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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.

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