MALARIA ELIMINATION IN ZANZIBAR - Soper Strategies
MALARIA ELIMINATION IN ZANZIBAR - Soper Strategies
MALARIA ELIMINATION IN ZANZIBAR - Soper Strategies
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<strong>IN</strong>DOOR RESIDUAL SPRAY<strong>IN</strong>G<br />
As noted above, IRS under sustained control includes full coverage<br />
for two years, followed by three years of targeted spraying in<br />
malaria “hot spots” (North B, Central and Micheweni districts),<br />
followed by focal spraying of clusters if an outbreak is detected.<br />
For costing purposes, we consider “targeted spraying” to be the<br />
equivalent of 20% of households and “focal spraying” to be the<br />
equivalent of 10% of households per year. An IRS program<br />
under elimination would be very similar, with the additional<br />
assumption that focal spraying would decline to zero under the<br />
elimination scenarios due to a reduction in the number of foci<br />
to be treated. 1<br />
Since IRS is withdrawn in the short-term for both sustained<br />
control and elimination, it is not included in the long-term<br />
costing of both phases. However, a recent review suggests that<br />
a combination of IRS with LL<strong>IN</strong>s provides a higher protective<br />
effect than both of the interventions implemented individually.<br />
If the recently documented reduction in malaria burden on<br />
Zanzibar is indeed due to a combined effect of IRS and LL<strong>IN</strong>s,<br />
sustained control will require continuation of both interventions,<br />
making it on average 40% more expensive compared to the<br />
sustained control scenario assumed in this analysis. This addition<br />
would change the cost comparison between sustained control<br />
and elimination, potentially resulting in elimination being cost<br />
saving in the short- to medium-term.<br />
DIAGNOSIS & TREATMENT<br />
There are four major differences between the diagnosis and<br />
treatment approaches under sustained control and elimination:<br />
1. Testing of all fever or history of fever cases: While this is also<br />
recommended under sustained control, the elimination<br />
scenarios assume almost universal health seeking behavior for<br />
fever and testing rates over time. This results in a continuous<br />
increase of the number of RDTs needed and makes RDTs<br />
the main cost driver of case management for elimination.<br />
70<br />
2. Inclusion of formal private sector: Under sustained control, the<br />
program’s objective is to test every febrile client in the public<br />
sector for malaria and treat all positive cases with ACT. The<br />
elimination program will need to expand this to include<br />
testing and appropriate treatment of all fever cases in the<br />
private sector as well. This will be a challenging policy to<br />
enforce and will likely require that the government provide<br />
ACTs and RDTs free to private sector facilities to encourage<br />
compliance.<br />
3. Treatment only in formal facilities: Since it is imperative that<br />
all malaria cases be captured by the surveillance system and<br />
appropriately addressed, the ZMCP will need to ensure that<br />
all fever cases are tested and treated in formal health facilities,<br />
including the many patients that currently seek treatment in<br />
the informal private sector. This will further increase costs<br />
1 It is important to note that some continued costs of IRS under<br />
elimination are built into the costing of surveillance, as input<br />
costs for outbreak response.<br />
related to ACTs and RDTs because a higher fraction of the<br />
population will be treated in facilities than under sustained<br />
control.<br />
4. Quality assurance with PCR: Unlike sustained control, it is<br />
recommended that an elimination program include use of<br />
PCR to consistently check the quality of RDT diagnosis<br />
conducted in peripheral facilities. The recommended<br />
approach would PCR test every positive test and 10% of<br />
negative RDTs and blood smears collected from the public<br />
and private sectors.<br />
The starting point for this analysis (including treatment seeking<br />
behavior, diagnosis rates, etc.) is taken from Zanzibar’s Roll Back<br />
Malaria Needs Assessment as well as its 2007 MIS survey. The main<br />
assumptions about the current state of treatment seeking behavior,<br />
and diagnostic/treatment practices are presented in Table 18.<br />
TABLE 18: ASSUMPTIONS ON HEALTH SEEK<strong>IN</strong>G BEHAVIOR AND DIAG-<br />
NOSTIC/TREATMENT PRACTICES USED TO COST ACTS AND RDTS FOR<br />
<strong>ELIM<strong>IN</strong>ATION</strong><br />
Health Seeking<br />
Behavior<br />
Testing Rates<br />
(RDT at $0.58)<br />
Treatment<br />
(ACT at $1.08)<br />
Number of<br />
Malaria Cases<br />
2009 (Estimates based<br />
on the 2007 MIS Survey)<br />
!" 50% public sector<br />
!" 26% private sector<br />
!" 24% seek no care<br />
!" 25% of all OPD<br />
patients in public<br />
sector<br />
!" 2% of patients in<br />
private sector<br />
!" All positive cases are<br />
treated with an ACT<br />
in both public an<br />
private sector<br />
!" 10% of people visiting<br />
the private sector are<br />
treated presumptively<br />
!" Based on<br />
extrapolations from<br />
the MEEDS data for<br />
2009<br />
2020 and thereafter (Estimates<br />
based on assumed changes over<br />
time related to ZMCP targets<br />
and/or recommendation for<br />
Chapter 1)<br />
!" 74% public sector<br />
!" 26% private sector<br />
!" 0% seek no care<br />
!" 35% of all OPD (equivalent<br />
to 100% of fever cases)<br />
!" 20% of all people seeking<br />
care in private sector (or all<br />
fever cases)<br />
!" All positive cases are treated<br />
with an ACT in both public<br />
an private sector<br />
!" 0.5% of people visiting the<br />
private sector are treated<br />
presumptively<br />
!" Based on results from the<br />
simulator described in<br />
Chapter 1<br />
Using these assumptions, the cost of case management increases<br />
four-fold over the course of an elimination program (see Figure<br />
27). The main drivers of this increase are greater volume of RDTs<br />
and the cost of quality assurance/control of those tests. Over<br />
time, almost all fever or history of fever cases are assumed to seek<br />
care from public and private facilities requiring a corresponding<br />
significant increases in the number of tests performed. In contrast,<br />
with the case load reducing over time, the cost of treatment will<br />
be very modest, representing less than 1% of the total cost of case<br />
management.<br />
Under both elimination scenarios, the number of confirmed<br />
malaria cases will constantly reduce over time. However, this is<br />
not the main driver of the reduction in the cost for treatment.<br />
Rather, this is primarily explained by the cessation of presumptive<br />
treatment in the private sector.