Malaria Elimination

Complexity of Malaria Control in Honiara City

2015-11-05T16:48:00.001-08:00

Honiara City is the economic center of Solomon Islands. It is a city of 76,000 people in the northern coast of Guadalcanal Island. People come to Honiara to look for employment, trade goods, visit relatives, shop, or study. Mobility of population towards the provinces occurs during Christmas, election and school breaks. This inward and outward movement of population carry malaria parasite with them in both directions. Malaria in Honiara City therefore is a mixture of malaria from other provinces (imported), locally acquired (from Honiara City) and relapse cases which can be both imported and locally acquired. Added to these are the false positive cases diagnosed either by microscopy or rapid diagnostic tests (RDT). Classifying the cases will demand a big effort from the malaria staff considering the huge number of cases numbering more than 2000 cases a year. Identifying the village with malaria transmission is necessary because of the limitation of resources owing to the economic condition of the country.
There are ways, however, to identify transmission areas other than investigating each and every malaria case. One is identifying villages with mosquito breeding site. The vector in Honiara City is Anopheles farauti. It breeds in swamps, rivers and creeks with abundance of algae. Honiara City is hilly with crisscrossing creeks and swamps in the valleys. Major rivers flow into the sea but waves usually create sandbars that block the flow of river creating the ideal breeding site for the vector.
Another way to identify villages with malaria transmission is by looking at the age group of the reported cases of malaria. Infants and children below 5 years old are assumed to be staying at home and not mobile as adults or working age group. Malaria in this age group is presumed to be contracted in their residence.
Malaria transmission score (MTS) can also indicate presence of transmission in a village. MTS is the longest number of months in a row with reported indigenous malaria in a village or locality. Villages/localities with one or more indigenous malaria a month for 6 to 12 months in a row are considered to have ongoing malaria transmission. It is based on 25 to 35 days incubation interval of malaria parasite.
The better way to identify village with transmission is to conduct active case detection by going house to house and get blood sample from the residents particularly infants and children below 5 years old. Honiara City vector borne disease control program (HCVBDCP) employ active case detection with spot mapping to identify and delimit boundaries of transmission areas. Villages/localities with positive smears can be concluded to be a transmission area but those with no positive smear still remain in limbo because only microscopy is in use for diagnosis. Low parasitemia may have been missed by the microscopist.
Use of more than one method to identify transmission area therefore is better. Applying intervention at the right place (i.e.ongoing transmission area) particularly vector control will produce better result. Transmission of malaria requires the presence of vector, host and parasite at the same place and time. Human behaviour adds to the complexity of malaria control in Honiara City. Non-use of mosquito net, staying and sleeping outdoor are common practices that put them at risk to mosquito bites. The human body itself provides complexity. Many people are immune or partially immune to malaria. This make them appear healthy despite malaria in their system feeding the transmission cycle. Non-compliance to malaria treatment and failure of health workers to administer complete anti-malaria medicine out of fear of adverse effects, also add to the difficulty if controlling malaria in th city.
The battle for malaria in Honiara City is ongoing and being won. Cases of 2015 are down 25% compared to 2014. Active case detection coupled with campaign to use mosquito net, indoor residual spraying, larval surveillance with larviciding, and improvements in quality of microscopy contribute to the reduction of cases. All these activities are guided by evidence provided by the reports from health facilities. Malaria in Honiaria City maybe complex but can be managed by integrated vector management (IVM) approach of HCC VBDCP team.

