Malaria Elimination

The Cost of Malaria Elimination

2012-01-11T23:20:00.000-08:00

Malaria elimination will incur cost. The cost will depend on the current malaria situation and the duration of the elimination plan. It can as little as a normal health operation cost if the situation has been reduced to less than a hundred a year per province or it can cost millions if the situation more than a thousand per province. Cost will also vary on the aggressiveness of the project and the kind of planned strategies. Cost efficient strategies are use of long lasting insecticidal nets (LLIN), microscopy instead of rapid diagnostic test (RDT) and focused deployment of inputs. The latter is the most important in reducing cost. To reiterate, the inputs must be taken to areas of active (ongoing) transmission. This is identified by use of malaria transmission scoring system (discussed in early issues of this blog) in the stratified areas of the community (also discussed in early issues of this blog).

Long Lasting Insecticidal Nets (LLINs) for Malaria Vector Control

2011-11-09T17:50:00.000-08:00

Malaria parasites are normally transmitted only through Anopheles mosquitoes. Insecticide treated nets have been in use for two decades already. It is extremely effective in many occasions but still malaria transmission persists. The problem lies in the availability of nets but largely in the regular use of mosquito nets. It is here where behavioural factors of the community members affect the program implementation. KAP surveys in the past showed relatively high knowledge about malaria transmission and high rate of net usage. It is more than 85% among the respondents in 2009 survey of selected provinces in the Philippines and yet the transmission still goes on. It is understandable that not everybody sleeps under mosquito nets. There are other factors involved like vector bionomics wherein the vector biting/resting habits are changed from indoor to outdoor. There are other factors related to the host as well.

Another KAP survey in the next two months is forthcoming. A KAP survey among malaria positive patients is included. There is a need to explore more on this segment of population in order to have a better understanding of the KAP of the victims themselves and incorporate the findings to craft a more appropriate control program. I am fortunate to handle this survey and will be reporting the result in this blog.

LLIN is undoubtedly a better approach to vector control since human bait is sleeping inside the net. Human behaviour is involved in its use. Knowledge level alone is not sufficient to preclude its use.Use of nets has to be maximized and quality/efficacy of LLINs needs close monitoring since nothing last forever.

Training the Frontline Workers

2011-10-20T16:05:00.000-07:00

Grand Regal Hotel Davao has been the venue of the latest training of the frontline health workers of the Philippine Department of Health. The health workers consist of Rural Health Midwives and Nurses. These workers have been the force in the elimination of polio in the country trough a house to house campaign in 2007. The participants were all from several provinces of Mindanao Island namely Agusan del Sur, Agusan del Norte, Davao del Norte. There were also participants from Butuan City. There were 123 participants divided into three batches held simultaneously.
The training consisted epidemiology of malaria, malaria signs and symptoms, malaria chemotherapy, vector control, endemic area stratification using the new system, malaria epidemic management and malaria epidemic prevention and malaria elimination.
The training was funded by the Global Fund through the Pilipinas Shell Foundation (PSFI). ACTMalaria Foundation organized the training. ACTMalaria Foundation has been supporting the development and conduct of training in the country and has been a major factor in the successful trainings in the country. Other training packages organized through ACTMalaria were Basic Malaria Management for Rural Health Unit Staff, Training on indoor residual spraying (IRS), Clinical Management of Severe Malaria for Physicians, Malaria Microscopy Training for Medical Technologist, Malaria Microscopy training for volunteer community workers, Training on Rapid Diagnostic Test and Training on Integrated Vector Control (IVM).

Presence of Malaria Transmission as the Basis for Action

2011-09-21T19:12:00.000-07:00

Timing of intervention is the most important factor in malaria elimination. Regular use of long lasting insecticidal nets (LLINs) provides solution to this factor as long as the net is used nightly by more than 80% of the population but LLIN alone will not eliminate the malaria parasite in humans. Treatment of malaria cases must be coupled with LLIN use. These two, i.e. LLIN and treatment of cases will only reduce the incidence of malaria but cases will still be present intermittently from the relapses (in P. vivax), or from malaria carriers. The latter is very important in elimination phase of malaria and it can only be detected through mass blood survey.

The current issue in the country program is when to conduct mass blood survey(MBS)? It is not practical to conduct in all endemic areas because of inadequacy of resources largely availability of microscopist as well as blood smear collectors (malaria canvassers). We can do away with MBS if LLIN and case detection and treatment worked. In some areas however, there is/are malaria carriers. They are asymptomatic persons carrying malaria parasite in their blood. They are left undetected unless we conduct MBS. The question is when to suspect the presence of malaria carriers in a community. To answer that issue we need to go back to the basic epidemiology of malaria.

