MALARIA CONTROL and PREVENTION STRATEGIES: EAST AFRICA REGIONAL

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MALARIA CONTROL and PREVENTION STRATEGIESEAST
AFRICA REGIONAL ETHIOPIA NATIONAL EFFORTS
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ScDev.NetMalaria Consortium Coalition against
Malaria in EthiopiaMedia Workshop on Malaria
Reporting Ethiopia, 22nd to 27th September
2006Global Hotel, Debre Zeit Road, Addis Ababa

• Adugna Woyessa Gemeda, EHNRI

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PRESENTATION OUTLINE

• MALARIA SITUATION
• BASIC CONCEPTS OF MALARIA CONTROL (MC)
• EAST AFRICA REGIONAL MC EFFORTS
• ETHIOPIA NATIONAL MC EFFORTS
• SUMMARY

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MALARIA SITUATION GLOBAL REGIONAL

• Malaria is one of the top health problems
• 515million( range 300-600 million Plasmodium
  falciparum during 2002(Snow et al., 2005)
  

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MALARIA SITUATION (1)

• About 2.4 billion people (41) are at risk of
  infection
  
• The proportion increases yearly due to
  deteriorating health systems, growing drug
  insecticide resistance, climate change, war
  

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MALARIA SITUATION (2)

• Malaria is prevalent in a total of 105 countries
  teritories
  
• 45 countries in WHOs African Region
• 21Americas Region
• 6..European Region
• 14Eastern Mediterranean
• 9.South East Asia
• 10Western Pacific

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MALARIA SITUATION (3)

• Malaria kills 1 million people/yr
• 90 of them in Africa (U 5 yrs mostly)
• High risk groups children, pregnant women,
  travelers, refugees, displaced persons,
  laborers entering endemic areas

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MALARIA SITUATION (4)

• Malaria increases poverty by significantly
  reducing productivity social stability
  
• Rural poor populations carry the overwhelming
  burden of malaria (access to effective treatment
  is extremely limited)

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MALARIA SITUATION (5)

• In rural areas, the infection rates are highest
  during the rainy season- a time of intense
  agricultural activity
  
• Families affected by malaria clear 60 less crops
  than other families (WHO, 1998)

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MALARIA SITUATION (6)

• It has been estimated to cost Africa more than
  US 12 billion every year in lost GDP, even
  thought it could be controlled for a fraction of
  that sum (RBM, 2003)

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MALARIA SITUATION (7)

• GLOBAL EFFORTS
• Eradication Campaign 1955 to 1969
• Malaria Control Program 1979 to 1993
• Roll Back Malaria (RBM) initiative 1998
• Global Fund to fight AIDS, TB, Malaria (GFATM)

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MALARIA SITUATION (3)

• Geographic range of malaria may change due to
• -Changes in climate
• -Land-use patterns
• - Urbanization,
• -Large scale migration of population

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BASIC CONCEPTS OF MALARIA CONTROL

• BIOLOGICAL BASIS
• STRATEGIES FOR CONTROL

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BILOGICAL BASIS

• Malaria is a focal disease with extremely varied
  epidemiology
  
• Based on the reservoir, the biting patterns
  vectorial capacity of the vector mosquitoes
  
• Grassi Ross discovered the role of mosquitoes
  in the parasite cycle
  
• They became the main target of control efforts

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BILOGICAL BASIS (1)

• Reduce breeding sites to drain swamps and
  marshes/limit populations of mosquitoes
  
• Examples of success in eliminating vector
  populations are
  
• -The Pontine marshes near Rome,
• -The Hula swamps in Israel

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BILOGICAL BASIS (2)

• The Sardinian project (1946 to 1951) against
  Anopheles labranchiae confirmed that it was
  difficult to eradicate an endemic vector by
  systematic larvicide application, or even when
  insecticides were available, by targeting adults
  by house spraying

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BILOGICAL BASIS (3)

• Macdonald (1957) mathematical models of malaria
  transmission
  
• Duration of prepatency in a mosquito after its
  infective blood meal, the
  
• Variable life span of female anopheline
  mosquitoes
  
• Transmission could be interrupted by reducing
  mosquito survival to less than the duration of
  sporogony
  

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BILOGICAL BASIS (4)

• More effective in controlling transmission than
  merely reducing the mosquito density
  
• Indoor residual spraying is far superior to
  larvicide application or space spraying to attack
  the mosquito populations

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BILOGICAL BASIS (5)

• Vectorial capacity the efficiency of a mosquito
  species to act as a vector of the malaria
  parasite
  
• Systematic house spraying not intended to
  destroy all Anopheles gambiae, but only those
  which are infected largely to be found
  indoors(White, 1999)

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BILOGICAL BASIS (6)

• The duration of mosquito survival after an
  infective bite forms the fundamental basis for
  the use of IRS or ITNs to control transmission
  

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BILOGICAL BASIS (7)

• The duration of sporogony is dependent on the
  prevailing temperature conditions
  
• P. falciparum sporogony inhibited when the
  ambient temperature falls below about 20oC
  
• It lasts app. 10 days at Temp. 25 to 30oC

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BILOGICAL BASIS (8)

• With P.vivax development is more rapid at the
  higher temp. (approx. 6 days) but proceeds,
  although slowly, even at temp. around 16oC
  (Macdonald, 1957).

