Pilot Introduction of long-lasting bednets and hammock nets in the Indigenous Comarca of Guna Yala, Panama

doi:10.21203/rs.3.rs-4614107/v1

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Pilot Introduction of long-lasting bednets and hammock nets in the Indigenous Comarca of Guna Yala, Panama

https://doi.org/10.21203/rs.3.rs-4614107/v1

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Background: After almost 70 years of using indoor residual spraying (IRS) as the primary intervention for malaria vector control, the Republic of Panama wanted to evaluate the operational feasibility, acceptability, and performance of distributing long-lasting insecticide-treated hammock nets (LLIHNs) and bed nets (LLIBNs) in the country.

Methods: A pilot study conducted in 2019 distributed LLIBNs and LLIHNs to cover all sleeping spaces in 15 high localities of the indigenous Comarca of Guna Yala and measured retention, coverage, use and physical deterioration, washing and drying practices, as well as people’s satisfaction with product characteristics post-distribution.

Results: Overall, 89.9% of enumerated sleeping spaces were covered during the campaign. Monitoring post-distribution showed that 82.7% of the population received messages about the campaign before it happened and 92.4% claimed to know the purpose of the net and how to care for and repair it. Adverse reactions to the LLINs were reported by 38.4% of the households. Two years after distribution, 86.3% of the LLINs were retained. Use was very high right after distribution (85%) but decreased to 57% six months after distribution and to 38% two years after distribution. The main reason for not using the LLINs was the reported absence of mosquitoes. Throughout the two years post-distribution, LLINs were preserved in good physical condition (4% torn), very few were washed with aggressive products (9%) or dried under the sun (15%), and LLINs were washed on average a bit less than once every two months. The average number of people per sleeping space was 1.34.

Conclusion: The LLIN distribution was operationally feasible. LLINs were initially well-accepted and cared for by these communities after distribution but use decreased drastically over the two years of follow-up. Further investigation into the reasons for low LLINs and corresponding tailored behavioral change efforts will be needed to ensure high LLIN use in these communities.

malaria

LLINs

LLIHNs

indigenous

Malaria is endemic in Panamá. Most malaria cases are caused by Plasmodium vivax and 99% of malaria cases are concentrated in mostly indigenous villages scattered throughout four regions of the country: Guna Yala, Panama Este, Darien, Ngäbe-Bugle (1). Based upon a consistent decrease in cases over the previous eight years, in 2018, the Republic of Panamá developed their first national plan for malaria elimination (2), committing to eliminate malaria by 2025. Two years later, Panamá joined the Regional Malaria Elimination Initiative (IREM) in Central America (3).

In Panamá, indoor residual spraying (IRS) had been the main vector control intervention since the 1940s. However, in 2018, acknowledging the need to use several interventions to achieve effective control of malaria vectors, the Ministry of Health adopted an integrated vector management approach and set the goal to achieve full coverage with either long lasting insecticide nets (LLINs) or IRS in target communities across all active transmission foci, as well as to use other complementary interventions, such as larvicides or environmental management, in high-risk areas (3).

Panama had previously piloted LLINs in 2008 but with limited impact, due to long-lasting insecticide treated bednets (LLIBNs) being chosen and distributed in malarious regions where a high proportion of the population slept in hammocks rather than beds / sleeping pads (2). Based on this experience, Panama was interested in introducing long-Lasting insecticide treated hammock nets (LLIHNs) alongside LLIBNs. The country was further encouraged by the impact of LLIHNs seen in other countries in Latin America and by the fact that LLINs were becoming the main vector control intervention in most countries (4). In indigenous areas of the Venezuelan Amazon, 56% of malaria cases were prevented two years after the distribution of manually insecticide treated hammock nets(5). In Suriname, a great reduction in malaria incidence was observed between 1989 and 1991 following distribution of treated hammock nets (6).

In 2018, the Panamanian Ministry of Health decided to evaluate the operational feasibility, acceptability, and performance of an LLIBN and LLIHN distribution. A pilot study was designed to distribute sufficient LLIBNs and LLIHNs to cover all sleeping spaces in 15 localities in the indigenous Comarca of Guna Yala and to measure LLIN retention, use and physical deterioration, LLIN washing and drying practices, as well as people’s satisfaction with LLINs characteristics after distribution. In this paper, we report on the results of this pilot study, which were used to inform the implementation of a subsequent national LLIN campaign in 2023.

