Digital Insecticide-treated nets (ITNs) mass distribution campaign in the particular context of covid-19 pandemic in Benin: lessons learned and challenges.

Background: In 2020, Benin has implemented a digital Insecticide-treated nets (ITNs) mass distribution campaign in the particular context of covid-19 pandemic and then, offered important lessons to share. This paper aims to describe the implementation process as well as the lessons learned and challenges from this campaign. Methods: A descriptive design was used for reporting the planning and implementation process of ITNs campaign. Moreover, the changes and adaptations related to covid-19 pandemic are well described. Results: A total of 3,175,773 households were registered corresponding to a total of 14,423,998 persons (13.55% more from projection). Moreover, 94.16 % (13,581,637 people) of enumerated population were protected. A total of 7,652,166 ITNs were distributed countrywide. Conclusions: High political commitment, engagement and support add to the nancial and technical supports from partners were the essential factors that make 2020 ITNs mass campaign success in Benin despite the particular context of COVID-19 pandemic. It is essential to maintain the prevention activities for malaria and this could substantially reduce the overall impact of the COVID-19 pandemic in the populations at malaria risk.

Conclusions: High political commitment, engagement and support add to the nancial and technical supports from partners were the essential factors that make 2020 ITNs mass campaign success in Benin despite the particular context of COVID-19 pandemic. It is essential to maintain the prevention activities for malaria and this could substantially reduce the overall impact of the COVID-19 pandemic in the populations at malaria risk.

Background
Malaria remains endemic and a serious threat to development in inter-tropic countries, with an estimated 228 million cases and 405,000 deaths in 2018, of which 93% of cases and 94% of deaths occurred in Africa region [1].
Vector control is a key component in malaria prevention strategies and has contributed to a signi cant decrease in malaria worldwide [2][3][4]. Insecticide-treated nets (INTs) remain one of the most e cacious vector control measure available against malaria [5,6] and its use has highly increased in sub-Saharan Africa in the past decade. The World Health Organization (WHO) recommends universal coverage goal in the populations at risk through mass campaign (with one net for every two people) [7]. The big challenge to the National Malaria Control Programs (NMCPs) is to reach and sustain this high coverage rate.
Benin's NMCP has adopted mass distribution policy since 2011 and on a triennial regularity, base on the INTs lifespan evaluation conducted in this country [8] as recommended by WHO [9][10][11][12]. The 4 th edition of the mass distribution campaign took place in 2020 and has been digitized. Indeed, the purpose of using digital tools for 2020 INTs campaign was to have more accurate data on the size of the population, and speed in data collection during the campaign as far as household enumeration and ITNs distribution phases are concerned.
In addition, during the campaign process, between the enumeration phase and that of the distribution itself, the covid-19 pandemic occurred and Benin also recorded its rst cases. Recognizing the heavy toll that malaria exacts on vulnerable populations in Africa region, WHO recommended continuing with the implementation of malaria control interventions such as ITNs and indoor residual spraying campaign. On this basis, the Government of Benin, through the Ministry of Health and the NMCP decided to continue with the implementation of the campaign with the distribution phase which was pending. For this it was necessary to revise the initial distribution protocol and take precautionary measures in order to minimize the risk of transmission of covid-19 during distribution.
This report aims to describe the implementation process of INTs mass distribution campaign in Benin during the covid-19 pandemic. The speci c objectives are: (i) to describe the planning process; (ii) to describe the changes and adaptations that occurred during the distribution due to the occurrence of the covid-19 pandemic; (iii) to share outcome, challenges and lessons learned from the mass ITNs distribution campaign.

Context
Benin's population is estimated at 12,114,193 inhabitants in 2020 [13]. The country is divided into 77 communes grouped into 34 health zones and 12 departments ( g.1). Malaria is endemic in all parts of country with seasonal variations. All of Benin's population is at risk of malaria infection which is the leading cause of morbidity and mortality. The incidence of the disease in 2018 was 18.5% in the general population with 1,755,597 con rmed cases of malaria in public health facilities and almost 2,251 deaths due to malaria, most of which are in children under ve years [14].
Digital aspect of the ITNs mass campaign Catholic Relief Services (CRS), supported the Government of Benin and the National Malaria Control Program in digitizing 2020 ITNs mass campaign. CRS commenced its work with planning and capacity building sessions with NMCP staff. There was training of campaign staff on the use of digital tools and over 27,000 participants at these sessions were digitally tracked using their biometrics as a mean of validating their attendance for each training session attended. The digital platform is the Cash-and-Asset Transfer Platform (CAT). A total of 3,382 smartphones and other technology tools and devices were used to perform a household enumeration to register households within the country to obtain a robust population database. It consists during the enumeration phase to collect using smartphones, household information (size, name, sex and age of household members ...), and then a coupon was assigned to the head of household with a unique Quick Response (QR). The same digital platform was used to track distribution of ITNs and verify that all households registered received the correct number of ITNs allocated to them. The data collected on CAT was available through an online dashboard, updated in real time, allowing eld supervisors to make important decisions effectively and e ciently tracking household coverage rates as households missed were identi ed using sequencing and geospatial analytical dashboards easily accessible for eld supervisors.
ITNs campaign implementation process Figure 2 shows the different sections and the implementation process of ITNs mass distribution campaign.

