Malaria Elimination

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.

Malaria Elimination by Area Strategy

2009-01-31T05:19:00.000-08:00

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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Pitfalls in Malaria Elimination

2009-01-11T07:17:00.000-08:00

Failure to eliminate malaria in a community can be due to one or more of the following:
1. Failure to recognize the five reservoirs of the malaria parasites.
2. Inadequate information to the community about the mosquito causation of malaria transmission.
3. Failure to design the intervention based on the malaria life cycle.
4. Failure to stratify the area within the flight limit of the mosquito vector.
5. Failure to sustain program implementation.
6. Failure to cover 100% of the population affected.
7. Failure to diagnose malaria properly.
8. Failure to update record of malaria in the community.
9. Failure to use data in decision making.
10. Failure to recognize and adjust to the changing malaria situation in the community.
11. Failure to adjust to the local situation.
12. Failure to change behavior of the community towards regular use of mosquito net.
13. Failure to consult experts in malaria.

Information Campaign Towards Malaria Elimination

2008-12-14T04:07:00.000-08:00

Do you remember who said the pen is mightier than the sword? I can remember the message but I cannot remember the author. Remembering the message is more important than the author. Information Education Communication (IEC) campaign is one of the control method that is sustainable. "Education is a lifetime possession" is a well known Filipino saying. Information is the start of learning which will lead to understanding that ends up to change in behavior. Malaria elimination requires a behavioral change which is the regular use of mosquito net. Mosquito net provides a barrier between man and mosquito. Impregnating mosquito net with insecticide converts it into a trap with a human bait inside at night time.

IEC in the community has been with the malaria control program since its inception and there are plenty of forms or channels of IEC used. There are community assemblies, radio or TV plugs, leaflets, posters, school campaigns, one on one information, and print media particularly the newspapers. COMBI or communication for behavioral impact has been devised and utilize all the channels of communication with the hope of changing behavior to the desired one. It uses all the channels to convey the message to the intended audience but the problem is the availability of the channels in the malaria endemic localities. The malaria endemic communities has the following characteristics; less degree of economic development, low literacy rate, hardly accessible, located in the foothill or mountainous areas, no electricity with high incidence of poverty. These characteristics make many communication channels inappropriate. Absence of electricity, mountainous location, and poverty eliminate the use of broadcast media as communication channel. Community assemblies are not very effective. Community assemblies make the attendees out of their work and not significant segment of the population attend. During community assemblies mothers tag along their children and they distract the attention of the participants. It is not effective if held only once. There is less repetition of the message. What is left among the channels are personal selling and print channels. Many malaria endemic communities have low literacy rate as mentioned previously. In KAP survey in 2003 among selected indigenous communities in the Philippines low literacy rate is noted but not zero. This gives us opportunity to use print media and if coupled with personal selling, two channel can be utilized. Communication for Behavioral Impact (Combi) approach necessitates repetitive information to have a behavioral change. It can be modified or designed to suit the characteristics of malaria endemic communities. The behavioral change need to prevent malaria or to use mosquito net or bed net therefore the necessary message is "Prevent Malaria..Use Mosquito Net". In areas where culture prohibits the use of mosquito net, or the vectors are exophagic, or early biters, the message should be "Prevent Malaria...Don't let Mosquito bites You". These messages are brief. It can be printed in a sheet of paper 8 1/2 x 11 and posted on every front door of each house. During posting it should be read loudly to householders and emphasized that it is read as "Prevent Malaria...Use Mosquito Net". This is teaching the household members how to read the content of the poster and this step is critical. Posting in the front door is also important because the household members passes through it several times in a day. When the door is close passers by will also be able to see the posters. Householders should also be advised to take care of the poster. Posters need to be visited every 2 to 3 months and those that are lost or torn must be replaced.There are posters that are designed for illiterate community members. They use pictures instead of words. This can also be used but it may not convey the exact message needed because pictures are subject to different interpretations. thus, not specific message reach the target audience. Poster needs to be complemented by personal selling. Community members who are visiting the clinic must be told that they should use mosquito net to prevent malaria and everybody in the household must be sleeping inside the mosquito net. The same message must also be told to each household during the conduct of active case finding or mass blood survey or every time a malaria control activity like vector control applications and the like. Posters can also be posted along the roads or pathways and any highly visible areas. Effective information campaign is very important in any malaria elimination campaign.

