MALARIA ELIMINATION IN ZANZIBAR - Soper Strategies

As discussed, private facilities that will be allowed to treat malaria
will need to be included in the surveillance and supervision
system. Appropriate training of health workers in the private
sector combined with aggressive IEC/BCC campaigns both
targeting the patient and the health worker should also be a
core component of case management efforts in an elimination
program. Quality of care is difficult to assess, but it will be
important that a number of relevant metrics be established and
regularly monitored to ensure that the private sector is meeting
the necessary standards for elimination.
Diagnosis
The current target of having 90% of all malaria cases seen in
health facilities to be microscopy or RDT confirmed by 2014
is sufficient for a control program (GFATM Malaria Proposal
for Round 8), but a more ambitious–and challenging–target will
need to be established as an elimination progresses. Specifically,
100% of malaria cases seen in both public and private health
facilities will need to be confirmed by RDT and/or microscopy.
Adopting and implementing an appropriate algorithm for malaria
diagnosis, including the use of different tools within the system,
will be central to achieving that target. Given the current state of
the health system and workforce, we recommend the following
algorithm (see Table 13):
1. All fever cases, regardless of the facility where they present,
should be tested using an RDT.
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2. All positive RDTs should be tested by polymerase chain
reaction (PCR) at the central level.
3. A 10% random sample of all negative RDTs should be tested
by PCR for quality control.
4. Where microscopy is available, all patients with a positive
RDT should be re-tested at the facility using microscopy
on both thick and thin films for species identification and
parasite density quantification.
5. All positive slides should be re-read for quality control at the
central level.
6. All negative slides (discordant results) will have to be re-read
for quality control, the result should be compared to the
PCR testing on the initial RDT taken (which indicated a
positive result) and, if possible, the patient should be traced
and tested again with PCR using a new sample. It will be
very important to document these discordant results and to
investigate the causes of the conflicting results.
FIGURE 23: ALGORITHM FOR MALARIA TESTING IN AN ELIMINATION
PROGRAM
Although the WHO guidelines recommend 100% of cases to
be confirmed by microscopy, the above proposed algorithm
was established taking into account the local context and new
diagnostic tools available. We recommend all fever cases to be
tested (i.e. not only suspected fever cases). As pointed out above,
this will increase the number of tests performed considerably over
time and will create a high workload on the health professionals
at all levels of the health care system. We therefore recommend
using RDTs for all fever cases. The sensitivity of these tests makes
them good enough to be used as a screening tool, especially when
compared to microscopy under field conditions (de Oliveira et al.,
2009). In addition, RDTs have also been shown to be the most
cost-effective methods to correctly diagnose malaria in a primary
health care setting (Chanda et al., 2009). Massive use of RDTs
will require robust systems for quality assurance (batch testing)
and quality control. We suggest using PCR for quality control
of all positive RDTs and a 10% sample of negative RDTs. The
results of the PCR tests can also be used for the parasite strain
database (see M&E section). The requirements related to the
use of more complicated diagnostic methods such as PCR are
discussed in the section “From ZMCP to ZMEP.”
In addition to ensuring broad coverage of diagnosis, both RDTs
and microscopy will need to be performed with a high degree of
precision. The quality control system (see Figure 24) will need
to be rigorously implemented. Fortunately the basis for such a
system already exists and a budget to cover all public and private
health facilities was developed for the unsuccessful health system
strengthening component of the round 8 Global Fund proposal.
In the proposal, the ZMCP was responsible for quality control
in the public sector. The ZMCP will need to find the necessary
funding–one option would be reapplying to the Global Fund–to
ensure that the proposed system becomes operational as soon as
possible. For the private sector, capacity development, training
of private facility technicians, the development of guidelines,
and supportive supervision will be done through ZAMELSO
(Zanzibar Association for Medical Laboratory Scientific Officers)
funded through the Rapid Funding Envelope and PACT
Tanzania. It will be important regularly evaluate the system and
to guarantee sustainable resources for this activity.