a. Macro-planning
Macro-planning consisted in quantifying the number of ITNs required to achieve universal coverage according to the 2020 population projection data. In addition, the strategies for the household enumeration as well as for the ITNs distribution are designed.
b. Drafting of the campaign protocol After the macro, the protocol of the campaign was written in great detail. This protocol was then validated by all stakeholders and consisted henceforth the campaign roadmap.

c. Micro-planning
Here it developed a comprehensive micro-plan for the 2020 mass distribution which contains a rigorous gap analysis and the procurement plans as well as all details on campaign processes and a roadmap. The roles and responsibilities of actors at different levels of the health pyramid (central, department, health zone (HZ), and commune) have been clearly described. At the department warehouses, quality assurance was conducted prior to distribution. Samples of ITNs from different batches were sent to Centre de Recherche Entomologique de Cotonou, to assess physical and chemical analyses such as stress analysis, insecticide content, fabric weight, netting, mesh size. A total of 837 ITNs are tested. All the samples conformed to the WHO procurement and use of ITN for malaria control requirements. Two days before the distribution phase, net are convoyed to each village leader.

e. Trainings
In order to create equal understanding among actors at different levels of the health pyramid on the campaign implementation strategies, trainings in a cascade manner were organized at central, department and district levels [15]. In each department, separate micro-planning workshops and training of trainers (ToT) sessions on implementation took place to train the health zone and district coordination groups. Signi cant adaptations were required for the training of the distribution supervisors and teams in light of the covid-19 pandemic and the urgency to get ITNs into households through the revised distribution strategy. Therefore, the following precautions have been taken: -Training was adapted to take place over three hours with a maximum of 18 people per class -Hygiene and safety measures were put in place (handwashing facilities, physical distancing, scanning of trainees' badges rather than ngerprinting, health check, etc).
-Rooms were cleaned thoroughly before and after every session -Content for the shortened training sessions is revised included door-to-door distribution techniques with the use of smartphones and hygiene measures and the importance of keeping at least one meter physical distance from any other person -Audiovisual les and the electronic version of the distribution guide are shared with the distributors at the end of the training to enable them to review the content of the training once at home -Whatsapp groups have been created between trainers and distributors to facilitate exchanges after training f. Households enumeration Household enumeration was conducted by volunteers whom had at least a grade 7 at secondary school. Each enumerator team is made up of two people. The rst person is equipped with smartphone in which he records the household's informations. The second person delivers to the household a voucher for ITNs in the form of coupon with a Quick Response (QR) code ( g. 3) which is the unique identi er of the household. The coupon is then later exchanged for the corresponding number of ITNs in the distribution phase during which, the coupon once scanned, generates all the household informations and display the accurate number of nets to be redeemed based on the applied distribution key (1-2 persons = 1 ITN; 3-4 persons = 2 ITNs; 5 -6 persons = 3 ITNs; ……..19-20 persons= 10 and more than 20 persons = 10 ITNs). The enumerator teams nally delivered key messages on malaria and the importance of sleeping under a ITN.
The teams progress from house to house so as to cover all the households in the geographical area assigned to them and had to register 60 households in rural areas against 70 in urban areas per day over a period of 16 days.