Study site

The Guna Yala Comarca is a semi-autonomous indigenous territory within the Caribbean coastline of the Republic of Panama. It shares a border with the Republic of Colombia to the east. The estimated 46,267 residents registered in 2019(7) were primarily of the Guna indigenous group, although two communities (La Miel and Puerto Obaldia) located near the Colombian border are ethnically Afro-Panamanian. Each Guna community is led by a saila and decisions are made in community meetings regularly held at Casas de Congreso. Guna people communicate in their own language and a high percentage of people sleep in hammocks (8).

The Ministry of Health (MoH) selected to conduct the LLIN pilot in the Guna Yala region due to its history of high malaria endemicity and unique vulnerabilities. In 2018, nearly 40% of the cases nationwide were detected in Guna Yala (9). The selection of communities for this pilot was based on an analysis of historical disease burden, where 13 localities were identified to report an incidence of over 5 cases per 1000 inhabitants between 2014–2017. Additionally, two Afro-Panamanian communities were included because of their proximity to these high-risk malaria areas, as well as their distinct environmental and social characteristics.

Household enumeration and LLIN quantification pre-distribution

To determine the number of nets to be procured and set targets for the distribution, an enumeration of households and sleeping spaces was conducted between September and October 2017, counting all beds, hammocks, and other sleeping spaces (see Additional file 1- Form 1). A buffer of 10% was applied over the number of beds and hammocks censed to account for any households not enumerated or population changes between the enumeration and the distribution date.

Social Behavior Change Communication (SBCC) to foster community acceptance and use of LLINs

SBCC activities were conducted before, during and after the campaign, targeting children, women, men, sailas, community health workers (CHW), local vector control technicians and school-teachers. Before the campaign, messages were disseminated via local Guna radio, and posters were hung in the offices of vector control technicians, at health centers, migration control points, stores, the houses of CHWs, and in the house of the Guna Congress in each locality. During the distribution, demonstrations of how to use LLINs were provided during community meetings (Congreso), and oral instructions and a leaflet were given to each household. After the distribution, CHWs continued disseminating information about net use and handling recommendations for LLINs, and posters were hung at schools. Such post-campaign efforts were concentrated in the first-year post-distribution.

Net distribution

LLINs were distributed and installed door-to-door between the 15th of June and the 23rd of August 2019 by vector control technicians and trained community volunteers. To avoid adverse reactions due to exposure to recently opened nets, all nets were removed from their plastic packaging and hung in an empty house on clotheslines for 24 hours before distribution. At the end, a mop-up round was conducted to distribute nets to households that were closed during the main distribution. Data on the number of bed nets and hammock nets distributed to each household was collected through a paper form to estimate campaign coverage (additional file 1 – Form 2).

Post-distribution verification

Between one and two days after completing net distribution in each locality, post-distribution verification visits were conducted in a randomly selected sample of 20% of households to verify whether the households had received LLINs for all sleeping spaces and to determine net usage immediately after distribution (additional file- form 3). The verification was done by the supervisor of the distribution teams by visiting these households and visually verifying all LLINs provided to the household during the campaign.

Post-distribution monitoring and evaluation

After distribution, two cross-sectional surveys were conducted to monitor LLIN retention, coverage, use, physical integrity, washing and drying practices, and population satisfaction with the nets. The first took place from the 4th to the 21st of February 2020 (dry season), six months after the original distribution, and the second from the 4th of July to the 21st of November 2021 (rainy season), two years following the original distribution. The aim was to visit all households in the localities that received LLINs. Net presence was visually verified by the survey teams. Physical integrity was measured in the field as per WHO protocols(10) in 4 LLINs per household (or less if the household had less LLINs). During the first round of monitoring, several questions were added to evaluate the outreach of the SBCC efforts made before and during the campaign. The full questionnaires used in the two rounds of monitoring are available in Additional file 1 – Form 4 and 5.

