MALARIA ELIMINATION IN ZANZIBAR - Soper Strategies

undertaken with support of the Karolinska Institute showed
no significant parasite resistance to AS-AQ and Coartem® with
clinical and parasitological response over 98.5% (Prof Anders
Björkman, personal communication).
THE ZANZIBAR MALARIA STRATEGIC PLAN
The overall objective of the Malaria Strategic Plan for Zanzibar
(2007-2012) (ZMCP, 2007) is to reduce the malaria incidence
by 70% from the 2006 baseline by 2012. Because of the low
prevalence already achieved, the plan also aims at early detection
to avoid epidemics or resurgence of malaria. To achieve this
ultimate goal, five specific objectives have been put forward:
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1. To prevent infection with malaria by reaching and
maintaining coverage of ITNs/LLINs at above 80% for
pregnant women and children under 5 years, complemented
by other vector control methods
2. To ensure effective case management by providing prompt
access for all to parasitological diagnosis (by microscopy or
rapid diagnostic test) and ACT
3. To prevent and control malaria in pregnancy, by increasing
and maintaining coverage of IPTp to 80% in both private and
public health sectors (at least two doses of SP) by promoting
the regular and correct use of LLINs
4. To provide effective epidemic preparedness and response, by
ensuring that for > 90% of health facilities, reports are on
time, investigation of reported epidemics is initiated within
24 hours and supplies are at hand to mount a response if
necessary
5. To assess the potential for sustainable elimination of malaria
from Zanzibar, using newly available data from surveillance
and operational research, as well as experience from
implementation
These specific objectives are to be supported by complementary
strategies on communication, management and coordination,
monitoring and evaluation, operational research and surveillance.
Although the current strategic plan does not aim for malaria
elimination, one of the specific objectives is to assess the potential
for sustainable elimination. As such, the preparation of an
assessment on the feasibility of malaria elimination is in line with
the national strategic plan.
HISTORY OF MALARIA CONTROL IN ZANZIBAR
Historically, malaria has been a major public health, social and
economic problem in Zanzibar, with the exception of a short
period during the malaria eradication program from 1958 to
1968. In the mid-1920’s, an early document on the epidemiology
of malaria in Unguja reported a parasite prevalence of 68%
among children 1-6 years of age (Manfield-Aders, 1927). In the
1930’s and 1950’s similar parasite prevalences were found in
both Unguja and Pemba, but after that parasite rates have shown
fluctuations mainly related to different malaria control efforts.
Before World War II environmental management, chemical
larviciding and quinine distributions to schoolchildren were the
main malaria control intervention tools in Zanzibar. Larvivorous
fish and mosquito nets were also used but with limited
success. After World War II spraying activities with DDT and
dieldrin were started. In 1961 the malaria control program was
upgraded to an eradication program. The eradication program
continued the bi-annual cycles of IRS with dieldrin and started
mass distribution of amodiaquine and primaquine resulting
in community parasite prevalences below 5%. However, the
eradication program failed to interrupt transmission, which
was blamed on technical, administrative and operational
shortcomings (Delfini, 1969). The eradication program was
terminated in 1968, though malaria control activities continued,
largely through the support of community volunteers. By the late
1970s, parasite prevalence had again increased to around 40% on
Unguja (Matola, 1984).
In 1984, Zanzibar assisted by USAID, launched a five-year
project to control malaria to a level where it no longer would
be a major public health problem (Minjas et al., 1989). The
main strategies included DDT spraying and chloroquine
administration through dispensaries. Results, however, were poor
due to inadequate coverage and operational problems similar to
the eradication period. In the 1990’s funding for malaria control
was limited. Nevertheless, in 1993 the new global strategy for
malaria control was adopted emphasizing prompt and effective
malaria treatment rather than IRS. This strategy was, however,
highly hampered by increasing resistance to chloroquine. The
start of the Global Fund to Fight Aids, Tuberculosis and Malaria
(GFATM) and the President’s Malaria Initiative (PMI) marked
a new era in malaria control for Zanzibar with a consistently
well-funded program since 2002 resulting in the above described
reduction in the malaria burden to date.