Driving
innovation in malaria control: research dialogue on challenges and
solutions

Projects in the spotlight

The Fund for Innovation in Development is supporting the following projects :

• The DIMORO project, led by MAÏA Africa, which aims to design and distribute an eco-friendly mosquito-repellent ointment in line with current practices and health standards. This project was subject to an impact evaluation focused on adoption conducted by Paris-Dauphine University-PSL and Innovations for Poverty Action, and was presented by researcher Elodie Djemaï.
• A project to assess the comparative effectiveness of insecticidal paints, led by Kilimanjaro Christian Medical University College in Tanzania, and presented by researcher Nancy Stephen Matowo. Project supported by L’Initiative:
• The SUCOPPA project in Benin, led by the University of Ambomey-Calavi, which is developing an innovative approach to promote better use of mosquito nets, presented by Armel Djenontin.
• The TRAPNET pilot project in Côte d'Ivoire which is trialing a mosquito trapping device, led by the Swiss Center for Scientific Research in Côte d'Ivoire, and presented by researcher Mohamadou Chouaïbou.

The four research teams were invited to present their findings, the methodological challenges faced, and their initial results.

This initial peer-to-peer exchange revealed the common challenges faced in different contexts, highlighted the synergies between the proposed approaches and innovations, and fostered interdisciplinary dialogue between teams operating in several African countries. This type of dialogue has proven useful in coordinating efforts to combat the pandemic, by producing shared knowledge in the public interest.

Amid current challenges in malaria control, the speakers highlighted the importance of developing new and innovative solutions aligned with the practices of the communities using them, as well as the need to make optimal use of existing solutions, and then combine these two approaches.

With support from FID, MAÏA Africa has therefore produced an innovative and cost-effective mosquito-repellent ointment, in keeping with current practices in Burkina Faso, to combat drug resistance, and designed for use in combination with traditional mosquito nets. In Tanzania, Kilimanjaro Christian Medical University College is assessing the comparative effectiveness of insecticidal paints to address growing resistance to traditional insecticides. In Benin, the SUCOPPA project at the University of Abomey-Calavi, supported by L'Initiative, has adopted a community-based approach to promote better use of mosquito nets. Finally, the Swiss Center for Scientific Research in Côte d'Ivoire is trialing TRAPNET, a new mosquito trapping device to combat mosquito insecticide resistance.

These various projects have all adopted an innovative approach, shared by FID and L'Initiative, with a broad-ranging scope, that addresses technological, social, and organizational issues, by focusing on community awareness and organization methods.

**"We've talked about technological innovation. We need to remember that unbridled innovation is not the answer, because there are already many tools available on the market. Innovation can also mean making optimal use of solutions that already exist, and this is something we support at L'Initiative." **Italic(Jane Deuve, L’Initiative)

The discussion between teams from different African countries also highlighted the conditions that make certain solutions transferable, providing food for thought for all those taking part. While the MAIA team praised the innovative and rigorous methods used to compare insecticidal paints, in order to improve control of vectors resistant to current pesticides, they also raised questions about their potential adaptation. The team asked whether it would be more effective and inclusive to focus on a single wall of a house, and attract mosquitoes to that place, rather than the more expensive solution of repainting the entire house.

Similarly, researcher Chouaibou Mohamadou from the Swiss Center for Scientific Research in Côte d'Ivoire pointed out the limitations of an insecticide-based approach: "New insecticides give rise to new forms of resistance, so we need to think “outside the box”.

Mosquito traps could offer an alternative solution.

In this regard, the World Health Organization recommends an integrated approach to malaria control, which combines the use of insecticide-treated mosquito nets with residual insecticide sprays in high-risk areas indoors, while emphazising the importance of preventing and managing insecticide resistance. To this end, the UN agency advocates the development of new technologies and methods of vector control, whether used alone or in combination with other solutions, which must be subject to rigorous testing to determine whether they have a place in global programs to combat this disease.

In Tanzania, the Kilimanjaro project is trialing an insecticidal paint composed of alternatives to pyrethroid pesticides, while also assessing the method and location of application. The paint is currently applied directly to the interior walls of homes, with the aim of combating current insecticide resistance. The purpose of these tests is to establish whether a solution already marketed in the United States and Europe could be adapted for use in Tanzania, as an alternative or in addition to spraying insecticides indoors. This relatively inexpensive solution has been widely accepted by communities, and could be easily incorporated into home construction and maintenance work, without the need for major changes in behavior.

The first stage of this research involves laboratory testing to determine the right formula, and develop the most effective possible paint, which is best suited to conditions in Tanzania. The research team compared different biological insecticide formulations, on different surfaces and materials, and with various application times. While preliminary, the initial results have been promising, particularly in terms of the mosquito mortality rate associated with some of the tested paints.

