MALARIA ELIMINATION IN ZANZIBAR - Soper Strategies
MALARIA ELIMINATION IN ZANZIBAR - Soper Strategies
MALARIA ELIMINATION IN ZANZIBAR - Soper Strategies
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NUMBER OF <strong>IN</strong>FECTED <strong>IN</strong>DIVIDUALS<br />
ESTIMATED COVERAGE LEVELS AND TIME TO ACHIEVE <strong>ELIM<strong>IN</strong>ATION</strong><br />
10,000<br />
9,000<br />
8,000<br />
7,000<br />
6,000<br />
5,000<br />
4,000<br />
3,000<br />
2,000<br />
1,000<br />
�� To maintain malaria free status, the surveillance system will<br />
need to rapidly detect a high proportion of all new malaria<br />
infections.<br />
8<br />
0<br />
ARROWS <strong>IN</strong>DICATE APPROXIMATE YEAR <strong>ELIM<strong>IN</strong>ATION</strong> IS<br />
PREDICTED UNDER EACH LEVEL OF CONTROL<br />
2009 2012 2015 2018 2021 2024 2027 2030<br />
YEAR<br />
COMPLETE CONTROL (RC=0, OR 100% EFFECTIVE COVERAGE)<br />
PARTIAL CONTROL (RC=0.5, OR EFFECTIVE COVERAGE AROUND 75%)<br />
SLIGHT CONTROL (RC=0.75, OR EFFECTIVE COVERAGE AROUND 65%)<br />
! The passive case detection system (i.e., health facilities<br />
including the private sector) will need to detect and treat<br />
a high proportion of imported infections to minimize risk<br />
of onwards transmission. By 2020, facilities should ideally<br />
be capable of detecting at least 75% of all new malaria<br />
infections arising in the population.<br />
! Every new case detected at health facilities–public and<br />
private–will need to be immediately investigated through<br />
visits to patients’ homes and screening of approximately<br />
100 neighboring households to identify additional cases<br />
(i.e., those missed by passive case detection).<br />
�� Estimates of Zanzibar’s importation risk (the number of<br />
infected people entering the island) are imprecise but suggest<br />
that maintaining malaria free status will be extremely difficult<br />
unless this risk is substantially diminished either by reduction<br />
of malaria in mainland Tanzania or through screening of<br />
travelers and/or high risk groups.<br />
! It will not be possible for Zanzibar to reduce LL<strong>IN</strong><br />
effective coverage (usage) below 75% unless importation<br />
risk is dramatically decreased.<br />
! More precise estimates of Zanzibar’s importation risk<br />
are urgently needed to better determine the need for and<br />
potential impact of additional screening measures (e.g.,<br />
border screening and/or screening of high-risk groups).<br />
Operational Feasibility<br />
To achieve the intervention coverage and surveillance detections<br />
rates required to achieve and maintain elimination, Zanzibar<br />
will need to improve key systems and services. It is not necessary<br />
for the health system to be “perfect” for Zanzibar to achieve<br />
and sustain elimination. However, specific improvements<br />
will need to be made in targeted areas. These improvements<br />
have been identified in past evaluations and strategic plans; to<br />
achieve elimination, the MOHSW will need to move beyond<br />
this planning to the concrete financing and implementation of<br />
the relevant improvements. In addition, specific operational<br />
recommendations include:<br />
�� Increase the proportion of people that receive prompt and<br />
effective fever treatment. This can be achieved by:<br />
! Improving health-seeking behavior through aggressive<br />
education and communication campaigns so that<br />
everyone with a fever promptly visits a high quality<br />
facility. Measures to ensure community ownership of<br />
the elimination program will be important to ensure<br />
continuation of desired behavior even when malaria is<br />
absent-“elimination fatigue.”<br />
! Ensuring universal financial access by providing malaria<br />
diagnosis and treatment for free in both the public and<br />
private sectors.<br />
! Ensuring adequate human resources and supplies at all<br />
public health facilities.<br />
! Testing all individuals with a fever or a history of fever<br />
cases presenting at health facilities. We recommend that<br />
a new diagnostic algorithm be adopted using RDTs as<br />
the main tool for fever screening at all levels, microscopy<br />
only at secondary facilities, and DNA PCR testing for all<br />
quality control.<br />
�� Improve the core facility-based surveillance system and<br />
establish a highly efficient complementary system to<br />
proactively detect and clear additional cases not presenting<br />
at health facilities. These improvements can be achieved by:<br />
! Expanding the current mobile phone-based case reporting<br />
system (Malaria Epidemic Early Detection System) to<br />
cover all health facilities, both public and private.<br />
! Establishing outbreak response teams in all districts with<br />
continued transmission risk (i.e, not in urban areas) once<br />
elimination is achieved, with sufficient staff and logistic<br />
support to rapidly investigate every new case and screen<br />
surrounding households.<br />
�� Increase the capacity and skill mix of the ZMCP to manage<br />
and implement the changed interventions required for<br />
elimination.<br />
�� Form an Elimination Technical Advisory Committee<br />
composed of 8-10 relevant independent experts to guide<br />
planning and implementation and a National Malaria<br />
Elimination Steering Committee, with representation from<br />
all relevant ministerial departments and key partners, to<br />
ensure continued leadership and financing of the program.<br />
�� Apply measures that restrict individual liberties (e.g.,<br />
mandatory house spraying or blood screening) only once all<br />
other possible measures have been exhausted in compliance<br />
with international legal frameworks.