East African Medical Journal

Malaria elimination in Kenya: Leveraging routine data amidst climate change

A.B. Kihara — 2024-05-17

No Abstract

Adherence to malaria case management guidelines in the treatment of uncomplicated malaria in Public Health Facilities in Kenya, 2023

C. Chege — 2024-05-17

Objective: To establish the level adherence to malaria treatment guidelines among of health workers in public health facilities in Kenya.

Design Setting: This was a cross-sectional, cluster sample health facility assessment.

Subjects: Health facilities offering outpatient services, health workers deployed there and febrile patients seeking services in those health facilities at the time the study.

Main outcome: Level of adherence to malaria treatment guidelines in the treatment of uncomplicated malaria.

Results: Overall, 170 health facilities offering outpatient services were recruited in the study, 223 health workers and 567 febrile patients were interviewed. Malaria parasitological diagnosis was provided in 86.5% of the facilities. Majority (77.7%) of the facilities stocked with at least one ArtemetherLumefantrine pack while 20% experienced total stock. The proportion of health workers exposed to in-service training on uncomplicated malaria case management, Artesunate use, access to malaria case management guidelines and received any supportive supervision during 3 months was 23.3%, 64.6%, 55.2% and 46.2%, respectively. Availability of malaria diagnostics and ArtemetherLumefantrine adherence was 54.5%. The proportion of febrile patents tested for malaria was 93.8% in high malaria risk areas and 27.6% in low malaria risk areas. The proportion of febrile patents managed in accordance with malaria guidelines was 88.8% in high malaria risk and 25.8% in low malaria risk areas.

Conclusion: The study indicated that health workers exhibited sub-optimal adherence to test and treat guidelines for uncomplicated malaria. There is a need to implement strategies aimed at bolstering adherence to treatment guidelines for uncomplicated malaria among health workers.

Assessing capacity in surveillance and response, resource availability and readiness score for malaria elimination in four counties and their sub-counties; Kenya, 2023

C. Kilonzo — 2024-05-17

Objectives: The objective of this study was to assess capacity in surveillance and response, resource availability and readiness score for Malaria Elimination in Four Counties and their Sub Counties.

Design: This was a retrospective cross-sectional study design that used routinely collected malaria program data using a tool adopted by NMCP (National Malaria Control Program) and modified to fit the country’s context, DistrictLevel Readiness for Elimination of Malaria Tool (DREAM-IT), developed by the University of California, San Francisco (UCSF) during a baseline survey in January 2023.

Setting: Four counties targeted for malaria elimination in Kenya namely, Kirinyaga, Nyandarua, Laikipia and Nyeri and their 21 sub counties.

Subject or participant: County and sub county health management teams in malaria related positions.

Intervention: Implementation of malaria elimination strategy in the four target counties in Kenya.

Main outcome measures: County and sub-county health management teams’ readiness score to implement surveillance, response, and avail resources for malaria elimination. Results: For surveillance and response, the readiness score was at 50 % both at the county and sub-county level and notably worst in one County at 30%. Resource availability was over 85% both at the sub county and county level, however, in one county resources in the county level were very low compared to the sub county.

Conclusion: In conclusion, there were variations noted across all the counties as illustrated by the readiness score at the county and sub county level. Need to improve on data management, data quality assurance mechanisms, human resource capacity building and prioritization of malaria activities at county and sub county level.

Assessment of health facility access to care, surveillance and response readiness and readiness score for malaria elimination in four counties, Kenya, 2023

J.G. Murangiri — 2024-05-17

Objectives: To determine capacity for; surveillance and response; access to care and readiness score for malaria elimination implementation amongst the sampled health facilities.

Design: A retrospective cross-sectional study that used routinely collected Malaria program data using a District-Level Readiness for Elimination of Malaria Tool (DREAM-IT) tool, adopted by the Ministry of Health and modified to fit the country’s context.

Settings: Four malaria elimination target counties in Kenya namely; Kirinyaga, Nyandarua, Laikipia and Nyeri.

Subject: Healthcare workers in twenty- four sampled health facilities offering outpatient and inpatient malaria services across all levels of care. Interventions: Implementation of malaria elimination strategy in Kenya.

Main outcome measures: Health facility readiness and score in Access to care (Case management), Surveillance and response for malaria elimination implementation.