Malaria Elimination in Solomon Islands

2015-10-12T19:02:00.000-07:00

Half a million people scattered in 9 island provinces separated by wide deep blue sea. That is Solomon Islands (SI), the happy isles in the Pacific Ocean. Melanesian people live here. One of the deadliest encounter in the second world war happened here in the so called Battle of Guadalcanal. Guadalcanal is also known for malaria. History books say malaria killed more soldiers than bullets. All the provinces of Solomon Islands are endemic for malaria. Malaria incidence in the country is more than a hundred per thousand population a decade ago and it is now down to less than 30/1,000 population by the end of 2014. The country is now aiming for malaria elimination by 2025, ten years from today. Is it possible to eliminate malaria in Solomon Islands (SI)? Some countries bigger and more populated than SI have done this. Why not SI? Money is not a problem. Global fund took back its money in 2014, excess of what it can absorb. Technical expertise from WHO and in country is always available. Medicines, insecticides, nets, and other inputs are effective and also available. All resources needed for elimination is available in the country. Malaria elimination in Solomon Island is no doubt, attainable.
The question now is how? The key to malaria elimination in SI is the people, both the health service provider and the recipient communities. The service provider runs the system and the community subscribes to the system. Elimination is not possible without one or the other. Community must be an active participant not just a passive recipient. Human resource specifically volunteers can be provided by the community. The number of service providers in SI is not adequate, the reach is limited. Here is where good planning is essential. Planning can anticipate problems. Success is not possible without a plan and plan assures attainment of goal. SI is a complicated country. Remote location, varied cultural beliefs and traditions, a different way of life... all these have to be considered in planning. Only Solomon Islander can understand these and therefore thay are the one that can make the appropriate plan to eliminate malaria in the country.
Eliminating malaria in SI is just the same as in other countries. Pinpoint the areas with ongoing transmission (real time) apply the intervention engage active community participation to sustain the control. Low population per village makes elimination easier. Average population in the village is usually less than 200. It is not enough to sustain stable malaria transmission.
Pinpointing transmission areas in SI now is easier. Cases are now listed with their names, age, sex, address, diagnosis and date of diagnosis. Village with ongoing transmission is now easy to determine. These are the villages with indigenous cases in the last months in a row (Malaria Transmission Score discussed in earlier blog post). Other ways to determine if there is transmission is through investigation of cases, active case detection and other surveys that may include vector studies but are not routinely done. The easiest way to determine the presence of transmission is by MTSS (Malaria Transmission Score System) because it can come from routine reports. Case investigation in elimination provinces is mandatory. These provide information about presence of ongoing transmission that necessitates rapid response and prevent further rise in cases. Delay is costly and may mean more malaria or even death. Simply put.... no transmission...no malaria.
Come and visit Solomon Islands... the happy isles.

2015-10-01T19:47:00.000-07:00

Hello fellow malaria workers. Some glitch prevented me from accessing my blog for quite a long time. I am now here in Solomon Islands and will be writing my experiences and views from this lovely islands in the Pacific. WELCOME BACK!

Targeting the Malaria Hot Spots, an Operational Perspective

2014-06-16T20:19:00.000-07:00

A hotspot of malaria transmission is defined as a geographical part of a focus of malaria transmission where transmission intensity exceeds the average level (3). Targeting the hotspots would mean the most infected and most diseased households would be prioritized with the added benefits of reducing transmission to the whole community. Identifying the hotspots is possible by mapping asymptomatic carriers or using serological tools (1) The World Health Organization defines a focus of malaria transmission as a defined and circumscribed locality situated in a currently or former malarious area containing the continuous or intermittent epidemiological factors necessary for malaria transmission (2). Foci of malaria transmission can be classified as residual active, residual nonactive, cleared up, new potential, new active, endemic, or pseudo-foci (2). Malaria endemic areas have been classified in different ways but in control and elimination perspective there are be only two, presence or absence of transmission in a locality, at the real time. The common denominator is presence of transmission at the current time (real time). It may be difficult to get this real time data given the state of information/report flow in malaria endemic countries but the program is blessed with very important but less utilized information which is the incubation interval. This must not be mistaken from incubation period. Incubation interval is the period between the occurrence of infective gametocytes in the primary case and their reappearance in the secondary case (2). It ranged from 20 to 39 days (~ 1 month) depending on the species. To oversimplify things for operational perspective the locality with indigenous malaria in the past three months connotes presence of transmission. Intensity of transmission may be high or low but the baseline is... there is active transmission. Our observation in the Laguna, Philippines showed this will be the localities which will have API > 10 at the end of the year. Localities, therefore, with three months of transmission must be the target for a more intensive control operation. References 1. Griffin, J. T., Drakeley, C., Churcher, T. S., Smith, D. L., Bousema, T., Ghani, A., … Sauerwein, R. W. (2012). Hitting Hotspots: Spatial Targeting of Malaria for Control and Elimination. PLoS Medicine. doi:10.1371/journal.pmed.1001165 2. World Health Organization (2007) Malaria elimination: a field manual for low and moderate endemic countries. Geneva: WHO. 3. Snow RW, Rowan KM, Lindsay SW, Greenwood BM (1988) A trial of bed nets (mosquito nets) as a malaria control strategy in a rural area of The Gambia, West Africa. Trans R Soc Trop Med Hyg 82: 212–215