Vector Control Application Towards Malaria Elimination

2008-12-08T17:55:00.000-08:00

Vector control shortens the life span of the mosquito vector. Vectors should not leave beyond the completion of the sporogonic cylce in order to cut malaria transmission. Sporogonic cycle is more or less ten days. The direct effect of vector control can be observed by reduction of the life span of the mosquito The dissection of the mosquito will determine the age of the caught mosquitoes. It should show as predominantly nulliparous mosquitoes. Using parous rate as indicator for the effectiveness of the vector control is tedious though and not enough personnel is available to monitor all areas of operation. A substitute indicator can be use like reduction of incidence within six months after the
the application of vector control. Monthly malaria cases has to be recorded and analyzed. If the cases persist or not reduced within four months, another vector control method need to be implemented or the areas assessed for effectiveness of the vector control.

Vector control alone will not eliminate malaria in a community. It should be complemented by active cases detection and treatment as well as active case detection every second week as mentioned previously. Parasites in all reservoir has to be eliminated.

Malaria Case Detection Plan

2008-11-30T04:06:00.000-08:00

Previously we address the need for diagnostic facility. It is one of the basic need for eliminating malaria in the community. Early diagnosis and prompt treatment is a must. Another requirement is case detection. Active case detection in the community is a must for malaria elimination. Cases have to be detected and treated early on the first week of illness especially cases of falciparum. They should be treated before the gametocytes appear in the peripheral blood and before they are picked up by the vector. People has to be employed or somebody has to take the task of looking for cases. They can be volunteers from the community or hire worker preferably from the same community. The key to success is the regular visit of the worker on every household every second week. If a worker has to be hired, his work load should be enough to visit every house every two weeks. The worker can be hired for a year or at least 6 months as long as there are still cases. Once the cases can no longer be found for 6 months, the area can then be placed under passive cases detection for as long as three years but once a new indigenous case is detected, there should be resumption of visits of every household every two weeks. During the visits, the hired worker has to educate the households on the importance of regular use of mosquito nets and to post materials containing the message "prevent malaria, use mosquito nets" on every door of the house. There should be supervision on the work of the hired personnel. Post on the doors can be monitored. It indicates that teh worker has visited the household. Workers can also be allowed to work in pair. Computation of the work area though, is individualized. Working in pairs promotes camaraderie and boost the efficiency of the workers. They can also be rotated in the other communities in the municipality or in other areas where their service is needed once their initial assignment no longer needs every two week visits.

Malaria Elimination Plan

2008-11-22T04:12:00.000-08:00

Requirements for a Malaria Diagnostic Facility

Diagnostic facility is one of the basic requirement in malaria elimination campaign especially when the cases are nearing zero. Quality of the microscopy has to be maintained since misdiagnosing a case will maintain the transmission of malaria in the community. The diagnostic facility need to have enough inventory of supplies and medicines against all species of malaria. Usually the inventory is neglected when the cases are nearing zero. Expiration of medicines and laboratory supplies are also expected since at nearing zero level they are seldom use and neglected. Regular monitoring of supplies and medicines and replacements of expired stocks is needed. The most important is that the supplies are available once it is needed. Storing them until they expire is fine as long as there are no malaria cases. The availability matters more that the wastage due to expiration rather than having delay in treatment of malaria case/cases. Keeping inventory for 50 malaria cases is enough as long as we have the supply chain readily available in short notice.

