MALARIA ELIMINATION IN ZANZIBAR - Soper Strategies

transmission foci, allow targeting of screening to high-risk
populations, and direct the scaling up or relaxation of surveillance
measures under the algorithm proposed below.
Existing Protocol
The recently drafted M&E plan and Early Epidemic Detection
and Response Plan (ZMCP, 2008) describe in detail the response
triggered by an (abnormal 2 ) increase in cases. The protocol
focuses on epidemic response rather than epidemic prevention.
It has 3 main components:
�� Confirmation of the existence of the suspected epidemic
�� Provision of relief to the affected population
�� Defining the extent of transmission and containment
(prevention of onward transmission to other areas)
Although the ZMCP (in collaboration with partners) recently
reacted to an outbreak in the Bambwini area, the necessary
resources (human, transport, consumables) are not in place to
ensure a rapid response by the ZMCP without having to count
on emergency contributions from partners. In the short-term,
the ZMCP will need to ensure financing for their outbreak
response team and set-up the necessary structures to enable a
quick and effective reaction following the protocol outlined in
the M&E and Early Epidemic Detection and Response Plan.
This protocol, adapted to the current malaria epidemiological
context, will need to be fine-tuned when the program moves
from control to (pre)elimination and maintenance.
Rapid Response Protocol for Elimination
We propose a protocol with different levels of vigilance in a limited
geographical area depending on suspected or demonstrated
ongoing transmission (see Figure 15). The different activities
described in the proposed algorithm are still based on the same
rationale–confirmation, treatment, prevention–but with a more
sensitive trigger mechanism and a more cautious approach in
terms of further investigation and response.
In the MEEDS health facilities, weekly malaria cases are
currently plotted into a chart with individual scale and threshold.
A situation of epidemiological alert is reported when the plotted
cases are over the threshold for two consecutive weeks. This time
delay (and number of cases) is unacceptable when elimination
has been achieved. The threshold will therefore need to change
over time when cases become extremely rare. As elimination is
approached, one case will constitute an outbreak and every
time a case is identified the response described below will need to
take place as rapidly as possible.
Level 0
Level 0 is the baseline with normal levels of vigilance. All fever
cases that present at the health facility (public or private) have to
be tested with an RDT (and where possible, with microscopy).
This passive case detection system has to detect a minimum of
50% of all passive case detection system has to detect a minimum
of 50% of all infections but ideally > 75%. This will require
additional activities to influence health-seeking behavior (IEC/
BCC) as described below. One positive RDT/Slide should trigger
an immediate reaction that consists of the following actions:
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2 Increase in cases for 2 consecutive weeks.
TABLE 4: REACTIONS FOR LEVEL 0 UPON DETECTION OF A
PARASITOLOGICALLY CONFIRMED CASE
Activity Assumption
Health Facility Fill in the case reporting
form (including residence
for mapping).
Collect and store samples
(RDT, thin/thick smear,
blood spot on filter paper)
Treat the patient with an
ACT
Notify the district AND
central level (voice call)
Reporting forms available
Health facility staff trained
Diagnostic and storage
supplies available
Drugs available
Functioning mobile phone
with credit
District Check contingency stocks Insecticides, spray pumps
and protective gear in stock.
ZMEP (Pemba/
Unguja)
Notify the local authorities/
village health committees
Immediately dispatch an
investigation team to the
health facility where the
case was identified (this
might be possible at the
district level)
Confirm if the index case is
a malaria case.
1 epidemiologist, 1
laboratory technician, 1
entomologist, 1 driver on
stand-by
Transport available, per
diem budgeted.
Investigation team has
diagnostic capacity to
retest/re-read the slide and
transport to send sample
(filter paper to central lab)
If the case is confirmed, investigate (using a standardized case
investigation form; SOP to be established) to determine if most
probably locally acquired (no travel history) or imported (history
of recent travel to malaria endemic country/region). Depending
on the results of the initial investigation, move to level 1 or 2.
Level 1
When an imported case has been detected by the passive case
detection and no other cases have been seen in the catchment
area of the health facility nearest to the home of the index case,
no further re-active case detection is required. However, the case
investigation team will need to follow up the case to ensure that:
�� The patient adheres to the given treatment;
�� Family members of the same household receive an LLIN for
personal protection; and
�� The traveler is briefed on how to protect him/herself against
malaria when traveling to a malaria endemic country.
Level 2
When the initial investigation suggests that the case might
be locally acquired, the response, both in terms of further
investigation and prevention of onward transmission, will need to
be more robust than when a case is likely to have been imported.
Table 5 gives an overview of the actions to be taken when a case
is likely to be the result of local transmission (level 2).