methyl in 2020 for the fourth year running and then switch to clothianidin in 2021 and 2022, and then back to pirimiphos-methyl in 2023 and 2024 and again to clothianidin in 2025. Other products coming to market and pre-qualified by WHO will be evaluated locally in field experiments and registered after all criteria indicated in Section 4.1 are met. The Insecticide Resistance Management Plan [16] guides insecticides use and management for malaria control in Kenya.

Mapping of insecticide resistance profile: The insecticide resistance profile map in Kenya needs to be updated. It is important for the DNMP to have vector distribution maps indicating levels of insecticide resistance and overlaid with risk factors such as changes in land use and pesticide use to guide interventions. A national database on routine vector and insecticide resistance surveillance data should be established through the DNMP in collaboration with partners. This information should be archived under the auspices of the DNMP and shared through unrestricted online access to stakeholders and WHO regional office database as reference and publications.

M&E tools and procedures: The capacity to effectively manage the expectation of policymakers and the public is critical. The DNMP manager needs up-to-date information on mosquito populations and malaria prevalence to ensure that each IRS spray cycle is appropriate and cost-effective. Timely flow of and sharing of data on mosquito species, infection status, and resistance to insecticides are some of the vital elements in planning a successful IRS campaign. Sharing of this information between the central and county level is critical to ensuring a sound basis of IRS planning and implementation. Timely information also enables correct assessment of entomological and epidemiological impact of IRS and quick resolution of potential setbacks in delivery of the intervention, as well as challenges posed by changes in the disease eco-epidemiology.

Reporting indicators and procedures: The DNMP, PMI, and other partners will facilitate scale-up of supervisory information flow in IRS by rolling out the mobile App (mHealth) for supervisors that will enhance program M&E. This App has five checklists, i) morning mobilization; ii) homeowner preparations; iii) storekeeper performance; iv) end-of-day clean-up, and v) data collection verification.

The DNMP and the Vector Control CoE will continuously assess the progress in implementation of the IRS strategy. Table 8 shows the performance indicators that will be measured by DNMP during implementation of the strategy.


Table 8: Performance indicators in IRS implementation strategy

Objective Strategy Impact/performance indicator

Data source

Responsible

Objective 1

To strengthen capacity for IRS operations as a contribution to universal access to malaria preventive measures to the populations at risk.

1. Strengthen human and infrastructure capacity to plan, implement, and supervise IRS operations in target counties 2. Adhere to best management practices in IRS to safeguard human and environmental health

Input Amount of funds available for IRS implementation strategy Amount of insecticides and equipment/supplies available for IRS

Program activity reports

DNMP, counties, vector control partners

Process No. of spray personnel trained (disaggregated by health personnel and spray operators) No. of targeted households identified No. of structures sprayed within the last 12 months No. of warehouses, stores, and soak pits constructed or refurbished



Output Proportion of targeted structures sprayed per cycle



Outcome Proportion of targeted population protected through IRS within the last 12 months Proportion of operations sites adhering to best management practices for IRS within the last 12 months Amount of insecticides used per structure Amount of insecticide used per spray operator Number of insecticide poisoning or environmental contamination reported in the last spray cycle Proportion of warehouse, stores and soak pits operational in the last 12 months





Data source

Responsible

Objective 2 To strengthen SBC in support of IRS implementation

3. Promote local and international partnerships towards resource mobilization for IRS 4. Mobilize communities and stakeholders to sustain vector control interventions

Input Amount of money available for SBC Malaria elimination messages available


DNMP, SBC, counties, vector control partners

Process No. of meetings on IRS held No. of people at national, county health leadership levels trained on malaria elimination No. of meeting held with partners and other stakeholders No. of media campaigns conducted

Program annual activity reports


Output No. of community-based civil society organizations participating in malaria elimination No. of people reached with malaria messaging Number of community members who comply and assist spray operators in household preparations Number of public and private sectors with line item on vector control in their annual budgets. ------------------------------------------- Outcome Proportion of community accepting and supporting IRS in the last 12 months



Program annual activity reports -----------------

DNMP, SBC, counties, vector control partners, private sector ---------------------

Objective 3 To strengthen evidence-based decision making for IRS through entomological and epidemiological surveillance, insecticide resistance monitoring and

5. Reinforce malaria epidemiology stratification for rational decision making on determination of target sites 6. Strengthen routing

Input Amount of funds available for entomological surveillance Operationalized IRS implementation strategy Motivated health facilities personnel


DNMP, KEMRI, counties, vector control partners

Process No. of people trained in entomological monitoring

Program annual




Data source

Responsible

operational research.