Malaria Elimination Update -Temotu Province, Solomon Island

2014-06-10T20:25:00.000-07:00

Background: Malaria elimination program for Temotu Province started on 2010 with the target of elimination by end of 2015 but there was a gradual increase in cases from 2012 and 2013 because of the absence of IRS in 2012 and the LLIN in use had passed their effective usefulness. In the fourth quarter of 2012 to the first quarter of 2013 there is more noticeable increase in cases because of small outbreaks in some villages. Replacement of LLIN was carried out in the third quarter of 2013 and IRS was conducted in the fourth quarter of 2013. Current Status: Lower incidence of malaria was reported from January to April 2014. There are 32 cases for 2014 as of this writing. Majority of cases are from local transmission (44%) usually isolated (sporadic) while the suspected relapse is 34%. Among the local transmission 57% are from children ten year old and below and among the relapse cases 82% are from the same age group. Malaria elimination program in Temotu is back on track. The very low incidence of cases for the first five months of the current year can be attributed to effective intervention. The slight increase in April comes from clustering of cases in the village of Maleu. This village needs investigation since the last IRS conducted was six months ago and replacement of LLIN was a month earlier than IRS. There was no reported adverse effect with primaquine among the directly observed treated cases. G6PD test was not done in these cases because it is not available locally. It is usually the relative of the patient who acts as treatment partner in those who live outside Lata. The malaria personnel supervise the treatment of those patients living in Lata. Current recommendation for the province are: a) intensive information campaign in Maleu for regular use of mosquito nets; b) conduct a second round of indoor residual spraying (IRS) in Maleu; c) close monitoring of clinics for more malaria testing of malaria suspects; d) remind patients in the clinics to use mosquito nets every night and stay indoor when it gets dark.

Identifying Active Foci of Malaria Transmission

2014-03-05T23:59:00.003-08:00

Malaria elimination requires zooming into the real time transmission areas. These are the areas where human, vector and host exist and the environmental conditions are favorable for transmission of malaria. These are the areas where intervention is most needed in order to control and eliminate malaria.
Identifying areas of active transmission is simple. First step is to divide the area by the smallest political subdivision and then by cluster of houses within 5 kilometer radius (about twice the flight range of the vector). This will be the smallest working area (SWA). Overlapping of SWA will become clearer when the malaria map shrinks with effective intervention. The next step is to identify the SWA with indigenous case or cases in the current month and in the previous three months. This is then the active foci of malaria transmission.
It is important that intervention in these active foci of transmission be through integrated approach i.e. there must be intervention against the parasite through active cases detection and treatment repeated every two weeks, vector control and community education and participation. Continues surveillance, both active and passive, is necessary because Plasmodium vivax relapse after a month and sometimes a year.
Identifying active foci of transmission is just the first step in malaria elimination and it is the most crucial.

Thematic Review Philippine MCP

2013-08-14T19:46:00.000-07:00

Stratification of malaria endemic areas is one of the issues raised in the ongoing thematic review of Philippine malaria control program. Stratification method of the Philippines is unique in the sense that it uses the presence of active transmission instead of annual parasite incidence (API). Donor agencies prefer API because they can see the magnitude of the problem i.e. how many case per population base per year. If the funding agencies prefer to use API then let it be but it must be for evaluation purpose and not for operation purpose. The country’s use of stratification is for operation purpose. It is being use to prioritize areas that needs intervention at the current situation (not last year’s situation presented by API). It responds to the dynamism of the disease. Malaria situation is in constant change. People move, mosquitoes fly, parasite transfers, microclimate which has influence on the factors of the disease also varies from hour to hour. A year is too long a period to base a decision to apply interventions.
Operations manual of MCP in the Philippines has several layers of prioritization and it is based on Malaria Transmission Score or MTS (please find malaria transmission scoring system in previous issues of this blog). It is a locally developed system to identify foci of active transmission. First priority are those localities with MTS of 12 or the localities with have reported indigenous malaria monthly in the past twelve months followed by those with indigenous case/s in the previous 3 months. The third priority are localities with indigenous case/s in the previous 6 months. The last priority are localities with sporadic cases of indigenous malaria and areas with malaria vectors but do not have reported or have no case of malaria. This prioritization focuses on areas which have ongoing transmission. Based on our study, localities with indigeneous malaria in three consecutive months will have an API greater than 10 per thousand population at the end of the year and greater if the string of months with malaria is longer.
To summarize API is useful for evaluation of the program and less useful as basis for implementation of interventions.

Stratification Workshop for Laguna and Quezon, Philippines

2013-03-19T20:13:00.004-07:00

Updating of stratification of endemic areas for the provinces of Quezon and Laguna, Philippines will be conducted on 21 and 22 March 2013. The workshop will include review on the stratification process and the basis for the method. Second part of the workshop will be planning for the elimination of malaria for the two provinces. Planning will include necessary activities to clear the malaria parasite in each community. Detailed plans and cost will be studied and the participants will decide if they plan will need additional resources form the National Malaria Control Program. The Province of Laguna is on third year of zero indigenous malaria while Quezon Province still has malaria on several barangays (villages). The workshop is based on the experience of Laguna Province in attaining zero malaria case in the past years.
The workshop is through the able leadership of Dr Lorenzo Sarmiento, the Regional Malaria Coordinator of CALABARZON with the support of Director Edgardo Gonzaga, MD, MSc.