In order for malaria transmission to occur there must be parasite host and vector together in one conducive environment. It would be tedious for the program managers to identify which among the communities has conducive environment on a weekly or monthly basis since environmental condition in each community changes on a daily basis. We can only deduce that if there is malaria case/s in a community the factors that favored transmission did occur. The next question is “Is there ongoing transmission?” Adequate LLIN coverage and case finding with treatment will, no doubt, cut the transmission. Sporadic cases will then be detected if there is/are malaria carriers in the area. This is the go signal to conduct MBS.

This has been our experience in the Province of Laguna, Philippines. Our last community under surveillance are Bautista and Santiago II. It’s been a year and a half since our last malaria case. We still have to wait for 3 ½ years more before we are declared a malaria free province.

Monitoring Malaria Control Program at the Provincial/District Level

2011-07-11T20:45:00.000-07:00

Program monitoring at the provincial/district level requires specific technical know how. Indicator most useful at this level is the new case/s per stratified area. These cases have to be investigated as to its source i.e. indigenous or imported with respect to that specific area. Once verified that it is indigenous case, the previous 2 months record of that particular stratified area is reviewed. If the record showed there were cases in the previous months then that area has ongoing transmission and needs immediate intervention. This is an application of malaria transmission scoring system written in previous issues of this blog.

Monitoring monthly malaria cases per stratified areas (stratification of malaria endemic areas was discussed in earlier blog entry) will also help determine the effect of interventions applied a few months earlier. The process starts with proper recording of cases per stratified area, a basic malaria record that should be found in every provincial/district malaria control office. This record is tabular in form and contains the monthly record of each stratified areas. Once an intervention particularly indoor residual spraying (IRS) or insecticide treated nets (ITN) distribution is conducted the month that the activity is implemented is shaded. The area is then observed through the monthly record in the succeeding months. The cases will be reduced, increase or remained the same. This will show the effect of the intervention applied. Usually there will be reduction of cases after the application of intervention but if it did not happened then investigation is necessary. It can be because of one of the following: the intervention in not effective, the intervention is not necessary (in areas where cases are imported), or the intervention was not applied (theft). Every intervention is expected to produce the desired effect. Donor agencies can use this process in order to determine that the money they give is being used properly and effectively. Malaria elimination is attainable. For more information you can contact me through my e- mail address or through DOH Philippines.

LLIN and Malaria Elimination

2011-05-05T19:37:00.000-07:00

Long Lasting Insecticidal Nets (LLIN) is flooding the malaria endemic communities of the world. Global Funds provided LLIN in malaria control project sites of the Philippines. Nets are useless unless they are regularly used and it is extremely effective in controlling malaria as what we have observed. In the early eighties, when insecticidal nets is still under development, we are fortunate to pioneers its use in the country. It is the one that enables our province to be free of malaria. We are not giving free nets during those times. We are just treating the nets of the households with insecticides provided by the program.Treatment of nets is coupled with campaign to use nets to prevent malaria. The main message is prevent malaria, use mosquito net or “iwasan ang malaria, magkulambo” in the local language. It is written in a poster and placed in every front door of the houses in the community. The message is repeated by the malaria canvassers who visit every household at two weeks interval to conduct active case detection. The same message will also be heard once a patient visits malaria clinic. Giving free nets is not enough. A sustained campaign to use net is a must and it should last for more than a year.Posters in every household have to be replaced every three months since rain sun and human tend to destroy them. Giving nets alone will not control malaria.

Our province is not a recipient of Global Fund and yet we were able to keep malaria at bay. Currently malaria is present only in two communities of about 3,000 households. The last cases (7cases, all P. falciparum) were recorded in 2010 in the months of April and May. It’s been a year since our last cases and I hope that they will be our last. We need to wait for 4 more years without indigenous malaria then we can be declared malaria free province.

Technical plus Managerial Skill

2011-03-28T23:39:00.000-07:00

Knowledge about malaria has advance too much yet the problem persists in many parts of the globe. There is a wealth of knowledge about malaria but choosing among these which is useful for elimination of the disease creates confusion. Eliminating malaria is not the problem but the operational aspect of elimination is the problem. There is a lack of skillful malaria control personnel to do what should be done. The skill needed is a mixture of managerial and technical and very few have these skills. Technical skill will pinpoint the areas with active transmissions while moving the resources towards these areas requires management skill and there are more managerial problems than technical problems.
Pinpointing the areas of active transmission has been discussed in the previous issues of this blog particularly the topic on malaria transmission scoring system. It is easy as long as the surveillance system (no matter how crude it is) is functioning. Moving or providing the needed resources into these areas is the bigger problem. That includes the problem of supply, access, local beliefs, cultures, politics, conflicts and many more factors as well as monitoring and evaluation.
Elimination of malaria is not just giving out nets or doing mass blood survey and giving treatments. The resources need to be in the areas where there is active or ongoing transmission. Resources that are not in areas of active transmission just add to the cost and not to the reduction of cases.

