Delivering an insecticide-treated net campaign in a complex operating environment: lessons from Anambra state, Nigeria

(2025) 24:313 Adeniyi et al. Malaria Journal https://doi.org/10.1186/s12936-025-05529-w Malaria Journal Open Access RESEARCH Delivering an insecticide‑treated net campaign in a complex operating environment: lessons from Anambra state, Nigeria Laitan Adeniyi1, Kunle Rotimi1, Elisabeth G. Chestnutt2*, Abiola O. Oluwagbemiga1, Saliu Ogunmola1, Nonso Ndibe3, Olusola Oresanya1, Julianna Smith2, Kolawole Maxwell1 and Tarekegn A. Abeku2 Abstract Background Malaria is one of the leading causes of morbidity and mortality in Nigeria. Distribution of insecticidetreated nets (ITNs) is an important vector control strategy. In 2022, despite security challenges and COVID-19 restrictions, an ITN distribution was implemented in Anambra state. This paper describes the adaptations made to the ITN distribution campaign to ensure the safety of personnel, communities and property during implementation. Methods Following national COVID-19 guidelines, the ITN campaign implemented a single-phase door-to-door distribution strategy. In May 2022, security risk categorization activity was carried out prior to the campaign to determine risk levels in each local government area (LGA) in the state. All LGAs and wards were classified into three risk categories as either high, medium or low. A set of adaptations were made to mitigate risk during the delivery of ITNs in high-risk locations. High risk LGAs were characterized by limited activities with comprehensive coordination involving both security agencies and existing community structures. The security situation in each LGA and ward was monitored during the campaign to ensure the correct set of actions were followed throughout. Results After conducting risk categorization, 11 out of the 21 LGAs in Anambra state were classified as high security risk. The adapted campaign strategy was implemented across all 11 LGAs. During the campaign 3,850,316 ITNs were delivered to 1,245,548 households across all 21 LGAs in the state. Engaging with community leaders and security agencies during the planning and implementation phases was critical for ensuring the safe delivery of ITNs to households in high-risk areas. Working with distributors from within the community and consistent use of communication technologies also helped to reduce the risk to personnel and supported the monitoring of the security situation and the progress of the distribution within each LGA. Conclusion Despite the insecurity in parts of Anambra state, ITNs were delivered to households in all LGAs. Engaging with existing community structures and appropriate use of technology can help to deliver malaria prevention interventions in security-compromised areas. The lessons from this campaign can help to inform and improve the strategies of future ITN distribution campaigns in complex operating environments. Keywords Malaria, Malaria prevention, Insecticide-treated nets, Vector control, Nigeria, Insecurity, COVID-19 *Correspondence: Elisabeth G. Chestnutt 1 Malaria Consortium, Abuja, Nigeria 2 Malaria Consortium, London, UK 3 State Malaria Elimination Programme, Akwa, Anambra State, Nigeria Background Insecticide-treated nets (ITNs) are the most widely used method of malaria vector control globally and are estimated to have averted 450 million malaria cases in Africa between from 2000 and 2015 [1, 2]. Over the last two © The Author(s) 2025. Open Access This article is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License, which permits any non-commercial use, sharing, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if you modified the licensed material. You do not have permission under this licence to share adapted material derived from this article or parts of it. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by-nc-nd/4.0/. Adeniyi et al. Malaria Journal (2025) 24:313 decades over 2 billion ITNs have been delivered in the Africa region, most of which have been delivered through mass distribution campaigns [3]. Planning and implementing mass campaigns often require complex logistics and a large number of personnel. Implementing mass ITN distribution campaigns can be especially challenging in settings affected by instability and conflict. Over one billion people globally live in areas affected by conflict or instability, many of which overlap with areas where malaria is endemic [4, 5]. Previous studies have shown that conflict disrupts access to health services [6]. These disruptions also affect access to malaria services and have been observed to lead to rises in malaria cases. For example, during a period of intense conflict in Ethiopia malaria cases increased by 1.3 million in one year [7]. Similarly political and social instability in Myanmar has seen malaria rise from 78,000 cases in 2019 to 584,000 cases in 2022 [7]. Therefore, maintaining access to malaria prevention in areas affected by conflict is especially important. Nigeria accounts for nearly 27% of global malaria cases and in recent years parts of the country have been experiencing periods of instability [7]. In Anambra state security challenges have affected access to health services in a variety of ways [8]. Stay-at-home orders and fear can prevent people from travelling to health facilities and security concerns can impede the delivery of health interventions and commodities to insecure areas [8]. An ITN distribution campaign was implemented in Anambra state in 2022. During the planning and implementation several adaptations were made to comply with COVID-19 restrictions and to ensure the safety of personnel and property in insecure areas. The adaptations made to comply with COVID-19 protocols included the use of a single-phase door-to-door distribution strategy and are described in detail elsewhere [9]. This paper describes the process of identifying areas with high security risk, implementing adaptations to mitigate security challenges and the lessons from delivering ITNs in a complex operating environment. Methods Anambra state and its malaria situation Anambra state is situated in the southeastern region of Nigeria, bounded by Delta, Imo, Enugu and Kogi states (Fig. 1). The state comprises 21 LGAs and 330 wards. In 2021, when the microplanning of the campaign was conducted, Anambra state had an estimated population of 6,322,000. The state experiences two distinct seasons: a dry season from N (...truncated)