Data collection during enumeration, LLIN distribution and post-distribution monitoring:

Data from enumeration, distribution, verification and the first post-distribution monitoring survey were collected on paper by trained Vector Control Technicians. Filled forms were individually reviewed by staff from NMCP and CHAI to ensure data consistency and were later entered into tailored Epi Info data collection screens by trained data entry staff. Owing to the adoption of DHIS2 as the common platform for data collection and visualization by the Vector Control Department, data for the second post-distribution monitoring survey were collected on DHIS2 version 2.36(11) using a DHIS2 Tracker program specially designed for the campaign.

Data analysis

Data were analyzed with R version 4.3.1(12) and graphs prepared using the package ggplot2 (13). Table 1 in the Additional File 2 lists and defines all the indicators reported here for the distribution, verification, and monitoring phases of the project, with their numerator and denominator. Most indicators, including coverage, use, and retention indicators, were calculated as proportions of households or sleeping spaces that met specific conditions (see Additional file 2). The only indicator quantified by a mean was the number of times that nets were washed in the last 6 months. The Proportional Hole Index (pHI) was calculated for each evaluated LLIN following WHO guidelines(10) and was used to calculate the percentage of LLINs in good (pHI < 64), damaged (pHI 65–642) and torn conditions (pHI ≥ 643). Where possible, values are disaggregated by type of net (bed or hammock net), by locality and by monitoring round. Two proportion Z-tests, t-tests and Fisher’s Exact tests were run to evaluate differences between monitoring rounds and between bed and hammock nets.

Distribution results

A total of 4818 sleeping spaces were registered during the 2017 enumeration, sixty five percent (n = 3140) were hammocks and 35% (n = 1678) were beds, leading to the procurement of 3430 LLHNs and 1830 LLIBNs. The campaign lasted 69 days between the 15th of June 2019 and the 23rd of August 2019 and distributed LLINs across 925 households. During the campaign, a total of 4433 sleeping spaces were registered, 2765 hammocks and 1668 beds. In 11 out of the 15 localities, fewer sleeping spaces were registered during the campaign than during the 2017 enumeration. A total of 2,723 LLIHNs and 1,609 LLIBNs were distributed (Additional File 3- Table 1 shows the number installed per locality).

Based on the enumeration data of 2017, the campaign covered 89.9% of enumerated sleeping spaces with an LLIN (86.7% of hammocks and 95.9% of beds), with two of the 15 communities reaching coverage of over 100% (Fig. 2A). Of the sleeping spaces found during distribution, 97.7% were covered with a LLIN (98.5% of the hammocks and 96.5% of the beds) (Fig. 2B). Overall, 4.2% of the households required a second visit to complete the distribution. At the time of distribution, 59.1% of the households already had some type of untreated net, anecdotally noted to be either made of fine mesh polyester or crafted by people using local fabric. In households that were reached during the campaign, the average number of people per household was 5.71 and the average number of people per sleeping space was 1.34.

During verification post-distribution, a total of 423 households were visited. It was observed that 95.6% of them had received at least one net per sleeping space during the distribution.

SBCC results

At the time of distribution, 82.7% of the households reported that they had previously received messages about the upcoming LLIN distribution through radio spots or brochures. During verification, 94.4% of the households claimed to have received information from the distribution team, 96.6% claimed to know the purpose of the net, 96.1% claimed to know how to wash it, 96.6% how to dry it, 95.9% how to handle the net when not in use and 95.6% how to repair holes that might appear. Overall, 92.4% of households where verification occurred gave positive or appropriate answers to all LLIN management questions.

Post-distribution monitoring results

A total of 548 households were visited in the first monitoring round and 463 in the second. Two localities were excluded from the second monitoring round (Carreto and Navagandi) due to lack of available personnel to conduct the fieldwork.

Satisfaction with the distributed nets

Six months after distribution, 93.3% of respondents claimed being satisfied with LLIN color, 93.2% with the fabric, 94.9% were satisfied with the size of LLIBNs and 92.1% with the size of LLIHNs. Two years after distribution, these numbers dropped to 76.5% satisfaction with LLIN color, 73.5% satisfied with their fabric, and 78.0% with LLIBN size. Satisfaction with LLIHN size changed the least, with 86.8% respondents still finding their size agreeable. Overall, 83.9% of surveyed households claimed to be satisfied with all LLIN characteristics (color, fabric, and size) six months after distribution and 48.2% two years after distribution (z-test p-value < 1.0 x10^− 5).

