Malaria Control–Elimination–Eradication: Zanzibar’s Perspective Abdullah S. Ali Manager Zanzibar Malaria Control Programme Zanzibar Ministry of Health and Social Welfare 6 December 2008
Malaria Control–Elimination–Eradication:
Zanzibar’s Perspective
Abdullah S. AliManager
Zanzibar Malaria Control ProgrammeZanzibar Ministry of Health and Social Welfare
6 December 2008
Zanzibar and Pemba
Outline• Zanzibar profile• Malaria situation in Zanzibar – circa 2000• Introduction of ACTs – 2003• Impact two years later – 2005• Scale-up of LLIN/IPTp coverage – 2006• Impact – 2007• Introduction of IRS – 2006• Impact with all 4 interventions – 2008• Conclusion
Zanzibar Profile
• About 1.1 million population: cosmopolitans society
• Geographically small - 2,330 km2
• Administratively, semi-autonomous; separate MOH from Tanzania Mainland
• Children under the age of five – 16%• Under five mortality rate – 87/1000
Malaria in Zanzibar - 2000• Leading cause of morbidity and mortality
• 50% of Out-patient consultations due to malaria
• Long waiting queues at clinics
• Low school attendance
1999 2000OPD Malaria Cases 314,554 268,813
OPD Attendance 591,074 521,191
Introduction of ACT – 2003• Why so early?
– Increased failure rate to CQ: >60%
• Who made decision/how?– Experts consensus (local and international)
• Funding? – Domestic and donor
• How quickly was transition implemented?– Within a year
• Challenges with shift to ACTs?
Malaria Situation – 2005
Malaria parasitaemia prevalence at two sentinel sites
NORTH A MICHEWENI
2003 All ages: 7.9 %Under 5: 9.4 %
All ages: 14.4 %Under 5: 23.9 %
2005 All ages: 3.3 %Under 5: 4.9 %
All ages: 13.4 %Under 5: 23.1 %
Prevalence of high density parasitaemia (>5,000 parasites/µL) decreased significantly on both islands between 2003 and 2006.
IPTp – 2004/05• Started in Feb 2004• Basic foundation laid down:
– training of health workers, guidelines, supervisory tools, etc.
• Given twice during pregnancy period using SP
• IPTp2 Coverage – 47.8% - 2005– 59% - 2007
Scale-up of LLINs – 2006• Technical decision: ITN distribution to
all under fives and pregnant women• ITNs use to both >70%
• GFATM Rd 4
• Challenges– Increased demand
from the community– Cost: IEC & distribution
Number of IRS and Coverage,2006–07
182,914
196,827
207,478
85%
91%
96%
150000
160000
170000
180000
190000
200000
210000
220000
1st cycle (Jun-Jul 06) 2nd cycle (Jan-Feb 07) 3rd cycle (Aug-Sep 07)70%
75%
80%
85%
90%
95%
100%
Sprayed Hosuses proportion of sprayed houses
Health Facility Data: Annual Malaria Diagnosis in Out-patient Department
(clinical and confirmed cases)
Trends in Plasmodium falciparum prevalence in Micheweni and North A districts
14
8
5
0.9
8
3
10
2003 2005 2006 2007
MicheweniNorth A
Trends in P. falciparum Prevalence in Micheweni and North A Districts
Malaria Situation – 2008Positivity Rate all health facilities Sept 2003 – Aug 2008
Prevalence survey May, 2007Age group/category Parasite positive by species
(# and%)Overall
(# and%)
S/size P. f P. m MixedChildren under five years 1026 3
(0.3%)1
(0.1%)0 4
(0.4%)Five years and above 5543 43
(0.8%)13
(0.2%)2
(0.04%)58
(1.0%)Subtotal sub-set general population
6569 46 (0.7%)
14 (0.2%)
2 (0.03%)
62 (0.9%)
Pregnant Women 759 0 (0%)
0 (0%)
0 (0%)
0 (0%)
Children with recent history of febrile illness
1097 4 (0.4%)
1 (0.1%)
0 (0%)
5 (0.5%)
Total 8425 50 (0.6%)
15 (0.2%)
2 (0.02%)
67 (0.8%)
M&E
• Routine monitoring of activities: quarterly basis
• Bi-annual evaluation of malaria control activities
• Establish strong malaria surveillance system
Mgmt of Progs. for Communicable Diseases in Sub- Saharan Africa
17
Typical Facility Selected for Early Implementation of MEEDS*
*Malaria Early Epidemic Detection System
Mgmt of Progs. for Communicable Diseases in Sub- Saharan Africa
19
Overview of MEEDS
Health facilitySelcom server
Weekly text message
Secure website
Transmittal of data
Text SMS for
acknowledgment/
feedback
Total Outpatient Visits Zanzibar, Weeks 1–45, 2008
0
500
1000
1500
2000
2500
1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51
Week
Num
ber o
f vis
its
>5 yr<5 yr
Confirmed Malaria Cases Zanzibar, Weeks 1–45, 2008
0
5
10
15
20
25
30
35
1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51
Week
Con
firm
ed m
alar
ia c
ases
>5 yr<5 yr
References1. Lemnge M. Ali AS, Khamis AA (2002) Therapeutic efficay of Chloroquine among
children with Uncomplicated plasmodium falciparum malaria in Zanzibar.2. RBM situation analysis in Zanzibar (2002)3. Lemnge M. Ali AS, Khamis AA (2002)Therapeutic efficay of sulphadoxine-
Pyrimethamine and Amodiaquine among children with Uncomplicated plasmodium falciparum malaria in Zanzibar.
4. Health Information System Ministry of Health (2003)5. Efficacy of Artesunate Plus Amodiaquine versus of that Artemether - Lumefantrine
for the treatment of Uncomplicated Childhood Plasmodium Falciparum Malaria in Zanzibar Tanzania (2005).
6. Impact of Artemisinin-based Combination Therapy and Insecticide Treated Nets on Malaria Burden in Zanzibar (2007):Achuyt Bhattarai, Abdullah S Ali, S. Patrick Kachur, Andreas Mårtensson, Ali K Abbas, Rashid Khatib4, Abdul-wahiyd Al-mafazy, Mahdi Ramsan, Guida Rotllant, Jan F Gerstenmaier , Fabrizio Molteni, Salim Abdulla, Scott M Montgomery, Akira Kaneko, Anders Björkman
7. World Malaria Report 20088. ZMCP 2007, Malaria Indicator Survey