MALARIA ELIMINATION IN ZANZIBAR - Soper Strategies
MALARIA ELIMINATION IN ZANZIBAR - Soper Strategies
MALARIA ELIMINATION IN ZANZIBAR - Soper Strategies
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US $<br />
FIGURE 27: COST OF RDTS AND QUALITY ASSURANCE/CONTROL FOR<br />
<strong>ELIM<strong>IN</strong>ATION</strong><br />
700,000<br />
600,000<br />
500,000<br />
400,000<br />
300,000<br />
200,000<br />
100,000<br />
0<br />
2009 2011 2013 2015 2017 2019 2021 2023 2025 2027 2029 2031 2033<br />
SURVEILLANCE<br />
RAPID DIAGNOSTICS TESTS QUALITY CONTROL ON RDT’S<br />
A robust surveillance system is one of the most essential<br />
components of an elimination program and, as such, the<br />
resources that must be devoted to surveillance under elimination<br />
will be substantially greater than under sustained control. There<br />
are three main differences between the surveillance approach<br />
assumed for elimination compared with that of sustained control:<br />
�� Inclusion of Private Sector: Since it is essential that all malaria<br />
cases be tracked under an elimination program (including<br />
those that do not present in public health facilities), an<br />
elimination surveillance program in Zanzibar must include<br />
all private facilities. We thus assume that the MEEDS system<br />
would be expanded to all public facilities under sustained<br />
control and all cases, including cases detected in the private<br />
sector, trigger an appropriate response.<br />
�� Case Investigation: Under an elimination program, all<br />
suspected or reported malaria cases must be investigated.<br />
This costing includes district case investigation teams that<br />
travel to the household of the malaria patient, determine the<br />
likely source of the malaria infection, and screen surrounding<br />
households. As discussed in the technical feasibility section,<br />
we assume 100 households surrounding each newly identified<br />
case will be screened.<br />
�� Outbreak Response: Successfully achieving elimination will<br />
require that malaria outbreaks (>3 secondary cases) that do<br />
occur are halted as quickly as possible through focused vector<br />
control, screening and treatment.<br />
While the costs of the first priority are fixed (i.e., the functioning<br />
of the MEEDS system) and therefore should be constant over<br />
time, the costs of case investigation and outbreak response will<br />
depend on the number of malaria cases. The estimates of the<br />
expected number of cases that will require case investigation<br />
are based on the simulations described in Chapter 1 and vary<br />
based on the two core scenarios costed here. To calculate the<br />
number of surveillance teams that would be required to conduct<br />
this response, the number of expected cases and corresponding<br />
number of households to be screened were extrapolated. These<br />
3 | Financial Feasibility<br />
variables were adjusted based on the heterogeneity of transmission<br />
on Zanzibar, with the highest transmission risk districts (>2%<br />
prevalence) receiving one team additional to the number<br />
indicated by the estimated households requiring screening each<br />
year. It is assumed that one team of 3 can screen 20 houses per<br />
day and would work for 24 days per month. Districts with no<br />
transmission risk would not conduct active surveillance. For<br />
both costing scenarios, it is assumed that two districts are high<br />
risk, six are medium risk, and two are no risk until 2020. After<br />
2020, it is assumed that 1 district shifts from high to medium<br />
risk. Salaries of surveillance officers, transport costs (one vehicle<br />
per team, including maintenance), and administrative overhead<br />
are all included in the costing. The surveillance cost also includes<br />
the cost of RDTs used to screen all households. The simulator<br />
from the technical feasibility chapter suggests that screening 100<br />
households for each detected case is extremely likely to prevent<br />
an outbreak but we still included a contingency budget for<br />
outbreak response of initially $100,000 (the cost of a targeted<br />
IRS campaign in a single district) and $50,000 once elimination<br />
is achieved (outbreaks are even less likely to occur following<br />
elimination because of the assumed reductions in importation<br />
risk).<br />
The technical feasibility chapter describes how the main cost driver<br />
for surveillance–the number of cases that will trigger household<br />
screenings–depends heavily on assumptions of importation<br />
risk. It is expected that reductions in malaria transmission on<br />
the mainland alone will not be sufficient to achieve the very<br />
low levels of importation risk assumed in scenario 2. As such,<br />
targeted screening of travelers entering the islands at the main<br />
seaports (Stonetown, Mkoani or Wete, and Mkokotoni) is also<br />
assumed and costed for this scenario.<br />
TABLE 19: ASSUMPTIONS ON REDUCTIONS OF IMPORTATION RISK FOR<br />
2 <strong>ELIM<strong>IN</strong>ATION</strong> SCENARIOS<br />
2010 2020 2030<br />
Importation risk: Scenario 1 2/1000/year 1/1000/year 1/1000/year<br />
Reduction because of malaria control<br />
measures on the mainland<br />
Importation risk: Scenario 2 2/1000/year 1/1000/year 0.4/1000/year<br />
As there is no technical guidance and few experiences in other<br />
countries on which to base the assumed approach to border<br />
screening, the costing of this added intervention is inherently<br />
rough. It is assumed that cost drivers would include ongoing<br />
human resources, RDTs, other basic consumables, and<br />
management overhead. Assuming that screening would be<br />
conducted on board the vessels with an average travel time of 4<br />
hours per trip and that a team can screen up to 30 passengers per<br />
hour, it was estimated that 25 teams would be needed to deal with<br />
the maximum ferry capacity of around 3,000 passengers a day.<br />
It is important to emphasize that this approach is intended to only<br />
be used for the purpose of the costing of reduced importation<br />
risk and not as a basis for operational decisions; if the MOHSW<br />
wishes to explore implementation of border screening in the<br />
near-term, the authors recommend that a much more detailed<br />
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