Adverse reactions

Six months after distribution, adverse reactions to LLINs were reported across 38.4% of the households where monitoring occurred, with 17.1% of the people in surveyed households claiming to have an adverse health reaction. Of the households that reported adverse reactions, 96.6% said that reactions appeared only when the nets were distributed, 0.5% at times since distribution and 2.9% all the time thereafter. Irritation of the skin was by far the most common reaction reported, occurring in 94.7% of households that reported adverse reactions. This was trailed by irritation of the eyes (45.7%) and headaches (9.6%). Very few households reported cases of nausea, vomiting or difficulty breathing. Reports of adverse reactions in the six months prior to the two-year monitoring exercise dropped to 8.3% of households and 4.3% of people surveyed. Skin irritation was reported in 100% of these households.

Retention, coverage and access:

Two years after distribution, households retained 86.3% of the nets initially distributed to them, having sufficient nets to cover 82.4% of sleeping spaces. Retention of LLIBNs was higher than retention of LLIHNs (86.4% versus 80.5% respectively, z-test p-value < 0.001). On the other hand, households were able to cite the reason behind net loss for 199 LLINs, which were: 39.2% LLINs were being used to sleep outside the home (in another house or outdoors), 30.2% were disposed due to damage, 17.6% LLINs were used for purposes beyond sleeping, 10.1% were given away as gifts, and 3.1% had theirs stolen; no LLINs were claimed to have been resold. Overall, 84.3% of the people had access to sleeping under an LLIN. Retention, coverage and access were not measured six months post-distribution.

Use

Net use decreased consistently over the monitoring periods in all localities (Fig. 3). Six months after distribution, the most common reasons for not using a net were reported as the perceived lack of mosquitos (31.0%), the inability of the nets to keep out sandflies (16.8%), that people found it too hot to sleep under the nets (15.4%) and having insufficient nets (10.7%). The other reasons were reported less than 10% of the time (see additional file 3 – Table 2). At this time point, there were no reports of nets being stolen or resold. Two years after distribution, the perceived lack of mosquitos was still the most common reason for not sleeping under a net the night before (24.3%), followed by people having either damaged (16.6%) or insufficient LLINs in the household (13.1%). No visited household mentioned sandflies at this time point. Two years after distribution, the percentage of LLINs used the night before was 30.1% (differences remained, with LLIBN use at 38.5% and LLIHN use at 26.0%, z-test p-value < 1 x10^− 10).

Figure 3: LLIN use across localities at verification, one year after distribution and two years after distribution globally (above) and by locality (below)

Physical integrity:

Six months after distribution, and across 1,800 examined nets, 12.4% of the LLIBNs and 4.5% of the LLIHNs presented holes. In total, 0.3% of all LLINs assessed were torn with no significant differences in the percentage of torn LLIHN s and torn LLIBNs (Fisher’s exact test p-value = 0.17) (Fig. 4). Two years after distribution, across 1,443 examined LLINs, holes were present in 47.3% of the LLIBNs and in 29.3% of the LLIHNs. In total, 4.1% of all LLINs evaluated were torn at this time point with significant difference between the proportion of torn LLIBNs and torn LLIHNs (Fisher’s exact test p-value = 0.003) (Fig. 5). Only 15.6% of the LLINs that developed holes were found to be fully repaired.

Washing, drying, and handling practices:

On average, households washed their nets 2.6 times in the last 6 months prior to the monitoring surveys and 22.3% of them washed them more than 3 times in the last six months. The number of washes in the six months prior to the survey increased between the first and second round of monitoring, (1.6 washes versus 4.0, t-test p-value < 1 x10^− 15). Washing practices were very similar across both rounds of monitoring, with households washing their nets most commonly with bar soap (70.1%), followed by just water (21.4%), detergent (8.5%) and chlorine (0.5%). There were no differences in the use of insecticide-damaging products (chlorine and detergent) between the first and second monitoring surveys (8.7% and 9.3% respectively, z-test p-value = 0.74).

