MALARIA ELIMINATION IN ZANZIBAR - Soper Strategies

Recommendations

Info

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. 64 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.
CONCLUSIONS This chapter considers the legal principles that would apply to the recommended malaria elimination decisions and analyzes several of the restrictive interventions that the country may wish to employ in an elimination program. It provides an overview of the relevant issues, principles, and considerations to provide a foundation for more detailed analysis later as relevant. The overall approach 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. Legislation enforcing the acceptance of IRS will most probably not be required in the short-term. But in the end stages of elimination and during the maintenance period, 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. People should be encouraged to seek care when they have a fever through IEC/BCC campaigns, and it is 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. Enforcing treatment or penalizing its refusal is 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 to protect their family and community. In terms of screening for active case detection, the program should consider methods that would be more easily accepted and that would have a similar impact if only a portion of the individuals are screened such as people with fever or a recent history of fever in stead of the general population. If a border screening approach is deemed technically necessary to prevent resurgence in the future, 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. 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. 2 | Operational Feasibility 65
Page 1:
PHOTO: © SASJA VAN VECHGEL MALARIA
Page 5:
ACKNOWLEDGEMENTS The feasibility as
Page 9 and 10:
EXECUTIVE SUMMARY Over the past sev
Page 11 and 12:
Financial Feasibility The optimal m
Page 13 and 14:
INTRODUCTION BACKGROUND In October
Page 15 and 16: FIGURE 2.1: AVERAGE MONTHLY RAINFAL
Page 17 and 18: CHAPTER 1: TECHNICAL FEASIBILITY IN
Page 19 and 20: to below 1% with IRS (Bhattarai et
Page 21 and 22: DEFINING IMPORTATION RISK As illust
Page 23 and 24: those regions from where the greate
Page 25 and 26: PROBABILITY OF ACQUIRING INFECTION
Page 27 and 28: NUMBER OF INFECTED INDIVIDUALS achi
Page 29 and 30: PERCENTAGE OF INDIVIDUALS INFECTED
Page 31 and 32: the same time, it is expected that
Page 33 and 34: test, about 80% of infections could
Page 35 and 36: CHAPTER 2: OPERATIONAL FEASIBILITY
Page 37 and 38: DATA COLLECTION METHODS A robust su
Page 39 and 40: most secondary cases but would occa
Page 41 and 42: TABLE 5: RAPID RESPONSE ACTION FOR
Page 43 and 44: up. It will also allow for the iden
Page 45 and 46: TABLE 7: PRE-ELIMINATION AND ELIMIN
Page 47 and 48: essential components of an eliminat
Page 49 and 50: THE ZANZIBAR HEALTH CARE SYSTEM THE
Page 51 and 52: community needs to be aware that fe
Page 53 and 54: conditions. Health worker motivatio
Page 55 and 56: A key challenge will be that as an
Page 57 and 58: The ZMCP is relatively well staffed
Page 59 and 60: elaborate entomological surveillanc
Page 61 and 62: COMMUNITY INVOLVEMENT ON ZANZIBAR Z
Page 63 and 64: �� Communities should, as far a
Page 65: preventive measures, mainly related
Page 70 and 71: elimination will raise two major fi
Page 72 and 73: INDOOR RESIDUAL SPRAYING As noted a
Page 74 and 75: analysis be conducted. Moreover, gi
Page 76 and 77: FIGURE 30: AVERAGE COST PER YEAR FO
Page 78 and 79: which are being explored by the glo
Page 80 and 81: portion of those costs). Before thi
Page 83 and 84: REFERENCES Afridi MK (2009). Use of
Page 85 and 86: Jacobs, Lesley A (9/2007). Rights a
Page 87 and 88: Sandberg, Ingstad K, Bjune G (2007)
Page 89: World Health Organization, Global M
show all

MALARIA ELIMINATION IN ZANZIBAR - Soper Strategies

Create successful ePaper yourself

Delete template?

Save as template?