Requirements for Planning Malaria Elimination

2008-11-21T07:39:00.000-08:00

Planning malaria elimination campaign has to be detailed in order not to miss any of the parasite in all its reservoir. There should be enough supplies and manpower with detailed itineraries and support facilities. The following has to be in place before a malaria elimination campaign:

Diagnostic facility
Effective medicine against all malaria species in the locality
Trained man power to conduct efficient active case detection every two weeks
Detailed itinerary to cover all the household and and ensure regularity of active case detection
Effective vector control either insecticidal nets or indoor residual spraying
Information materials to encourage the community to use mosquito nets regularly
Effective field supervision to ensure the quality of case finding and vector control
Monthly analysis of data and institution of corrective measures whenever appropriate
Supervisors with good analytical and leadership skill
Good logistic management

Quality in each of the above requirements has to be assured.

Computation for requirement for the plan will be the subject of the next blog.

Important Pointers to Malaria Elimination

2008-11-15T19:16:00.000-08:00

Malaria elimination is possible. All the tools and methods are available. The most important is recognizing and attacking the parasite in all of its reservoir.

Parasites in the infected mosquito vector
Parasite in humans at the clinical or symptomatic period
Parasite in the humans at the pre-patent and incubation period
Parasite in humans at the carrier state
Parasite in humans at hypnozoite stage

Vector control either IRS or ITN/LLIN. This will remove the parasite in the first reservoir in the list above
Passive case detection (PCD) and active case detection (ACD) for the parasite reservoir in the second item in the list.
ACD two weeks after the former visit to catch the parasite in the third reservoir and be treated before the development of gametocytes
Mass blood survey to detect and remove the parasite in the fourth reservoir
Use of Primaquine and continuous Surveillance to address the hypnozoite

All of the above activities have to be in place for a period of one to two years and surveillance up to three years in order to detect reintroduction of malaria from importation and relapses. Take note that the species of parasite are taken as one and the stages in the human host are disaggregated. These are all related to operationalization of malaria elimination plan. Now we have a direction to follow and the next step is planning a country malaria elimination and operationalization of the plan. Keep in touch.

Malaria Control Program Management

2008-11-13T06:53:00.000-08:00

The success of malaria control program depends on the human resource and the commodities available. Managing the people is as important as managing the commodities. Program Managers should have enough managerial skills. Usually in the health system a physician manages the program though we now that the medical curriculum does not have managerial subjects.

Stategies, activities and resources do not complete a malaria control program. People has to be managed. Managing people requires skill. They are skills in leadership, motivation, counselling, organizational, planning , controlling, coaching and several other skills very much different from technical skills required to implement the malaria control program. Program management require several layers of supervision or middle managements. Each layer of supervision requires a different skill than the other layers. Lets take the lowest layer... the frontline workers or the spraymen. Spraymen have lower educational attainment. Spraymen has to be trained before they are deployed to the community. They may pass the training but they may perform differently when they are deployed in the field. They will perform depending on the assigned tasks as well as the factors that motivate them. Money (salary)is not the best motivating factor in fact workers may perform just enough for their perceived value of their pay, or in management term, optimization . Their immediate supervisor plays the key role in motivating them. This gives rise for the need to train this immediate supervisor to develop his skill in motivating his subordinates. Motivating skill is just one of the management skills needed by the supervisor. They also need coaching, counselling, monitoring skill etc. Imagine that each layer of supervision requires this basic skill of management. Program manager must not only be skilled technically but also managementwise. Efficient use of human resource requires good manegerial skill.

Malaria Control Program success does not only rest from commodities but largely to human resource implemeting it. Extracting the best output from human resources need skillful managers. This adds to the attainment of success of the Malaria Control Program.

We have discussed monitoring and evaluation previously but it is related to the techincal aspect of the program. Monitoring and evaluation related to malaria control program mangement will be discussed further later.

Malaria Control Program Monitoring

2008-11-09T00:53:00.000-08:00

Monitoring is the most neglected part of any malaria control program. Publications related to the program are centered mostly on vector control and treatment. The most important part of malaria control program is monitoring. Usually, monitoring is an integral part of the malaria control program most specially if there is external funds involved, and this monitoring is focused on how the money is spent. There are many malaria control programs indicators. This is also dictated by the program funding agency.

