Achievements of 20002004 Country RBM Plan

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Achievements of 2000-2004Country RBM Plan

• Dr. Tewolde G/Meskel
• Manager, NMCP

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1 Background

• Eritrea adopted RBM initiative in 1998
• National Conference on RBM held in Mendefera in
  July 1999
  
• The draft five years country malaria control
  strategic plan for 2000-2004 discussed and
  launched
  
• Annual malaria action plans continued to be
  updated based on the 5 yrs Strategic POAs

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2 Objective of RBM FYP (2000-2004)

• General objective
  To reduce malaria to such a low level
  that it is no longer a major public health
  problem in the Country.

• Specific Objectives
• Reduce Malaria morbidity by 80 from 1999 levels
• Reduce malaria mortality by 80 from 1999 levels
  and
  
• prevent epidemics of malaria

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3 Strategies

• Case Management(Early detection and prompt
  treatment)
  
• Integrated Vector Management Use of ITNs,
  Environmental Management, Larviciding, Indoor
  residual spraying in selected villages
  
• Epidemic Prevention (preparedness, monitoring of
  sentinel sites, forecasting/meteorological
  
• Capacity Building (Training of HWs, CHAs, PHTs
  etc)
  
• Health Promotion
• Operational Research
• Monitoring and Evaluation

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4 RBM partners

• FINCNCIAL AND TECHNICAL SUPPORT
• WHO
• WHO/PHARPE (Italian corporation)
• UNICEF
• USAID
• World Bank (HAMSET)
• GFATM (Since 2004)
• JICA/Unicef (Since 2004)
• Ministries MoA, MoE, MoI, MoLWE, Local
  Government, Dep. of Environment among others
  
• Associations
• Youth and Women Associations
• PFDJ, Zonal, sub zonal and village
  administrators
  

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5 Major Accomplishment A Capacity
building/Training

• Refresher training on Malaria Microscopy for 133
  laboratory technicians
  
• Training workshop on Epidemic Preparedness and
  Forecasting for Zonal Malaria Coordinators and
  NMCP HQ staff organized by the NMCP/HQ and EHP.
  
• Planning workshop on the Village Pilot Project
  for the control of mosquitoes in Eritrea
  organized by the NMCP HQ and EHP.
  
• Training on data management and evaluation of
  malaria case management at health facilities
  organized by the NMCP HQ and WHO.
  

Participants of the refresher training for
laboratory tech.
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5 Major Accomplishment

• A Capacity building/Training Cont.
• Training on Anti Malarial Drugs efficacy studies
  conducted by NMCP HQ and Zones.
  
• Training on operational research methodology
  conducted for Zonal Malaria Coordinators and NMCP
  HQ staff by Tulane University, USA.
  
• Training on malaria entomology field techniques
  provided for Malaria Technicians by EHP through
  ICIPE experts.
  
• Training on data management and analysis given to
  the Zonal Malaria Coordinators and NMCP HQ by
  Tulane University, USA.
  
• Data management training provided for zonal Data
  clerks and NMCP HQ staff by WHO.
  
• Training on mosquito sample processing, larvae
  and adult identification, blood meal and
  sporozoite ELISA for the HQ technical staff.
  

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5 Major Accomplishment
A Capacity building/Training Cont.
Personals trained in case management in the last
five years
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5 Major Accomplishment

• A.2 Case management Slide crosschecking,
  Procurement and distribution
  
• At national level, slide crosschecking for
  slides sent from zones has been conducted
  
• Antimalarial drugs (1st and 2nd line drugs) and
  other supportive drugs
  
• Microscopes, reagents and other laboratory
  supplies
  
• Rapid diagnostic test kits for HFs with out
  microscopy
  
• were procured and distributed to all HFs

A malaria microscopist crosschecking slides sent
from zones
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5 Major Accomplishment
Summary of Blood Films Cross-Checked At NMCP For
Malaria Parasite in 2004
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5 Major Accomplishment

• C Integrated vector management
• 1 ITN distribution bed net re-impregnation
• ITNs procured and dispatched to all zones
• Insecticides for bed nets impregnation and
  re-impregnation procured and distributed to all
  zones based on their request
  