Malaria Elimination and Indoor Residual Spraying

2010-12-06T03:20:00.000-08:00

Malaria elimination necesitates vector control either by indoor residual spraying (IRS) or insecticide treated nets. Indoor residual spraying entails more cost and inconvenience since all the household utensils, and all the belongings that are in the wall have to be removed and to replace them to their former location after the spray has dried. This is very inconvenient on the part of the householder as well as the operator/sprayman. The cost of insecticide, the salary of the sprayman, the travel allowance, the need to use prescribed spraycan and the relatively short effectiveness of sprayed insecticide works against the cost effectiveness of indoor residual spraying against use of insecticidal nets particularly Long Lasting Insecticidal Nets (LLIN).

Indoor Residual Spraying, however, can be immediately applied in case of epidemics. It doesn’t need behavioral change in case the community is foreign to net use. IRS for elimination of malaria may not be ideal. Malaria elimination is a long process. The shortest can only be three years. LLIN can cover this length of time with just one application/distribution thus reducing the workload in contrast to twice a year application of insecticde through IRS. Saving in workload can be shifted to active case detection thus detecting cases early before the development of gametocytes.

Fighting Malaria in the Frontline

2010-11-25T02:32:00.000-08:00

Malaria can not be won by fighting from the meeting room. It is won by fighting in the frontline where decision, appropriate for the situation, is implemented with decisiveness. The key to malaria elimination is the frontline worker and its supervisor. Close monitoring of the worker and the incidence of malaria will guide the worker where and when to apply the intervention. Intervention has to address the five locations of the parasite with consideration of its life cycle most especially the duration of each stage in its life. The seven steps to malaria elimination as mentioned in the previous issue has to be carried out and this is a proven well thought design. These steps have to be understood well by each frontline worker. Seeing the result of his work will motivate the front line workers to perform better and lift up his spirit that he is contributing to the improvement of the world. Let us shrink the malaria map through local acts. As somebody mentioned “Think Globally, Act Locally”.

Seven Steps to Malaria Elimination

2010-11-17T00:35:00.000-08:00

vivax

These steps will address the parasite in all its location in the community which are in the infected mosquito vector, in the liver at the incubation period, in the blood at the clinical stages, in the asymptomatic carrier, and after the relapse of the hypnozoite. This model worked in our province Laguna, Philippines

Another IRS Training

2010-11-11T23:18:00.000-08:00

Another training for indoor residual spraying is in plan for December 1 and 2, 2010. It will be at the Province of Rizal. The Pilipinas Shell Phils. Inc.(PSFI) point person from Rizal Province called up and notified that about 20 participants will be attending. They were from the 6 endemic municipalities of Rizal. The training will consist of didactic, demo-return demo and field practice. It will be a two day training. The second day will be devoted to actual spraying of houses in the endemic barangay. It will be identified later when all the plans are finalized. I'll keep you updated. For inquiries feel free to send e- mail.
IRS is the vector control to supplement long lasting insecticidal nets or insecticide treated nets. It deposits insecticide in the walls in powder form so that the dust clings to the hairy legs of the mosquito. It a very expensive and tedious operation and in the Philippine Manual of Operation is is just a supplementary vector control. The primary vector control in the country is insecticide treated nets.

Training on Indoor Residual Spraying at Tarlac City, Philippines

2010-11-04T01:54:00.000-07:00

A two day training on indoor residual spraying (IRS) was held on 27 and 28 October 2010 at Tarlac City, Philippines. There were 21 participants. They came from the provinces of Tarlac and Bulacan. The training participants were rural sanitation inspectors of selected endemic municipalities. There were also volunteers among the participants. The training included the basics on malaria control program, i.e. life cycle of the vector and parasite, principles of vector control, mantling and dismantling of spraycan, chemicals used in indoor residual spraying, operating principles of spraycan, demonstration and return demonstration on proper use of spraycan and proper application and safe handling of insecticide. The following day was devoted to field practice wherein each participant conducted actual spraying of houses.
The training was supported by the Department of Health Center for Health Development 3 (DOH CHD3) and the Global Fund through its primary recipient Pilipinas Shell Foundation incorporated (PSFI).

