MALARIA ELIMINATION IN ZANZIBAR - Soper Strategies
MALARIA ELIMINATION IN ZANZIBAR - Soper Strategies
MALARIA ELIMINATION IN ZANZIBAR - Soper Strategies
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essential components of an elimination program, will require<br />
new M&E activities and indicators. In terms of programmatic<br />
monitoring we recommend the following:<br />
�� At the health facility level: To ensure case management is<br />
conducted properly, we recommend increasing the frequency<br />
of supervision with more regular supervision visits to facilities<br />
that are not performing well. Standardized supervision tools<br />
should be used, and health workers should receive feedback<br />
after every visit. All levels, including the community using<br />
representatives of existing community (health) committees,<br />
should be involved in the supervision activities to increase<br />
accountability and ownership.<br />
�� At the community level: IEC/BCC and community-level<br />
activities will need to be regularly supervised and evaluated<br />
using standardized tools so that activities/messages can be<br />
adapted without having to wait for the results of surveys.<br />
�� At the ZMCP level: The necessary M&E activities will need<br />
to be set-up to evaluate the ZMCP. We recommend that the<br />
ZMCP should not only be monitored through internal M&E<br />
systems but also should be evaluated by either their direct<br />
supervisors or external evaluators. These evaluations will<br />
be especially important for the activities that the ZMCP is<br />
directly responsible for. These include:<br />
! Laboratory QA/QC: As a critical component, the<br />
quality of the QA/QC itself needs to be evaluated. We<br />
recommend evaluating the QA/QC activities (re-reading<br />
of slides and PCR) at least once a year, but more frequent<br />
evaluations will be initially necessary.<br />
! Data analysis and data base management: The quality<br />
of the statistical and epidemiological analysis should be<br />
evaluated at least once a year. In addition, the database<br />
will need to be regularly checked for inconsistencies<br />
between the different data sources.<br />
! Rapid response: It will not only be important to evaluate<br />
how many identified foci have been treated but also how<br />
fast the response was to a notified case. We recommend<br />
that the team internally reviews the strengths and<br />
weaknesses of each intervention each time a team deals<br />
with a foci.<br />
! Other activities: The ZMCP will ultimately be responsible<br />
for the timely delivery of other monitoring activities<br />
described elsewhere in this chapter such as drug resistance<br />
monitoring and entomological monitoring including<br />
insecticide resistance, even if they are not directly<br />
responsible for their implementation.<br />
Drug Resistance Monitoring<br />
The ZMCP will also be responsible for the monitoring of<br />
resistance patterns in both the parasite and the vector. These<br />
patterns will define the effectiveness of the drug regimens and<br />
insecticides used and therefore need to be carefully followed up.<br />
Especially for drug resistance monitoring, the elimination setting<br />
will be challenging, and methodologies will need to be adapted.<br />
2 | Operational Feasibility<br />
In the actual epidemiological setting it has become increasingly<br />
difficult to pursue regular drug monitoring testing by using the<br />
classic modified in-vivo WHO methodology adapted for East<br />
Africa (EANMAT, 2002). The protocol requires a relatively large<br />
number of malaria cases (between 80-100 children under five<br />
years of age) with a parasite load of > 2,000 parasite per µl in<br />
each treatment arm to be enrolled. The last drug efficacy study<br />
carried out in Zanzibar in two sites (Micheweni and North A<br />
districts) was done in 2005. This study showed good efficacy<br />
of both ACTs recommended for Zanzibar (Martensson et al.,<br />
2005). Since then the case load in the two sites has been too low<br />
to enroll enough pediatric cases. There are 2 alternative methods<br />
to in vivo tests that can provide indications of drug efficacy or<br />
resistance: In vitro testing and genotyping.<br />
In vitro testing on parasite isolates requires samples to be<br />
collected from patients before they are treated. These tests<br />
provide estimates of trends of possible decrease in susceptibility<br />
to drugs. The technology requires good laboratory facilities, and<br />
the collection of sufficient samples in an elimination setting will<br />
be challenging.<br />
Genotyping of parasites using polymerase chain reaction (PCR)<br />
is a more recent but promising technique that can be used for<br />
resistance testing. The blood samples required can either be<br />
collected in ordinary test tubes or on filter paper. In addition,<br />
the Karolinska Institute has developed a method that allows PCR<br />
genotyping to be performed on RDT samples, facilitating regular<br />
monitoring. Genotyping can detect the presence of genetic<br />
alterations associated with resistance to anti-malaria drugs.<br />
Recently, markers have been identified which relate to tolerance/<br />
resistance to the partner drugs in ACT. These methods have<br />
already been used to evaluate resistance on Zanzibar (Sisowath<br />
et al., 2005), and there are now emerging reports of potential<br />
markers of resistance to the artemisinin compounds. There are<br />
some advantages, (simple collection of samples to be tested) and<br />
disadvantages, (costs, sophisticated equipment and training), to<br />
the implementation of genotyping. In addition, even if markers<br />
for detection of mutations towards resistance to artemisinin<br />
based drugs have been recently identified, confirmation of the<br />
association between given mutations and actual drug resistance<br />
remains difficult.<br />
Apart from these relatively complicated techniques, case reports<br />
and spontaneously reported treatment failure are potentially<br />
useful and simple methods to detect drug resistance. It requires<br />
less investment in time, money and personnel and can be done<br />
on an ongoing basis in the health facilities. Patients are treated<br />
following the treatment guidelines and told to come back to<br />
the health facility if fever persists. Cases coming back should be<br />
further investigated. Two possible biases should be taken into<br />
consideration: adherence to treatment regimen is not guaranteed,<br />
and patients can decide to not return on their own to health<br />
facilities.<br />
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