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.

The Spread of Malaria

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

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.

Malaria Elimination by Area Strategy

Malaria is an endemic disease. That means it is confined to areas which supports its transmission. It is located in areas where there are human, mosquito vector and parasites. Identifying these areas are easy. Is is usually done by adequate investigation of malaria cases from an area. If the movement of the cases are just within the community, then it can be assumed that there is local malaria transmission. The assumption that there is local transmission must be collaborated by the age group of the cases. Usually there are younger age group particularly children below five years old or more specifically children below one or infants. These are usually the group of population which stay in the community.

Once the presence of malaria transmission in a community is established malaria control strategies can now be implemented and it should be directed to all the parasite pool or reservoir in the community namely: parasite in the mosquito vector, parasite in the liver at the pre-patent stage, parasite in the liver at the hypnozite stage, parasite in the blood at the erythrocytic stages, and parasite carried by asymptomatic carriers. Each specific control strategies were already mention in the earlier blogs.

Once the presence of transmission is established in every community then planning can be made by area until all the communities are covered. This is best exemplified by islands endemic with malaria like the islands of Sulu and Tawi-Tawi in Philippines. It can be carried out island by island. Once an island is cleared of malaria, the next island will follow or activities can be done simultaneously in all the islands if the resources permit. Continues surveillance will then be put in place in order not to re-introduce malaria in a cleared island. Similar strategy can be applied in mainlands. The key is effective evaluation of data to determine the transmission areas or communities with ongoing transmission and not just historical data of malaria in the community. Ongoing transmission can be identified by the presence of indigenous malaria cases in the past three months. (This has also been the subject of previous blog.) Identification of areas with ongoing transmission is the most critical step towards elimination. Once the parasite is eliminated in each reservoir it would be easier if every health worker is aware of the possibility of re-introduction of malaria into the community,hence they should be vigilant to report malaria suspect or identify people from other malaria endemic communities. Reaching malaria elimination status is not possible if the community is not aware of mosquito causation of malaria and a significant segment of the population especially those who had malaria do not regularly sleep under the mosquito net.
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