Malaria Elimination in the Philippines

2010-08-16T23:31:00.000-07:00

Malaria elimination in the Philippines is within reach. There are effective medicines and insecticide. Taking these to the right area is where the challenge lies. It is the program management aspect that need to be improved. Currently the set up is not standard though the elimination of malaria will require a vertical set up. In the devolved set up, the local government units has its own set of priority and in the level where malaria is low it will not be a priority of the local government units. These low incidence is the period wherein vigorous search for cases is needed since active case detection every two weeks is a must and occasional mass blood survey may be necessary.
There are areas that are hardly accessible because of terrain and/or presence of armed groups. These are affecting the elimination goal. Resources not necessarily human resource can be made to reach the hardly accessible areas and in areas with armed groups. Imagination has to be exerted in order to reach the elimination goal. Mabuhay ang Pilipinas!

Malaria in San Pablo City, Philippines

2010-03-11T19:41:00.000-08:00

Dr Lorenzo Sarmiento, the Regional Malaria Coordinator of Calabarzon called a program implementation review on 3-5 March 2010. It was a frutiful review. Representative from San Pablo City Dr. Mercydina Caponpon presented the program implementation in San Pablo City. The city has been malaria free for more than 5 years until 2006 when three cases of malaria were detected in Barangay Santiago II. They were all cases of Plasmodium vivax. The City Health Office conducted several malaria control measures like distribution and use of mosquito nets, cases finding and even thermal fogging with the assistance of the Provincial Health Office. The following year an epidemic occurred in the same barangay as well as in its contiguous Barangay of San Roque, Alaminos Laguna, The epidemic was placed under control in two months although in the succeeding year sporadic cases of malaria occurs. Eighty six cases were recorded in San Pablo City and 186 cases in Alaminos. Vector control measures consisting of indoor residual spraying, and insecticide treatment of nets were employed together with early detection and prompt treatment. These activities reduced the cases remarkably that in 2008 there are no malaria recorded in San Pablo City although eight cases were recorded in Alaminos side. By 2009 no new cases were recorded in Alaminos but before the year ends new cases of malaria was detected in San Pablo City until January 2010.
There are only a few remaining foci of malaria in Laguna. These are being addressed by local health authorities with the cooperation of the communities involved. In San Pablo City the community leaders are taking febrile community member to the health centers and they were screened for malaria. Early detection of cases i.e. in the first week of illness has a bearing on the control program. It provides treatment of cases before the development of gametocytes thus preventing it to be taken by mosquito vector hence prevention of transmission. Just recently mass blood survey in An Pablo City detected two asymptomatic malaria cases, probably the reservoir of malaria in San Pablo City. If there are no more asymptomatic cases in San Pablo City then the city can look forward to a malaria free San Pablo City.
Regular visit of each house every two weeks on target communities made elimination of foci of malaria possible. This is the same principle applied in control of malaria in the whole province. Elimination of malaria in the province is within reach.

Malaria Case Investigation

2010-02-04T00:06:00.000-08:00

Reintroduction of malaria in a malaria freed areas needs detailed investigation to point out the source and prevent spread of the disease again in the area. The initial purpose of investigation is to classify whether the infection is acquired locally i.e. within the community or from other community. Recall of the places visited 2 weeks before the development of symptoms is very important.Usually the patient find it hard to recall when they do not consult immediately after the development of symptoms or they have been misdiagnosed in the early consultation. If the history of travel cannot be firmly established they there is a need to look for other cases in the community through conducting blood smear examination of all the community members with symptom of fever or malaria. Once another case is identified and established as indigenous then other control methods has to be in place in order to prevent further spread f the disease or to eliminate it again from the community.

Identifying Active Foci of Malaria Tansmission

2009-12-02T22:25:00.000-08:00

Elimination of malaria will need a tool to accurately point to the specific foci of active transmission. This will focus the intervention into the right location where it is needed. We can imagine high incidence of malaria as overlapping foci of malaria. Each foci has all the elements needed for the parasite to continue its cycle of life. This will need susceptible hosts, mosquito vector and human plasmodium species. Natural malaria transmission will not occur in the absence of one. The initial guide for the malaria worker to point out the foci of malaria transmission is the stratification of area as to non endemic and endemic areas. The size of these areas has to be within the flight range of the vector mosquito or within the smallest political unit possible. The next step is to classify the malaria cases in these areas as to he source i.e. indigenous or imported. After knowing the areas with indigenous cases, review the cases of that area in the past three months. Areas with the case/cases in the past three months are the foci with active transmission.

