MALARIA ELIMINATION IN ZANZIBAR - Soper Strategies

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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: 38 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).
TABLE 5: RAPID RESPONSE ACTION FOR LEVEL 2 Level 2 (locally acquired case) Re-active Case Detection Mass screening with RDTs regardless of the presence of fever in 100 house-zholds around the index case and any subsequent case detected through ACD. Case Management Treatment of RDT positive cases from screening and follow up visit to ensure 100% adherence. Entomological Investigation Mapping of potential important breeding sites in the Shehia Investigate the vectorial capacity in the village of the index case and 2-3 control villages in the Shehia Review LLIN/IRS coverage levels in the Shehia using GIS database Integrated Vector Control LLIN “top-up” in all houses screened. Focal IRS in the Shehia depending on the results of the entomological investigation. IEC/BCC Immediate start of IEC/BCC campaign in the whole district 2 | Operational Feasibility FIGURE 22: SURVEILLANCE AND RESPONSE ALGORITHM FOR ELIMINATION 39
Page 1: PHOTO: © SASJA VAN VECHGEL MALARIA
Page 5: ACKNOWLEDGEMENTS The feasibility as
Page 9 and 10: EXECUTIVE SUMMARY Over the past sev
Page 11 and 12: Financial Feasibility The optimal m
Page 13 and 14: INTRODUCTION BACKGROUND In October
Page 15 and 16: FIGURE 2.1: AVERAGE MONTHLY RAINFAL
Page 17 and 18: CHAPTER 1: TECHNICAL FEASIBILITY IN
Page 19 and 20: to below 1% with IRS (Bhattarai et
Page 21 and 22: DEFINING IMPORTATION RISK As illust
Page 23 and 24: those regions from where the greate
Page 25 and 26: PROBABILITY OF ACQUIRING INFECTION
Page 27 and 28: NUMBER OF INFECTED INDIVIDUALS achi
Page 29 and 30: PERCENTAGE OF INDIVIDUALS INFECTED
Page 31 and 32: the same time, it is expected that
Page 33 and 34: test, about 80% of infections could
Page 35 and 36: CHAPTER 2: OPERATIONAL FEASIBILITY
Page 37 and 38: DATA COLLECTION METHODS A robust su
Page 39: most secondary cases but would occa
Page 43 and 44: up. It will also allow for the iden
Page 45 and 46: TABLE 7: PRE-ELIMINATION AND ELIMIN
Page 47 and 48: essential components of an eliminat
Page 49 and 50: THE ZANZIBAR HEALTH CARE SYSTEM THE
Page 51 and 52: community needs to be aware that fe
Page 53 and 54: conditions. Health worker motivatio
Page 55 and 56: A key challenge will be that as an
Page 57 and 58: The ZMCP is relatively well staffed
Page 59 and 60: elaborate entomological surveillanc
Page 61 and 62: COMMUNITY INVOLVEMENT ON ZANZIBAR Z
Page 63 and 64: �� Communities should, as far a
Page 65 and 66: preventive measures, mainly related
Page 67: CONCLUSIONS This chapter considers
Page 70 and 71: elimination will raise two major fi
Page 72 and 73: INDOOR RESIDUAL SPRAYING As noted a
Page 74 and 75: analysis be conducted. Moreover, gi
Page 76 and 77: FIGURE 30: AVERAGE COST PER YEAR FO
Page 78 and 79: which are being explored by the glo
Page 80 and 81: portion of those costs). Before thi
Page 83 and 84: REFERENCES Afridi MK (2009). Use of
Page 85 and 86: Jacobs, Lesley A (9/2007). Rights a
Page 87 and 88: Sandberg, Ingstad K, Bjune G (2007)
Page 89: World Health Organization, Global M

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