MALARIA ELIMINATION IN ZANZIBAR - Soper Strategies

preventive measures, mainly related to vector control, achieve
high levels of coverage and usage. To mop up the last cases and to
maintain zero transmission, every locally acquired new case and
all imported cases must be identified as soon as possible to avoid
onward transmission and, important in terms of public health, to
avoid malaria epidemics with potentially devastating effects in a
non-immune population.
Any response to a public health event necessarily relies primarily
upon a population’s willingness to comply, which in turn requires
trust between the public and the public health system. The
balancing act embodied in the MSEHPA requires a recalibration
every time American values evolve in response to local and
world health events. Following the anthrax scare and the events
of September 11th, the dangers of public health emergencies
increased and, more importantly, Americans’ perception that
the threat had increased made them more tolerant of privacy
infringements. It was this shift in the public’s perception that
allowed the government to adapt its public health codes to
meet this changing environment and the public’s perceptions.
Similarly, for a malaria program on Zanzibar, it will be
essential to ensure the population understands and perceives
a high risk of malaria resurgence despite the fact that the
disease is no longer visible.
VECTOR CONTROL
Similar to herd immunity as a result of high vaccination coverage,
preventive vector control measures such as IRS and LLINs not
only protect the individual but also the community as a whole.
As discussed in the technical feasibility chapter, in the absence of
a perfect surveillance system, low levels of vector control coverage
will lead to the resurgence of malaria on Zanzibar. Over time, the
population in Zanzibar will lose its immunity to malaria disease
and malaria resurgence can therefore lead to explosive malaria
epidemics with high levels of mortality in all age groups. The
technical working group thus recommends maintaining high
coverage with IRS until high levels of coverage and usage with
LLINs has been robustly demonstrated.
To achieve high IRS coverage, individuals and private companies
must allow IRS teams to access their premises to spray the walls
with an insecticide. The nature of spraying activities, which often
requires moving furniture out of the house, can easily be seen as a
violation of people’s privacy and refusals, although not common in
the Zanzibar context, have been documented, especially in upperclass
residential areas. The coverage required to have impact on
the community level for IRS is > 85%. In line with the principle
of “necessary and proportional” and results of the previous IRS
campaigns in Zanzibar (overall coverage > 95%) legislation
enforcing the acceptance of IRS will most probably not be required
in the short-term. However, ultimately IRS will only be used in
the management of foci and acceptance might wean over time
given the reducing disease burden. In addition, when trying to
cut transmission in a newly identified focus, coverage levels would
ideally be close to 100% (in a limited area) and the risk of resurgence
and its consequences in the absence of other control measures might
justify legally enforced acceptance or fines in case of refusal.
2 | Operational Feasibility
LLINs pose an additional challenge, as coverage does not equal
usage. As mentioned above, IRS can only be scaled back when
LLIN coverage will be close to 100% assuming that this will
lead to usage levels of > 80% which is required to have the
required impact on transmission. While distributing nets is far
less intruding people’s privacy compared to IRS, obliging people
to actually use them can clearly be seen as a breach of privacy.
In addition, given the high transmission potential and high
importation risk in Zanzibar, prevention using LLINs will be a
long-term initiative that requires consistent implementation. As
such, it will always be better to secure the voluntary compliance or
“buy-in” of the population (e.g., through a widespread education
campaign) than to force behavior change and compliance through
restrictive measures. Such restrictive measures might initally
yield the intended results, but could lead to increasing popular
resentment against the intervention and the entire program and
corresponding declines in compliance below the starting level. In
other words, achievement of public health goals requires public
informed consent. The overall approach therefore recommended
by this group, which is also required under international law
as described above, is for the government to first try the least
restrictive measures that might achieve the objectives of a
malaria elimination program before employing other options
in order of increasing restrictiveness.
CASE DETECTION (SURVEILLANCE)
Rapid case identification is both important to achieve elimination
and to maintain zero transmission. There are three requirements
related to case detection and surveillance that might have legal
implications:
�� All fever cases must get tested to ensure high malaria case
detection rates.
�� All positive cases, with or without symptoms, must be treated
to avoid onward transmission and notified to the central
health authorities.
�� All cases will require further investigation, including travel
history and contact tracing.
The first requirement is highly influenced by the population’s
health seeking behavior. While people can be encouraged to
seek care when having a fever through IEC/BCC campaigns, it
is almost impossible and, in our opinion, not desirable to use
law enforcement to ensure people to go for testing. Once at the
health facility, people should provide oral informed consent
before being tested and the results should obviously remain
confidential.
When a person tests positive, treatment should be given not
only to cure the patient but also to avoid onward transmission.
While it is unlikely that a symptomatic patient refuses treatment,
asymptomatic carriers might be reluctant to take drugs for an
infection that has so far not caused any symptoms. Pro-active
case detection, explained in Chapter 1, specifically aims at
identifying asymptomatic carriers, and keeping in mind the
above mentioned principles, it is probably justified to either
enforce treatment or penalize refusal of treatment. The treatment
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