Malaria Control Sulu Experience

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

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

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

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

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

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

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.