Malaria Tawi Tawi and Sabah Conflict

2013-03-13T17:47:00.001-07:00

Displacement of people from Sabah to Tawi Tawi because of armed conflict may have an effect in the malaria situation of Tawi Tawi. Tawi Tawi is one of the problem areas for malaria control in the country. The problem of malaria comes from the geographical make up of the province. It is composed of several islands and islets endemic for malaria. Return of people from Sabah to these islands makes them vulnerable to malaria because of their low immune status and their lack of information about transmission of malaria in the province. Given the current situation, health authorities and malaria workers in the province must now be informing the displaced population on the risk of contracting malaria and must be distributing nets. Microspcopists have to be alerted and medicines have to be positioned for the expected rise of cases in the next two to three months. Surveillance system has to be rapid and focused. The situation may derail the ongoing success of the national malaria control program under the support of the Global fund through the Pilipinas Shell Foundation and the Department of Health.

Bednet Utilization Survey of 2012

2013-03-11T00:15:00.000-07:00

A survey was conducted in the provinces covered by the Global Fund Project of the Philippine with the objective of comparing the data with the previous survey particularly the knowledge and attitudes on malaria and its control and prevention, the condition of insecticide treated nets (ITNs) given by the project through direct observation and arrive at an estimate of damaged nets in the sampled population, the current practices in washing, maintenance (including repair of holes) and safekeeping associated with owning mosquito nets. It was also conducted to generate data for program monitoring and evaluation.
Highlights
Bednet ownership remains high at more the 98% of the households. Bednet usage among the respondents declined from 95 % to 93.4%. Benet usage among children under five years old likewise declined from 99.3% to 96.0%. Net usage among pregnant women remains the same at 88%.
There is continuous reduction of malaria cases in the country and in many communities zero incidence are frequently recorded. Among the 141 malaria diagnostic test facilities surveyed only 8.5% (12/141) had positive test for the study period (September, 2012). This may have an effect on the usage of net as the fear of acquiring malaria is lessened because of lowered incidence.
Fifty four hospitals were surveyed. There were 145,285 discharges from these hospitals in the study period (January to October 2013) and 0.2% (348/145285) of them were due to malaria. Among the 348 cases malaria 224 were included in the study sample and P falciparum constituted 83% (186/224) of the cases. There were 5 deaths (2.2%) among the sample. Review of records revealed 56.7% of treatment followed the protocol of the National Malaria Control Program.
Recommendations
Campaign for regular bed net use should diminish with the reduction of cases in a community. Reintroduction is always possible because of neighboring endemic areas or returning workers from endemic areas/countries. Ensure 100 % net ownership. New families or migrants have to be identified and provided with LLIN. Fast release of blood test and readily available medicines for malaria in all facilities will discourage self medication, encourage early consultation hence treatment of malaria cases before the development of gametocytes (especially Pf). Medicines for must be available even if the community has been cleared of malaria. Plan active case detection (ACD) diligently considering the workload of the microscopists and the need to provide the result within 24 to 48 hours. RDT and medicines can also be made available during ACD and MBS and those patients with symptoms can be diagnosed and treated onsite immediately. Replacements of net in areas with persistent transmission must be taken into consideration. Priority areas are those with indigenous cases in the past three months as provided in Malaria Manual of Operation. Intensify intervention activities in areas with many cases of malaria in children under five years old. Monthly review of Philippine Malaria Information Service (PhilMIS) report will be able to identify these areas. Copies of simplified malaria treatment protocol should be provided free to every hospital physician in the endemic provinces and at cost to private hospital physicians to recover cost of reproduction. Increase smear follow-up. It will determine the response of parasite to the treatment as well as providing opportunity to remind the patient on the use of net. Follow – up of cases is necessary at this phase of malaria elimination.
The survey was able to generate information that needs immediate attention and identified potential problem that may delay the attainment malaria elimination goal of the country.

