MALARIA ELIMINATION IN ZANZIBAR - Soper Strategies
MALARIA ELIMINATION IN ZANZIBAR - Soper Strategies
MALARIA ELIMINATION IN ZANZIBAR - Soper Strategies
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progresses, it is envisaged that the IDSR will adopt a similar<br />
system and technology to collect data on other diseases.<br />
Strengthening for Elimination<br />
While the MEEDS provides a strong foundation for elimination<br />
surveillance, we recommend a number of additional important<br />
actions to strengthen HMIS to the necessary level.<br />
Over time, the HMIS will need to be improved to contribute<br />
to the surveillance targets described above. This improvement<br />
will be closely connected with overall strengthening of the health<br />
system described below, but there are also specific steps related to<br />
the capturing and recording of malaria data that must be taken.<br />
These include:<br />
�� Health facilities, including private clinics, should over time<br />
only report (parasitological) confirmed cases.<br />
�� Laboratory data should not only capture the number of tests<br />
done and their result but should also record the number of<br />
fever cases to enable calculation of the testing rate (number<br />
of slides/RDTs divided by the number of fever cases), an<br />
important indicator for the evaluation of health care workers<br />
efforts in terms of case detection.<br />
�� Malaria and severe anemia admissions will be less important<br />
to record as such, especially in the long run. Initially, the<br />
proportion (not the number) of severe cases might go up and<br />
the age profile might shift towards more adults, but eventually<br />
all cases should be detected before severe cases occur.<br />
In addition, the necessary efforts will need to be made to ensure<br />
that the data collected reach the ZMCP in a timely manner.<br />
Monthly health facility and laboratory data from the HMIS<br />
can be used to cross check data received through the MEEDS.<br />
Our assessment did not include a thorough review of the HMIS<br />
system and more practical recommendation to strengthen the<br />
HMIS are therefore not within the scope of this report. With the<br />
MEEDS system soon covering most public health facilities, the<br />
weakness of the HMIS should not stand in the way of moving<br />
towards malaria elimination.<br />
Ideally, the MEEDS would be incorporated into the HMIS to<br />
minimize parallel systems. However, given the critical role of the<br />
MEEDS in malaria elimination and the ongoing evolution of<br />
the HMIS, we recommend keeping the MEEDS as a separate<br />
system until the HMIS is deemed strong enough and/or<br />
elimination has been achieved. When such integration does<br />
occur, it will be critical to ensure that it is done carefully so that<br />
there is no disruption and that the important attributes of the<br />
MEEDS are not lost in the process.<br />
If Zanzibar does pursue an elimination target, we recommend<br />
gradually expanding the MEEDS system to include all health<br />
facilities, including private facilities that will be allowed<br />
to provide malaria treatment. This will ensure that all cases<br />
observed at facilities are rapidly reported as well as incorporated<br />
into the slower HMIS reports. As the elimination program<br />
progresses, health workers should be encouraged to use the<br />
MEEDS cell phone system to immediately notify a case once it<br />
is detected rather than waiting for weekly reporting. In a setting<br />
36<br />
with little or no transmission, one case can spark an epidemic or<br />
represent an outbreak already underway and must be followed<br />
up as rapidly as possible. Lastly, we recommend exploring the<br />
possibility of geo-locating detected malaria cases/carriers.<br />
There is currently a proposal to develop a composite database<br />
including all the structures already geo-located by the Ministry<br />
of Land as well as the household database collected by ZMCP for<br />
IRS. Once this occurs, it may be possible to geo-locate all malaria<br />
positive cases reported by health facilities, which will facilitate<br />
identification of transmission foci and appropriate response by<br />
the program.<br />
The operational requirements to scale up the MEEDS in terms<br />
of staffing, diagnostic capacity and, more in general, guaranteed<br />
access to care are discussed in the health systems strengthening<br />
section of this chapter. Before the end of 2009, all public health<br />
facilities will be part of the MEEDS (Fabrizio Molteni, personal<br />
communication), and the necessary training and equipment are<br />
covered with PMI funding. Future operating costs are discussed<br />
in Chapter 3.<br />
Active Case Detection (ACD)<br />
Given the relatively high importation risk (estimated at 2-8/1000<br />
inhabitants/year), even with a strong passive detection system,<br />
secondary infections will be common and it is likely that many<br />
malaria cases may go unnoticed. Patients may choose not to<br />
seek treatment at a formal facility and some parasite carriers will<br />
not present with symptoms. In an elimination program, these<br />
cases represent a significant threat of resurgence (especially when<br />
prevention will be scaled down) and must be addressed. The<br />
principle means of doing so is active case detection (ACD). Many<br />
different ACD approaches have been used, but there is little<br />
evidence on the comparative benefits and disadvantages of each<br />
(Macauley, 2005). As such, it is important for Zanzibar to carefully<br />
develop the ACD approach that seems to best fit its conditions<br />
and then consistently evaluate and revisit that approach. ACD<br />
methods can be described in 2 broad categories: re-active case<br />
detection and pro-active case detection. The reaction triggered<br />
by the detection of a case through these systems is discussed<br />
under the analysis and response section of this chapter.<br />
Re-Active Case Detection (RACD)<br />
This approach is triggered by the detection of a confirmed case<br />
through the passive system (e.g., MEEDS), with surveillance<br />
officers following up the case and screening family members and/<br />
or surrounding households to determine if it represents broader<br />
transmission. Our simulations indicate that once elimination<br />
is achieved, under a scenario where preventive measures are<br />
maintained and PCD detects > 70% of infections, RACD might<br />
not be necessary. However, if PCD only detects around 50%<br />
of all infections, approximately 100 households will need to be<br />
screened for each case detected (both passively and through the<br />
screening) even when nets and/or IRS coverage is > 75%. The<br />
operational feasibility of RACD thus depends on the number<br />
of cases detected and the level of passive case detection achieved.<br />
However, screening 100 households is the threshold needed<br />
to meet the WHO definition of elimination and is as such the<br />
upper limit required. Screening 50 houses would already avoid