This method utilizes the incubation interval information of the parasite.
Incubation interval is the period from the gametocyte stage in one victim to the earliest appearance of gametocyte in the secondary victim. It is in the range of 25 to 35 days (pp.83,Malaria Elimination A field manual for low and moderate endemic countries, WHO, 2007). Once the foci of active transmission is pinpointed all locations of the parasite has to be attacked. These locations are in the blood at the clinical stage, in the liver at the hypnozoite stage, in the mosquito vector, in asymptomatic carrier, and in the liver at the pre-patent stage. These locations has to be addressed within the month. Unless all of these locations are addressed the parasite will be able to continue its life cycle refilling all the its former locations and transmission resumes. (This is related to the article written earlier with the title "Malaria Transmission Scoring System")

Malaria Control Sulu Experience

2009-10-23T04:53:00.000-07:00

Sulu is a province in Mindanao, Philippines composed of islands. They are inhabited by several groups of indigenous populations mainly Tausug. Malaria in Sulu is classified as coastal malaria and the vector is Anopheles litorralis. It breeds in brackish water in areas covered by mangroves. There is no forest malaria in Sulu. Malaria control in Sulu is complicated by the distance between the islands and there is no regular transport in many of them. The main problem of malaria control in this area is logistics management as well as transport of malaria control personnel. Malaria in Sulu has been lowered significantly because of improve availability of logistics and currently the cases are in near elimination level. To eliminate malaria in the area careful logistics management as well as careful analysis of the need to deploy malaria personnel is the most critical decision. It has to be carefully planned in order to address the location of the parasite in the five locations as mentioned in the previous discussion.
Information dissemination is the most important at this stage. Every person has to be told that they need to be prevented from mosquito bite to prevent malaria. This message has to be in strategic location i.e areas where most of the population visit which is usually market places, piers and boats. This has to be complemented by the availability of diagnostic and treatment facilities located strategically.
Data form these diagnostic facilities has to be reviewed frequently in order to guide the deployment of malaria control personnel who will conduct indoor residual spraying and case finding activities either active case detection and bimonthly visit or by mass blood survey whichever is needed by the area. Malaria control or elimination in Sulu and other island provinces needs careful planning and sound management of implementation.

Malaria Problem of Sulu and Tawi Tawi Islands

2009-09-14T19:01:00.000-07:00

Sulu and Tawi Tawi are island provinces in the southern Philippines. Both have island municipalities and barangays. Malaria in these provinces are classified as coastal malaria. They are transmitted by Anopheles litoralis mosquiotes. This mosquito breeds in coastal mangrove areas. They are early biters.
Most of the people live in the coastal areas. Houses are constructed on stilts along the shores. Motorized bancas are the usual mode of transportation. People here belong to the indigenous population groups of either Tausug, Samal and Badjao.
Malaria control in this group of island is faced by several problems. Foremost is the distance between the islands aggravated by peace and order problems in many islands. Another problem is the behavior of the vector i.e. peak biting density. The vector in the area is early biter hence mosquito net is quite inappropriate. This situation require extra effort in terms of program management particularly logistics and monitoring and evaluation. Please wait for the next issue.

Malaria Control for Palawan, Philippines

2009-08-16T06:13:00.000-07:00

Palawan is the number one province in terms of malaria. To every Filipino malaria is on top of the mind once Palawan is mentioned. This is however unjust for the province. Palawan is a very interesting, beautiful exotic and exciting province.

Malaria in Palawan is not everywhere in Palawan. They are in pockets of sitios, islands and forest.Palawan is a big Province. Its length is equal to Luzon Island. The biggest island of the Philippines. It is managed as one province but the area is very large to manage if we will use the same ratio of personnel per municipality similar to Luzon. This is one area that affect the malaria control program of the province. The province needs additional health personnel and it should be computed based on the land area and not to the ratio of the population.

Another area that needs improvement is the program component itself particularly health education. It is no longer acceptable at his point in time that the people still don't know the way they get malaria. Several decades of the program should have reached all the segment of the population of the province but yet it is not. Probably the channel of communication used is not the most effective way to use. Radio, community assemblies, poster, mass movement (launching) had been tried and yet the knowledge is still at undesirable level. Maybe the presence of the indigenous population or the high inward migration from other provinces add to the problem. Health education for Palawan need not be complicated. A simple poster saying "iwasan ang malaria magkulambo" is enough. This has been tried in Laguna, duplicated in Subic outbreak recently and it worked. Cases in Subic went down dramatically to more than a hundred a month after the use f this poster. This poster if use correctly is able to give information 24/7 to the community. Even if the education level is low it will permeate in to the community. This should be complemented by personal selling by the health workers who will ask the clients to sleep inside bed nets every night including all the members of the household.

