Saturday, May 1, 2010

Malaria control ... in Zanzibar, Tanzania

Dear Colleagues

It is good to see a report of malaria control success in Africa. In this case the story is about Zanzibar. It is also good to see that a department head in the Zanzibar Malaria Control Program (ZMCP) is alerting to the need to pay attention so that the progress is not reversed. The insider joke in malaria circles is that malaria has now been eradicated in Zanzibar three times!
Of course, the warning is that it will come back again, unless there is the correct follow up.

As you will see from the article, there are concerns in Zanzibar that there will not be the resources to maintain an adequate surveillance system and not enough resources to mount a timely response when malaria resurgence is detected.

Some work I did in 2007 on modeling the behavior of mosquitoes and malaria under a multiple malaria control intervention scenario alerted me to the relative speed and ease in treating cases of malaria and reducing the prevalence of malaria, and the even more rapid rebuilding of malaria in a community once the conditions for mosquitoes and malaria transmission exist again.
TANZANIA: Zanzibar's malaria success a potential banana skin

ZANZIBAR CITY, 25 April 2010 (IRIN) - Efforts to combat malaria in Zanzibar have seen the prevalence rate come down from 35 percent before 2008 to below 1 percent, but health officials are worried the gains could be reversed.

“Despite the achievements in reducing malaria, a lack of funds for awareness[-raising], indoor residual spraying and surveillance, is a challenge. Also, we have a problem with people’s resistance to behavioural change, particularly in keeping the environment clean and in the use of mosquito nets,” said Mwinyi Msellem, head of the diagnostic unit at the Zanzibar Malaria Control Programme (ZMCP).

As malaria prevalence heads towards zero, the population is also losing its natural immunity to the disease, meaning that population screening will become increasingly important, said Msellem. Malaria prevalence was below one percent, according to the Roll Back Malaria Indicator Survey of 2007.

ZMCP interventions include case management through the treatment and training of health workers, and integrated vector control through the use of insecticide-treated bednets, environmental hygiene and indoor spraying.

The prevention of malaria in pregnancy has also been a key malaria control intervention although the use of prophylaxis medication by pregnant women is low at 40 percent against a target of 85. “Most pregnant women attend clinics when they are close to delivery so they just get the last dose,” he said. Two doses are recommended.

Along with past interventions, emphasis is on new case monitoring and research. “When you get this kind of success you have to increase surveillance,” he noted.

Early epidemic detection system

A Malaria Early Epidemic Detection System has also been established to monitor new cases at 52 of Zanzibar’s 150 health facilities. “Weekly, they [the health centres] send text messages to our server indicating the number of patients, those tested for malaria, and the number diagnosed with malaria,” said Msellem. Comparisons are then drawn against previous weekly reports.

“If an increase is noted, we have to investigate and check breeding grounds,” he said. The health centres reported 1,671 confirmed malaria cases in 2009, of which 618 were children under five.

According to the Ministry of Health and Social Welfare, health centres have been showing 2-3 percent malaria prevalence, with no change noted since the short March-May rains.

Emerging challenges

Challenges are, however, emerging in disease monitoring, behaviour change and funding.

Among the problems is difficulty getting monitoring data from the health facilities, he said. Mobile phone technical errors sometimes also interfere with data collection.

“Each district also needs its own surveillance and response team and there is a need for more trained personnel,” he said. “To set up this system you also need a lot of money.”

Refusal to test and be treated for malaria has also been noted as cases decline, raising the risk of onward transmission or even death. This is because some people believe malaria has already been eliminated, said ZMCP.

Mariam Mussa, 34, a small trader and mother of three in Tunguu village south of Unguja, one of Zanzibar’s constituent islands, said: “I thank God that the last time one of my children had malaria was in May [2009]. In the past we used to have malaria frequently.”

Situation remains fragile

“Although malaria is down, the situation remains fragile. Sustainable commitment by the government, including having its own funds for the anti-malaria programme and awareness of the need to keep the environment clean, is important to control mosquitoes,” Juma Muchi, a doctor, told IRIN.

The likelihood of donors and the government withdrawing support due to the recorded success is a major concern, according to ZMCP’s Msellem. “We need to sustain control measures to avoid a resurgence… Malaria prevalence was reduced to 1-2 percent in the 1970s, and then people relaxed… If we do not have proper strategies and do not work together - yes there is a fear of sliding back.”

“Maintaining the gains in fighting malaria is probably the biggest challenge facing Zanzibar now,” said Asha Abdallah, the Minister of Employment, Youths, Children, and Women.
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It should also be noted that Zanzibar is a small island ... part of Tanzania ... and widely reported as a success story in Africa for malaria control.

I have a big issue with the donor community and the implementing agencies associated with malaria control in Africa regarding the amount of money disbursed, the cost efficiency of what has been done, and the cost effectiveness of the interventions. As far as one can see, the issue of longer term sustainability is not part of the immediate program planning ... with the WHO suggesting that some three times as much money is needed annually for malaria control than is currently being disbursed.

There are some serious question here that need answers!

Peter Burgess

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