MALARIA ELIMINATION IN ZANZIBAR - Soper Strategies

has very few side effects and is beneficial to the patient (who
might become symptomatic in a later stage), while not treating
poses a serious epidemic risk with high morbidity and mortality
in the population. Enforcing treatment or penalizing its refusal
is therefore both necessary (to avoid secondary cases and even
deaths) and proportional. We recommend that legislative options
for enforcing treatment or penalizing its refusal are explored.
We do not recommend any form of isolation, admission or
quarantine as this is against the principles laid out in the IHR
and technically not justifiable. However, infected people should
be encouraged to use an LLIN, not only to protect themselves
but also their family and community.
Once a case is identified, the proposed surveillance mechanisms
require not only immediate notification but also a thorough
case investigation. Malaria is a notifiable disease but Zanzibar
has currently no legislation related to surveillance activities.
While it may be legislated that residents must admit health
officials into their dwellings to collect blood and/or travel and
health information, it will be far more effective to educate and
encourage public support of a campaign involving these methods.
In addition, case investigations will be complemented by re-active
case detection using mass screening in the population around
an identified case. In keeping with the principle of first trying
less restrictive approaches, the program should consider methods
such as only screening people with fever or a recent history of
fever that would more easily accepted and that would have a
similar impact.
Finally, one of the most important individual rights
considerations in the process of conducting surveillance is privacy.
In the modern information age, health information sharing has
become particularly effective in developing strategies to promote
public health and to combat specific health threats; however, the
handling of this information must be vigilantly administered,
as its mishandling can have consequences ranging from loss of
employment to embarrassment and harsh social stigma. It is
important to ensure that aggregated data is stripped of personal
identifiers, surveyed persons are provided with a copy of local
privacy of medical information law to know their rights, and
adequate controls are put into place to prevent public disclosure
of personal information.
BORDER SCREENING
Health measures to which travelers are subjected generally
require their prior oral informed consent. However, this is not
the case when there is evidence of an imminent public health risk,
in which case travelers may be advised or compelled to submit
to examination, vaccination or other measures–but only to the
extent necessary to control the risk. A traveler possessing valid
proof of prophylaxis may only be denied entry if there is verifiable
evidence that the prophylaxis was or is ineffective. Under the
new IHR, if a traveler fails to consent to a health measure, he
may be denied entry. The IHR also require that measures not be
more restrictive of international traffic and trade than reasonably
available alternatives that would achieve the appropriate level of
health protection.
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Many of the border screening interventions that might be
employed in an elimination program would arguably not meet
these criteria. For example, a single infected individual does
not pose a major risk of reestablishing local transmission–he
might not go to areas with significant vector activity and/or he
might present with symptoms and be cured at a health facility
before coming in contact with a vector. As such, requiring every
traveler to undergo a test might not be proportionate to the risk.
Moreover, simply relying on the surveillance system to detect
cases once they are in the country and trigger an appropriate
response might be an equally or more effective approach than
trying to detect all cases at the border. Lastly, care must be taken
to avoid potential discrimination in screening programs especially
when screening is targeting a high-risk sub-group. In that case a
robust scientific justification will be required to ensure that the
selected sub-group has not been identified based on prejudicial
biases. In addition, all other rights such as the right to privacy
and the dignity of those being screened should be upheld.
If a border screening approach is deemed technically necessary
to prevent resurgence, it is recommended that, as with other
interventions, travelers initially be offered a clear explanation
and provide informed consent to participate. Only if this clearly
undermines the effectiveness of the intervention should the
testing be made compulsory.
PRIVATE SECTOR
A State has much greater latitude to regulate commerce within the
country and to control activities of private businesses, including
the storage and distribution of medications. Making contractors
legally and financially accountable for preventing and eliminating
mosquito-breeding habitats at their worksites, for example,
would not be considered a rights intrusion. But the government
will have economic considerations that should drive it to regulate
commerce only to the least extent necessary to accomplish the
public health objective. For example, requiring that private hotels
both spray all buildings and cover all sleeping spaces with LLINs
would impose an additional cost on them, while the additional
health benefit might be limited. Any requirements of private
businesses should also consider the recommendations on other
interventions discussed above, e.g., if businesses are required to
regularly screen their migrant workers, they should provide those
workers with informed consent prior to testing.
Another factor to consider in the imposition of public health
measures that benefit the many sometimes at the expense of the few
is a government compensation program. The U.S. government
enacted several compensation programs whereby individuals
who were injured by a vaccine could sue the government rather
than the manufacturer. The MSEHPA also requires that a State
compensate private owners for the temporary or permanent
use of their materials or facilities by authorities during a state
of public health emergency. For an elimination program, this
might include compensating private pharmacies for prohibiting
them from selling anti-malarials (if a decision is taken to restrict
anti-malarial use to public facilities) or compensating individuals
for the effects of adverse reactions to drugs and/or insecticides.