Tailoring malaria interventions to high–risk groups in Senegal

In Senegal, as in the rest of the malaria–endemic world, pregnant women and children under the age of five bear the greatest burden of severe illness and death due to malaria. However, they are not the only groups at high risk of malaria.

In many places, specific groups of people may be placed at particular risk of malaria infection because of unique aspects of where and how they live. For many, their occupation can make them harder to reach with malaria interventions and more likely to be exposed to mosquito bites. PATH’s Malaria Control and Elimination Partnership in Africa (MACEPA) is working with the Senegal National Malaria Control Program to target interventions to reach such high–risk populations, and make sure they have the right tools and services to address their specific needs.

Two high–risk groups in Senegal include talibés—boarding students at Koranic schools—and gold miners. While both groups face heightened malaria risk, the reasons for this increased risk are quite different.

Talibés, who are predominantly boys five to 18 years of age, attend religious schools called daaras to learn about the Koran and cultural values. Many of these schools are residential, meaning the students study and reside in their classrooms. Consistent use of long–lasting insecticidal nets to prevent malaria infection is often challenging in this environment, and the children often spend time outdoors at night where they are exposed to mosquitoes, which may be contributing to a higher malaria burden in talibés compared to other children.

Gold miners are similarly at higher risk of malaria than the average person in Senegal due to where and how they spend their time. Gold miners are a very mobile population, traveling across Senegal’s regional and sometimes even country borders to work seasonal mining jobs.

This mobility makes it difficult for the health system to keep track of the individual members of this group and ensure they receive the routine malaria prevention services they need to reduce their risk of infection. Further, many of the mines they work in are found in areas with limited access to health care.

In addition to being missed by routine malaria interventions, gold miners face a higher risk of exposure to malaria because of the nature of their work and living conditions. Gold miners often spend time outside at night and sleep in temporary or informal structures near their worksites that can’t be protected by indoor residual spraying, making it easy for malaria–carrying mosquitoes to bite them.

High–risk groups like talibés and gold miners have specific malaria prevention needs that are difficult to address, and there is currently a lack of specific targeting of tailored malaria surveillance and intervention approaches for these populations. To address this problem, MACEPA conducted a study to evaluate the implementation of tailored interventions targeting talibés and gold miners in Senegal’s Kaolack and Saraya Districts, respectively.

In this study—which was initiated and sponsored by the Malaria Elimination Initiative at the University of California, San Francisco (UCSF) with funding from the Bill & Melinda Gates Foundation—MACEPA and UCSF compared the impact of the standard malaria control activities currently implemented in Senegal with the addition of targeted interventions for these high–risk groups. The interventions tested included routine delivery of long–lasting insecticidal nets (LLINs), education around malaria prevention behaviors, and community case management—in which peer talibés and gold miners were trained as community health workers (CHWs) to provide malaria testing and treatment at the schools and gold mining sites. To measure impact, the team monitored the prevalence of the malaria parasite and self–reported intervention coverage before and after delivery of the tailored interventions.

Among the talibés, the addition of the targeted interventions was both successful and well–received. At the end of the study, malaria prevalence among the talibés had significantly decreased, and LLIN use had increased by more than a third. Community case management—in which the talibé trained as CHWs providing malaria testing and treatment to their fellow students—was shown to be both very well accepted and feasible, with all respondents saying they are comfortable being tested by a peer CHW, and almost 90% of schools reporting that they had a peer CHW conduct testing and treatment by the end of the study.

All respondents also indicated that they were comfortable using the LLIN. The primary barrier to the students receiving testing and treatment during the study was shortages of malaria rapid diagnostic tests.

However, this specific set of targeted interventions was not as effective at addressing the needs of the gold miners. At the end of the study, there was no change in LLIN usage among gold miners, and malaria prevalence remained the same. The miners indicated that they were not comfortable using the LLINs—potentially because of particularly high temperatures during the time of the study, rendering the nets uncomfortable to sleep under—and only one–tenth said that the first place they would go to receive malaria testing was their fellow gold miner trained as a CHW.

These vastly different results among two high–risk groups reveal an important truth in malaria programming: there is no one–size–fits–all approach to the fight against malaria. The same tools and approaches have different impacts depending on the context of where they’re deployed—including epidemiological, social, cultural, and environmental contexts, among others. High–risk populations, in particular, require tailored interventions to effectively address the specific challenges presented by their unique contexts.

In this case, the talibés were reached with these interventions in the place where they lived and studied. The LLINs were hung in the place where they would sleep every night, and the CHWs who visited their schools were members of their own community. Conversely, the gold miners are very mobile. There is high turnover at the mines, with miners arriving to perform seasonal work. In fact, only 30% of miners present at the end of the study had been present at the site at the onset of the study, indicating significant movement of miners into and out of the area over the course of the study.

This can make it challenging for CHWs to deliver services to these populations, and miners may not be as willing to visit CHWs who aren’t familiar to them—even if they are a fellow gold miner.

As a result of this study, the team recommended that LLIN use among talibés could be effective if targeted specifically to them, possibly combined with the distribution of preventative malaria medication and net–hanging education. They also indicated that training a talibé to provide malaria testing and treatment was both feasible and acceptable. One way the LLINs could be tailored to fit the boarding school context could be to consider larger nets that can cover multiple talibés in large sleeping spaces.

On the other hand, the results suggested that a different approach would be needed for the gold miners. The MACEPA team recommended new strategies that might work better for a population on–the–go, including leveraging peer networks to engage directly with mobile gold miners, providing preventative malaria medication, and using a different vector control tool they might find more appealing, such as repellants.

Up next, the MACEPA team plans to pilot targeted interventions for another high–risk, mobile population in Senegal—nomadic pastoralists who migrate periodically to seek pastures for their livestock. PATH MACEPA and the Senegal National Malaria Control Program are working hard to ensure high–risk groups throughout Senegal find the set of malaria interventions that fit just right.

Together, we are helping overcome challenges to protecting those most at risk of malaria, and accelerating progress towards a malaria–free Senegal.