MALARIA ELIMINATION IN ZANZIBAR - Soper Strategies

essential components of an elimination program, will require
new M&E activities and indicators. In terms of programmatic
monitoring we recommend the following:
�� At the health facility level: To ensure case management is
conducted properly, we recommend increasing the frequency
of supervision with more regular supervision visits to facilities
that are not performing well. Standardized supervision tools
should be used, and health workers should receive feedback
after every visit. All levels, including the community using
representatives of existing community (health) committees,
should be involved in the supervision activities to increase
accountability and ownership.
�� At the community level: IEC/BCC and community-level
activities will need to be regularly supervised and evaluated
using standardized tools so that activities/messages can be
adapted without having to wait for the results of surveys.
�� At the ZMCP level: The necessary M&E activities will need
to be set-up to evaluate the ZMCP. We recommend that the
ZMCP should not only be monitored through internal M&E
systems but also should be evaluated by either their direct
supervisors or external evaluators. These evaluations will
be especially important for the activities that the ZMCP is
directly responsible for. These include:
! Laboratory QA/QC: As a critical component, the
quality of the QA/QC itself needs to be evaluated. We
recommend evaluating the QA/QC activities (re-reading
of slides and PCR) at least once a year, but more frequent
evaluations will be initially necessary.
! Data analysis and data base management: The quality
of the statistical and epidemiological analysis should be
evaluated at least once a year. In addition, the database
will need to be regularly checked for inconsistencies
between the different data sources.
! Rapid response: It will not only be important to evaluate
how many identified foci have been treated but also how
fast the response was to a notified case. We recommend
that the team internally reviews the strengths and
weaknesses of each intervention each time a team deals
with a foci.
! Other activities: The ZMCP will ultimately be responsible
for the timely delivery of other monitoring activities
described elsewhere in this chapter such as drug resistance
monitoring and entomological monitoring including
insecticide resistance, even if they are not directly
responsible for their implementation.
Drug Resistance Monitoring
The ZMCP will also be responsible for the monitoring of
resistance patterns in both the parasite and the vector. These
patterns will define the effectiveness of the drug regimens and
insecticides used and therefore need to be carefully followed up.
Especially for drug resistance monitoring, the elimination setting
will be challenging, and methodologies will need to be adapted.
2 | Operational Feasibility
In the actual epidemiological setting it has become increasingly
difficult to pursue regular drug monitoring testing by using the
classic modified in-vivo WHO methodology adapted for East
Africa (EANMAT, 2002). The protocol requires a relatively large
number of malaria cases (between 80-100 children under five
years of age) with a parasite load of > 2,000 parasite per µl in
each treatment arm to be enrolled. The last drug efficacy study
carried out in Zanzibar in two sites (Micheweni and North A
districts) was done in 2005. This study showed good efficacy
of both ACTs recommended for Zanzibar (Martensson et al.,
2005). Since then the case load in the two sites has been too low
to enroll enough pediatric cases. There are 2 alternative methods
to in vivo tests that can provide indications of drug efficacy or
resistance: In vitro testing and genotyping.
In vitro testing on parasite isolates requires samples to be
collected from patients before they are treated. These tests
provide estimates of trends of possible decrease in susceptibility
to drugs. The technology requires good laboratory facilities, and
the collection of sufficient samples in an elimination setting will
be challenging.
Genotyping of parasites using polymerase chain reaction (PCR)
is a more recent but promising technique that can be used for
resistance testing. The blood samples required can either be
collected in ordinary test tubes or on filter paper. In addition,
the Karolinska Institute has developed a method that allows PCR
genotyping to be performed on RDT samples, facilitating regular
monitoring. Genotyping can detect the presence of genetic
alterations associated with resistance to anti-malaria drugs.
Recently, markers have been identified which relate to tolerance/
resistance to the partner drugs in ACT. These methods have
already been used to evaluate resistance on Zanzibar (Sisowath
et al., 2005), and there are now emerging reports of potential
markers of resistance to the artemisinin compounds. There are
some advantages, (simple collection of samples to be tested) and
disadvantages, (costs, sophisticated equipment and training), to
the implementation of genotyping. In addition, even if markers
for detection of mutations towards resistance to artemisinin
based drugs have been recently identified, confirmation of the
association between given mutations and actual drug resistance
remains difficult.
Apart from these relatively complicated techniques, case reports
and spontaneously reported treatment failure are potentially
useful and simple methods to detect drug resistance. It requires
less investment in time, money and personnel and can be done
on an ongoing basis in the health facilities. Patients are treated
following the treatment guidelines and told to come back to
the health facility if fever persists. Cases coming back should be
further investigated. Two possible biases should be taken into
consideration: adherence to treatment regimen is not guaranteed,
and patients can decide to not return on their own to health
facilities.
45