Following washing, most nets were dried in the shade, with only a minority of households choosing to dry their nets in the sun: 8.1% at the six-month mark, and 15.3% after two years (z-test p-value < 0.001). Households were finally asked about their management practices for LLINs while not in use. Over both monitoring surveys, 41.5% of households reportedly chose to keep them hung over their sleeping space, 37.9% raised and wrapped aside, and 14.2% fully stored away. These percentages were very similar in both monitoring rounds.

This pilot study aimed to evaluate the operational feasibility, acceptability, and performance of LLIBNs and LLIHNs distribution, before scaling them up and adopting this intervention within the national integrated vector control management strategy. It demonstrates that an LLIN campaign is feasible and initially well received by the population in this setting, but it shows that LLIN use decays drastically over time, emphasizing the need for targeted SBCC efforts to sustain use.

The campaign had great acceptability in all localities, covering 97.7% of all sleeping spaces found during the distribution with very homogenous coverage across localities. The high acceptability may be linked to the fact that 59% of the households already had some kind of net before the distribution (untreated nets crafted by people using local fabric or made of mesh polyester), and to SBCC efforts made before and during the campaign that resulted in 83% of the people being aware of the distribution before it happened and 94% claiming to receive information about net purpose, use and handling during distribution. SBCC and community mobilization efforts may have also contributed to the low percentage of households that had to be revisited (4%). Hence, SBCC efforts should be replicated in future campaigns.

The campaign achieved a high coverage of the sleeping spaces registered in 2017 (89.9% of enumerated sleeping spaces were covered). We compared this coverage with that of the sleeping spaces found during the campaign (98%). Considering that in most localities fewer sleeping spaces were recorded during the 2019 campaign than during the enumeration of 2017, that there were leftover LLINs after distribution, and in the absence of major known demographic changes, we suspect that some households were missed during distribution, especially in the community Maguebgandi. This highlights the importance of 1) continuing to conduct an enumeration of sleeping spaces before distribution in future campaigns to have a realistic denominator for the estimation of real campaign coverage, and 2) implementing a real-time monitoring system to monitor coverage during the campaign and rapidly spot underperforming localities (e.g. Maguebgandi) where to take action to bolster coverage before the campaign ends. The adoption of a digital data collection system for LLIN distributions will help the country execute the latter in upcoming campaigns.

Interestingly, 12% less hammocks (compared to 1% less beds) were recorded during the distribution than in the enumeration exercise of 2017. This could be due to the miscounting of daytime resting hammocks as sleeping spaces. Both the enumeration of 2017 and the distribution of 2019 aimed to only count and cover hammocks used to sleep, however, due to communication challenges posed by the local language, some hammocks may have been wrongly classified as sleeping spaces. This could explain the discrepancies in the number of sleeping hammocks counted in 2017 versus the ones counted during the campaign. Efforts should be made in future campaigns to overcome such communication barriers and accurately identify all hammocks used to sleep before and during the campaign.

The number of procured LLIHNs and LLIBNs provided more than sufficient nets to achieve high coverage. This suggests that the buffer could be even smaller if an enumeration of sleeping spaces is conducted shortly before the campaign. WHO recommends using a buffer of 10% when census data is older than 5 years (14). The cost of the pre-campaign sleeping space enumeration could be partially offset by the resulting procurement of a more accurate number of LLINs. This further supports the need for an enumeration of sleeping spaces short before future campaigns. Assuming the default 1.8 people per net for LLIN quantification purposes (15) will not be an adequate strategy in this setting, as the average number of people per sleeping space was 1.34.

Despite ventilating the nets for 24h before distribution, 38.4% of the households reported having adverse health reactions among their members. Several other studies have identified that adverse reactions can affect community perceptions towards LLINs and significantly reduce LLIN use (16–21). Hence, such reactions may explain the rapid decay in LLIN use observed in this pilot. This association should be further investigated, the ventilation strategy should be revised, and ventilation time potentially increased in future campaigns.