Workshop on Feasibility of Malaria Elimination in the Philippines

2013-02-04T23:24:00.000-08:00

A workshop was conducted by Philippine Department of Health on the feasibility of malaria elimination in the country. All of the regional coordinators reported reduction of cases to a few communities in each province. The current approach was compared with the malaria eradication approach of the past and the main differences lies in the vector control method used. Indoor Residual Spraying (IRS) is the main vector control in the malaria eradication era while currently it is the insecticide treated nets (ITN). Another difference is the way the areas are stratified. Stratification in the eradication era use annual parasite incidence (API) while the current program utilizes the presence of transmission regardless of the level of malaria in the area. The current stratification method pinpoints the areas with ongoing transmission. It is the area where vector control is most necessary. Control of transmission will result to a lower level of malaria as a consequence.
The problems that will negate the attainment of malaria elimination level in the country were also discussed. They are armed conflict in the in some areas, malaria in indigenous population, geographically isolated area particularly small islands in the southern part of the country, reintroduction of cases from Overseas Filipino Workers(OFW), gaps in the surveillance system. Generally the malaria workforce in attendance have high hopes that malaria will be eliminated in the country within the decade.

Philippine Malaria Elimination News Update

2012-12-09T20:00:00.003-08:00

Malaria Control program implementation review was held 4 and 5 of December 2012. National and Regional coordinators attended the program review. Center for Health Development (CHD) Cagayan presented their malaria situation as well as CHD CARAGA, CHD Zamboanga and CHD Central Luzon. All presentations revealed reduction of cases to less than a hundred each. Total malaria cases at the national level from the first ten months of 2012 are down to five thousand level compared to 9.124 cases of 2011. The remaining province with high incidence of malaria is Tawi Tawi.
Tawi Tawi province is composed of several islands in the southern part of the country. It is the second in terms of number of malaria cases. The reduction on cases is low compared to Palawan,the province with the highest number of malaria cases. Access to services in Tawi Tawi is difficult because of the sea barrier. Public transportation in these areas were infrequent especially in island municipalities and “barangays”. The vector in these areas is Anopheles litorralis an early biter hence mosquito net is not an ideal vector control measure in the area. Space spraying or other methods of insecticide application need to be explored. This province will drag the country’s attainment of malaria elimination status hence the solution to the problem has to be found as soon as possible.

Philippine Malaria News

2012-12-02T23:52:00.001-08:00

A handbook for malaria M&E is soon to come out. The handbook list program indicators based on the Malaria Control Program Medium Term Development Plan. The handbook identifies the source of data and the significance of the indicator. It also contains the monitoring and evaluation tools for each administrative level and each facility. It will be presented to the Regional Malaria at the National Program Implementation review comes first week of December 2012.
Monitoring malaria program has to be systematic since malaria may occur in an explosive manner. One has to monitor the monthly incidence of malaria in every level. Once cases were detected… zoom in on the affected area and review the data of the area. Review the result of case investigation if any, the input indicators and study the problems related to the particular problematic input. Once the problem is identified, solution has to be made and changes or adjustments have to be implemented. Frequent reviews and rapid action is important in malaria elimination. Identified selected important indicators and not all indicators is necessary to help achieve the goal of malaria elimination. It has to go down to basic… logical frame analysis.

