I I
,
(WP)MAUICP/CTD/30S-B Report series number: RS/9SIGBll4(PHL) English only
REPORT
~ MEETING ON INTENSIFIED CONTROL MEASURES
Convened by the REGIONAL OFFICE FOR THE WESTERN PACIFIC OF THE WORLD HEALTH ORGANIZATION
Manila. Philippines 24-27 October 1995
I Not for sale Printed and distributed
by the World Health Organization Regional Office for the Western Pacific Manila. Philippines January 1996 ",HO/WPRO LffiRj\Q IIflnjla PA~
(J
1 AP~ 1996
NOTE The views expressed in this report are those of the participants in the Malaria MeetinB on Intensified Control Measures and do not necessarily reflect the policy of the World Health Organization.
This report has been prepared by the World Health Organization Regional Office for the Western Pacific for govenunents of Member States in the Region and for those who participated in the Malaria Meeting on Intensified Control Measures which was held in Manila, Philippines, from 24 to 27 October 1995.
CONTENTS
SUMMARY 1. INTRODUCTION ...................................................................................... 1 1. 1 Objectives ........................................................................................... 1 1.2 Organization ........................................................................................ 1 1.3 Opening Ceremony ................................................................................ 1 2. PROCEEDINGS ........................................................................................ 1 2.1 General ............................................................................................... 1 2.2 Regional situation in 1994 ........................................................................ 2 2.3 Epidemiological indicators ....................................................................... 4 2.4 Diagnosis and treatment .......................................................................... 6 2.5 Vector control ...................................................................................... 9 2.6 Management ....................................................................................... 11 2.7 Training ............................................................................................. 12 2.8 Cooperation with nongovenunental organizatiOns and other partners .................. 12
3.
CONCLUSIONS AND RECOMMENDATIONS ............................................... 13 3.1 Conclusions ........................................................................................ 13 3.2 Recommendations ................................................................................. 14 TABLES: TABLE 1 - MICROSCOPICALLY DIAGNOSED CASES IN MALARIA ENDEMIC COUNTRIES OF THE WESTERN PACIFIC REGION, 1984-1994 ............................................................................ 2 - MALARIA EPIDEMIOLOGICAL DATA IN NINE MALARIA ENDEMIC COUNTRIES OF THE WESTERN PACIFIC REGION (1994) ................................................................................. 3 - QUALITY OF EPIDEMIOLOGICAL INDICATORS ...................... 5
TABLE 2
TABLE 3 ANNEXES'
ANNEX 1 - LIST OF PARTICIPANTS ...................................................... 17 ANNEX 2 - DETAILED PROGRAMME OF THE MEETING ......................... 21 ANNEX 3 - REGIONAL DIRECTOR'S OPENING ADDRESS ........................ 23 Keywords:
IMalaria - prevention and control I Western Pacific I Philippines
SUMMARY
At a meeting in Kunming, Yunnan Province, China in November 1993 the nine malaria endemic countries of the Western Pacific Region of WHO made renewed commitments to intensified malaria control programmes and set regional targets to be attained by the year 2000. The meeting described in this report was convened to review progress in malaria control following the meeting in Kunming, to discuss technical problems encountered, to identify solutions and to outline implementation strategies for the period 1996-1997. Among the nine countries, some are clearly making significant strides in implementing their intensified control strategies and controlling malaria while others have yet to get started. A wide range of technical issues was discussed by the participants including those relating to epidemiological indicators, diagnosis and treatment, vector control, management, training, and relationships with nongovernmental organizations and other partners. Many problems discussed were common to most programmes and have yet to be solved, while in some cases concrete examples of solutions were identified. The recommendations that resulted from the meeting are specific, mostly technical in nature and focus on the major problems faced by malaria control programmes in the Western Pacific Region.
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I. INTRODUCTION
1.1
Objectives
In November 1993 representatives from the nine malarious countries within the Western Pacific Region (WPR) of the World Health Organization (WHO) met in Kunming, YUDDaD Province, China, to present and discuss country plans of action for intensified malaria control and their implementation. WHO staff and national programme manageD from seven of the nine countries met in Manila, Philippines from 24 to 27 October 1995 to review progress since the meeting in Kunming and to set future directions for malaria control in the Region. The objectives of the meeting were: (I) to review progress made in implementing plans and control measures since the Kuruning meeting; (2)
to discuss technical and operational problems encountered in implementation and identify solutions; and to identify priority implementation issues and mitigation measures for 1996-97.