entomological surveillance including insecticide susceptibility monitoring

and insecticide resistance testing No. of health facilities submitting timely and complete malaria case reports

activity reports

Output Proportion of targeted people trained in entomological and insecticide resistance monitoring Reports on insecticide resistance Entomological profile maps Epidemiological profile maps Proportion of counties conducting entomological surveillance



Outcome Proportion of entomological sentinel sites fully operational in the last 12 months A national database on insecticide resistance A reliable and timely DHIS-2



Risk analysis and mitigation measures: Any plan faces constraints and challenges that threaten the realization of its objectives. Success of IRS strategy requires dedicated and motivated personnel as well as the involvement of many stakeholders. Table 9 lists issues that challenge successful implementation and mitigation measures.


Table 9: Risk assessment and mitigation measures in IRS implementation strategy

Strategy Potential risk Mitigation measures

1. Strengthen human and infrastructure capacity to plan, implement, and supervise IRS operations in target counties

Retention and motivation of permanent workers Lack of funds Donor fatigue Funding uncertainty Lack of motivation of seasonal workers

Provide incentives and career path for personal development, training, refreshers courses, and supervision Diversify donor base and encourage equipment sharing across sectors Strengthen local administration’s involvement in resource mobilization

2. Adhere to best management practices in IRS to safeguard human and environmental health

Environmental contamination Insecticide poisoning Lack of compliant storage facility for insecticides at county level

Adhere to Best Management Practice Manual in IRS Identify or construct warehouses in IRS counties

3. Mobilize communities and stakeholders to sustain vector control interventions

Lack of interest in IRS Political instability

Strong coordination mechanism and leadership in the DNMP Strong advocacy and evidence of impact on malaria Case studies of success stories

4. Promote local and international partnerships towards resource mobilization for IRS

Rumors, myths, and perceptions of IRS Community compliance

Strong SBC campaigns County government leadership involvement

5. Reinforce malaria epidemiology stratification for rational decision making on determination of IRS target sites

Poor quality of data Staff morale

Support operational research and surveys and publications Provide a career path for personal development

6. Strengthen routing entomological surveillance including insecticide susceptibility monitoring

Competing priorities Lack of funds

Provide strong evidence of IRS impact on malaria reduction Diversify donor base

Operational research: Kenya has unique research capacity to carefully monitor the impact of IRS either through direct comparison of IRS target sites and non-IRS sites (as a control) or for KEMRI to conduct a randomized control study to provide this information. Having the malaria impact data is important for advocacy to communities and evidence to solicit donor support for IRS. Collaboration between DNMP and KEMRI, partners, and tertiary institutions to address challenges or issues surrounding malaria vector control interventions should be well funded to address operational issues such as impact of indoor interventions on outdoor malaria transmission, behavior of resistant malaria vectors around ITNs or sprayed walls, impact of pyrethroid resistance on malaria transmission and epidemiological and entomological indices to determine an IRS exit strategy.


5. IRS Budget

5.1 Quantification assumptions with known parameters

This budget template will form the basis for detailed planning and budgeting for annual operational work plans for IRS. The budget is meant to guide and mobilize in-country resources and facilitate targeted submissions to development partners and donors that will be encouraged to support IRS. The effectiveness and efficiency of an IRS campaign will also rely on the capacity of the implementing personnel and motivation. The capacity to correctly quantify procurement needs (insecticides, spray equipment, and spray team sizes, based on housing and population data) is vital to the success and timeliness of spray campaigns.

In each spray round, the cost of the IRS operation will depend on the number of structures to be sprayed, the unit cost of the insecticide of choice, the duration of the spray round, and the operational costs (spray operator allowances, training, transport, supervision, and storage and disposal facilities).

In order to maximize the efficiency and effectiveness of the spray teams, each spray team will consist of no more than six spray operators supervised by a team leader. A supervisor will supervise three teams. The total number of seasonal spray operators required is based on the number of structures to be sprayed, the average number of structures each spray operator can cover in a day, and the anticipated period of spraying cycle. Experience in the last two spray rounds in Homa Bay and Migori indicate that, one spray operator can spray an average of nine structures per day. Using an organophosphate insecticide, (pirimiphos-methyl – ActellicR), IRS spraying activities are conducted once a year starting from January/February and completed before the rainy season in March to May. Table 10 uses Homa Bay County, where known and calculated key parameters are given to quantify IRS requirements [37]. FludoraR fusion that is proposed for 2021 IRS campaign is less costly (about US$ 17 per sachet) compared to ActellicR and as such, cost calculation of insecticide per structure would be applied to this lower price.

