MALARIA ELIMINATION IN ZANZIBAR - Soper Strategies

�� Data on (potential) vector breeding sites: Geo-referenced
data should be collected on permanent water bodies and
irrigation schemes (both functional and non-functional).
Construction works (e.g., roads and buildings) are potential
breeding sites and should be inspected by environmental
health engineers and the data collected should be incorporated
in the ZMCP managed GIS database. This information
would allow for (rapid) environmental measures to decrease
potential anopheline breeding sites.
CONCLUSION
A strong surveillance system will arguably be the most important
component of the Zanzibar elimination program. The system
will need to detect, register and report every single malaria case. A
robust analysis of the data will allow for an appropriate outbreak
response and might enable the prediction and/or identification
of foci. There are three main methods used to collect data for
surveillance: passive case detection, re-active case detection and
pro-active case detection. The MEEDS, which will cover all public
health facilities by 2010, provides a unique opportunity to improve
the passive case detection system and should be further scaled up
to also include relevant private health care facilities. Re-active case
detection is an entire part of outbreak response, initially triggered
by an increase in cases for two consecutive weeks but eventually
by one single RDT and/or microscopy confirmed malaria case.
Depending on the risk of onward transmission, mainly defined
by whether the index case is probably locally acquired or not, the
scale of the response will differ–large for locally acquired cases and
limited if the case is probably imported. Pro-active case detection,
like border screening and testing of high-risk groups or areas,
often complements passive case detection in elimination program.
We do not recommend starting pro-active case detection for the
moment. More operational research is needed to help define
both high risk areas and groups. The surveillance system will also
need to include entomological surveillance and the surveillance of
human and environmental factors such as population movements,
meteorological data, and the mapping of breeding sites.
MONITORING AND EVALUATION
(FROM CONTROL TO ELIMINATION)
Monitoring and evaluation will guide the reorientation of the
program (from pre-elimination to elimination to prevention
of reintroduction) by documenting progress towards the
goals of each phase. In the end phases of elimination, robust
monitoring will be needed to demonstrate that transmission has
been interrupted. The WHO guideline for malaria elimination
specifies phase-specific goals, programmatic milestones, M&E
interventions, outcome indicators, and impact indicators. The
table below brings together the most relevant information on
M&E in an elimination program.
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TABLE 6: M&E FOR CONTROL AND THE DIFFERENT PHASES OF AN
ELIMINATION PROGRAM
Goal Reduce
morbidity
and
mortality
Activities Prompt and
effective
treatment,
high
coverage
with
preventive
measures
Milestone
(data,
indicators,
threshold)
Control Pre-
elimination
Fever cases
tested
Positive
slide/RDT
! SPR (<
5%)
M&E Tools Routine
data
collection
Selected
Variables
Surveys
# Fever
cases
# Positive
slides/
RDTs
Coverage
indicators
(LLINs,
IRS, …)
Halt local
transmission
nationwide
Improve
diagnosis
(confirmed),
surveillance,
epidemic
preparedness
and response
# of cases
Population at
risk
! Cases/1000/
year
(< 1/1000/
year)
Routine data
collection
Surveillance
data (including
evaluation
of quality of
reporting)
Malaria risk
stratification
Surveys
Population at
risk
# Parasitological
confirmed cases
# Reports
received on time
Elimination Prevention of
Re-introduction
Halt local
transmission
nationwide
Active case
detection, case
investigation,
targeted
control
interventions
(foci)
# of cases
Origin of each
case
! Number
of locally
acquired
cases
(zero)
Surveillance
data
(elimination
database;
quality of
reporting)
Case
investigation
reports
Genotyping
(strain
database)
Seroprevalence
survey
(baseline)
Seroprevalence
surveys
#
Parasitological
confirmed
cases
Origin of cases
Strain of each
case
Prevent the
re-establishment
of local
transmission
Prevention in
travelers, border
control, vigilance
Elimination
database
Sero-prevalence
surveys
Sero-prevalence
< 3 years and/
or general
population
The WHO also proposes a set of indicators for the pre-elimination
and elimination phase for five program components (enabling
environment, surveillance, case management, vector control
and entomological surveillance). Targets are only specified for
a limited number of indicators and some, such as the “formal
endorsement by the government” indicator, even seem to be
variables that do not require continuous follow up.