Comparison of IRS versus LLIN in Palawan, Philippines

2012-11-26T04:24:00.001-08:00

A retrospective study was done to compare malaria cases 12 months before and after the the application of vector control measures namely long lasting insecticidal nets (LLIN) and indoor residual spraying.
There were 112 barangay (village) with LLIN distribution in 2010. There were 2,825 malaria cases in the preceding 12 months prior to net distribution and the reported cases twelve months after were 1,824. There were 1001 less cases (35.43%, p<0.05)
There is no uniform effect of the net distribution. Twenty-three villages had increased number of cases. It was lesser in 67 villages while 22 villages had no change on number of cases. Among these were 14 villages without any case of malaria before and after net distribution. There were 89.45% more in cases in those villages with higher incidence after the LLIN distribution.
Malaria cases before and after addition of IRS in areas with LLIN distribution.
Indoor residual spraying (IRS) is a supplementary vector control measures in malaria endemic areas. It is an additional vector control measures in many localities of Palawan, Philippines. The whole villages was not subjected to IRS but only portions called purok/sitios (localities) hence the comparison was made at the locality level. Review of records showed IRS was applied in 466 localities in the Province of Palawan. There were 2,695 malaria cases in the twelve month period before the IRS. Malaria cases recorded in the succeeding twelve months after the IRS were 2008 a reduction of 25.5%, the reduction, however is not statistically significant.
There are 115 (24.7%) localities where the cases were higher, lower in 198 (42.5%) and were unchanged in 153. In localities with unchanged number of cases 113 (24.2%) have no case before and after IRS. Among areas where the cases are higher, the increase is 158.3% while the reduction were only 58.9% in areas with reduced incidence.
Cases of Plasmodium falciparum malaria before and after IRS at locality level
There were 2143 reported cases of malaria by passive case detection before IRS. At the end of twelve months there were only 1400 cases of P falciparum, a reduction of 65.3%. There were localities that had an increase in cases after IRS. It was observed in 96 localities. In areas with increased cases it rose by 285% while in areas with reduced cases the reduction was merely 65.8%. There was no change in 65 localities and half of which has no case of P.falciparum before and after IRS.
Comparing the Pf cases in LLIN plus IRS areas before and after the intervention may reflect the effect on transmission on a particular species. Reduction of cases was observed in 42.5% of the localities but if Pf cases alone was compared the reduction was observed in 53.7% of the localities. Comparison of cases showed there was reduction of 65.8% of Pf cases compared to reduction of 58.9% only if all the species were included. It showed more effect to Pf than the other species. Higher incidence of Pf case was observed in 27.6% of localities but cases of Pf in these localities was higher by 285%. Statistical analysis showed the difference is not significant.
Comparing the areas where changes in the incidence was not observed showed LLIN has the least. There was no change observed in 19.6% of LLIN areas while in LLIN plus IRS areas there was no change in 32.8% of the areas. The bulk of the latter were areas where malaria case is zero before and after vector control and it can be considered ineffective activity. Improving the targeting system for IRS will reduce the cost and the unnecessary use of insecticide. This targeting can be improved by utilizing MTS system in order to identify areas with active transmission of malaria. Targeted IRS is an effective tool for malaria control (G. Zhou et al).
The study is retrospective and is done in field condition. There are other factors that may have an effect in the data like case finding and treatment, and IEC activities that may result in the reduction of cases. Quality of spraying and insecticide resistance factors may have affected the outcome of IRS. These factors were not controlled in this study.
Malaria cases were lesser in both LLIN and LLIN plus IRS areas. In both groups there were areas where cases were either higher or lesser in the succeeding twelve months after the interventions. There are more areas under LLIN that had lesser cases (59.8%) than LLIN plus IRS areas (42.5%) although the areas may not be comparable because it is by village in the LLIN areas while in LLIN plus IRS areas is by locality. Comparing malaria cases between the two groups the LLIN plus IRS area had 25.5% (p>0.05) less cases twelve months after the intervention while in the LLIN areas there were 35.43% (p<0.05) less cases. Statistical analysis of data showed the difference in localities with additional IRS is not significant. Although there is reduction it is outweighed by the increases and there are many localities that may not have been sprayed particularly localities without reported indigenous malaria case.
Discussion
Malaria transmission score (MTS) is a locally devised system in lieu of annual parasite incidence (API) to prioritize areas for intervention. There was reduction in both areas but the difference in mean MTS is greater in LLIN areas (0.59) although the mean MTS is lower in LLIN plus IRS areas (0.15). MTS is preferably applied at the locality level in than by village level if the radius of the area is more than twice the flight range of the vector. The vilages of Palawan on the average is ~20 hectares hence MTS must be at the locality level. Application of MTS at the village level will result to higher MTS because of the contribution of every locality.
Conclusions
1. LLIN alone or combined with IRS reduce malaria incidence in general. 2. In some areas the cases had increased instead after vector control. 3. LLIN produces significant reduction of cases compared to IRS but IRS tends to reduce Pf cases more than the other malaria species. 4. Both LLIN and IRS reduce the malaria transmission score (MTS) Recommendations
1. Strengthening promotion of regular use of LLIN because it significantly reduces malaria incidence. 2. Addition of IRS to control vector has to be well planned and targeted appropriately to supplement LLIN in areas where MTS reached 4 and above i.e. malaria transmission is ongoing. Quality of IRS has to be assured through better supervision as well as use of effective insecticide. 3. Use IRS in cases of Pf outbreaks 4. Use MTS in making decision to conduct IRS and distribution of LLIN.
Acknowledgement
The author wish to thank PSFI for permission to use the data, Mr. Darius dela Cruz and Antero Rebueno, for providing PHILMis reports, The Faculty of UPCPH, for generation of research idea, Dr. Jeffrey Hii, Mr. Allan Schapira and WHO for their support in the development of the proposal, The ACTMalaria Foundation, and DOH NCDPC for their confidence.