Table 10: Example of parameters for quantification of requirements

Key parameters Estimates Data source

Population size (e.g. Homa Bay) 1,131,950

Kenya National Bureau of Statistics in 2019

No. of targeted structures 312,634 PMI VectorLink end of spray report 2018 [37]

Average household size in Homa Bay 4.3

Kenya National Bureau of Statistics in 2019

Surface area covered per bottle of insecticide 250m2

Manufacturer - pirimiphos-methyl

Concentration (a.i/m2) of insecticide 300g/L

Manufacturer - pirimiphos-methyl

Application dosage 1-2g/m2 Manufacturer - pirimiphos-methyl

Average size of structure 92m2 PMI VectorLink cost analysis 2018

Area sprayed (100m2) 406,170 x 92 = 37,367,640m2 PMI VectorLink cost analysis 2018

One bottle/sachet 2.7 structures PMI VectorLink end of spray 2018

Cost of pirimiphos-methyl US $ 24 per bottle Manufacturer - pirimiphos-methyl

Insecticide cost/structure US$ 6.3 PMI VectorLink cost analysis 2018

Cost per structure sprayed US $ 26.1 PMI VectorLink cost analysis 2018


Key parameters Estimates Data source

No. of structures/ spray operator/ day 9 structures

PMI VectorLink end of spray 2018

IRS campaign period 24 days A 6-day work week

No. of spray operators per team leader 6 SOPs

No. of spray teams per Supervisor 3 teams

Community supervisors 1 team leader per sub-location

No. of IEC mobilizers 1 mobilizer for 200 households

County coordinators 1

County logisticians 1

No of pump technicians 1

No. of wash persons per site 1 per two team

No. of storekeepers per site 1 per operations site

No. of data clerks 1 for 400 entries per day

No. of security guards (D/N) 2 per site

IRS data transporters 2 per sub-county

No. of vehicles to transport spray operator 1 per 2 teams

Supervision vehicles 2 per sub-county and 2 per county

No. of drivers As per number of vehicles hired

County warehouse managers 1 per warehouse

Finance assistants 1 per sub-county

Entomological technicians 1

The expense reports for the 2017 and 2018 spray rounds in Migori and Homa Bay give some guidance on cost implications per category of IRS operation which can be used to calculate the budget [37]. All line items can be calculated based on targeted structure, cost of spraying per structure and the spray period. A list of equipment, PPE and consumables required and a template to develop a budget are given in Annex I and Annex J respectively.

5.2 Quantification assumptions with unknown parameters

IRS in Kenya is currently focused on reducing levels of malaria transmission in western Lake region, where eight counties with the highest malaria burden are located. According to the 2019 Population Census [2], the inhabitants in these counties totals 9,418,986: Homa Bay, 1,131,950; Migori, 1,116,436; Kisumu, 1,155,574; Siaya, 993,183; Vihiga, 590,013; Kakamega, 1,867,579; Bungoma, 1,670,570; and Busia 893,681.

In calculating the number of structures occupied by this population sizes, it is assumed, based on Kenya Population Census of 2019 that an average household in western Kenya has 4.3 persons. Therefore, for example in Homa Bay, with a population of 1,131,950 in 2019, the number of estimated structures would be 1,131,950 divided by 4.3 = 263,244 structures. However, sprayable types and surface area in square meters should be verified by conducting a GR that measures a representative sample of different types of structures (5-10%) of the


total structures and assesses other GR indicators. With this information, and taking into account the number of structures that can be sprayed per bottle, the amount insecticide formulation for procurement can be calculated.

Example 1: If one bottle of ActellicR can spray 2.7 structures [37], and 15000 structures are targeted, the number of bottles/sachets required would be 15000 divided by 2.7 = 5,556 bottles. It is always important to add a 7-10 % buffer to cushion any unexpected structures.

Example 2: To determine how many spray operators, team leaders, and supervisors are needed, the assumption is that: one spray operator can spray 9 structures each workday [37] during a 24-day spray campaign that targets 15,000 structures; that 6 spray operators are supervised by one team leader; and that 3 teams are supervised by each supervisor:

Divide the number of structures to be sprayed by the number of structures a spray operator can spray per day and divide this by the days in the campaign: 15,000/ 9/ 24 = 69 spray operators.

Of the 69 spray operators, divide by 6 to get the number of team leaders = 69/ 6 = 12 team leaders.

Of the 12 team leaders, divide by 3 to get supervisors = 12/ 3 = 4 supervisors.

