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In December 2020, with Pakistan in the grips of thepandemic, 8,000 volunteers in the country’s restive tribal region managed todistribute nearly 1.5million mosquito nets to more than half a million households in the country’s remote tribal areas withoutcontracting a single known case of COVID-19. How they did it offers a valuablelesson about how health authorities, by collaborating with communities andother stakeholders, can keep new health threats from disrupting the ongoing battleagainst other life-threatening diseases, including malaria.
While the pandemic hasdirectly affected the economy, lives and livelihoods of millions, it has had adomino effect on the efforts to prevent other communicable diseases such asmalaria, HIV and tuberculosis. The Covid-19 pandemic is putting enormous stresson healthcare systems in countries with limited resources, Covid-19 has hinderedtheir ability to respond effectively to these communicable diseases. The pandemic and countries’ efforts to contain it havedisrupted the delivery of essential health services and commodities.
With nearlya million confirmed Covid-19 cases (978,847) and almost 23,000 (22,642) deaths asof mid-July, Pakistan reached the peak of its own pandemic in mid-June. Measuresby the government have flattened the curve. Pakistan went into a nationwidelockdown in April 2020, which was then extended until May 9, 2020. After thefirst wave of cases, the lockdown was eased and, since then, Pakistan has been implementing“smart lockdowns”—short-term restrictions at Covid-19 hotspots, based onsurveillance data—to curb the spread of the virus. Smart lockdowns, whileallowing for the economy to recover, also enabled health programs to resumedelivery of essential health services by allowing health workers outsidetargeted hotspots to remain mobile.
But in thepandemic’s early stages— from late May to mid-July 2020—the pandemic andmeasures to contain it had a profound impact on malaria elimination efforts. Thenationwide lockdownled to the closure of healthcare facilities and a 30% decline in screening of suspectedmalaria cases[1].Because many of the symptoms of malaria and Covid-19 are similar, patients werereluctant to seek treatment due to fear of being misdiagnosed with Covid-19 andforced to isolate. To reduce this fear, the government issued Covid-19advisories to the general population, encouraging anyone ill to seek treatment.There was a shortage of protective gear, such as personal protective equipment(PPE) kits, sanitizers and masks for health workers, but once supplies werereplenished, the delivery of essential health services resumed. Face-to-face training and capacity-building programs,supervisory visits, mass awareness and distribution campaigns were disrupted aswell. In-person training eventually resumed, albeit while observing social-distancingrules, which reduced the number of participants and training time.
Pakistan’smalaria program turned to alternative media, including WhatsApp, radio andmosque announcements, to carry out mass awareness campaigns. As the pandemicfirst unfolded in Pakistan in May and July of 2020, when some projectactivities such as field data validation were delayed, social media channelswere eventually used to share and validate data.
Anothervital success story in Pakistan’s efforts to fight malaria amid the pandemicwas its Long-Lasting Insecticidal Nets (LLIN) distribution campaign in its verychallenging tribal areas (referred to as Merged Tribal Areas (MTAs)[2],where roughly 5 million people in 558,300 households live across a rugged and remoteterritory covering 27,500 square kilometres on Pakistan’s northwest border withsouthern Afghanistan. Years of conflict in the region have made it a particularlydifficult place to deliver health services. Historically, access to healthcarein this region has remained poor, compounded by a weak public health infrastructure,shortage of healthcare providers, limited utility services and securityconcerns. As a result, MTAs reported the highest Annual Parasite Index (API) of12.9 in Pakistan in 2019.
The Directorateof Malaria Control (DMC), with support from the Indus Hospital and HealthNetwork (IHHN) and funding from The Global Fund, conducted a LLIN distributioncampaign in 2018. A remarkable 2.5 million nets were distributed in 11districts of Balochistan, Sindh, Khyber Pakhtunkhwa, and Tribal Districts. Asimilar distribution campaign was planned in MTAs between June and September of2020 by the Integrated Vector Management Program (IVMP) with the Government ofKhyber Pakhtunkhwa (KPK) as an implementing partner. However, the campaign hadto be pushed back to December 2020 due to the pandemic. Then, to reduce therisks inherent in gathering residents to collect nets in one place, DMC shiftedits distribution strategy to going door-to-door. The campaign was technically supportedby Alliance for Malaria Prevention, the World Health Organization and funded byThe Global Fund.
DMCadopted a whole-of-society approach in implementing its campaign. A tripartite contract,clearly defining roles and responsibilities, timeframe, and budget-sharing wassigned by the DMC, the KPK and The Indus Hospital. For security reasons, DMCcollaborated with security forces to get the necessary permissions and guidancein navigating the region to implement the campaign.[3] Similarly, community leaderscalled maliks were also engaged to drive awareness about the campaign. Thebulk of the distribution was done by community volunteers who were trained to strictlyfollow standard operating procedures (SOPs) and guidelines for distribution,which included wearing masks, regular hand washing, sanitizing, and socialdistancing. Since the volunteers belonged to the local community, they were wellaware of the social and cultural norms—which would have an impact oncommunity’s trust and thus their acceptance of the nets. They distributed 1.49million nets to 530,395 households in only a week and not a single volunteerwas confirmed as having been infected with Covid-19.
Distributionof LLINs is a key vector control measure, intended to protect population atrisk of malaria in highly endemic districts. Against the backdrop of theongoing global pandemic, gains made in fighting malaria over the past decademust not be jeopardized. Pakistan’s success in quickly adapting its distributionand training strategies for malaria in an extremely challenging and hard-to-reachpart of the country offer a lesson in how not to lose ground against malaria despitethreats posed by ongoing and future pandemics.
This articlewas developed with input from Dr. Muhammad Mukhtar (DMC, Pakistan), Dr. AbdulMajeed (DMC, Pakistan), Dr. Hammad Habib (DMC Pakistan), Dr. Shaista Ilyas (IntegratedVector Management Programme), Dr. Bushra Jamil (Common Management Unit forAIDs, TB and Malaria), Dr. Razia Fatima (Common Management Unit for AIDs, TBand Malaria) and Dr. Mah Talat (Indus Hospital and Health Network)
[1] Reported by Directorate of Malaria Control Pakistan
[2] FATA (previously) was officially merged with Khyber Pakhtunkhwa (KPK)province on 31 May 2018 and is since known as Merged Tribal Areas (MTA)
[3] The military restricts domestic and international humanitarian accessto MTAs conflict zones
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