Results: Most of the study health facilities were government- owned (public) and level 2. Kirinyaga recorded the best performance in case management. Surveillance and response was performed over 50% in Kirinyaga and Nyandarua, and was poorly performed in less than 40% in Nyeri and Laikipia.

Conclusion: In elimination settings, a case-based surveillance system with increased sensitivity and specificity as part of broader strengthening of the passive surveillance systems is key. High-quality and prompt case management that allows testing and treatment of all suspected and confirmed malaria cases respectively should be put in place to reduce transmission, especially in lower-level health facilities where majority of people seek care. More investments in health systems in readiness for malaria elimination implementation in Kenya is required.

Effect of Piperonyl Butoxide (PBO) long lasting insecticide treated nets (llins) on malaria incidence and test positivity rate compared to standard llins after mass net campaign in Kenya, 2021

L. Kariuk — 2024-05-17

Objective: This study aimed to compare the effectiveness of Piperonyl Butoxide (PBO) Long -Lasting Insecticidal Treated Nets (LLINs) and standard LLINs on malaria incidence and Test Positivity Rate (TPR).

Design: This was a retrospective cross-sectional study using routinely collected data on malaria incidence and test positivity rate in Kenya Health Information System (KHIS) from a county where PBO LLINs and standard LLINs were distributed.

Setting: Malaria incidence and positivity rate data from Siaya and Busia counties where standard LLINs and PBO LLINs were distributed respectively was extracted from KHIS. The two counties are within Lake endemic zone with malaria prevalence at 19% and high intensity of insecticide resistance. Interventions: Deployment of PBO and standard LLINs.

Main outcome measures: Malaria incidence and test positivity rate. Results: Malaria incidence decreased from 612.8 cases in 2020 to 590.5 cases in 2021 and TPR decreased from 54.6% in 2020 to 47.4% in 2021 after the distribution of standard LLINs. In Busia where PBO LLINs were distributed, Malaria incidence increased from 436.9 cases in 2020 to 525.4 2021 after distribution due to increased blood examination rate from 84 per 100 populations to 106.3 per 100 populations in 2021. Test positivity rate decreased from 48.3% in 2020 to 43.1% in 2021 after distribution of PBO.

Conclusion: The PBO LLINs were more effective than standard LLINs in reduction of malaria incidence and test positivity rate in an area with high intensity of pyrethroid resistance.

Effectiveness of larviciding as a supplementary malaria vector control intervention in the lake endemic zone: A case study of Busia county, Kenya, 2022-2023

E.C. Sigei — 2024-05-17

Background: Malaria is a leading cause of morbidity and mortality globally, mostly in tropical countries, accounting for more than one million deaths annually. Community-based larval source management using larviciding was recently introduced as a complementary tool within the context of existing Integrated Vector Management strategies. This study aimed at generating evidence on the effectiveness of microbial larvicides in reduction of mosquito larval densities in the mapped aquatic habitats to improve malaria control.

Methods: The biolarvicides BACTIVEC® Bacillus thuringiensis var. israelensis and GRISELESF® Bacillus sphaericus were used. Products applications were made aquatic habitats findable and fixed in selected areas of seven sub-counties in Busia County during the period of January to December 2022. Larval densities were determined using a standard WHO protocol at each study area prior to and after larviciding.

Results: Anophilines and Culicines larval species of mosquitoes were both present in all the surveyed accumulated open water bodies. The larval type of breeding habitat predominance rates was in the order; Rice fields (24%), Dams (23%), Swamps (21%), Puddles (12%), Lagoon (9%), Fishpond (4%), Streams and Seepage pool (3%) each respectively, and Rivers (1%). Prior and post larviciding, the average reduction in relative larvae colonization rate in all habitats aggregated was 95% (P <0.001).

Conclusions: The study showed the potential effect of larviciding using biolarvicides of bacillus group to control vectors of mosquito borne diseases and its integration with indoor residual spraying and insecticide treated nets in malaria prevention.

Effects of Community Malaria Case Management to the overall malaria incidence in Busia county, Kenya, 2022

E. Onyango — 2024-05-17

Objectives: The objective of the present study was to determine whether Case Management of Malaria (CCMm) by Community Health Volunteers (CHVs) affect the trends of malaria incidence in Busia Kenya, 2018-2023. Specifically, the study aimed at determining the proportion and trends per year for those tested and treated for malaria in health facilities and Community Units and to correlate the trends with annual malaria incidence, out-patient malaria cases, weather patterns, climate change and commodity availability at the community level.