5.3 Estimated budget summary for six new counties in western Kenya

The GOK has plans to scale up IRS to other counties in western Kenya, Table 13 illustrates an estimated budget for Kisumu, Vihiga, Kakamega, Siaya, Bungoma, and Busia) using the population as the basis for calculating the number of targeted structures and the amount of insecticide required. The proportion of line item expenses from the PMI VectorLink Report 2018 for Homa Bay and Migori counties are used to calculate spray operations costs. It should however be noted that due to administrative costs loading by PMI, the costs would be less if IRS campaign was conducted by DNMP.

Table 11: Annual budget for six new endemic counties in western Kenya (in US $)

Itemized operations KSM VHG KKM SAY BUG BUS

Targeted population in each county

1,155,574 590,013 1,867,579 993,183 1,670,570 893,681

Targeted structures 268,738 137,212 434,321 230,973 388,505 207,833

Number of spray cycles per year

1 1 1 1 1 1

Insecticide used OP OP OP OP OP OP

Total number of structures to be sprayed annually

268,738 137,212 434,321 230,973 388,505 207,833

Number of structures for which financing is already secured

0 0 0 0 0 0

Gap to be covered 268,738 137,212 434,321 230,973 388,505 207,833

Total Insecticide needed

99,533 50,819 160,860 85,545 143,891 76,975

Insecticide cost 2,388,783 1,219,665 3,860,628 2,053,091 3,453,375 1,847,403

Total cost of insecticide

2,388,783 1,219,665 3,860,628 2,053,091 3,453,375 1,847,403

Spray operations and Administration costs

2,902,372 1,481,893 4,690,664 2,494,506 4,195,850 2,244,594


Itemized operations KSM VHG KKM SAY BUG BUS

Equipment (pumps, PPE, etc.)

322,486 164,655 521,185 277,167 466,206 249,399

Planning, Training and Supervision

279,488 142,701 451,694 240,212 404,045 216,146

Community mobilization (SBC)

271,426 138,584 438,664 233,283 392,390 209,911

Environmental compliance

271,426 138,584 438,664 233,283 392,390 209,911

Entomology monitoring and reporting

274,113 139,957 443,007 235,592 396,275 211,989

Total cost per year 6,710,093 3,426,039 10,844,505 5,767,134 9,700,529 5,189,354

Cost per structure sprayed

25.0 25.0 25.0 25.0 25.0 25.0

Cost per person protected

5.8 5.8 5.8 5.8 5.8 5.8

Grand Total cost 6,710,093 3,426,039 10,844,505 5,767,134 9,700,529 5,189,354

Domestic funding 0 0 0 0 0 0

Domestic in-kind contribution

- - - - - -

External resources by donors

0 0 0 0 0 0

Financial gap 6,710,093 3,426,039 10,844,505 5,767,134 9,700,529 5,189,354

KSM-Kisumu; VHG-Vihiga; KKM-Kakamega; SAY-Siaya; BUG-Bungoma; BUS-Busia.


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7. Suggested Reading

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16. WHO: Malaria Surveillance, Monitoring and Evaluation: A Reference Manual. 2018. https://apps.who.int/iris/bitstream/handle/10665/272284/9789241565578-eng.pdf?ua=1

17. WHO: Report of the twentieth WHOPES working group meeting, WHO/HQ, Geneva, 20–24 March 2017. Review of Interceptor G2 LN, Dawaplus 3.0 LN, Dawaplus 4.0 LN, Sumilarv 2 MR, Chlorfenapyr 240 SC. Geneva: World Health Organization; 2017. https://apps.who.int/iris/bitstream/handle/10665/258921/WHO-HTM-NTD-WHOPES-2017.04-eng.pdf?sequence=1

18. Noor AM, Kinyoki DK, Mundia CW, Kabaria CW, Wambua JM, Alegana VA, Fall IS, Snow RW (2014). The changing risk of Plasmodium falciparum malaria infection in Africa: 2000 to 2010. Lancet, 383: 1739-1747.

19. WHO: Framework for a National Plan for Monitoring and Management of Insecticide Resistance in Malaria Vectors. 2017. https://apps.who.int/iris/bitstream/handle/10665/254916/9789241512138-eng.pdf?sequence=1

https://www.embuni.ac.ke/images/Docs/KenyaVision2030PopularVersion.pdf

https://sustainabledevelopment.un.org/content/documents/21252030%20Agenda%20for%20Sustainable%20Development%20web.pdf

https://sustainabledevelopment.un.org/content/documents/21252030%20Agenda%20for%20Sustainable%20Development%20web.pdf

https://www.usaid.gov/sites/default/files/documents/1864/2017-pmi-eleventh-annual-report.pdf