Indicators: Malaria and Economics

2012-10-31T09:13:00.002-07:00

There are different classifications of Health Program indicators. They are classified into input, output, process, impact and outcome . While I am reading a book in stock market investment (1) I came across another way to classify indicators by economists. It classified indicators with reference to time of occurrence and found it very similar to the way Malaria Transmission Score (MTS) was developed. Indicators were classified as Lagging, Leading, and Coincident Indicators. This classification is important to malaria control program because incidence of malaria varies in every locality and at different point in time as was observed in the microstratification of malaria endemic localities of Palawan province, Philippines.
Lagging indicators are those that changed after the occurrence, leading indicators are the opposite of lagging indicator while coincident indicators are those which show what’s really transpiring right now.
In malaria control program we can classify API as lagging indicator because it had occurred a year ago. It is not the situation right now. Conducting intervention based on API may not be very effective since a situation may be totally different a year ago. Vector density, rainfall, humidity, population movement are examples of leading indicator. They may lead to high incidence of malaria if the parasite coexists in the area. Coincident indicators are MTS and weekly malaria morbidity report. They tell the presence of malaria transmission right now.
The presence of malaria transmission indicates all the factors for malaria transmission in the locality are present hence the best time to apply intervention namely vector control, case detection and treatment. Using API (lagging indicator) for decision to apply intervention has been a wasteful activity as we experienced before. Using lagging indicator (vector density, humidity etc) is wasteful either because the parasite may not appear/introduced to the locality. Increasing efficiency of vector control operation will result to better and more economical use of resources and most of all unnecessary use of insecticide.
Bibliography 1. Horowitz, A. Guide to making money in any market, St. Martin’s Press, New York, 2010 pp69-71

Eliminating Malaria in the Philippines

2012-10-03T19:55:00.000-07:00

This paper aims to analyze the positive and the negative factors in the country for malaria elimination in the country and recommend the steps toward eliminating malaria in the country.
The positive contributing factors

Diagnostic and treatment facilities are in place. DOH have trained microscopist or Rapid Diagnostic Test facility (RDT) in almost all municipalities with malaria problems through the support of GF. This can diagnose malaria early enough before development of gametocytes preventing transmission. Vector control particularly long lasting insecticidal nets (LLIN) has wide coverage exceeding 80% on the endemic areas. Reporting system called Philippine Malaria Information System (PhilMIS) is functioning and information is readily available. Reports can be generated instantly. Local program managers have been trained and capable of responding to a malaria problem.
The negative factors

Local insurgency and kidnapping in some areas prevents delivery of malaria program services. Multitasking of program managers. Relegation of the program to a lower priority program when the incidence is lowered.
Recommendations

Establish malaria elimination hub per region who will monitor the incidence weekly. Establishment of malaria rapid response team at the provincial level who will conduct mopping operation at the local level. Operation in incidence area must include campaign to use LLIN, distribution of LLIN if needed, Active case detection (ACD) every two weeks for three months and mass blood survey (MBS) at the end of three months if there are still malaria cases detected. Sustain passive case detection in all provinces to detect re-introduction of malaria.
The operation mentioned above will wipe out the parasite in every nook eliminating its presence in the locality. This approach has been tested in Laguna, Philippines by the author.

Malaria Control Program Training for Philippines

2012-07-27T17:46:00.001-07:00

The Philippine Department of Health (DOH), World Health Organization (WHO), The Pilipinas Shell Foundation (PSFI) and ACTMalaria Foundation are collaborating a training on Malaria Control Program Management for the Philippines, The training will be on 31July to 10August 2012. The training covers epidemiology of malaria, vector control with practicum on indoor residual spraying, program management, problem analysis, logistics management, and other aspects of malaria control. The resource persons and facilitators were from the academe (Dr Pilarita Rivera), experts from WHO (Dr Jeffrey Hii, Dr. Lasse Vestergaard, Ms Arlene Santiago), DOH program managers (Dr. Mario Baquilod, Dr. Rhoda Cruz, Dr Gil dela Cruz), and from NGO ( Mr Dominador Cabugayan of PSFI, and Dr Lus Escubil). ACTMalaria Foundation assists in coordination of the training. This training has been one of the foundations for success of the Philippine malaria control program and ACTMalaria Foundation contributed tremendously in management of the trainings.