• Extensive campaign related to bed
• net re-impregnation conducted
• Re-impregnation sites expanded
• from HFs level to kebabi/village level
• Re-impregnation materials procured
• locally and provided to each re-impregnation
  site
  

CHAs involving in bed net re-impregnation
campaign in Hamelmalo health station
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No. of ITNs distributed bed nets Re-impregnated
in the last five years
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5 Major Accomplishment

• C Integrated vector management
• 2 Indoor residual spraying
• Spray pumps and spare parts for spray pumps
  procured and distributed
  
• Insecticides (DDT and Temephos) for indoor
  residual spraying procured and distributed
  

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Spraying activities conducted by year
2 Indoor residual spraying cont.
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5 Major Accomplishment

• B Integrated vector management
• 3 Environmental management and larviciding

Mattocks, Shovel, sickles, hoes and wheel barrows
for EM procured and distributed to zones
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5 Major Accomplishment

• D Epidemics Prevention and control
• Manual on malaria epidemic forecasting and
  preparedness for prediction, prevention,
  detection and control of malaria epidemics in
  Eritrea was prepared and distributed to the
  malaria control staff.
• Epidemics thresholds have been developed for
  health facilities based on past data.
  
• Key malaria control staff members trained on
  malaria epidemic forecasting and preparedness.
  
• Twenty sentinel sites for epidemic detection
  established and provided necessary equipments.

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5 Major Accomplishment

• D Epidemics Prevention and control Cont.
• Guidelines and standard operating procedures for
  sentinel sites developed and distributed to all
  zones.
  
• Weekly and monthly malaria morbidity and
  mortality data, climatic data (temperature,
  rainfall and humidity) collected in each site and
  graphs made for each parameter so that malaria
  incidence can be monitored.
• Antimalarial drugs, insecticides and other
  necessary materials were procured for emergency
  and kept in stock.
  

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5 Major Accomplishment

• E Health Promotion
• A malaria communication strategy was developed
  based on the formative research on communitys
  KAP and health seeking behaviour conducted
  
• Intensive health education on malaria and its
  control for general population, community leaders
  and influential people
  
• IEC campaigns using brochures on malaria
  treatment and danger signs, posters on ITN use,
  
• Weekly radio and television spots,
• Mobile video unit presentations (MVU) and
  billboards (by ESMG)
  

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5 Major Accomplishment E Health
Promotion (Cont.)

• E.1 Health promotion activities conducted by
  zones during the African and National Malaria
  Weeks
  
• Bicycle race, SARA clubs
• Student competition
• Distribution of broachers using students
• Foot race with slogans containing malaria
  massages
  
• Mass treatment of bed nets
• Mobilizing community for conducting environmental
  management
  
• Seminars for village administrators, community
  leaders and elders

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5 Major Accomplishment

• E.2 Health promotion activities conducted in
  cooperation with ESMG Cont.
  
• Three video spots and two radio spots in
  Tigrigna, Tigre and Arabic produced and aired
  through ERITV and Dimtsi Hafash respectively
  (Africa and National Malaria weeks)
• Mobile video presentations made in remote
  villages
  
• Six billboards which reflect the proper use of
  bed nets two in Tigrigna, two in Kunama and two
  in Tigre
  
• Brochures
• Treatment guideline produced and distributed to
  zones

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5 Major Accomplishment

• F Operational Research
•  Study on geographical distribution and
  behavioral patters of anopheline mosquitoes in
  Eritrea conducted and result of the study
  published in international scientific journals
• Malaria parasitological survey
• Health facility malaria case management
  assessment conducted in Debub and Gash-Barka
  zones.
  

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5 Major Accomplishment
F Operations Research Cont.

• CQSP and ARTAQ efficacy studies conducted in
  six sites (Adiquala, Goluj,, Tesseney Tokombia,
  Sawa and Hagaz)
  

A laboratory technician examining malaria slides
from one efficacy study site
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Anti-Malarial Drug Therapeutic Efficacy Results
(Year 2004)
A ARTAQ Treatment outcome
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Anti-Malarial Drug Therapeutic Efficacy Results
(Year 2004) cont.
B CQ SP Treatment Outcome
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Result by age group from sites with adequate
sample size
Anti-Malarial Drug Therapeutic Efficacy Results
(Year 2004) cont.
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Results of five and above patients for Tesseney
hospital with adequate sample size (2002 , 2003
and 2004)
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5 Major Accomplishment
F Operations Research Cont.