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https://www.pmi.gov/docs/default-source/default-document-library/implementing-partner-reports/kenya_irs2_2013.pdf?sfvrsn=4


https://apps.who.int/iris/bitstream/handle/10665/259205/9789241512978-eng.pdf?sequence=1

https://apps.who.int/iris/bitstream/handle/10665/272284/9789241565578-eng.pdf?ua=1

https://apps.who.int/iris/bitstream/handle/10665/258921/WHO-HTM-NTD-WHOPES-2017.04-eng.pdf?sequence=1

https://apps.who.int/iris/bitstream/handle/10665/258921/WHO-HTM-NTD-WHOPES-2017.04-eng.pdf?sequence=1




Annexes

Annex A: CoE that Validated the IRS Strategy in October 2019

Name Affiliation Name Affiliation 1 Zeddy Bore PMI VectorLink, Kenya 16 Damaris Matoke KEMRI 2 Elie Bankineza PMI VectorLink, Kenya 17 Edith Ramaita MoH – VBNTD 3 John Githure Consultant 18 Cassain Mwatele KEMRI 4 Njagi Kiambo MoH - DNMP 19 Michael Njoroge MoH – DNMP 5 Grace Ikahu MoH - DNMP 20 Mbungu Meshak MoH – DNMP 6 Charles Mbogo KEMRI 21 Ahmeddin Omar MoH – DNMP 7 Luna Kamau KEMRI 22 Lenson Kariuki MoH – DNMP 8 David Mburu Pwani University 23 Milka Njunge Sumitomo Chemical 9 Richard Oxborough Abt-PMI VectorLink, UK

10 Bernard Abong’o KEMRI

11 Eric Ochomo KEMRI

12 James Mwangi PS Kenya

13 Angela Ngetich PS Kenya

14 Lydia Kibe KEMRI

15 Ismail Abbey MoH - DNMP


Annex B: Example of IRS Timeline for One Spray Round per Year

Key activities

Planning period Spray period Rainy season Report

Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun

Pre-spray activities

Partner/IRS Strategy bi-monthly meetings (strategy, insecticide selection, spray location, timing of operations, etc.)

Present plan and progress with CoE

Geographical reconnaissance/mapping

Environmental assessment

Conduct vector sentinel site surveillance (bioassays, susceptibility, vector composition and behavior

Logistics, financial and administrative assessment

Procure insecticide, equipment, and transport

Draft environmental assessment

Draft operational budget

Revise and approve SEA and budget

Conduct pre-season environmental assessment

Establish training schedule

Conduct training of county coordinators, supervisors, and team leaders

Recruit and train spray operators

Administer medical fitness test to spray personnel

Develop and disseminate IEC materials


Key activities

Planning period Spray period Rainy season Report

Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun

Distribute insecticide and equipment to operational sites

Do detailed micro-planning

During spraying

Do door-to-door mobilization

Conduct spraying

Conduct supervision

Conduct mid-season environmental inspection

Track timing, quality, and coverage of spraying and environmental compliance

Post-spray activities

Decommission operational sites

Do clean-up, repairs, and disposal of wastes

Evaluate coverage and other indicators from data collected

Conduct post-season inspection

Conduct wall bioassays

Conduct IRS review meeting with stakeholders

Evaluate impact of IRS on vectors and malaria

Write and disseminate end of spray report


Annex C: Pre-Spray Inspection Checklist for Environmental Compliance

IRS Environmental Inspection Report Form

Pre-Spray Storeroom and Soak Pit Inspection

Date of Inspection : _____/_____/_______

County: _______________ Village: ______________

Inspectors : _____________________________ ____________________________

BMP Requirement Y N Comments/Recommended Actions Completion Date

if Applicable

Storage facility located an adequate distance from schools, homes, and water bodies/flood plains

Distance to nearest sensitive receptor _______ m

Double locks on pesticide storage

Facility guarded 24 hrs/day

Windows barred and screened

Adequate lighting

Danger signs with skull and crossbones

Guards have boots, whistles, and flashlights, phones

Pesticides properly labeled

Material Safety Data Sheets (MSDS) readily available in storeroom

Extra MSDSs for transport vehicles

Adequate PPE in inventory for the number of operators expected (helmets, neck shield, face shield, dust mask, coveralls, gloves, socks, boots)

Number of operators to work out of this operations center: _________

Number of full sets of PPE available: _________

1. First aid kits for storeroom and transport vehicles fully stocked (band aids, gauze, antibiotic cream, eye wash, hydrocortisone

Number of transport vehicles expected to be used: ______



if Applicable

cream/calamine, aspirin). 2. Spill kits for storeroom and for vehicles (sand bucket, long-handle brush with stiff bristle, shovel, fire extinguisher)

Number of fully stocked first aid kits: ______________

Number of spill kits in inventory: ______________

Emergency response procedure posted in stockroom (with phone numbers)

Spill response procedure posted

Insecticides past their expiration date Expiration date of pesticides in inventory: _____/_____/_______

Containers for waste available and clearly marked

Items in the storeroom stocked on pallets and according their type

Maximum storage height (2 m) exceeded and/or aisles blocked?