Malaria Control Program Indicators
The best indicator to gauge whether the activities are effective is the incidence of malaria. It is the end effect of the various malaria control activities combined. There are several indicators today. These are Annual Parasite incidence (API), Slide Positive Rate(SPR), Annual Blood Examination Rate (ABER), Number of houses sprayed, Number of mosquito nets treated with insecticide, Number of nets per house, Number of person per net, Proportion of P.falciparum infections, Insecticide resistance rate, Proportion of cases below five year old, Proportion of pregnant women sleeping under the mosquito net, and many more. The list is mind boggling. Many of them are not part of regular program report and extra effort is needed in order to gather these information. Use of this data confounds the program manager and the donors in the effect of the project. At this point there is a need to differentiate program indicators from project indicators. Many will disagree if somebody says this or that indicator is not necessary. For the interest of the program the most important indicator is the number of cases in the stratified area per month. This reflects the total effect of all the intervention activities carried out. Currently, each activity has its own set of indicators. Activity indicators creates a false feeling that the interventions made will have an effect in the malaria incidence. Everybody is satisfied if performance target is achieved. This is where many of the projects' failed to achieve the optimum expected result. Malaria is a localized disease and elusive as well. Without proper stratification process the success rate of a project is lessened. There is a lot of insecticidal nets distributed globally and still it is not enough in the perspective of the funding agency. This is similar to the eradication strategy of blanket implementation. We are seeing the reduction of cases because of the sheer magnitude of the nets distributed. It is likened to a shotgun projectile creating greater chance of hitting the target. There are observations that some are already using mosquito nets distributed to dry fish or their crops. Malaria is a localized disease and monitoring this must also be localized. The best way to monitor malaria is to have a record of the incidence per stratified area and then mark the month when the activity, particularly indoor residual spraying or treatment/distribution of net (or LLIN), is applied. The area is then monitored longitudinally every month. Regular observation will then be able to identify problems areas or areas that needs attention. Every problem has to be solved and each problem has its own individual solution although some may have similar solution. This method will determine whether the intervention is effective or is not needed in the first place. The effect of good monitoring system is reduction of wastage and increase in program efficiency. It is not conscientious to waste resources with environmental implications like insecticide.

Malaria Epidemic Prevention

2008-11-05T17:26:00.000-08:00

There are already many works related to malaria epidemic. There is malaria epidemic early warning system, the third quartile method, the cumulative sum method and there is also malaria forecasting. Any of the systems has some drawbacks. Take for example the malaria forecasting. This takes into consideration a lot of factors like climate change, vegetation, rainfall,humidity, landscape but in a third world country where malaria communities are located, these information are hardly available. It is very difficult to predict where will malaria occur. It is uncertain where among the malaria endemic communities will malaria incidence rise. At the macro level it is easy to predict that malaria incidence will rise but in the perspective of malaria control program personnel it is very difficult to pinpoint which community. Among the malaria control program personnel predicting means where will you take your resources. You might be expecting cases in one community to find out later that the other community had the problem.
Epidemics of malaria is said to be present when there is unusual number of cases in a community. The question is can you prevent epidemic? There are condition where we can say malaria epidemic might occur. Examples of these are the presence of insecticide resistance or there is drug resistance. But can we prevent epidemic? The answer is yes...but how?
In epidemic we rely on microscopically diagnosed malaria to make it certain that it is a real malaria epidemic and not due to other febrile illness. If we look at an epidemic curve, we see the rise and peak of the incidence of malaria. The question then is...when did the infection or to make it more specific, when did the infective mosquito bit the cases? Reviewing our books (please refer to my previous blogs)the bite was made two weeks earlier at least taking into consideration the incubation and the pre-patent period in the host. That means if we detect any malaria epidemic we are already two weeks delayed. Our interventions then maybe too late. Knowing the importance of the incubation and pre-patent periods we can then apply these information in our malaria control specially in epidemic prevention. First we do stratification using the MTSS (please refer to my previous blog), then we look at the areas where there is active transmission. These are the areas where there are indigenous cases in the previous three consecutive months (again refer to my previous blog). These are the areas where the factors favorable for transmission is present hence there is transmission. Next action is to attack the parasite in these areas in all its reservoir. These are: (1)case finding and treatment to address the parasite in in humans with symptoms, (2)vector control to address the parasites in the infected mosquitoes,(3) another rounds of case finding and treatment every two weeks to address the parasite in the incubation and pre-patent period in the earlier visit, (4) mass blood survey if there ares still malaria cases on the second month to address the parasite in the asymptomatic carrier, (5)Primaquine and continues surveillance for 3 years to address the parasite in the hypnozoite stage. If any of these sites is missed then there will be resumption of transmission. This approach will lead you to elimination of malaria in that foci. Expand it to other areas and into the whole country then elimination is foreseeable. To sum it up as long as there is malaria foci, epidemic is set to occur. You can prevent epidemic and eliminate malaria as well. More to come!
Happy blogging.
That is in essence the history of our malaria control in Laguna, Philippines. If you wish to read about how we did it you can request a copy. The trade-in is promote my site to ten malaria worker you know of. Please spread this information. My e amil address is giljan9@yahoo. com
My other blogs www.tipsphilippines.blogspot.com and www.pinoybody.blogspot.com