Methods: The research involved a retrospective cross-sectional study encompassing for Busia County as the study site involved analysis of routinely collected malaria program data which was abstracted online from the Kenya Health Information Systems.

Results: The proportion of Suspected Malaria Cases being tested in the community by the Community Health Volunteers compared to those tested at Health facilities increased from 11% in 2019 to 45% in 2022. The rate of malaria infections per month has remained almost constant, with peak infections occurring in May every year, except May 2020. Over time, the contribution of CCMm in overall malaria case management and incidence has increased, with more Malaria cases being treated at the Community as from mid-2022. The incidence of Malaria has remained high over the years.

Conclusion: Community Case Management of Malaria improves access to Malaria treatment services but does not in itself reduce the Annual Malaria Incidence in Busia County.

Effects of Facility-based Malaria surveillance monitoring and evaluation mentorship model on data quality in Kakamega County, Kenya

F. Sakari — 2024-05-17

Objectives: This paper aims to describe the impact of the facility-based malaria surveillance monitoring and evaluation (SME) mentorship model on data quality in Kakamega County, Kenya.

Intervention: Facility-based mentorship for malaria surveillance, Monitoring and Evaluation

Methods: This is a retrospective study that analysed routine data collected during routine malaria data quality assessments (mRDQAs) in Kakamega County before and after implementing the facility-based SME mentorship program. The study assessed data quality indicators, including completeness, timeliness, accuracy, and consistency, through mRDQAs conducted by trained SME mentors.

Results: A total of 35 SME mentors were trained, and 1,403 healthcare workers were mentored in 225 (100%) targeted health facilities. The study found significant improvements in data completeness, timeliness, and accuracy following the mentorship program. Timely reporting increased from 96% to 99%, completeness of reports from 96% to 100%. Data accuracy improved for several key malaria indicators. Cross-checks revealed discrepancies between baseline and round two assessments, with reduced accuracy in Cross-checks between Laboratory and Pharmacy registers and a significant increase in Artemisinin Combined Therapy (ACT) stock management log and pharmacy register, suggesting potential overreporting.

Conclusion: The study underscores the positive effects of facility-based mentorship on malaria data quality through improvements in completeness, timeliness, accuracy, and other data quality aspects. It acknowledges areas requiring attention, including data consistency and system attributes. It recommends strengthening data quality through checks, audits, custom tools, and continuous capacitybuilding activities for new and experienced healthcare workers.

Evaluating coverage of malaria vaccination with RTS’s among children aged 6-24 months in selected sub-counties in the malaria-endemic western Kenya Region, 2019 – 2022

A. Oginga — 2024-05-17

Objective: To assess malaria vaccination coverage, dropout rates, and proportion of unimmunized children aged 6-24 months in the malaria lake endemic zone, Kenya.

Design: A retrospective cross-sectional study using routinely reported national program data from health facilities (2019 – 2022).

Setting: The study was conducted in 26 selected sub-counties of the Malaria Lake endemic zone, Kenya.

Participants: Children 6-24 months of age residing in the malaria lake endemic zone, Kenya.

Intervention: Vaccination using malaria vaccine (RTS, S) dose 1 to 4.

Main outcome measures: Malaria vaccination coverage, malaria vaccine dropout rate, and proportion of unimmunized children.

Results: There was a gradual increment in the uptake of malaria vaccine (RTS, S) doses 1 to 4 during the study period. The uptake of malaria vaccine (RTS, S) 4 was 50% of the desired 80% coverage. The dropout rate progressively declined between malaria vaccination (RTS, S) 1 to 3 within the threshold of 10%. Dose 4 showed the highest dropout rate (57%). There was a decline in the proportion of unimmunized children below 1 year over the study period.

Conclusion: Malaria vaccine coverage was satisfactory in doses (1, 2, 3), while uptake of dose 4 was low by two years at (37%). This calls for strategies aimed at enhancing malaria vaccination integration in the second year of life. Additionally, there is a need to unravel factors associated with high dropout rates and devise measures for minimizing or eliminating dropout. Enhancing community engagement and advocacy is potentially key for better coverage and maximum protection.