Recording thermometer in storeroom

Fire extinguisher inside and outside storeroom

Leak-proof floor in storeroom

Leak-free roof

Soap and water available

Antidotes to pesticides available nearby Distance to nearest health facility: _______

Storeroom supervisors know signs of poisoning and location of nearest treatment facility

Prepared to administer pregnancy tests

Is a soak pit located near IRS storage facility?

Is the soak pit located away from water bodies, steep slope, or flood-prone area?

Are soak pit and surroundings cleared of vegetation and cleaned?

Are the washing areas properly sloped to drain to the soak pit, with no leaks or cracks?

Are the lines to dry the clothes present and strong enough to carry the load?



if Applicable

Are there skull and crossbones hazard signs on all exposed sides?

Is the gravel adequate and well placed and prepared to act as a filter?

Is the soak pit correctly fenced, gated, locked and strongly built?

Are showers and toilets with adequate privacy and drainage present at site? (1 /gender)?

Additional Comments __________________________________________________________________________________________________________________


Annex D: Mobilizer Data Collection Form

COUNTY: __________ SUB-COUNTY: ____________________________ DIVISION: _____________ LOCATION: ________________________

SUB-LOCATION: _______________________________

DATE: ____________________ MOBILIZER NAME: ____________________________________ MOBILIZER ID: ________________

SIGNATURE: _________________________________

Name of head of household

IRS structure ID

Eligible structure

sensitized?

If not sensitized,

why?2

People sleeping in the structure

Adults reached with IRS

messages Acceptance

of IRS IEC

Materials

Household ID1 -

Structure suffix (01,

02, 03, etc.) Yes No Total

population Pregnant women

Children <5 Males Females Yes No

# Brochures

distributed

- -

-

-

Total number of eligible structures

found

1The household ID is the 6-digit number located on the IRS card

2Reason for not mobilizing: 1= Nobody home 2= Adult not present, 3=Refused, 4=Other

TEAM LEADER NAME: ___________________________________ Arithmetic Verified: Yes / No Physical Spot Check: Yes / No

Date Verified:______________________ Signature:________________________________

SUPERVISOR NAME: _____________________________________ Arithmetic Verified: Yes / No Physical Spot Check: Yes / No

Date Verified:______________________ Signature:_______________________________


Annex E: Spray Operator Data Collection Form

COUNTY: _____________ SUB-COUNTY: _________ DIVISION: ______________________________ LOCATION: ______________

DATE: ______________________ SPRAY OPERATOR NAME: _______________________________________

SPRAY OPERATOR ID: __________________

⃝ Tick if public dormitory institution

TEAM LEADER NAME: _______________________ TEAM NUMBER: _______________ SPRAY OPERATOR SIGNATURE:_________________

# SACHETS RECEIVED: _____________________ # SACHETS RETURNED FULL: ________________________

# SACHETS RETURNED EMPTY: _________________________

Head of Household

Name

IRS Structure ID Eligible Structures Eligible Rooms

Mosquito nets Signature/fingerprint of

household representative who witnessed

spraying

Household ID1

- Structure Suffix

(01, 02, 03, etc.)

Sprayed Unsprayed

Fo

und

Spra

yed

To

tal # A

vaila

ble

# P

regnant

Wom

en

Sle

epin

g U

nder

Net

# C

hild

ren <

5

Sle

epin

g U

nder

Net

Sprayed? (√)

Total Population

Pregnant Women

Children <5

Not Sprayed?

(√)

Reason Total Population

Pre

gnant

Wom

en

Child

ren <

5

Male Female Male Female

-

-

-

-

Total 1The Household ID is the 6-digit number located on the IRS Card

2Reason for not spraying: 1= Sick, 2= Locked, 3=Funeral, 4=Refused, 5= Structure no longer eligible, 6= Other

TEAM LEADER NAME: _______________________________________ Arithmetic Verified: Yes / No Physical Spot Check: Yes / No Date Verified:___________________ Signature:________________________________

SUPERVISOR NAME: ________________________________________ Arithmetic Verified: Yes / No Physical Spot Check: Yes / No Date Verified___________________ Signature________________________________

DATA CLERK NAME: __________________________________________ Data Clerk ID: ________________ Signature____________________________________ Date Data Entered:__________________________


