MALARIA ELIMINATION IN ZANZIBAR - Soper Strategies

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