Insecticide resistance status in anopheles Gambiae Sensu Lato (S.L.) in four malarial epidemiological zones in Kenya, 2023

E. Ramaita — 2024-05-17

Objective: This research aimed at determining the status of insecticide resistance in the Anopheles gambiae s.l malaria vectors to different classes of insecticides in the four malarial epidemiological zones in Kenya.

Design: A retrospective descriptive cross-sectional study of routinely collected insecticide resistance monitoring programme data.

Setting: The study considered five counties within four malarial epidemiological zones: Kwale (Coast endemic), Kirinyaga (Low transmission zone), Nandi (Highland endemic prone zone), Baringo (Seasonal transmission zone), Marsabit(seasonal transmission zone).

Methods: Three to five days old adult mosquitoes that emerged in the insectary from larvae collected from breeding sites in Kirinyaga, Baringo, Kwale, Marsabit and Nandi counties were tested for susceptibility to pyrethroids, organophosphates, organochlorines and piperonyl butoxide (PBO)-pyrethriod synergist as per WHO insecticide resistance bioassay procedure. Identification of all bioassayed mosquitoes was done using appropriate morphological keys.

Results: Confirmed resistance in Anopheles gambiae sl. to pyrethroid deltamethrin was observed in Kirinyaga, Kwale and Marsabit counties. Further, resistance to the pyrethroids permethrin was observed in Kwale and to lambdacyhalothrin in Kirinyaga. The findings on susceptibility to the test insecticide were as follows; permethrin in Kirinayaga, deltamethrin in Nandi Hills and lambdacyhalothrin in Kwale. Additionally, susceptibility of Anopheles gambiae sl. to organochlorines, organophosphates, and PBO pyrethroid synergist was observed in Kirinyaga, Baringo and Kwale respectively.

Conclusion: The data from the present study showed confirmed insecticide resistance majorly to the pyrethroids across the five epidemiological zones but there was susceptibility to organochlorines, organophosphates, and synegistpyrethroid classes across all the zones. Continued insecticide resistance monitoring and management in areas with observed resistance is key in ensuring the effectiveness of insecticide-based vector control interventions in place.

Monitoring Health Workers’ adherence to malaria case management guidelines for patients with severe malaria at Public Health Facilities in Kenya, 2023

B. Machini — 2024-05-17

Objectives: Among the suspected severe malaria patients admitted in the public health facilities in Kenya, to identify those that are correctly diagnosed, assess the health workers’ adherence to malaria case management guidelines, health facility and health worker readiness to implement the policy.

Design: Cross-sectional, cluster sample survey.

Setting: All 47 counties in Kenya, 2023

Subject: 49 Government and 42 faith-based hospitals were assessed, 318 inpatient health workers from paediatric and medical wards were interviewed and 2073 files for patients admitted with suspected malaria were examined.

Main outcomes: testing suspected malaria patient, recommended treatment based on severity criteria and test results.

Results: Among all patients 42.6% had documented at least one feature of malaria severity and 36.8% were diagnosed as severe. Adherence to severe malaria treatment guidelines was 54.6%, 96.7% of all hospitals provided malaria microscopy, 82.4% stocked artesunate and 41.8% had at least one ward with displayed artesunate poster, 36.5% of health workers were trained on artesunate, 45.3% accessed malaria case-management guidelines and 28.3% had been supervised.

Conclusion: Despite high level health worker adherence to test and treat policy for severe malaria, there was a significant irrational use of artesunate for non-severe patients with microscopy confirmed positive test. There is a need to focus on programmatic interventions directed to rationalize the use of artesunate. Health workers' supervision, case-management training, dissemination of guidelines and job aids should be programmatic priority.

Performance of the test-and-treat policy for uncomplicated malaria in Kenyan Health Facilities in 2022

F.O. Odhiambo — 2024-05-17

Objective: To assess the capacity of health facilities in Kenya to implement the test-and-treat policy, adherence to the guidelines in outpatient departments, and health facility factors associated with adherence to the guidelines.

Design: Retrospective review of health facility data from a routine crosssectional survey.

Setting: Public and faith-based facilities in Kenya, 2022.

Participants: Suspected malaria cases visiting outpatient departments in health facilities.

Intervention: Implementation of the test-and-treat strategy for malaria case management.

Main outcome measures: Adherence to the policy was a composite indicator defined as confirmed malaria cases receiving Artemether- Lumefantrine (AL), or negative-testing patients not receiving antimalarials, or untested patients not receiving antimalarials.