Annex F: Team Leader Data Collection Form

COUNTY: ______________________ SUB-COUNTY: ____________________________ DIVISION: ______________________________ LOCATION: ___________________________ SUB-LOCATION: _______________________________

DATE: ______________________ TEAM LEADER NAME: _______________________ TEAM NUMBER: ____________ TEAM LEADER SIGNATURE: ____________________________⃝ Tick if public dormitory institution

# SACHETS RECEIVED: _____________________ # SACHETS RETURNED FULL: ________________________ # SACHETS RETURNED EMPTY: _________________________

SUPERVISOR NAME: _______________________________________ Arithmetic Verified: Yes / No Physical Spot Check: Yes / No Date Verified__________________ Signature___________________________

Sachets

Receive

d

Sachets

Returne

d Full

Spray

Operato

r Name

Spray

Operato

r ID

Eligible Structures Eligible Rooms Mosquito nets Insecticides

Total

Found

Sprayed Unsprayed

FoundChildren

<5

Total

Sachets

Returne

d Empty

Lost/

Damage

d

#

Sprayed

Total

Pop

Pregnan

t

Children

<5

# NOT

SprayedReason

Total

Pop

Pregnan

t

Sprayed

Total #

availabl

e

#

Pregnan

t

#

Children

<5


Annex G: Example of Spray Team Leader and IRS Supervisor’s Checklist

Source WHO 2015

Date:

County

Sub-county

No. of spray operators

Name of village being sprayed

Estimate number of target structures

Name of team leader

What was the spray operator doing on your arrival

Observe the use of protective clothing

Procedure before starting to spray (tick) Yes No

Are the residents informed? Yes No

Are food items, water containers, cooking utensils covered, removed? Yes No

Are the residents outside during spraying? Yes No

Are the animas outside during spraying? Yes No

Is the sprayer filled correct? Yes No

Is the sprayer pressurized correctly? Yes No

Is the sprayer pressure gauge checked frequently and pressure maintained as per guidelines?

Yes No

Is the sprayer handled and carried correctly? Yes No

Is the sprayer shaken periodically before and during spraying? Yes No

Is the nozzle held at a constant distance from the target (45cm Yes No

Is the nozzle moved at a constant speed over all surfaces? Yes No

Is proper footwork performed so that adjacent swaths overlap? Yes No

Is the pressure released when the sprayer is not in use? Yes No

Is distribution of insecticide on wall adequate? Yes No

Is distribution of insecticide on roof/ceiling adequate? Yes No

Does spray operator spray behind and under furniture? Yes No

Does spray operator spray under the eaves? Yes No

Does spray operator spray behind the doors? Yes No

Does spray operator avoid environmental pollution? Yes No

Does spray operator eat, drink or smoke without first washing? Yes No

Does spray operator complete daily record form? Yes No

Any comments from household members? Yes No

Any comments from village or community leaders? Yes No

Positive feedback


Areas requiring attention and action

Proposed solutions and recommendations

Team leader/ District IRS supervisor’s name and signature


Annex H: Key SBC Messages for IRS

Pre-spraying

• IRS is part of the Ministry of Health’s commitment to fight and eliminate malaria in Kenya.

• IRS is paid for by the Government and so no charge to your household and it is voluntary.

• The insecticide used has been tested and found to be effective against malaria carrying mosquitoes.

• The insecticide is meant to kill mosquitoes that transmit malaria in your house.

• IRS operators will spray the insecticide on the interior walls and ceilings of your house to kill resting mosquitoes.

• The insecticide is safe for you and your family if you follow the precautions and instructions given to you.

• It kills not only mosquitoes, but also other insects such as fleas, bed bugs, and cockroaches. Therefore, if you see them moving around after spraying, it is because they have been disturbed by the smell but will eventually die when they come into contact with the insecticide.

During spray

• On the day of spraying, an adult should be at home to open the door for the spray operator.

• On the morning of spraying, all movable household items, including all utensils, drinking water, and food should be moved outside.

• Pets and animals should also be removed from the house and tethered so that they do not re-enter the house until at least two and half hours after spraying.

• Items that cannot be moved outside should be moved to the center of the room and covered with nylon papers that the spray operator will provide.

• Every household is asked to provide about 7.5 litres (half a jerry can) of water to help in mixing the insecticide.

• Eating, drinking, and smoking while the spraying is going on is strictly prohibited.

• Community members are discouraged from offering food or drinks to the sprayers when they are still in PPE.

Post-spraying

• People and animals must stay away from the sprayed structure for two hours.

• Open doors and windows for another 30 minutes after the two-hour closure to allow fresh air to circulate before moving back the items.