(3) 1.2
Or&anjzatiou
The meeting was held at the World Health Organization Regional Office for the Western Pacific (WPRO) in Manila, Philippines. The detailed programme for the meeting is given in Annex 2.
1.3
Qpenina Ceremony
In his opening address, Dr S.T. Han, Regional Director of the Western Pacific Region of the World Health Organization stressed the need for all malaria control programmes to demonstrate significant improvements in the malaria situation. He pointed to the successes already achieved by some countries as examples of how quality of life can be improved while at the same time instilling confidence that something can be done to overcome the burden of malaria. In order for all countries to accomplish this, Dr Han urged participants to further intensify their efforts and renew their commitment to achieve the goals set by the Region before the year 2000. The text of the Regional Director's Opening Addess is given in Annex 3. The Chairman for the meeting was Dr Ho Keong Bin, Malaysia, the Vice-Chairman Dr Mey Bouth Denis, Cambodia, and the Rapporteur was Dr Bernard Bakote'e, Solomon Islands.
2. PROCEEDINGS
2.1
General
The concept of intensified malaria control means using a combination of available measures, directed against parasite and vector, to achieve a marked reduction in sickness or
r
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death due to malaria. It aims to greatly reduce the incidence of malaria in selected areas, improve the quality of life of the people living in those areas, and instill confidence that something can be done to overcome the burden of malaria. It reflects increased attention to multisectoral and multidisciplinary approaches, and emphasizes that each person has the potential to make a long-term difference in his or her health status. The control measures used may include early case detection, rapid diagnosis, microscopic examination of blood slides, monitoring of treatment failure cases, mass blood surveys with treatment of persons found to be positive, rapid coverage of population with pyrethroid-treated mosquito nets, envirorunental management measures to eliminate heavy larval breeding in selected areas, indoor residual housespraying, ultra-low-volume backpack space spraying around houses, and community awareness campaigns to promote their participation and involvement. Increased technical and fmancial support to national malaria control programmes is also involved. 2.2
ReKional situation in J994 A review of the 1994 malaria situation throughout the Region showed the following: malaria morbidity was high in Papua New Guinea (estimated at 194 cases per 1000 inhabitants per year) and Solomon Islands (347 per 1(00); - incidence was intermediate in Cambodia (34 per )()OO), Lao People's Democratic Republic (38 per 1(00), Malaysia (33 per 1(00), and Vanuatu (27 per 1(00); incidence was low in China (0.89 per 1(00), Philippines (5.5 per 1(00), and Viet Nam (4.3 per 1(00).
Some important progress was noted since 1992. The Philippines reported a decrease in incidence by 43%, Solomon Islands by 18%, and Viet Nam by 20%; in China, incidence remains very low (less than 1 per thousand population at risk). Marked reductions in incidence are also occurring in Vanuatu despite the incomplete data reported for 1993 and 1994 (see Tables 1 and 2). Table 1. Microscopically diagnosed cases in malaria endemic countries of the Western Pacific Region, 1984 to 1994 (in thousands) Country Cambodia China Lao PDR Malaysia Papua New Guinea 1984 65.0 904.0 7.2 32.1 150.3 101.3 12.1 28.0 58.8 1424.8 1985 129.2 563.4 21.2 49.5 182.5 103.1 40.8 24.9 18.4 1193.0
1986 211.4 363.1 21.7 44.1 140.4 102.6 58.1 22.4 87.4 1058.4
1987 63.1 211.0 34.9 36.6 165.0 154.1 12.8 26.6 130.1
1988 16.1 134.0 31.1 50.7 83.9 154.9 65.0 26.9 151.5 181.3
1989 119.1 88.6 34.6 65.3 121.8 115.5 65.3 31.8 142.8
1990 123.8 89.0 21.5 50.5 104.9 86.2 116.5 28.6 139.6 160.6
1991 m.1 83.0 41.0 39.2 86.5 86.4 141.4 11.1 188.0 798.3
1m 91.0 14.0 38.5 36.8 86.5· 110.4 153.4 13.3 140.0 743.9
1993 99.2 58.5 41.8 39.8 66.8 65.0 126.1
1994
85 62.1 52.6 58.9 65.0·· 61.9 131.6
Philippines Solomon Islands Vanuatu
14.6**· 156.1 667.8
3.8·" 140.1 661.0
Viet Nam Total
894.8
7lIO.8
• Estimated figure based on 1991 data •• Estimated figure based on 1993 data *** Data are incomplete for these years
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Table 2. Malaria epidemiological data in nine malaria endemic countries of the Western Pacific Region (1994) CGunlry PopuIatIoa at risk
No. or mlcr .. oplcoUy DIll... pol C - (API)
DeatbI reported (N1IIIIIIer per 108 _
Cambodia China LaoPDR Malaysia Papua New Guinea Philippines Solomon Islands Vanuatu Viet Nam Total
2 SOOOOO
8' 012 62101 52601 58958
(34) (0.89) (31.5) (33.3)
I 009* (40.3) 43 (0.06) 609 (43.S) 28 281 (1.6) (8.6)
10000000 1400000 1110689 3243638
6' 000** (20) 61959 (5.5)
11 258309 319 lOS 142944 32495513
NA 49 (12.9) 13 (9)
131 681 (341.3) 3801 (26.6)
140120
(4.3)
604 (1.8) F.otlmated al 10 000 deaIbs
Wl90358