Results: Malaria diagnostic services were offered in 95% of the facilities, while AL availability was 86%. Hospitals contributed 69% of the 1068 outpatient consultations. Adherence to guidelines was observed in 60.4% of the cases. The odds of adherence were higher in public health facilities (OR 3.1, 95%CI 1.57- 6.15) and facilities with malaria treatment posters (OR 2.8, 95%CI 2.00-3.78). Factors independently associated with guideline adherence were public health facilities, availability of information, education, and communication (IEC) materials (OR 1.8, 95%CI 1.30-2.59), stockout of malaria Rapid Diagnostic Tests (mRDTs) (OR 0.3, 95%CI 0.22-0.39), and availability of pediatric AL packs (AL 6s) (OR 2.3, 95%CI 1.71-3.20).

Conclusion: Most facilities could test and treat malaria cases. However, adherence to guidelines was relatively low and mainly observed in public facilities and those with malaria IEC materials and commodities. The National Malaria Control Program (NMCP) should strengthen commodity security and IEC material dissemination.

Role of data quality and health worker capacity in an artefactual increase in malaria incidence: An investigation of cases in Kwale County, Kenya, 2021

F.O. Odhiambo — 2024-05-17

Objective: To investigate the reported increase in malaria incidence in Kwale County, Kenya, in 2021.

Design: Retrospective review of health facility records and key informant interviews.

Setting: County and sub-county hospitals in Kwale County, Kenya.

Subjects: Hospital records of suspected malaria cases managed in hospitals and healthcare workers in public hospitals in Kwale County.

Interventions: Implementation of the test-and-treat guidelines for malaria.

Main outcome measures: Data quality (timeliness, completeness, data accuracy, and overall system assessment).

Results: Of the 17,607 suspected malaria cases identified in the study, 40.1% were children under five years, and 59.1% were females. Msambweni and Kinango hospitals used microscopy, while Kwale and Lunga Lunga hospitals also used rapid diagnostic tests (mRDTs) for diagnosis. Confirmed malaria cases were 1,633, peaking in February. The overall test positivity rate (TPR) was 9.3% (microscopy 9.2%, mRDT 19.5%). Kwale Hospital had the highest TPR (17.3%). The source documents completion rate was 42%, while monthly report timeliness was 58%. There was inadequate sensitization on revised surveillance tools, no written reporting guidelines, nor established malaria control targets in the study hospitals.

Conclusion: The apparent increase in incidence was due to poor data quality. The Ministry of Health should strengthen the dissemination of malaria policies and cascade capacity building on malaria surveillance and data management to all healthcare workers.

Tracking the performance of malaria surveillance indicators using routine Kenya Health Information System data across the epidemiological zones in Kenya, 2021-2022

B. Machini — 2024-05-17

Objectives: Assessment of malaria surveillance performance indicators to determine completeness of malaria reports, testing rates, incidence rates, blood examination rates, positivity rate and treatment rates across epidemiological zones in Kenya.

Design: Cross-sectional retrospective review.

Setting: All government health facilities in Kenya

Subjects: Suspected malaria cases tested and treated as reported on Kenya Health Information System (KHIS), 2021 to 2022.

Main outcomes: Reporting rate, testing rate, malaria incidence, blood examination rate, treatment, and positivity rate.

Results: The malaria reporting rates for MOH 705 was 100% in year 2021 and 98% in year 2022, MOH 706 was 88% in year 2021 and 90% in year 2022, MOH 743 was 89% in year 2021 and 94% in year 2022. The testing rate was 79% in year 2021 and 87% in year 2022. Malaria incidence rate was 75 and 83 cases per 1000 population in year in year 2021 and 2022 respectively. Blood examination rate was 18 and 19 tests per 100 population in year 2021 and 2022 respectively. The treatment rate was 102% in year 2021 and 97% in year 2022. The test positivity rate was 29% across the years. The Lake endemic zone had the highest burden contributing to 77% and 82% in year 2021 and 2022 respectively

Conclusion: To reduce malaria burden, improvement should target level two heath facilities that serve a large population of patients. Capacity building and mentorship of health workers on adherence to malaria case management could enhance the patient quality of care.