LLIN retention two years post-distribution was very high (86%), LLINs were retained in good physical condition (only 4% torn), very few were washed with aggressive products (9%) or dried under the sun (15%), and LLINs were washed on average a bit less than once every two months (implying less than 20 washes over three years). This suggests that people retain their nets and adhere to the washing and drying recommendations provided, and that LLINs could preserve their bioefficacy for the three-year mark (although LLIN bioefficacy was not measured to confirm this). These results contrast with findings from Nicaragua (22), Guatemala (23), the Dominican Republic (manuscript under revision) and Brazil (24), where significantly higher washing frequencies, greater use of aggressive products, much more frequent drying under the sun or higher percentages of torn nets were observed. These differences could be due to population characteristics but also to the intense SBCC and community engagement efforts implemented in Panama at the beginning of this pilot (25). These results suggest that there is no need for top-up campaigns or alternative distribution channels in Guna Yala when campaigns achieve high coverage, but that SBCC efforts should be maintained in future campaigns.

Use decreased significantly from 85% of people sleeping under an LLIN six months after distribution to 38% two years after distribution despite households still having sufficient LLINs to cover 82% of their sleeping spaces at that time. Lack of mosquitoes was the main reported reason for not using the net in both surveys (reported by 24% of people). However, the first survey of this pilot project (when high LLIN use was observed) was conducted at a time when mosquito densities are lower (dry reason) and the second survey (when low LLIN use was observed) at a time when mosquito densities are higher(26) The observed differences in use may, hence, be due to overall year-round low mosquito densities in these communities (although there is not enough entomological surveillance data to verify this hypothesis). Variations in risk perceptions could be another factor affecting use, as the first survey (showing high use) was conducted during the high malaria transmission season and the second (showing low use) during the low transmission season. A relationship between LLIN use and vector abundance, risk perception and transmission seasons has been observed in other countries(27, 28) and WHO guidelines state that in areas where mosquito densities are low or where malaria transmission is low, individuals and communities may perceive less benefit to using nets(15). We therefore recommend investigating the impact of risk perception on LLIN use to identify specific SBCC strategies that can sustain use in Guna Yala and similar elimination contexts where LLIN are currently the sole form of vector control in use. One important factor in such investigation will be to establish an entomological surveillance system to determine whether indeed vector densities are low year-round.

Some differences were observed between LLIHNs and LLIBNs during this pilot, suggesting a slightly lower performance of LLIHNs compared to LLIBNs. Two years post-distribution, retention of LLIBNs was slightly higher than retention of LLIHNs (86% versus 80%) and LLIBNs use was higher than LLIHNs use (54% of LLIBNs used versus 40% of LLIHNs). Possibly because of greater use, the percentage of torn LLIBNs (6%) was higher than that of LLIHNs (3%). The lower retention and use of LLIHNs could be because some hammocks are used to rest during the day (not to sleep) in these communities. LLIHNs distributed to such type of hammocks may have been discarded or left unused. This issue should be further investigated to better understand coverage and retention of LLIHNs, and whether specific actions need to be taken to improve the performance of LLIHNs.

This pilot project has four main limitations. Firstly, the reasons for rejecting LLINs during distribution were not evaluated. Secondly, the first monitoring survey conducted six-months post-distribution did not count the total number of LLINs in the households, hence, attrition and overall coverage of sleeping spaces could not be calculated at that point in time. Thirdly, recall bias related to the reasons for losing the LLIN, or social desirability bias around approval of the nets or SBCC efforts may have occurred. Fourthly, bioefficacy assays could not be conducted to assess the killing effect of LLINs due to the absence of a susceptible colony in the country. Finally, LLIN use data was not disaggregated by sex, age, or specific population groups, yet such disaggregation is very important to identify gaps in protection as, in elimination settings, malaria tends to be concentrated in specific populations, such as adult males (29, 30).

The results of this pilot project were used to shape the strategy for the 2023 mass distribution campaign. First, the same distribution plan was followed in the campaign as in the pilot. Second, an enumeration of sleeping spaces was conducted closer before the campaign to quantify the needed LLINs and have the best possible denominator to calculate real campaign coverage. Third, a digital data collection system with dashboards (DHIS2) was implemented for all phases of the campaign (household registration, distribution and monitoring) to track campaign coverage in real time and promptly identify any gaps. Fourth, ventilation continued and was extended beyond 24h days in some localities. Fifth, the monitoring surveys were improved to estimate retention and coverage in every monitoring round, with a view to better understanding decay in such indicators. Sixth, the sampling method for LLIN monitoring was changed to reduce the number of households to be visited, and hence, make the monitoring more time and labor efficient. Seventh, physical integrity will be evaluated in one randomly selected LLIN per household, instead of in four, to further reduce workload. Finally, bioefficacy testing will be conducted to better understand the killing performance of LLINs over time.