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BILOGICAL BASIS (9)

• Blood-fed Anopheles females become heavy
  vulnerable after a feed, flying to a nearby
  surface, where they rest commence digestion
  (Gillies, 1972)
• Usually the meal is taken during the night, the
  mosquitoes will seek a secluded corner or hard
  surface as a refuge

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BILOGICAL BASIS (10)

• If this surface is treated with insecticide, the
  mosquito may acquire a lethal dose
  
• The mosquito may survive with a sub-lethal dose
  acquired
  
• It takes a blood meal every 2 to 3 days in order
  to accomplish oviposition

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BILOGICAL BASIS (11)

• Thus, before a mosquito can transmit malaria
  parasites, it will very probably return to feed 2
  or 3 times, at each occasion it is vulnerable
  to exposure to insecticide

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BILOGICAL BASIS (12)

• The role of the insecticide applied to the walls
  of a hut, room, or mosquito net is to provide a
  sufficient dose to kill the mosquito before the
  infection becomes patent (Gillies, 2001)

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STRATEGIES FOR CONTROL

• Malaria control is too complex to be addressed by
  a single approach
  
• The strategy tailored to the prevailing
  ecological epidemiological conditions (Mouchet
  Carnavale, 1998)

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STRATEGIES (1)
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STRATEGIES (2)

• The immune status of the population the
  patterns of malaria seen will be different in
  these four situations
  
• This will affect the strategy of control
• Oriented to three outcomes

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STRATEGIES (3)

• MORTALITY CONTROL
• TRANSMISSION CONTROL
• ERADICATION

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STRATEGIES (4)

• MORTALITY CONTROL
• The major impact of malaria is the death of
  individuals in any community
  
• To prevent death appropriate treatment
• Little impact on morbidity has little or no
  effect on transmission
  
• Holoendemic, this morbidity results in a major
  burden on the population
  

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STRATEGIES (5)

• MORTALITY CONTROL
• Main thrust of the current Global Malaria
  Control Strategy (Table below)
  
• Relies on chemotherapy
• No particular program is required, nor nationwide
  strategies the development of local priorities
  
• Effective strategy to cope with epidemics of
  malaria in emergency situations (WHO, 2000)
  

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Global Malaria Control Strategya
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STRATEGIES (6)

• Not sustainable in the long term in malaria
  control
  
• Unskilled sources are frequently inappropriate
  are often infective treatment may promote drug
  resistance in the parasite population

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STRATEGIES (7)

• TRANSMISSION CONTROL
• Vector control properly applied
• Appropriate treatment
• Effective in most epidemiological conditions
• Effective control strategy for sustained attack
  on the malaria problem
  
• Adaptable to the use of ITNs IRS

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STRATEGIES (8)

• Implemented in specific circumstances or on a
  wide scale
  
• Requires coordination the development of
  strategic plan to intervene against malaria
  (Kouznetsov, 1977)
  

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STRATEGIES (9)

• Trained personnel in epidemiology vector
  control as well as planning, mapping,
  communications to coordinate supervise the
  operations
• Prerequisites in countries which have made
  commitments to controlling malaria

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STRATEGIES (10)

• Concerns have been raised by some authorities
  (Coleman et al.,1999 Marsh, 1992) that
  transmission control will eventually reduce local
  immunity acquired from long standing infection in
  the population
• Effective transmission control will reduce the
  incidence of infection re-infection in the
  community, eventually people will lose their
  acquired immunity

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STRATEGIES (11)

• Therefore, such interventions should be planned
  in a sustained manner
  
• The technique can be incorporated into national
  malaria control schemes on a stage-structured
  basis in areas of high priority

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STRATEGIES (12)

• Create barriers to seasonal encroachment of
  vector populations the potential for
  transmission to invade populated areas or towns
  (Leeson, 1931)

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STRATEGIES (13)

• ERADICATION OF MALARIA
• Considered only in certain areas
• Where it has been eradicated
• Where it has been reintroduced
• In areas of hypoendemic malaria (sufficient
  resources little likelihood of future
  reintroduction)
  
• It is time limited, once it has achieved its
  objective, can be terminated (WHO, 1957)

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EAST AFRICA REGIONAL ETHIOPIA NATIONAL EFFORTS

• EAST AFRICA REGIONAL MALARIA CONTROL
  PREVENTION EFFORTS

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East Africa Region
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East Africa Region

