MALARIA ELIMINATION IN ZANZIBAR - Soper Strategies
MALARIA ELIMINATION IN ZANZIBAR - Soper Strategies
MALARIA ELIMINATION IN ZANZIBAR - Soper Strategies
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<strong>IN</strong>TRODUCTION<br />
BACKGROUND<br />
In October 2007, Bill and Melinda Gates put malaria elimination<br />
and eradication back on the global agenda (Roberts and Enserink,<br />
2007). Their bold statements, together with the impact recently<br />
seen from traditional malaria control interventions (WHO,<br />
2008) have meant that several countries in sub-Saharan Africa<br />
are considering malaria elimination once again. Apart from the<br />
recently published World Health Organization (WHO) guidelines<br />
on malaria elimination (WHO, 2007; WHO EMRO, 2007a)<br />
and prevention of reintroduction (WHO EMRO, 2007b), few<br />
up-to-date reference documents are available to guide countries<br />
in the comprehensive planning for a malaria elimination program.<br />
In most countries, the institutional memory from the Global<br />
Malaria Eradication Program (GMEP) era has been lost. While<br />
one can read old accounts, many critical factors, from the control<br />
environment to the governance structures and health systems in<br />
place, have changed. Moreover, the current (WHO) guidelines set<br />
out a number of contextual prerequisites that effectively exclude<br />
developing countries in sub-Saharan Africa.<br />
Zanzibar is one of the countries in sub-Saharan Africa that<br />
recently expressed its willingness to move from control towards<br />
elimination. Although elimination efforts have twice before failed<br />
in Zanzibar (in the 1960’s under the GMEP and in the 1980’s in<br />
a project funded by the United States Agency for International<br />
Development (USAID), the epidemiological context and the<br />
geographically limited island setting has always been considered<br />
as a model site for elimination (Schwartz et al., 1997; Minjas et<br />
al., 1988). As in most of sub-Saharan Africa, elimination efforts<br />
in Zanzibar failed both as a result of administrative issues and<br />
mosquito resistance to DDT used in indoor residual spraying (IRS),<br />
the main strategy of the GMEP. However, the recent increase<br />
in funding, mainly through the Global Fund to Fight AIDS,<br />
Tuberculosis and Malaria (GFATM) and the U.S. President’s<br />
Malaria Initiative (PMI), coupled with the introduction of highly<br />
effective treatment, long-lasting insecticide-treated bed nets for<br />
prevention, and new insecticides for IRS has again raised the<br />
government’s interests in the possibility of malaria elimination.<br />
RATIONALE AND OBJECTIVES<br />
In Zanzibar, the introduction of Artemisinin-based Combination<br />
Therapy (ACT) for malaria treatment in 2003 has been associated<br />
with a two-fold decrease in malaria prevalence in under-fives by<br />
2005. Another ten-fold decrease was seen between 2005 and 2006<br />
after the introduction of LL<strong>IN</strong>s (Bhattarai et al., 2007). More<br />
recent data further justify Zanzibar’s move toward elimination.<br />
In 2008, more than 70% of under-fives and pregnant women<br />
slept under an insecticide-treated bed net; 96% of houses<br />
were covered with IRS during the last spraying cycle; the slide<br />
positivity rate is below the 5% WHO threshold to move towards<br />
pre-elimination; and the most recent survey revealed only 0.8%<br />
malaria prevalence (ZMCP, 2008).<br />
The Zanzibar Ministry of Health and Social Welfare (MOHSW)<br />
and the ZMCP are now faced with a number of important<br />
strategic questions. Should they seek to completely eliminate<br />
malaria transmission from the islands or maintain it at roughly<br />
current low levels? How should they change the current<br />
intervention approach based on that goal? When can they begin<br />
scaling back interventions without causing a resurgence of<br />
malaria? These are technically complex questions, the answers<br />
to which are further complicated by the dearth of attention to<br />
and research on elimination in recent decades. Given this lack<br />
of information, the MOHSW and ZMCP decided to conduct a<br />
thorough assessment of the feasibility of malaria elimination on<br />
the islands to answer these and other critical strategic questions.<br />
The primary objective of the feasibility assessment exercise was<br />
to provide the MOHSW with as robust as possible evidence<br />
to enable it to make informed decisions about the future of its<br />
malaria program and associated investment in the health system.<br />
A secondary objective was to develop tools and lessons learned to<br />
facilitate similar exercises by other countries considering malaria<br />
elimination.<br />
METHODOLOGY<br />
CONCEPT AND GENERAL FRAMEWORK<br />
To our knowledge, there are no recent examples of country level<br />
feasibility assessments for malaria elimination. In order to develop<br />
a framework for this exercise, historical WHO reports and<br />
guidelines, including the only textbook on malaria eradication<br />
by Emilio Pampana (1969), from the GMEP era were reviewed.<br />
The review revealed that although the WHO encourages<br />
countries to assess the feasibility of malaria elimination, apart<br />
from a list of questions, they don’t provide a framework or<br />
methodology for this exercise (WHO, 2007). Historically,<br />
technical, administrative, and practical feasibility were clearly<br />
defined, but recommendations on assessing feasibility were<br />
ambiguous (Pampana, 1969). Technical feasibility was more or<br />
less assumed and formed, together with the fear for emerging<br />
resistance of the Anopheles mosquito to DDT, the basis for the<br />
GMEP (WHO, 1955). Administrative and practical feasibility,<br />
which included financial feasibility, on the other hand were not<br />
taken for granted, especially in developing countries and were<br />
encouraged to be evaluated by doing a pre-eradication survey<br />
and dealt with during a pre-eradication program (WHO, 1961).<br />
However, pre-eradication surveys were only recommended<br />
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