g. Mass distribution
The campaign was spread out in two phases. As it was the rst time that Benin implemented a digital ITNs campaign, a pilot phase at the scale of a health zone was organized as a prelude to the national phase in order to understand the di culties and constraints related to the use of digital tools.
-Pilot phase: Fixed distribution strategy The initial approach was xed distribution strategy. During the pilot phase which has implemented in one health zone (Abomey-Calavi/Sô-Ava) in Atlantic department, ITNs distribution was done at xed sites at the village level at a public place chosen for this purpose. Each household presented their coupon in exchange for ITNs. The number of ITNs to be allocated per household is displayed by the smartphone once the coupon has been scanned.
The distribution teams involved in the distribution phase (planned for 4 continuous days, with 2 days extra) were composed of four xed agents ( g. 4) -National Phase: Door-to-door distribution During the nationwide phase, between the enumeration phase and the distribution phase, covid-19 outbreak occurred. Fixed distribution approach was not suited to this context. It has therefore become necessary to revise the distribution approach. Thus, the distribution protocol was revised into a door-todoor distribution approach. By this approach, a distribution team directly delivered ITNs to recipients at their homes. The number of distribution team members has remained the same, however their roles have been revised to adapt to the new distribution approach (Fig. 5)

Monitoring of household enumeration coverage
External monitoring was carried out by an external rm during the household enumeration. A rapid monitoring was carried out using Lot Quality Assurance Sampling (LQAS).
All of 77 communes were monitored. Monitoring results were shared at time with the actors and supervisors, in order to return to complete enumeration in low coverage areas.

Supervision and coordination
At the national monitor and district supervisor levels, planned eld-based activities were reduced in scale. A daily scrutiny of the distribution data uploaded from the smartphones and a virtual meeting each evening allowed supervisors and monitors to focus on problem areas and challenges that could then be addressed and resolved. At the local level, supervisors focused on ensuring that distribution teams adhered to the covid-19 safety measures, as well as ensuring planning and management of the daily team movement plans. Their responsibility included checking the health of distribution team members each day and not allowing them to continue if they showed any covid-19-like symptoms. As yet, results of the local supervision have not been thoroughly analyzed, although anecdotally, it seems that it was quite a challenge for distribution teams to adhere closely to the distancing regulations. In addition, a whatsapp group has been created at the national level which integrates the actors at different levels in order to resolve the di culties and situations during the distribution.

Communication
The plan for communication included radio and television slots, town announcers and advocacy at every level. Advocacy meetings were completed in advance of the household registration phase, engaging leaders for the entirety of the campaign process. In advance of implementation of the revised strategy, messages were modi ed slightly to inform about the change of strategy, the new dates and the measures being taken to prevent transmission of covid-19. As well as radio, television and town announcers, mobile messaging and audio call messages (for the less literate) were used. Community leaders were involved in local mobilization and were asked to be alert to any miscommunication that they heard about the ITNs or covid-19 and to report these to the community supervisor. Following the distribution, communication reinforced the messages passed to households by the distribution teams, i.e. proper airing of new ITNs, use of ITNs, hanging techniques and measures to prevent covid-19.

Results
Household enumeration outcome A total of 3,175,773 households were registered (more 9.3% from projection) corresponding to a total of 14,423,998 persons (13.55% more from projection) ( Table 1). The real ITNs needs are therefore known after the enumeration. It was after the household enumeration that ITNs are conveyed to the villages. Table 1 Registered population, households, and LLINs needs after household registration ITNs distribution outcome Of the 8,609,873 ITNs procured, 7,652,166 were distributed through mass distribution to the bene ciaries. The balance from the procurement was kept to be used for routine distribution. A total of 3,240,259 households were served in the whole country, which corresponds to 93.35 % of enumerated households. Moreover, 94.16 % (which corresponds to a total of 13,581,637 people) of enumerated population received ITNs during the distribution phase (Table 2). Table 2 Households served and distributed ITNs