Updates on Malaria Control in Palawan

2012-07-12T23:12:00.001-07:00

Malaria incidence in Palawan is at its lowest. It is about five thousand cases in 2011 from twenty thousand cases ten years ago. Malaria in Palawan is mostly in the southern part of the island in the municipalities of Quezon, Narra and Rizal. Reduction of the cases is the combined effort of the Provincial Government through Kilusan Ligtas Malaria (KLM), Pilipinas Shell Foundation (PSFI) the principal recipient of the Global Fund, the Department of Health, Center for Health Development(CHD), and the Local Government Units. The program is aided by volunteer microscopist in every barangay (Barangay is the smallest political unit in the country) who also administer treatment if blood is found positive for malaria parasite.
At the beginning of the year, through the initiative of the CHD, microstratification of endemic areas was conducted. It is necessary to stratify at the locality level in Palawan because the Barangays of Palawan has bigger land area than the other barangays in the rest of the country. The average size in Luzon, the largest island of the country, is 1.9 Sq Km. In Palawan the average land area for a barangay is ~20 sq km. It is more than twice the flight range of the local mosquito vector. Stratification requires review of incidence per barangay and since it will be microstartifiaction in Palawan, review of data by sitio was conducted.
Malaria incidence per sitio in Palawan showed the occurrence of the disease in not consistent. They are mostly small outbreaks and the occurence in not uniform year on year in the same locality. As a result of this microstratification there will be more focus of intervention increasing the cost-efficiency of the activities and reducing the amount of insecticide needed for vector control.
Palawan contributes more than 80% of the cases in the country. Reduction of cases in Palawan will immensely reduce the total incidence of malaria in the country.

Heading Towards a Malaria-free Philippines

2012-06-29T17:36:00.000-07:00

Malaria cases in the Philippines down to 9,375 cases in 2011 from 19,644 cases in 2010, a 52% reduction. This is from the report of Dr. Mario Baquilod of the Infectious Diseases Office (IDO) of the Philippine Department of Health presented during the malaria monitoring and evaluation validation workshop held in Davao City on 26 to 28 June 2012. The Malaria Morbidity Rate for 2011 is 9.5/100,000 population from 21 in year 2010.
Estimated total population of the country is 92 million. The population at risk to malaria is 14 million. Malaria is still present in 51 out of 81 provinces of the Philippines. Seven provinces are presently in the process of assessment for declaration to malaria-free status. Several strategies are adopted by the national malaria control program to reach the current status. Strategy 1 is stratification wherein active transmission areas are identified using locally developed tools. Strategy 2 is early diagnosis and prompt treatment. The aim of which is to treat cases before the development of gametocytes particularly Plasmodium falciparum cases. Strategy 3 is strengthening vector control operation. It is hinged in nightly use of long lasting insecticidal net (LLIN), supplemented by indoor residual spraying (IRS) if needed. Strategy 4 is strengthening surveillance and epidemic management. Strategy 5 is ensuring quality of services. Strategy 6 is intensification of health promotion and Strategy 7 is building local capacity to manage and sustain malaria control program. All of these strategies are embodied in Malaria Manual of Operation.
The current status of the malaria program is a joint effort of the Global Fund, The Department of Health, ACTMalaria Foundation, Pilipinas Shell Foundation (PSFI), Tropical Disease Foundation (TDF), the Local Government units and hundreds of volunteer health workers and microscopists. The march towards malaria free Philippines is accelerating.

Stratification of Malaria Endemic Areas in the Philippines

2012-03-29T08:25:00.000-07:00

Stratification of malaria endemic areas in the Philippines was modified in 2009.endemic areas were classified either (a) stable transmission area (b) unstable transmission areas (c) sporadic transmission areas and (d) malaria prone areas.

Stable transmission areas are those localities with case or cases of indigenous malaria for 6 consecutive months or more in a year.

Unstable transmission areas are those with case or cases of indigenous malaria for less than 6 consecutive months in a year.

Sporadic transmission areas are those with occasional indigenous cases in the past three years. There are some years without a case of indigenous malaria.

Malaria prone areas are those without any indigenous malaria for the past 5 years.

Stratification is applied to the smallest political unit of the municipality. If the land area of smallest political unit is more than the flight range of the local vector it is then subdivided further.

Stratification helps focus the application of intervention. The first priority is the stable transmission areas followed by the unstable transmission areas. Prioritization is further aided by presence malaria transmission (please see malaria transmission scoring system). Those areas with indigenous malaria cases in the past three months are the immediate priority. These are the areas with ongoing transmission which will contribute to the increase in annual parasite incidence(API)at the end of the year. This stratification method is one of the key factors in shrinkage of malaria map of the Philippines.

Bed Utilization and KAP Survey

2012-03-15T07:43:00.000-07:00

The Bed net utilization and KAP survey for the provinces under the global fund provinces of the Philippines is done. A high net ownership and utilization is the major finding. Knowledge level is quite high if the all the answers containing mosquito bite is considered correct and it will just be more than half if we are going to consider multiple response wrong even if they have mosquito bite in the response. The project had an enormous impact in terms of reducing the cases of malaria. The country can consider for malaria elimination as the program goal. Just two provinces remain problematic but it is being worked out.

You can request a copy of the report through my email giljan9@yahoo.com

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.