Another aspect of the malaria control program of Palawan is the use of data actual data for application of intervention. Since Palawan is a big province, the stratification of the province must be at the sitio level since a barangay in Palawan is usually large in terms of land area and they are more than the flight range of the mosquito vector. Blanket malaria control operation is doing great at present but the cost will not be sustainable once the project's life is through. This has been observed in the province if we review the history of the malaria control program of Palawan i.e. from malaria eradication period to Palawan Integrated Area Development Project (PIADP),to Japaneses Cooperation Project and the current Global Fund Project through Pilipinas Shell Foundation (PSFI). Ebbs and peaks will be noted in the graph depending on the presence of control projects.

The current malaria control project in Palawan is supported by the Global Fund and Pilipinas Shell Foundation in cooperation with the provincial arm Kilusan Ligtas Malaria(KLM). The project is doing well currently although not at the desirable level if we consider the cost incurred. Some improvement can still be made but this is through refinements in project activities particularly in focusing the interventions to transmission areas. Currently the operation is at the barangay level. Refinement can be made to the sitio level to have more impact at a lower cost. The size of the barangay is confounding the focus of intervention resulting to higher cost. Data has to be reviewed and analyse to pinpoint the areas where intervention was applied and yet did not contributed to the reduction of cases. Usually these are the areas which recorded high incidence of malaria but in reality these are areas have no transmission but only used by the patients as their residence hence recorded as malaria transmission area.

There are more areas of the project that will need improvement and it will be discussed in the next issue of this blog.

Malaria Elimination

2009-05-17T18:18:00.000-07:00

The world of malaria control is at a lost. Information is voluminous and it causes many a people to loose tract. Various systems and agencies dealing with malaria have their own interest and focus. Some focus on drug, others on vector control and others on program management and in each aspect they are finding more advances but still the problem persists. Progress in control has gained a lot but in terms of eliminating the the disease it is quite slow.
The problem needs basic evaluation and it needs visit to the basic of malaria, the epidemiology.
The basic of malaria epidemiology includes the human host, the mosquito, the parasite all interacting in one place called the environment. The factor neglected in this epidemiology is time. Time is needed by the parasite to develop from one stage to another. There are stages that will not be seen by the common diagnostic method. This provides elusiveness to the parasite and the cause of failure for elimination to proceed. Putting time factor into consideration will give us five sites or reservoir where parasite can be located at any one time in a community. Each of these reservoir has to be addressed in order to eliminate the malaria parasite in a community because missing one site will only feed the other site soon after. These site are: in the host in the clinical stage i.e. those who are ill and have positive blood smear; in the the host in the carrier state i.e. those who have no symptoms but have parasite in the blood smear; in the the host at the incubation and pre-patent stage i.e. the parasites are still in the liver stage; in the host at the hypnozoite stage i.e. dormant stage of P. vivax and P. ovale; and lastly in the mosquito vector. Each of these locations of the parasite has to be addressed by the program management in order to eliminate the malaria parasite in the community and widen it to the province and to the entire country and to the whole world. The elimination of parasite or eradication of parasite is feasible. the armaments are already available but the man who will orchestrate the elimination is still not in place. Proper program management is the key for elimination to proceed and there is a dire need for good program managers.

Malaria Epidemic in Subic, Zambales, Philippines

2009-04-29T00:43:00.000-07:00

Resurgence of Malaria in Subic, Zambales, Philippines is happening fueled by economic boom. Yearly outbreaks has been a regular occurrence in the last three years.Each year bigger than the previous. Outbreaks is fed by continuous movement of a significant number of migrant workers brought about by economic activities in the area.

Subic is a former American naval base. The naval base was returned to the Philippines immediately after the eruption of Mount Pinatubo.It was converted to a free port zone and incentives were given to attract foreign investors and provide job opportunities to the country. Several investors locate into the free port area and these attracted workers not only from the province of Zambales but also from other provinces of Luzon. One of the investor is a ship building company. Building ship is a huge investment and a huge task. It requires earth movement to house a ship building facility and it also need a huge manpower complement. Mountains have to be leveled wherein the assembly area will be built as well as to provide accommodation to its workers. Roads has to be built to provide access. Workers has to be recruited to provide the hands for the construction of all the facilities. Workers has to be in great number to implement the project on time. These activities provide human host is feeding the life cycle of malaria by providing susceptible hosts.