Tracking the testing and treatment of uncomplicated malaria using routine data in Public Health facilities in Kenya, 2022

R. Mwaganu — 2024-05-17

Objective: To assess consistency in testing and treating uncomplicated malaria in public health facilities, Kenya 2022. Specifically, the study aimed at determining the treatment rate for malaria-positive cases, the proportion of health facility reports with correct treatment of malaria-positive cases, the proportion of health facility reports with correct Artemether-Lumefantrine (AL) dosing, and concordance of malariapositive cases and correct AL dosing.

Design: Retrospective cross-sectional review of routinely collected data by public health facilities reported on the Kenya Health Information System (KHIS).

Setting: Government-owned (public) primary health facilities in Kenya, 2022.

Main outcome measures: Concordance on malaria-positive cases treated and AL dosing.

Results: Overall treatment rate was 98.2%, with health facilities in level 3 having the highest treatment rate (99.5%). Level 4 health facilities recorded a treatment rate (102.1%), hence an overtreatment rate of 2.1%. Reports on the treatment of only patients that tested positive were 53.7% across the three levels of care, with level 2 (56.2%), level 3 (50.5%), and four health facilities having the lowest proportion (38.7%). Only 57.1% of the reports had the correct number of tablets dispensed based on the patient's weight band. The overall performance on reports concordance with patients who tested positive and were treated with the right number of tablets based on their weight band. Levels 2 and three achieved 43.8% and 39.5%, respectively, while level performed lowest at 26.3%.

Conclusion: Gaps in data concordance on treating malaria-positive cases and AL dosing were evident, alluding to non-adherence to malaria treatment guidelines.

Trends of adherence to malaria testing and treatment guidelines by Community Health Volunteers in Kakamega county, Kenya

F. Sakari — 2024-05-17

Objectives: The objective of this study was to identify the trends in adherence to testing and treatment guidelines for Community Case Management of malaria (CCMm) by community health volunteers in Kakamega County.

Design: This was a descriptive retrospective study design using data collected on CCMm as reported on the Kenya health information system. Trends of community case management of malaria were assessed between January 2019 and December 2022.

Setting: Community units implementing CCMm in Kakamega County, Kenya

Outcome Measures: Adherence to community case management of malaria guidelines by community units implementing community case management of malaria.

Results: Kakamega County has seen a rise in malaria cases managed at the community level, from 63,686 in 2018 to 133,614 in 2022. The annual testing ranged from 95% in 2018 to 18% in 2020, while treatment rates ranged from 104% to 97.5%. The mean testing rate was 57%, and treatment rates remained consistent throughout the months, except for over-treatment (104%) in December 2018. Testing rates vary across years and sub-counties with no significant variations in treatment rates. There are 31.5% community units implementing CCMm as at December 2022. The county has a community health volunteer’s turnover of 7% between 2017 and 2022.

Conclusion: There has been an increase in the number of malaria cases managed in the community in Kakamega County. There are variations in testing rates across the years and between sub-counties. There are no significant variations in the treatment rates.

Vector control interventions towards elimination of malaria in 4 selected counties, Kenya, 2023

C. Kilonzo — 2024-05-17

Objectives: The objective of the present study was to assess the capacity to implement malaria vector control interventions in four counties, in Kenya, earmarked for elimination.

Design: This was a retrospective cross-sectional study design that used routinely collected malaria program data using a tool adopted by National Malaria Control Program and modified to fit the country’s context, District-Level Readiness for Elimination of Malaria Tool.

Setting: All the sub-counties constituting the four counties (Kirinyaga, Nyandarua, Laikipia and Nyeri).

Subjects: County and sub county health management teams.

Intervention: Implementation of vector control strategies targeted for malaria elimination in the four study counties.

Main outcome measures: County and sub-county health management teams’ readiness to deploy vector control strategies in the four study counties.

Results: Out of 21 sub-counties, 11(52%) implemented vector control interventions for malaria vector control. Kirinyaga County implemented malaria vector control strategies: proactive indoor residual spraying, mass net distribution campaign, continuous or targeted distribution of insecticide treated nets in 3 sub-counties and larval source management in two sub-counties. Five of 11 (45%) sub-counties conducted mapping of vector breeding habitats and 1(4.8%) conducted malaria vector entomological surveillance.

Conclusion: In conclusion, the four counties targeted for malaria elimination lacked adequate capacity to implement malaria vector control interventions owing to their having limited resources to implement malaria vector control interventions. To achieve and maintain malaria elimination in the four counties there is an urgent need to mobilize adequate resources for conducting malaria vector control interventions.