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