Malaria Epidemic Detection and Control

2008-11-03T15:22:00.000-08:00

Malaria is said to be in epidemic if the the number of cases exceeds the average cases of the last three to five years in the same period of time. It is advised to observe the data per stratified area. (Please refer to my blog on stratification dated October, 2008). Detection of epidemic requires updated report of cases weekly or at least monthly. Once epidemic is detected alarm should be sounded. Notice must be given to the community. They should be told to prevent mosquito bite through sleeping under the mosquito nets (This is the most important action). Local leaders must be notified as well, and the epidemic control system is activated. Activities for control of the epidemic includes residual house spraying, case finding and treatment, and health education. Every reservoir of the parasite has to be addressed in order to completely control epidemic. There are five reservoir of the parasites. They are the infected mosquito vector, the infected host at the incubation or pre-patent stage,the infected host at the symptomatic stage, the asymptomatic carrier state, and the hypnozoite. (This was discussed in previous blog). Failure to address any of the site will be the source of parasite for resumption of transmission later.

A flow chart for epidemic control is available upon request through my e-mail giljan9@yahoo.com
The flow chart is very helpful for application in smallest stratification area.
www.tipsphilippines.blogspot.com

MTSS Application

2008-11-01T01:00:00.000-07:00

Malaria control program efficiency has to be raised. Malaria control program activities include case finding and treatment, vector control, information education, surveillance, monitoring and evaluation. More than half of the cost of malaria control program is incurred in vector control specifically pesticides. Pesticides contribute to deterioration of the environment in addition to its prohibitive cost.
Improving program efficiency means getting the desired goal at the least cost possible. Efficiency of the program implementation needs improvement in all of the activities of the program. Malaria transmission scoring system (MTSS)helps in identifying the community that needs immediate attention. A community malaria transmission score of 1 (MTS 1) needs the attention of the program manager. It can be imported case/s or indigenous case/s. This case/s has to be investigated. The community has to be informed. The community has to be under observation for secondary cases. MTS of 2 needs the same attention as MTS 1 but enhanced case finding (those with fever) must be in place. In MTS 3, verification of data that there is local transmission needs immediate vector control. MTS of 4 needs the same action as MTS 2 that is active case detection. If the MTS reached 5, suspect problems like insecticide resistance, presence of malaria carrier and other operational problems like poor quality of indoor residual spraying, low coverage of insecticide treated nets or low usage of insecticide treated nets. Action will then be related to the result of problem identified. Continuous reduction of cases will be observed if the intervention methods are effective. There must be ACD every to weeks until six months without new cases. After the cessation of the ACD, the area has to be placed under surveillance with passive case detection to catch relapses. Malaria cases has to be treated before the development of gametocytes.
In the initial use of MTSS, start with the community with MTS of 12. Application of the aforementioned system will lead to elimination of malaria in the community. It seems plausible huh! Try it. That is the secret of our effective program that leads to malaria elimination in our province. Next topic will be malaria epidemic management and prevention. Happy blogging.