• Do not paint, plaster, or clean the sprayed walls for nine months after the spraying.

• Sweep the house and clear all dead insects by burying them or throwing them into a pit latrine, if available.

• If any itching or soreness is observed after the spraying, flush with lots of water, report to any IRS official and visit the nearest local health facility for professional advice.

• As has been told to you before, if you or your family suspect you have malaria, seek treatment at the local health facility.


• To maximize protection against malaria, you must continue using bed nets even after your house has been sprayed.


Annex I: List of Equipment and Supplies for IRS

Spray Pumps Stores - reusable

Sprayer Nylon rope (30m2) Fire Extinguisher – CO2

Spare Parts Kit Barrel (Triple Rinse) Fire extinguisher – Dry Powder

Nozzle Tip Barrel (Water Storage) Hand Washing Barrels

Control Flow Valve (CFV) (separate in case of Hudson Basin (20-litre) 10 litre bucket (for spill Kit)

Basin (40-litre) Dust Pan - for spill kits

Spray Gear Jerry can (20-litre) 50 cm training stick

Face shield Jug (2-litre) 1 M training stick

Apron for washers Clear bag Pliers

Gum boots (pair) Polythene sheet (3 meters) - Spray Operators Adjustable spanner

Haversack/bag Polythene sheet (3 meters) Other Screw Drivers

Helmet Calculator Atropine

Helmet brackets Tool kit Pregnancy test kits

Overalls Oil dispenser Medical Gloves

Reflective vests – for mobilizers, First Aid kit Syringes

Rubber gloves - short (pair) Bucket Thermometer

Rubber gloves - long (pair) Shovel Tooth brush

Neck protection hoods Rake Measuring Cylinder

Goggles for washers and storekeepers Whistle for security guard Spot light

Warning sign - store Megaphones+ Batteries

PPE - consumable Warning sign - soak pit PRINTED FORMS

Dust mask Padlock (pcs) Daily Spray Operators card

Socks (pair) Spill Kit Daily team leader's records

Towel Dust pan for spill kit Daily IEC/BCC Mobilizer Card

Thermometer

Team Leaders Summary Form (Locational)

Stationery goods - consumable Post Spraying Activity Feedback form

Notebook (pcs) Store - consumable Daily Insecticide Tracking and Distribution Card

Pen (pcs) Washing soap (bar of 5 pcs) Spray Performance Tracking Sheet

Flip chart (pcs) Filter cloth (A4 size)/Sieve QA Tool for daily/BCC Mobilization card

Masking tape (roll) Chalk (box of 150 pcs) QA Tool for daily spray card

Marker (pcs) Lubricating oil (1-litre) QC Tool for Spray data collection

Spray card (pcs) Batteries - C or D cell (pair) QC Tool for Spray data Entry

Rubber bands (pkt) Liquid soap (20-litre jerry can)

Store Ledger Books Temperature monitoring form

Insecticide stock booklets Daily mixed insecticide returned from field tracking form Banners

Team Leader Health Checklist

Request notes Spill response procedure

Delivery notes MSDS - 11 pages

Goods Issued Note Emergency Response procedure


Goods Received Note Vehicle accident Response

Temperature Monitoring sheet

Gender Policy vehicles inspection certificates

Serialized insecticide tracking sheet Drivers Policy - 2 pages

Airtime – Tele-calling Vehicle daily Log sheets

Airtime - Bundles personnel certificates

Sanitary towels Personnel contracts - 2 copies


Annex J: Example of Capital and Operational Budget for an IRS Program

Item No of Units Unit Cost Total Cost

CAPITAL

Baseline epidemiological and entomological review and survey

Environmental impact assessment

Compression sprayers

Equipment, spares, and replacement parts

Tool kits

Protective sheeting to cover household goods

Transport: truck/boats for 3–4 spray teams

Transport: supervisors’ motorcycles

Transport: coordinators’ 4x4s

Malaria camps – storage and base

RECURRENT

Spray insecticides

Salaries of spray operators for 4–8 weeks (adjust to minimum wage)

Personal protective equipment (overalls, gloves, helmets, face shields with screen)

Collection and disposal of empty sachets containers

Travel and per diems for supervisors and coordinators for duration of the campaign

Transport hire and fuel costs

Annual training of coordinators and supervisors

Annual training of spray operators

Annual IEC and community mobilization materials

Annual review of environmental compliance and pesticides management

Monthly, quarterly, and annual operations management meetings

IRS data entry and summary report sheets

Malaria prevalence surveys (optional)

Entomological studies and sentinel sites

Annual post-spray review and annual report production

Source: WHO 2015

this publication is a ministry of health document

Documents