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

Acknowledgments

The end ….For more information contact:

znzrbmcp@zanlink.com

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