Zambales is a malaria endemic province as well Bataan, its neighbor province. Malaria incidence on Zambales is low previously but occasionally outbreaks occur. Zambales is a mountainous province and indigenous people, the Aetas, is present in the area. Malaria vector is also present in the area.

Malaria epidemic in Subic has been occurring three years in a row. Malaria parasite and its mosquito vector is already in the area long before the economic boom. Movement of workers into the area contributed to the increase in the number of malaria cases owing to several factors. Migrant workers has no immunity since most of them came from non-endemic areas, they are not aware that the malaria exist in the area, and they are not aware that they get malaria from mosquito bite. The sheer number of workers going into Subic every quarter is a management dilemma. About 15,000 to 17,000 new workers arrived for the site construction as well as base workers for ship building. They come from as far as northern Luzon to as far as Bicol and other Islands of the Philippines. Movement of workers and its sheer number make health system inadequate. Local Health authorities cannot cope with the demand.

Health authorities of Subic has been doing its part. They are providing diagnosis and treatment, vector control and health education. They provided net in cooperation with the National Department of Health and the Global Fund through the Tropical Disease Foundation. The interventions made were not perfect. It is not adequate to start with, they cannot cope with the number of workers and its turn over. They are limited in providing vector control. Nets distributed are taken along by the workers once their work contract is through. Another set of workers come in to replace those that finished their work contract not knowing of the danger they face. A new set of unprotected and unaware highly vulnerable workers come in. The health authorities are also limited in information dissemination. They cannot put billboards that will warn the workers since the area is a tourist destination and authorities fear they will drive away tourist. The country as a whole will also be affected in the long run. Workers may reintroduce malaria into their home province.

The local health authorities need to double or quadruple their efforts. They have to increase their diagnostic and treatment facility by increasing the number of microscopist and ensure the availability of medicines all the time. The National Health Office can augment microscopist initially. Vector control may not be adequate or effective because the housing condition is not conducive for indoor residual spraying. Net distribution is not sustainable because of the frequent turnover of workers. The best option is to go to the people. Inform the workers and the ommunity that they need to use mosquito net and prevent malaria themselves. This can be done only thorugh simple poster using a recycled 8x11 bond paper with the message "Iwasan ang malaria Magkulambo" and post it in every door of the house, along the road, in the vehicles and in any area visible to the workers but not to the tourist. This needs replacement every two months. This needs a bold decision since people will be encourage to use the net though it will not be provided. It is putting their health on their own hands. Human nature dictates that if there is danger they will be reacting to it. In the case of Subic malaria, promoting the net use without providing one is a test on how human react to the threat. Monitoring the sale of nets in the public market is good indicator that people are responding. It is always a preconceived idea on part of health providers that people are not capable of buying nets on their own. In times of need through proper guidance of health authorities people will protect themselves. Those who cannot really afford to buy nets are the ones that can be assisted by the health authorities for provision of free nets. This is placing health into the hands of the people. The health authorities' role then is to maximize the use and availability of the diagnostic and treatment facility and guide the people what to do.

Local Health authorities cannot do it alone. They need the cooperation and assistance of all agencies operating in Subic both government and non-government, local and international. Information is power. Forewarned is forearmed. Inform the people. Good Luck Subic!!!

Vector Control and Malaria Elimination

2009-04-09T00:33:00.000-07:00

Vector control against malaria consist mainly of Insecticide Treated Nets (ITN) or Indoor Residual House Spraying (IRS). Both of them are effective as long as they are used properly. The current practice is to apply vector control one to two months before the peak season. The purpose of application before the peak season is to taper the incidence of malaria and prevent the seasonal peaks. This very effective in averting the occurrence of the peak but this will only lead to control or reduction of cases and not elimination. This only reduces cases but not necessarily the transmission.
Malaria elimination requires vector control as soon as transmission in a community is identified. It must be done any time of the year in order to prevent the transfer of the parasite to other people which will become another source of parasite to perpetuate the cycle. The most important point is to identify the area or community where there is active or ongoing transmission at the moment. All the control measures then must be applied at the same time in order to eliminate the sources of parasite in all of its location in the community. To reiterate, they are in the mosquito vector, in humans with symptoms of malaria, in asymptomatic malaria carriers, in human with malaria at the pre-patent and incubation period and lastly in the human with hypnozoites in their liver. Failure to address anyone of each location will perpetuate the species and keep the malaria cycle go on and on and on.

