Malaria Control in Emergencies

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Malaria Control in Emergencies
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Leading Causes of Childhood Deaths
Source WHO estimates of the causes of death in
children, 2000-03 Bryce, Lancet, 26 March 2005
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Major Causes of Death in emergencies for Sudan Wad Kowli Camp February, 1985
Somalia Gedo Region 7 Camps, January, 1980
Measles ARI Malaria Diarrhea Other
Source Centers for Disease Control and
Prevention, Famine-Affected, Refugee, and
Displaced Populations Recommendations for Public
Health Issues. MMWR, 199241(No. RR-13)8.
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Background

• Malaria is a parasitic disease caused by one of
  four protozoan parasites
• Plasmodium falciparum (most severe and
  life-threatening) vivax, ovale, malariae
• 300-500 million clinical cases/year
• Over 1 million deaths/year
• 90 in sub-Saharan Africa

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Background II

• Complicated transmission requiring correct
  conditions for the vector, host, climate
• Physiologically most vulnerable
• Children less than five years old
• Pregnant women

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Background III

• Marked antimalarial drug and insecticide
  resistance rates
• Few drugs available
• Available drugs costly and often have complicated
  dosing regimens
• Years of vaccine research have produced few
  hopeful candidate vaccines

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Vector Female Anopheles

• Parasite enters human host when an infected
  mosquito takes a blood meal
• Bites at night (6 PM to 6 AM)
• May rest indoors or outdoors

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Transmission Cycle
Parasites multiply in human liver and
bloodstream, causing fever chills
Human
Infected mosquito bites person
Mosquito bites infected person
Mosquito
Parasites multiply in mosquito gut and migrate to
salivary gland
Adapted from RBM What is Malaria? Infosheet
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Burden of Malaria in Emergencies

• Estimates of population of concern are
  underestimated
• 2/3 of the 21 million people of concern to UNHCR
  live in malaria endemic areas
• WHO estimates 30 of malaria deaths in Africa
  occur in wake of war, local violence or other
  emergencies

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Vulnerable Populations

• Groups marginalized politically or socially
• Southeast Asia- populations living on the borders
• Groups unable to access limited resources
• Physically/mentally disabled, unaccompanied
  minors, elderly, those with other illnesses or
  weakness
• Groups isolated from humanitarian efforts
• Fleeing Goma, Bukavu into central forest of DRC
  in 1987

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Factors Associated with Increased Risk of Malaria

• No or poor housing
• Location of camps/settlements often not planned
  well
• Placing camp in well known flood plain (e.g., TZ)
• Deliberate movement to areas near water
• Overcrowding
• Proximity of livestock
• Mobility may have limited contact with health
  facilities
• Compromised immune status

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Factors II

• Control strategies used in stable, non emergency
  setting need to be adapted
• May create political difficulties
• Drug policies in host country may not be current
• Changing national malaria treatment guidelines is
  a laborious process
• Time is insufficient for this process
• Needed drugs may not yet be registered for use in
  the host country and may be unfamiliar to workers
  who need to use them
• Need to think of refugee affected area and
  impact on host/national population

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Malaria Control Objectives

• Enhance overall case management
• Promote use of laboratory-based diagnosis (both
  microscopy and rapid diagnostic tests RDTs)
• Implement treatment guidelines that use highly
  effective malaria drugs
• Understand treatment seeking behaviors of
  targeted populations
• Improve access to and utilization of effective
  malaria prevention interventions
• Use appropriate vector control measures
• Ensure access to those at increased risk of
  malaria (pregnant women, infants, non-immunes)

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Objectives II

• Increase and improve knowledge, skills and
  practice related to malaria control
• Focus on partner organization personnel, as well
  as community
• Ensure effective communication and coordination
  among all involved agencies
• Promote beneficiary participation in malaria
  control programmes
• Engage refugee communities as partners from the
  beginning of a project through its duration

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Objectives III

• Reinforce surveillance and monitoring and
  evaluation of malaria control programmes
• Develop a standardized, minimum set of indicators
  to be used for surveillance
• Establish systems to monitor implementation of
  control interventions use standardized data
  collection tools and case definitions
• Use evaluations and assessments to compile
  lessons learned and identify best practices

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Initial Assessment

• Malaria risk within host country
• Ongoing malaria control activities of host area
• Climatic conditions
• Surveillance patterns
• Establishing actual numbers of cases
• Multiple systems of surveillance?
• Differing versions of case definition what are
  you measuring febrile illness or malaria?
• Efficacy of current treatment guidelines
• Used at the camp
• National or regional data

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Assessing the risk

• Resettlement area

Local malaria situation is clearly defined
No
Yes
Endemic region
Non-endemic region
Rapid Epi investigation needed
Immune status of refugees
People not at risk of malaria. Region could be
prone to malaria outbreaks
Little or No immunity
Coming from endemic areas
All age groups are at risk
Children and pregnant women are at risk
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Health Clinics in Established Camps
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Phases of Emergencies

• Emergency Phase
• Focus on decreasing morbidity and mortality
  through prompt access to effective treatment with
  artemisinin-based combination therapy
• If feasible, supplement with prevention,
  targeting groups at highest risk of severe
  malaria and death

Source UNHCR Strategic Plan for Malaria Control
2005-7
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Phases II

• Stabilization phase
• Sustainability
• Institute community vector-control strategies
  achieving high coverage
• 60 of population with insecticide-treated
  materials (ITMs)
• 85 shelters with indoor residual spraying (IRS)
• Intermittent Preventive Therapy (IPTp)

