MALARIA ELIMINATION IN ZANZIBAR - Soper Strategies
MALARIA ELIMINATION IN ZANZIBAR - Soper Strategies
MALARIA ELIMINATION IN ZANZIBAR - Soper Strategies
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COST<strong>IN</strong>G <strong>ELIM<strong>IN</strong>ATION</strong><br />
As described above, the costs of a potential elimination program<br />
were calculated by modeling the financial implications of the<br />
technical and operational recommendations using two scenarios:<br />
one which includes the core recommendations of this report and<br />
one which includes the lowest possible level of intervention that<br />
could feasibly sustain elimination (assuming dramatic reductions<br />
in importation risk).<br />
TABLE 16: ASSUMPTIONS OF 2 <strong>ELIM<strong>IN</strong>ATION</strong> SCENARIOS USED FOR<br />
COST<strong>IN</strong>G<br />
Prevention<br />
(LL<strong>IN</strong>s)<br />
Scenario 1 Scenario 2<br />
2020 2030 2020 2030<br />
75%<br />
coverage<br />
75%<br />
coverage<br />
75%<br />
coverage<br />
but start of<br />
progressive<br />
scale down<br />
The assumptions and calculation related to LL<strong>IN</strong> coverage and<br />
surveillance are explained below. Assumptions on the risk of<br />
importation are based on estimates from the technical feasibility<br />
chapter and assume that control on the mainland will reduce<br />
importation by 50% by 2030. In addition, scenario 2 assumes a<br />
further 60% reduction through further control on the mainland<br />
and implementation of border screening on Zanzibar (see below).<br />
LONG-LAST<strong>IN</strong>G <strong>IN</strong>SECTICIDE-TREATED NETS<br />
No LL<strong>IN</strong>s<br />
Importation 2/1000/year 1/1000/year 2/1000/year 0.4/1000/<br />
year<br />
Surveillance:<br />
Passive Case<br />
Detection<br />
Surveillance:<br />
Reactive<br />
Active Case<br />
Detection<br />
Surveillance:<br />
Proactive<br />
Active Case<br />
Detection<br />
50% of all<br />
infections<br />
detected<br />
100<br />
households<br />
screened/<br />
detected<br />
case<br />
77% of all<br />
infections<br />
detected<br />
100<br />
households<br />
screened/<br />
detected<br />
case<br />
50% of all<br />
infections<br />
detected<br />
100<br />
households<br />
screened/<br />
detected<br />
case<br />
77% of all<br />
infections<br />
detected<br />
100<br />
households<br />
screened/<br />
detected<br />
case<br />
None None None Border<br />
screening at<br />
ports<br />
The need to sustain universal coverage with LL<strong>IN</strong>s and/or IRS<br />
was one of the central recommendations of the technical feasibility<br />
assessment. As it is expected that IRS will be reduced to focus<br />
on just “hot spots,” it will thus be important to maintain LL<strong>IN</strong><br />
coverage at a substantial level throughout the program, including<br />
after interruption of transmission has been achieved (scenario 1).<br />
However, if vulnerability is reduced and the surveillance system<br />
is strong enough to detect the majority of cases that do emerge<br />
on the islands, it is possible that LL<strong>IN</strong> coverage could be scaled<br />
back over time and eventually abandoned altogether (scenario 2).<br />
The specific timelines and assumptions used in the costing are<br />
detailed in the table below.<br />
US $<br />
3 | Financial Feasibility<br />
TABLE 17: PROGRESSIVE SCALE DOWN OF LL<strong>IN</strong>S FOR SCENARIO 2:<br />
COVERAGE OVER TIME BY LEVEL OF <strong>MALARIA</strong> TRANSMISSION RISK<br />
ITN Coverage 2011-2020 2021-2023 2024-2026 2027-2029 2030-…<br />
High Risk<br />
(3 districts)<br />
Medium Risk<br />
(5 districts)<br />
No/Low Risk<br />
(2 districts)<br />
Overall<br />
(Population-<br />
adjusted)<br />
100% 100% 100% 100% 0%<br />
100% 100% 50% 0% 0%<br />
100% 0% 0% 0% 0%<br />
100% 62% 40% 18% 0%<br />
Both scenarios keep 100% coverage until 2020 to ensure that the<br />
75% usage (effective coverage) that is needed to reach elimination<br />
is sustained. Under scenario 2, LL<strong>IN</strong>s will then be progressively<br />
scaled down, first in districts that are estimated to be at no/low<br />
risk, followed by districts at medium and high risk, with all areas<br />
having abandoned LL<strong>IN</strong>s beginning in 2030. Risk was estimated<br />
at a district level from the ZMCP 2007 Malaria Indicator Survey,<br />
assuming districts with 0% prevalence were at no/low risk, those<br />
with prevalence between 0% and 1% were at medium risk, and<br />
those with prevalence >1% were at high risk.<br />
It is assumed that, as with sustained control, LL<strong>IN</strong>s under each<br />
scenario will be distributed through mass campaigns every three<br />
years. To facilitate interpretation, the costs associated with these<br />
campaigns are smoothed over the full three-year period.<br />
As illustrated in Figure 26, scaling back LL<strong>IN</strong>s will reduce cost<br />
considerably. As coverage in scenario 1 is equal to sustained<br />
control, this reduction represents cost savings compared to both<br />
the elimination and sustained control phases.<br />
FIGURE 26: COST OF LL<strong>IN</strong> DISTRIBUTION FOR <strong>ELIM<strong>IN</strong>ATION</strong> SCENARIOS:<br />
EXPECTED REQUIRED COVERAGE AND LOWEST FEASIBLE COVERAGE<br />
2,000,000<br />
1,800,000<br />
1,600,000<br />
1,400,000<br />
1,200,000<br />
1,000,000<br />
800,000<br />
600,000<br />
400,000<br />
200,000<br />
0<br />
2009<br />
2011<br />
2013<br />
2015<br />
2017<br />
2019<br />
2021<br />
2023<br />
2025<br />
2027<br />
2029<br />
2031<br />
2033<br />
“UNIVERSAL COVERAGE SCENARIO” PROGRESSIVE SCALE BACK AND NO NETS<br />
AFTER 2030<br />
69