• Firs and second rounds village pilot project on
  Bti and Bs as alternatives to Temephos
  

Members of the entomology teams checking breeding
sites for larvae in one of the village pilot
project villages, Ghindae
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5 Major Accomplishment
F Operations Research Cont.

• Treatment seeking behavior study conducted in
  Gash-Barka zone.
  
• Susceptibility and Bioassay studies conducted in
  Anseba and Gash-Barka zones.
  
• The entomology lab/Insectary established in
  Mendefera is functioning partially.
  
• Another two entomology labs/Insectaries one in
  Anseba and the other one in Gash Barka?Tessenei
  near completion

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5 Major Accomplishment

• F Operational Research (Cont.)
• ITNs availability, use and re-treatment study
  conducted in Anseba, Debub and Gash-Barka zones
  
• Based on the preliminary result of the ITN use
  and availability survey (Sep 2003) in 3 zones
  showed that
  
•  46 of HHs in malarious areas have at least 2
  ITNs
  
• 63 of
•  56 of 5-14 slept under ITNs the previous night
• 50 of adults slept under ITNs the previous
  night
  
• 40 of pregnant women slept under ITNs the
  previous night
  

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2004 Major Accomplishment (Cont.)
F Operations Research Cont.
Opening Session on RBM 5 years
Evaluation Survey Training
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F Operational Research (Cont.)

• The RBM evaluation survey
• Result of the RBM survey helped the program to
  identify its weaknesses and strengths and to
  prepare the next five year RBM strategic plan
  based on the findings.
• Based on the preliminary report of the 2004 RBM
  survey in 4 zones
  
• 60.2 of
• 48.7 of 5-14 slept under ITNs the previous
  night
  
• 53 of pregnant women slept under ITNs the
  previous night
  
• Percent of house holds owning two or more ITNs in
  the three zones was found to be 66 percent
  

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Proportion of Households Owning Nets and
Re-treatment Rates, Eritrea 2001 and 2004
Figure 2
100
87.7
81.6
79
73
80
67.9
62
60
2001
Percent
2004
40
20
0
Own any net
Own ITN
ITN re-treated in
6months
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Proportions of Children and Pregnant
Women Using ITNs, Eritrea 2001 and 2004
65.4
70
59
53.4
60
50.4
50
40.1
39.3
40
2001
Percent
30
2004
20
10
0

5 slept under
Preg mother
ITN
ITN
slept under ITN
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Proportion of Households Participating in
Environmental Malaria Control, Eritrea 2004
100.0
80.6
80.0
60.3
58.6
57.4
60.0
44.5
Percent of Households
40.0
20.0
0.0
Anseba
Debub
Gash-
Northern
Natiional
Barka
Red Sea
Average
Zone/Zoba
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Key Problems/Issues Identified from the RBM Survey

• Case management still a weak area
• Clinical and counseling practice/skills of
  clinicians are weak
  
• Patients are presenting late for treatment
• RDTs uses in hospitals and health centers where
  the functioning microscopy available.
  
• Sustainability and enumeration issue of CHAs
  (Drop out rate of the trained Community Health
  Agents is very high due to lack of incentives)
  
• Most processes such as planning, policy
  formulation etc are top down
  
• Sustainability of ITN distribution

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Key Problems/Issues Identified from the RBM
Survey Cont.

• Extensive and detailed malaria mapping/stratificat
  ion of the country has not yet been done.
  
• Monitoring and supervision of environmental
  management and IRS is poor
  
• Lack of monitoring vector resistance and
  efficacy of currently use insecticides
  
• Integration with IMCI, safe motherhood and IDSR
  are weak
  
• Lack of integration of various data sources for
  routine malaria data
  
• In-service training weak and inadequate
• Shortage of trained staff at all levels

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Key Problems/Issues Identified from the RBM
Survey Cont.

• Lack of organized community- based management
  information system.
  
• Slow implementation of malaria communication
  strategy
  
• Weak inter-sectoral collaboration (line
  ministries, Associations)
  
• Inadequate community participation
• Involvement of partners and communities in
  planning and monitoring is still weak
  
• Involvements of NGOs are very low
• Health workers IPC/counseling skills are
  inadequate
  
• Shortage of trained staff at all levels

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Key Problems/Issues Identified from the RBM
Survey Cont.

