MALARIA ELIMINATION IN ZANZIBAR - Soper Strategies

elaborate entomological surveillance recommended in the
surveillance section above will require the necessary human
resource capacity for entomological surveillance (mainly assistants
for field work) and for the management of the necessary
entomologically evidence-based vector control activities.
SURVEILLANCE AND RESPONSE UNIT
Surveillance Unit
The Surveillance Unit would be responsible for all activities
needed to achieve high case detection rates. For passive case
detection this implies that they would not only be responsible for
the analysis of the data coming from the different health facilities
but also for the training of staff and QA/QC of the different tests
used in collaboration with the M&E and Operational Research
Unit. The unit should also have a focal point for all active case
detection activities if operational research suggests that active
case detection of high risk groups or specific areas is required.
The number of cases that need treatment will go down over time
(to almost zero), but all fever cases will need to be tested to ensure
that every case is identified to then avoid onward transmission.
This will lead to an increased number of tests to be done, with
few being positive and increased need for QA/QC of all tests used.
The introduction of DNA PCR, as proposed in the HSS chapter,
necessitates the hiring of competent laboratory staff at the central
level. The constant need for fever testing, most probably in an
environment where health workers might be less motivated as
most tests will be negative, justifies the need to have training on
malaria diagnosis on a regular basis. Training capacity should
ideally be decentralized with training coordinators at the district
level and a laboratory trainer of trainers for each island under the
coordination of the ZMEP laboratory focal point. Ideally QA/
QC (PCR Unit) capacity should be established on each island
under the overall coordination of the laboratory coordinator of
the ZMEP. This might not be possible from the start, as the
program will need to build up the necessary expertise at the
central level before establishing a PCR Unit on each island.
Response Unit
Once a case is detected, the foci will need to be investigated
and treated in the shortest delay possible to avoid any onward
transmission or, in the worst case, an epidemic in a population
that over time will become non-immune. The response unit we
propose should be lead by an epidemiologist and consist of two
sub-units: A unit for rapid investigation/analysis and a rapid
response unit. The coordinator of those units should be given full
authority to start an investigation every time a case is detected
and, based on the epidemiological assessment and analysis, start
the appropriate and necessary malaria control interventions to
clear the foci and avoid onward transmission. This obviously
assumes that data on any detected case are transmitted
immediately to the central unit. Where possible and appropriate
(remote parts of Pemba, for example) capacity should be built
at the district level to start the epidemiological investigation so
that no time is lost. Both units would have to closely collaborate
with the surveillance and vector control units respectively. For
2 | Operational Feasibility
example, the epidemiological investigation should include an
entomological assessment, and the necessary staff should be
drawn from the vector control unit to help do this.
A separate active case detection unit only makes sense if the
program decides to do pro-active case detection. In case the final
recommendations, based on operational research recommended
in this report, only suggest to do re-active case detection (case
detection based on a passively detected index case) we suggest to
collapse the active case detection and rapid response unit into one.
M&E AND OPERATIONAL RESEARCH
The M&E and Operational Research Unit will need the
competency to manage complex databases and use complex
geo-statistical software (see Surveillance and M&E sections in
Chapter 3) and will need to hire and/or train additional staff for
these tasks. We also recommend establishing a special reporting
unit to respond to the often complicated financial and narrative
reporting requirements of international donors.
Operational research will be an important component of
the elimination program and will most likely be done in
collaboration with international partners/research institutes like
ZAMRUKI and the CDC. Often these organizations employ
their own staff, but close collaboration with the ZMEP and its
different departments will nevertheless increase the program’s
workload. We therefore suggest creating a position to coordinate
all operation malaria-related research so that overlap is avoided
and to ensure an efficient collaboration with the different
departments within the program.
COMMUNICATIONS DEPARTMENT
We recommend that the ZMCP start a separate communication
department. This department will play an essential role not only
to achieve elimination but maybe even more to maintain it. It
should be responsible for health education, both at the health
facility and community level, and for mass communication
campaigns explaining certain unpopular measures such as
border screening, prophylaxis in migrant workers or a malaria
elimination tax on tourists. While the latter can be easily
coordinated from the central level, we propose to have at least one
health education coordinator for each island. They should work
in close collaboration with the districts and the communities
and further decentralization in this unit is strongly encouraged.
Initially the campaign should focus on achieving elimination
through the testing of all fever cases and the continuous use of
preventive measures while in the end stages the campaign will
have to address the fact that for a disease that no longer affects
the population, certain measures/health seeking behavior will
still be required.
We also believe it will be extremely important to have a public
relations department responsible for all communications related
to potential border screening, prophylaxis in at-risk groups and
imposed malaria elimination taxes. The ZMEP should develop
a communications strategy targeting the tourism industry at
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