• Epidemic malaria predominates
• Highland fringe regions between stable unstable
  transmission
  
• Repeated epidemics of different magnitudes

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East Africa Region
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SUMMARY OF KEY STRATEGIES (RBM, 2005)
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FIRST LINE DRUG END OF 2004 (RBM, 2005)

• Coartem
• Ethiopia, Kenya, Uganda, UR Tanzania
• ASU AQ
• Burundi, Sudan (S)
• Zanzibar

• ASU SP Sudan (N)
• AQ SP Rwanda
• CQ Somalia
• CQ SP Eritrea
• Quinine commonly for the treatment of failure
  severe cases

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Global Fund (GFATM)

• Created to finance a dramatic turn-around in the
  fight against AIDS, TB, Malaria
  
• These diseases kill over 6 million people per
  year
  

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GFATM (1)

• To date, the GF has committed US 5.5 billion in
  132 countries to support aggressive interventions
  against all three diseases
  
• 109 million bed nets to protect families
• Deliver 264 million ACT for resistant malaria

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Summary of committed disbursed malaria funds
available from the GFATM (in US)
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ETHIOPIA MALARIA CONTROL PREVENTION NATIONAL
EFFORTS
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ETHIOPIA MC (1)

• Part of global efforts to eradicate malaria
• One of the three African countries that joined
  the eradication campaign
  
• Eradication campaign in tropical countries not
  achieved (Zulueta, 1998) due to climatic, social
  economic conditions different from those
  prevailing in the temperate zone

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ETHIOPIA (2)

• Following the decentralization integration of
  malaria control with basic health services
  
• Accelerated implementation of malaria control
  activities (training, technical support)
  
• Roll Back Malaria initiative, 2000 (Abuja)
• Partnership down to community level
• Global Fund support

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ETHIOPIA (4)

• RBM MOVEMENT a joint initiative between WHO,
  UNICEF, UNDP, the World Bank
  
• To halve the worlds malaria burden

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RBM Partnership in Ethiopia

• Federal Ministry of Health (Chair)
• Regional Health Bureaus
• WHO (Secretary)
• UNICEF (Co-Secretary)
• Development Cooperation of Ireland
• Italian Co-operation
• USAID
• Merlin
• CRDA
• Malaria Consortium
• MSF Group
• Anti-Malaria Association
• PSI
• NetMark
• AMREF
• American Red Cross

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ETHIOPIA (3)

• Malaria control strategies (GMCS)
• Case management
• Selective vector control (IRS, ITNs)
• Epidemic prevention control
• Health Service Extension Program

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NetMark in Ethiopia

• NetMark project in November 2004
• East African Group (EAG) Selam Enkilf
• Demand creation/BCC Radio, print, road shows,
  TV, etc.

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New Product Addition!
Selam Enkilf Insecticide Treated Net
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Selective Vector Control

• Indoor Residual Spraying
• DDT Malathion (areas with resistance to DDT)
• RHBs conduct reclassification of localities in to
  spray rounds conduct the actual spraying
  operation
  
• Annually 20 30 of the epidemic prone areas
  sprayed covering 900,000 to 1,000,000 unit
  structures
  

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Epidemic Prevention Control

• Guideline revised, 2004
• Regional training
• Operational fund for malaria surveillance
  -WHO-RHB US29,942
  
• Contingency stock of CoArtem
• -FMOH 30,000 treatment doses
• Quinine contingency stock of US19,900

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IEC, Social Mobilization Advocacy

• Malaria Social Mobilization Week, August 2005,
• Africa Malaria day 2005
• Malaria communication implementation tools based
  on needs and evidence
  

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Abuja Targets?
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Abuja Targets?
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Global Fund-Ethiopia

• Global Fund Round-2 Malaria Proposal US 77
  million for five years
  
• US 17.8 million 1st year, US 14.4 million
  for the 2nd year
  
• Procurement 85 of the 1st the 2nd year fund
  has been allocated for the purchase of drugs,
  ITNs, etc.
  

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GFATM (1)

• Lab supplies reagents
• Others such as desk top computers, Spray pumps
  procurement, meteorological equipments
  
• 1st 2nd year program implementation a total of
  US 31.5 million has been utilized from US 32.6
  million (96.6 )
  

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SUMMARY

• Malaria control is a complex task that makes its
  bases on sufficient knowledge of malaria
  epidemiology
  
• Concerted efforts adequate resource supply with
  sustainable program is required for the success
  of malaria control (RBM, GFATM, others)

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SUMMARY

• Political commitment of governments is crucial
  and community involvement are crucial aspects of
  malaria control (Tigray, North Ethiopia)
  
• Technological developments operational research
  should support the control efforts (RDTs,
  LLITNs)
  

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MANY THANKS !!!!