• Transportation for supervision/monitoring of
  malaria control activities is poor.
  
• Low Per diem rate
• Financial system is not sensitive to tracking
  the budget and expenditure
  
• Operational research on malaria still
  inadequate
  
• Supervision, monitoring and evaluation of
  interventions are weak
  
• The registration of births and deaths in Eritrea
  is not yet well developed, and thus the true
  percentage of deaths from malaria is not known.
  

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5 Major Accomplishment

• G Monitoring and evaluation
• Regular supportive supervision to zones
• Monthly meeting for NCMP staffs HQ
• Quarterly meeting for malaria zonal coordinators
• At the end of each year, an assessment workshop
  has been conducted
  
• Five year RBM evaluation dissemination workshop
  conducted

Malaria quarterly Coordination meeting
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Overall Impact of Malaria Control Efforts in the
country
Impact on morbidity Overall malaria morbidity
in OPD has been reduced by 84.5 of the year
1999 level.
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Overall Impact of Malaria Control Efforts in the
country
Impact on mortality Over all malaria deaths have
been reduced by 84 of the year 1999 level.
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Overall Impact of Malaria Control Efforts in the
country

• Impact on case fatality
• Case fatality rates have reduced from 2.3 to 0.9
  and from 2.4 to 0.3 for under five, and five and
  above respectively

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• Impact on bed net re-impregnation rate
• Bed net re-impregnation rate increased from 17.2
  in 1999 to 83.5 in 2004
  

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Overall Impact of Malaria Control Efforts in the
country

• Impact on diagnostic capacity of lab.
  Technicians
  
• Cross-checking of slides has helped
• In identifying laboratory technicians who need
  re-fresher training and give them refresher
  training
  
• Make extensive supervision to these sites
• improve diagnosis of malaria parasites by the
  lab technicians following training and
  supervision
  

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Overall Impact of Malaria Control Efforts in the
country

• Impact of free ITN distribution
• Free distribution of ITNs and mass
  re-impregnation campaigns have contributed to
  empowering people to use personal protection.

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Major Contributory factors for the over all
reduction in malaria

• High ITN coverage, re-impregnation and
  utilization.
  
• Introduction of combination therapy of CQSP as
  first line drugs.
  
• Early diagnosis and timely case management.
• High levels of community awareness and
  participation for environmental vector control.
  
• Effective and functional partnership of country
  and outside RBM partners
  
• Commitment and dedication of the Government,
  MOH, malaria control staff and general health
  workers.
  

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Major Contributory factors for the over all
reduction in malaria cont.

• Technical and financial support received through
  RBM initiative.
  
• Effective planning and implementation of program
  activities at central and zonal level.
  
• Continuous supervision, regular monitoring and
  evaluation of program activities at central and
  zonal level.
  
• Unusually low rainfall and shorter rainy
  seasons.
  

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Challenges

• Sustainability of community participation,
  ownership support for CHAs incentives
  
• Sustainability of community based interventions
  (bednet issues, source reduction, case
  management).
  
• Lack of continuous monitoring and impact
  evaluation
  
• Cross-border malaria concern in the future

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Challenges cont.

• The significant reduction of malaria morbidity
  creates other challenging issues/factors
  
• -(i) low immunity of population,
• tendency to develop severe malaria
• prone to malaria epidemics
• -(ii) challenge of sustaining the
• achievements and successes obtained.
• -(iii) creates complacence/relaxation among
• population, MOH, Partners among others

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Challenges cont.

• Early diagnosis using Microscopy at lower level
  of HFs (health stations and clinics).
  
• AMDs resistance concern and change process to new
  first AMDs (Artesunate combinations).
  
• Coordination of Activities among IMCI, IDSR, EH
  and RH
  
• Meteorology Unit decided to charge us for the
  data despite our partnership in HAMSeT and
  construction of 8 Meteorological Stations in the
  Country.
• Perdiem issue !!!!

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KILL MOSQUITOES !!!KILL MALARIA !!!!!Let Us
Work Seriously to Sustain the Achievements
!!work harder smarter !!!in the coming 5
yrs
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Thank you for Listening !!!!!!!