Application of MTSS in the malaria control program

2008-10-29T03:16:00.000-07:00

Now comes the topic of applying MTSS in the control program. Since we want to identify the priority area for the application of control methods we need to identify the proper area where our intervention gets the most impact. We need to stratify the area into its smallest size possible using the political boundary if the area is small enough within the flight range of the vector mosquito. The we review the cases of that area in the past three months. If the cases there are indigenous then there is active or ongoing transmission there. If there is only a month with malaria case/s we will not be sure that there is transmission going on in that area. It can be imported hence our intervention there will be a wastage or maybe no impact. Remember that using MTSS we are interested in the presence of transmission and not in the number of cases and control of this transmission will result to less total cases at the end of the year.

Malaria Transmission Scoring System

2008-10-27T19:59:00.000-07:00

Malaria situation in a given community varies from year to year depending on the prevailing factors of transmission.. It maybe the same if the situation is more or less similar to the previous year but most often it is not. Malaria Transmission Scoring System (MTSS) is based on incubation interval, which as previously discussed, is around 30 days. If there is transmission of malaria form one person to another, the shortest time for the disease to manifest in the secondary victim is around thirty days or equal to the incubation interval (or is the incubation interval itself). In a community (please take note of the method of stratification taking into consideration the flight range of the vector) this will appear as string of months or successive months with indigenous malaria case. It only means there is epidemiological association among the cases. This is the essence of MTSS. We are identifying areas with ongoing transmission. This is different from historical data like annual parasite incidence.

MTSS is a scoring system as the title declare. Malaria Transmission Score is defined as the longest string of months in a year with indigenous malaria. If we take into consideration a community with monthly indigenous cases for the whole year the score will be 12 . A score of 6 then means the longest string of months with indigenous case of malaria is 6 months. Suppose the record of a community shows 6 months with reported indigenous cases, and in these 6 months four occur in succession, then the score is four. To reiterate MTS score is the longest string or successive months in a year with reported indigenous malaria case.

From our data, MTS score is directly proportional to the annual parasite incidence. The cut off score is three. If the MTS score reached 3 then most likely the API will be more than ten at the end of the year. We can see that it has some predictive value and this is of crucial importance in malaria control operations.

My next topic will be application of MTSS in the field of malaria control operation and it will be followed by malaria epidemic prevention. towards elimination.

Stratification

2008-10-26T20:13:00.000-07:00

Stratification or grouping has been in malaria control program since the time of malaria eradication. It is use to classify communities and help identify the activities in each class and the order of priorities. Examples of stratification are by incidence i.e. Annual Parasite Incidence; by topography e.g. plain, coastal, mountainous, foothill; by transmission e.g. stable transmission, unstable transmission, sporadic transmission. Most of these use incidence of malaria into consideration.
Stratification mentioned above are based on historical incidence of malaria. Historical incidence is not an ideal data to use in stratification. Malaria is a dynamic disease as mentioned in my previous blog. Current situation is not exactly the same as the previous year especially in areas where there is unstable malaria. Use of historical data maybe fine if the area has stable transmission i.e. year round, but with the current situation where wide use of insecticide treated net is ongoing, many areas will be in the unstable classification. At this point predicting which area need intervention is difficult and usually this is the source of wastage. Vector control accounts for more than half of the cost of intervention. Improving efficiency will thus be important since cost is not just one factors to think of but the unnecessary use of insecticide.

In my topic about malaria epidemiology I mentioned that there are three factors needed in order to enable transmission of malaria from one person to another. Each factor is influenced by several factors like humidity, rainfall, immunity of the population, lifespan of the vector and others. If there is transmission i.e. there are secondary cases, it only means that the ingredients for transmission are favorable. We see this secondary cases at least 30 days more or less on the following month. Strings of months with cases means there is active malaria transmission in that particular area. That is one of the basis of Malaria Transmission Scoring System which will be the topic of my next blog together with the conclusion of this topic on stratification.

We are now entering into the most important topic of malaria control which is the Malaria Transmission Scoring System. Have a rest. Please post any comment or any question. I will be very glad to respond.