SourceUNHCR Strategic Plan for Malaria Control
2005-7
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Phases III

• Returnee settings
• Rehabilitation and reconstruction efforts should
  focus on effective malaria treatment and
  high-coverage community prevention
• Should have equivalent access to services as that
  of local populations
• Offer long-lasting insecticide-treated nets
  (ITNs) as part of repatriation package and
  adequate health education during pre-departure
  and transit

SourceUNHCR Strategic Plan for Malaria Control
2005-7 http//www.unhcr.org/protect/PROTECTION/45
6ac23a2.pdf
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Challenges to malaria control in Emergencies

• Increased vulnerability of displaced populations
  i.e. malnutrition
• Increased risk of epidemics - movement of
  non-immunes to high malaria transmission areas

Source BBC News, Darfur refugees coming into
Chad, 2006
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Housing
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Environmental Degradation
Potential Breeding Sites
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Challenges II

• Breakdown of health services or existing health
  facilities overwhelmed
• Appropriate response beyond local/national
  capacity
• Unstable government or no government
• Ongoing conflict, insecurity - long term planning
  difficult (e.g. Southern Sudan)

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Challenges III

• Many partners - UN organizations, NGOs
  responsible for providing health services with
  local/national authorities
• Often, poor or no inter-agency communication
• Lack of technical knowledge of malaria among
  operational agencies
• Physical and transport barriers - delays in
  access to supplies

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Challenges IV

• Security concerns prevent consistency
• Operational research - many gaps in knowledge,
  few funds available
• Lack of data on malaria burden in emergencies
• Lack of information on drug or insecticide
  resistance

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Clinical Diagnosis

• Common approach for diagnosis in endemic
  countries
• Current or recent history of malaria fever
• Sensitive, but results in over-diagnosis and
  over-treatment
• Increased drug pressure, which enhances
  likelihood of developing antimalarial drug
  resistance
• Adverse drug reactions
• Increased cost
• Misdiagnosis of non-malarial fever

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Diagnostics
Low to Moderate Transmission
Prompt parasitological confirmation of diagnosis
recommended before treatment
Suspected severe malaria parasitological
confirmation if available, if not, treat on
clinical grounds
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Microscopy

• Considered gold standard for diagnostics
• Can identify species and level of parasitemia
• Often not used in emergencies
• overwhelming load of patients
• lack of electricity
• inadequate supplies/training

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Rapid Diagnostic Tests (RDTs)

• Detect specific antigens (proteins) produced by
  malaria parasites
• Rapid, easy to use, results in 20 minutes
• Cost 0.70
• Prone to deterioration through heat and humidity
• Difficult to see results in situations of low
  parasitemia
• Late readings

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Case Management

• Gold standard for treatment of uncomplicated
  malaria is an artemisinin-based combination
  therapy (ACT)
• New Emergency Health Kit (NCHK) contains
  Artemether/Lumefantrine co-formulated in a single
  tab (Coartem)
• Requires fatty food with dose
• Other combinations available
• Sulfadoxine-pyrimethamine (SP) and Amodiaquine
  (AQ)
• Artesunate (AS) with SP
• AS/AQ (co-formulated, single dose, Coarsucam)

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Severe Malaria

• Pre-referral therapy artesunate suppositories
• Requires rapid referral to in-patient unit
• Quinine (QN) drug of choice but requires a higher
  level of care
• Kakuma 2007 outbreak insufficient skills in
  in-patient unit to use QN loading dose as
  recommended

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Intermittent Preventive Therapy (IPT)

• Pregnant women at higher risk
• severe maternal anemia, maternal death, low birth
  weight and higher infant mortality rates
• IPTp recommends at least two doses of SP (targets
  ANC visits)
• Monthly doses - HIV women
• Requires good record keeping
• Infants (IPTi)
• A few trials with promising results
• Not currently recommended but may be promising
  intervention

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Insecticide Treated Nets (ITNs)

• Individual-level protection
• Community-level protection
• Portable
• Requires re-treatment every 6 months unless
  long-lasting ITNs used (LLITNs)
• Can target most vulnerable populations in areas
  of high transmission
• Disadvantages expensive start-up costs, need
  distribution strategy, high level of resale,
  retreatment requirements, incorrect use

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Indoor Residual Spraying (IRS)

• Logistically feasible
• Target specific areas where malaria is unstable
• Community level effect requires 85 coverage
• Timing important
• Every six months
• Resistance increasing
• Should pre-stock materials

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Other Preventive Measures

• Insecticide treated clothing, top sheets and
  blankets Afghan camps
• Hammock nets Cambodia and Vietnam
• Larviciding works best when breeding sites are
  limited and relatively permanent
• Aerosol spraying not generally recommended

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Insecticide Treated Plastic Sheeting (ITPS)

• Insecticide treated plastic sheeting (ITPS)
• Combined shelter and malaria control tool
• Major effect on mosquito mortality in trials
• Proportion killed depended on surface area
  covered
• Mode of action and efficacy more closely
  resembles IRS than ITNs
• Confers limited personal protection inside home
  but, applied at community level, works as a
  control by decreasing mosquito longevity
• Currently at trial level

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Current Issues

• Which interventions can be targeted to those most
  in need IRS versus ITNs?
• Cost-effectiveness of strategies
• Chronic shortages of food and non-food item
  distribution impact on resale of ITNs

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Current Issues II

• Substandard medications
• Overall, lack of effective monitoring and
  evaluation in malaria control

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Thank You!
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