In Côte d'Ivoire, the TrapNet project has already demonstrated its clinical efficacy in laboratory tests and has now entered the next phase of proving its effectiveness under medical conditions. The research team conducted a pilot trial to evaluate the efficacy and acceptability of its new anti-malaria mosquito trap, compared with conventional mosquito nets.

Conducted in the north of the country, this study measured epidemiological, entomological, and socio-anthropological indicators, focusing particularly on differences in age and gender. Preliminary results have shown that TrapNet could have a major impact on public health, due to its capacity to :

• increase the effectiveness of any mosquito net, even after multiple washes;
• combat insecticide resistance by limiting the propagation of resistant genes;
• work without insecticides.

The device is also particularly cost-effective: it does not require new insecticides or complex technologies, and means that existing mosquito nets can be reused. These results have paved the way for large-scale intervention studies, and for TrapNet's incorporation into malaria control strategies in various geographical locations. In respect to this last point, the Maïa team suggested reviewing the trap's design to ensure the widest possible adoption and acceptance. This demonstrates the synergies that can be developed between research teams working on the adoption and effectiveness of these solutions.

While not constituting impact studies, the methods presented enabled rigorous testing of the effectiveness of a specific solution in a given setting, by comparing it to other uses and devices. These tests have therefore produced reliable data that can be used to combat malaria.

According to Claire Bernard, Deputy Director of FID: "Community take-up is an essential factor in the effectiveness and deployment of the innovative solutions tested, and research plays a vital role in assessing the extent and forms of take-up."

Nonetheless, a variety of research approaches and methodologies must be used to assess this data, whether at different times during projects or simultaneously. In Benin, the SUCOPPA project has continued to conduct socio-anthropological research (notably through the STRAPA project) which has revealed the main reasons for the low uptake of malaria prevention tools among pregnant women: lack of awareness, and inattention to asymptomatic human carriers, a key factor in transmission. SUCOPPA covers two key study components in two distinct disciplines:

• A socio-anthropological component which aims to describe and analyze knowledge and practices relating to malaria risk and prevention in the community (among pregnant women, women who have recently given birth, and school-age children), as well as to review existing community awareness tools used by local stakeholders, and assess the acceptability of a new approach developed together with local communities.
• An entomological study component which aims to assess entomological transmission, vector resistance to insecticides, and the role of asymptomatic carriers in transmission.

In Burkina Faso, the DIMORO project conducted a large-scale socio-anthropological survey of daily hygiene practices among 1,000 households, to assess whether families were willing to use the mosquito-repellent ointment. A more qualitative, community-based, and participatory approach was then used to tailor the product to the sensory preferences of mothers, while working with African entomologists to ensure its efficacy and safety.

The team then asked economists from Paris-Dauphine University to conduct a randomized impact evaluation to precisely assess how much participants would be willing to pay for the product, and the impact that price fluctuations could have on take-up of the ointment. The below video follows the implementation of these successive research phases throughout the project.

The results of the impact evaluation shed light on the conditions, extent, and forms of take-up of the ointment based on price, including its use in combination with other devices, demonstrating that:

• High prices are a barrier to both the purchase and continued use of the ointment.
• Use was greater among households that received the ointment for free.
• Households clearly understood that the ointment should be used in combination with other prevention or protection devices: the use of mosquito nets remained widespread, however, people tended to use the ointment as a substitute for mosquito-repellent coils and spirals. If product use was restricted due to financial constraints, families tended to apply the ointment to their children first and foremost.

For each project presented, the studies conducted provide scientific evidence and key insights into the ways and extent to which target populations have adopted these solutions. These results can either be used to inform the scale-up process, as with DIMORO, or to implement awareness-raising initiatives better tailored to local settings and target groups, as in the case of SUCOPPA.

"The takeaway from these discussions is the importance of combining multidisciplinary approaches and a range of perspectives, including those of epidemiologists and anthropologists, to fully understand uses, practices, and economists' views on how price can affect take-up. We can see the value in looking at one or several solutions from these different perspectives." Claire Bernard, FID.

Dialogue between research teams from various disciplines can also be helpful for addressing common methodological issues, particularly the bias associated with self-reporting on the adoption of solutions. To address this issue, the MAÏA project team cross-referenced data from several sources—actual number of pots used, records, and comparisons with declarations—to produce more objective results; a method that can be applied to other settings. Research, particularly in epidemiology, also plays an essential role in assessing the short-, long-, and medium-term effectiveness of malaria control solutions.

After the seminar, the research teams will continue these discussions on the transferability of innovations, approaches, and research methodologies.