LLIN were initially well-accepted and cared for by indigenous populations, but LLIN use decayed rapidly over time highlighting the need for tailored SBCC efforts to sustain use over the lifespan of the LLINs. The reasons for such decay in use should be further investigated to inform SBCC efforts. This pilot project generated a number of operationally important recommendations to be taken into account for the scale up of LLINs in Panama. Most of these recommendations have already been adopted into the country’s 2023 LLIN campaign.

LLIN

Long-lasting insecticide treated nets (both bednets and hammock nets)

LLIBNs

Long-lasting insecticide treated bednets

LLIHNs

Long-lasting insecticide treated hammock nets

IRS

Indoor Residual Spraying

DHIS2

District Health Information System − 2

Ethics approval and consent to participants

This pilot introduction of LLINs was led by the vector-borne disease department of the Ministry of Health and implemented as programmatic data collection and program evaluation. Participants’ verbal consent was obtained before the household surveys. The data collected during this pilot introduction of LLINs is safely stored in the Ministry of Health official malaria data repository and is only accessible to the Ministry of Health staff and certain staff from the Clinton Health Access Initiative that supported this project.

Availability of data and materials

The data used to produce this article is available from the repository Figshare with DOI https://doi.org/10.6084/m9.figshare.26065087.

This project contains the following files:

LLIN pilot Guna Yala 2019 - DATA DICTIONARY.csv
Data collection forms.pdf
Distribution_data.csv
Verification_data.csv
HH_Monitoring_data_r1_2020.csv
HH_Monitoring_data_r2_2021.csv
Net_monitoring_r1_r2.csv

The data are available under the terms of the CC BY 4.0.

Competing interests

The authors of this study do not have any competing interest to declare.

Funding

This work was supported, in whole or in part, by the Bill & Melinda Gates Foundation, OPP1109772 and INV-002736. Under the grant conditions of the Foundation, a Creative Commons Attribution 4.0 Generic License has already been assigned to the Author Accepted Manuscript version that might arise from this submission. The Ministry of Health of the Republic of Panamá covered the salaries of the staff that distributed and monitored the LLINs. The Bill & Melinda Gates Foundation had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Authors' contributions

O.G., M.A. and M.M. conceived and planned the study. C.A. coordinated study implementation. N.P. and M.M. trained field staff and coordinated and supported the data collection in the field. B.G.E. and L.F.M. conducted the data analysis. M.M., B.G.E., N.P. and L.F.M. drafted the manuscript. C.P., T.B. and S.C. reviewed and finalized the manuscript. All authors critically reviewed and approved the final manuscript.

Acknowledgements

We would like to thank the regional health authorities for their coordination support, all regional vector control technicians for the tireless efforts in conducting the surveys and measuring the integrity of nets and all sailas (i.e. community leaders) and participants from Guna Yala who agreed to participate in this survey.

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No competing interests reported.

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Pilot Introduction of long-lasting bednets and hammock nets in the Indigenous Comarca of Guna Yala, Panama

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Abstract

Figures

BACKGROUND

MATERIALS AND METHODS

Study site

Household enumeration and LLIN quantification pre-distribution

Social Behavior Change Communication (SBCC) to foster community acceptance and use of LLINs

Net distribution

Post-distribution verification

Post-distribution monitoring and evaluation

Data collection during enumeration, LLIN distribution and post-distribution monitoring:

Data analysis

RESULTS

Distribution results

SBCC results

Post-distribution monitoring results

Satisfaction with the distributed nets

Adverse reactions

Retention, coverage and access:

Use

Physical integrity:

Washing, drying, and handling practices:

DISCUSSION

CONCLUSIONS

Abbreviations

Declarations

References

Additional Declarations

Supplementary Files

Status:

Version 1