Discussion
The 2020 ITNs mass distribution campaign in Benin was remarkable. It has not only been digitized for rst time in Benin, but also the distribution has been implemented in the particular context of the covid-19 pandemic and then offered important lessons.
The bene t of digitizing the ITNs distribution campaign was particularly obvious. It enabled accurate and e cient implementation phases of the campaign. It also enabled the speed in data collection and monitoring as far as household enumeration and ITNs distribution are concerned. In the context of covid-19 pandemic, the use of the digital tools and dashboards enable eld teams and supervisors to review the distribution data, reports and maps generated each day from any location in real time as prompt monitoring and supervision feedbacks were shared by overseeing supervisors via WhatsApp and other communication tools. The digital platform was also used to send key malaria messages in form of short messaging service (SMS) on malaria, the use and care of the ITNs distributed to households to inform about the bene ts of the nationwide ITN distribution and the ITNs they have received.
In addition, several other key factors enabled the mass campaign to continue during the covid-19 pandemic, and deserve to be highlighted: Strong support from the Government of Benin, through the Ministry of Health and the NMCP, to continue with the implementation of the ITNs campaign in advance of the high transmission malaria season despite the outbreak of the covid-19 pandemic.
Effective coordination between international partners (Global Fund, World Health Organization, RBM Partnership to End Malaria, Alliance for Malaria Prevention, Bill and Melinda Gates Foundation) and the NMCP and in-country partners (the United States President's Malaria Initiative, Catholic Relief Services) Regular communication between the main campaign funder (Global Fund) and the NMCP for timely decision-making to avoid delays Rapid problem-solving (for example, sourcing of covid-19 protective materials for campaign workers) by the NMCP with support from the Ministry of Health and partners Flexibility in modifying procurement procedures to minimize delays in the campaign implementation Use of an electronic system for data collection that facilitated a "no touch" approach during the ITN distribution and payment of campaign workers.
Results of this campaign showed that the enumerated population is greater than the projection (13.55% more). However, since net quanti cation had been made with a buffer (30% security stock), this increase did not have an impact on the quantity required to ensure universal access. The door-to-door distribution of ITNs to households provided an acceptable distribution coverage rate (94.16 %) and offered an opportunity for demonstrating net-hanging and face-to-face health education on ITNs use and ways of reducing net wear and tear [16]. The door-to-door delivery approach was greatly appreciated by the population. Fixed point distribution was used during the pilot phase, but this approach is not suited to the context of the covid-19 pandemic in terms of compliance with barrier measures. A multi country comparison of ITN delivery strategies based on 14 surveys from ve African countries did not nd a signi cant association between delivery strategy and ownership of a net from the campaign [17][18][19][20][21].
Despite the satisfactory results of the 2020 ITNs campaign, some key challenges deserve to be shared: Change in distribution protocol:The rst challenge is the change in distribution protocol (door-to-door approach instead of xed distribution previously planned) while campaign is already underway. The initial protocol was therefore quickly revised by a technical team.
Challenges with covid-19 protection materials: Given covid-19 pandemic, additional materials had to be ordered with short notice and delivery time. The biggest challenge was related to the availability of protection materials in su cient quantities on time. It was di cult to procure large quantities of certain materials such as masks, because masks were really seeking in the response against covid-19.
Challenges with payment the actors: At the end of the each activity phase digital timesheets were generated from the system that was used to enable the e cient payment of staff for the number of days work as registered on the system using the unique Quick Response (QR) code provided for each staff to validate their presence on the eld for each day's activities. However, as payment has be done through mobile money account, incorrect phone numbers and unreported team replacements affected the on-time payment of some actors.
Availably of supervision teams: the same supervision teams are sometimes involved in other response activities against Covid-19.
Budget implications: Changes to the budget were made quickly in line with the new door-to-door strategy, taking into account Benin's speci c geographic and logistical context and available human resources. Given the urgency of the covid-19 situation and remaining funds in the country's grant, the Global Fund was able rapidly to approve the amendments. Important modi cations included the necessary increase in days for community mobilization, brie ngs and training, supervision and distribution as well as for purchase of personal protective equipment.
ITNs mass campaigns are a major intervention for malaria prevention and also for other arthropod-borne diseases, such as dengue, lariasis and viral infections [22,23]. The burden imputable to malaria is heavily concentrated in sub-Saharan Africa where cases associated with covid-19 are increasing [24]. Although covid-19 has the potential to cause substantial disruptions to health services, due to response measures limiting usual programmatic activities, it's important to continue to prevent malaria by adapting control activities to the context of the pandemic. Recent modelling study showed that the interruption of planned ITNs campaigns due to covid-19 pandemic could lead to a loss of life-years over 5 years that is of the same order of magnitude as the direct impact from COVID-19 in places with a high burden of malaria [25].

Conclusion
Benin has implemented the digital ITNs mass distribution campaign in the particular context of the covid-19 pandemic. Despite the great challenges of its implementation due to covid-19 outbreak, the campaign was successfully implemented and contributed to increasing household ownership and population access to ITNs, and therefore contributes to the achievement of the Global Technical Strategy for Malaria 2016-2030 goals. High political commitment, engagement and support add to the nancial and technical supports from partners were essential factors for this success.

Declarations
Authors' contributions RA, CA, BH, DDE, YC, EE, NA, FT, SS, LS and AOH designed the study. RA, CA, NA, EE and AOH coordinated the campaign implementation. RA drafted the manuscript and analyzed the data. BH, AOH, YC, CA and EE critically revised the manuscript for intellectual content. All authors read and approved the nal manuscript.