Bed nets and Malaria

2009-03-26T23:12:00.000-07:00

The natural transfer of malaria from one person to another is only through mosquito bite. This information is not very much known to the community. There are still many misconception regarding malaria transmission or causation in the community. Even if the person know that one gets malaria through mosquito bites they still take the risk by not using mosquito nets even if they own one. They pose problem in malaria elimination.
Mosquito net is very effective in prevention of malaria especially if treated as long as a significant segment of the community (>80%) sleeps in it on a nightly basis. The bigger the segment of population sleep inside the mosquito net then the greater the chance for the elimination of malaria in the community. Untreated nets is a barrier to the access of the mosquito to the human. Treatment of nets with insecticide converts it to a trap with human bait inside thus killing the mosquito vector. Using insecticidal nets alone without corresponding treatment of infected persons will delay the elimination of malaria since untreated malaria infection may last for years. In the presence of undetected malaria carriers transmission of malaria will persist in the community maybe at a low level but will soon explode when control methods are relaxed. Campaign for the use of mosquito net is one of the pillar in the elimination of malaria and the most significant information activity towards malaria elimination.

There are, however, mosquito vectors that will not be affected by mosquito nets as preventive measure. They are the vectors that feed outdoors and rest outdoors and the early biters. There are still no vector control strategy for these mosquitoes. The people however must know that they get malaria from mosquito.This information may lead the people to react and prevent or protect themselves from mosquito bite. Use of long sleeve shirt and long pants will provide a barrier form mosquito. Practices like burning materials to create smoke that will drive away mosquitoes or burning the ordinary mosquito coil may help. Application of insect repellents may help. Research on this topic is needed.

The Spread of Malaria

2009-03-18T18:54:00.000-07:00

Malaria is an intracellular parasite. It lives inside its host cell. In humans, they are either inside the red blood cells or liver cells. They get out of the parasitized cell only when it ruptures releasing merozoites. Their stay outside the cell is very brief not lasting longer than an hour. This time is not enough for the immune system to react to the presence of the parasite. Once they get inside another cell then they can no longer seen by the immune system.
Even if the parasite is inside the cell they can travel long distance through either through the flight of the infected mosquito or through the movement of the human host in its activities. The spread of the parasite through the mosquito vector is limited by its flight range as well as the life span of the vector. The spread of the parasite through the human host is limitless considering the ease of transportation nowadays and the lifespan of the human.
Using the above mentioned information there is great chance of the malaria parasite to spread to areas where there is vector mosquito. This information likewise help malaria control officers to eliminate the parasite in a community. The first and foremost step is to identify the communities with indigenous malaria case/s in past two weeks. These are the communities with malaria transmission. The second step is to apply vector control either indoor residual house spraying or insecticide treatment of mosquito nets. The third step is to request the community members to sleep inside the mosquito nets every night regardless of the vector control method applied. The fourth step is to conduct case finding and prompt treatment of those found positive for malaria. The fifth step is to conduct follow up smear every week to those found positive plus house to house case finding activity. The sixth step is to conduct case finding every two weeks until after two to six months from the last malaria case in the community. The seventh step is to set up surveillance system to detect introduce malaria case/s before the second week of illness.
TThe steps mentioned earlier will lead to elimination of malaria in the community.It will seem complicated or costly but with step by step application this will only be burden in the initial implementation and cost of intervention will diminish at the end of sixth month.

Information and Malaria Elimination

2009-02-11T04:46:00.001-08:00

Literature for malaria is voluminous. A beginner as well as the old timers find a deluge of information and more are still in the investigation and writing. People usually loose tract of the important information for malaria elimination. There are so many information that misleads, or more appropriately, detracts the malaria worker. These information, if not properly filtered, will make the focus of work deviate from the proper activity to implement. There are so many research that are very technical but cannot be applied in the community. There is already useful and appropriate information enough to eliminate the malaria in the community. What is sorely lacking are the skilled persons to implement the necessary intervention at the proper place and time. Skill in managing the program has to be upgraded. I refer to the skill in handling people as well as the technical skill needed to decide on the proper intervention measure to apply. Program management at different levels of the health system needs different skill. Middle managers has to be equipt with the proper technical and human resource management skills. He or she has to be technically skilled to analyze malaria data as well as in motivating, organizing, supervising and monitoring workers. Leadership skill has to be acquired too.
Malaria control will not be successful if the human resource will not be guided properly. There is enough tools to eliminate malaria. There are effective medicines and insecticide, nets to prevent man-mosquito contact, information when and where to apply intervention, rapid diagnostic test for the hard to access areas and transportation to reach these areas. WE HAVE ALL THE MEANS TO ELIMINATE MALARIA. WE ONLY NEED TO APPLY THEM PROPERLY. AND IT ALL DEPENDS ON HUMAN WHO MANAGES THE RESOURCES.