661 :I4S
(5.4)
API (annual parasite incidence) = nwnber of cases per 1000 people per year • Estimated at 5 000 deaths •• Estimated based on 1993 data
In Malaysia, incidence has remained steady, although the incidence data showed a marked jwnp between 1993 and 1994. This was due to a change in reporting and recording with regard to Orang Asli (aboriginal) areas. Papua New Guinea has been without reliable epidemiological data since 1992 so it is not possible to characterize the malaria situation there. Cambodia and Lao PDR reported substantial changes in their incidence denominators (population at-risk) making comparison difficult. Solomon Islands and Vanuatu are distinctive cases, being small countries with extrabudgetary support that is being put to good advantage. Solomon Islands has started an intensified malaria control programme beginning in the highest incidence area of the country and using a wide variety of intervention measures targeted to specific epidemiologic situations. Vanuatu is also progressing well, identifying areas of high risk and applying interventions in a stepwise strategy that will eventually cover the entire country. Certain islands are being identified for the application of intensive control measures similar to. those being applied in Solomon Islands. Lao PDR is beginning to strengthen its malaria control programme under the provision of a World Bank Loan. Specific provinces have been targeted under the loan for intensified control measures. Cambodia is making progress in selected areas, benefiting from substantial external support and collaboration with a variety of nongovernmental organizations. Drug resistance continues to be a major problem in the west but in the east the situation remains relatively less
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continues to be a major problem in the west but in the east the situation remains relatively less serious. Intensified control measures have been targeted for Kampong Speu and Kampong Som provinces. Viet Nam bas reported drops in malaria incidence. This is clear evidence that its control programme is making an impact in all regions despite problems caused by drug resistance. The widespread use of artemisinin and its derivatives has improved treatment markedly and saved many lives. The severe malaria problem in the Mekong delta bas been identified as a potential target for environmental management, as part of an intersectoral, intensified strategy. China with its vast population continues to experience malaria problems in the southern provinces including Hainan Island. Widespread use and good community support for insecticide-treated mosquito nets bas been a major factor in reducing malaria in the central parts of the country. The malaria situation in Malaysia has been stable over the past ten years. The original malaria eradication of the 19705 and its successor, the vector-borne disease control programme, has been successful in eliminating malaria from most of Peninsular Malaysia and Sarawak. Malaria remains a major health problem only in Sabah and among the aboriginal population living in the deep jungle areas of Peninsular Malaysia. Intensified control measures were initiated in Sabah at the beginning of 1995 that have produced concrete changes in the malaria situation there. During 1994 Papua New Guinea carried out an extensive review of its malaria control activities. A new plan of action was produced that revised the original, ambitious plans for insecticide-treated mosquito nets. That plan is slowly being put into operation. A recent outbreak of malaria in Chimbu Province has emphasized the need for better preventive and emergency control measures in the Highlands region. Madang Province has also been identified for implementing more effective malaria control activities. The Philippines programme also underwent an extensive review and re-orientation following the Kunming meeting. New strategies have been put into place that focus on key problem areas, making more use of insecticide-treated mosquito nets and less use of the traditional practice of DDT residual spraying. Renewed emphasis has also been placed on providing rapid diagnosis and appropriate treatment at all levels of the health services. Tawi-Tawi, Palawan, Mindoro Occidental, Ifugao, and Davao Oriental Provinces have been identified as priority areas for malaria control. 2.3 EpjdemjolQl:icai Indicators
There is a clear need for better reporting and standardization of basic malaria indicators. This is contingent on the quality and coverage of malaria information as part of the general health information system. As a result, the capacity of individual countries to collect, compile and analyse malaria data varies widely. These differences must be taken into account when comparing country indicators. Each country has its own set of goals based on morbidity and mortality indicators. These are usually stated in terms of reductions in annual incidence and annual number of malaria deaths. They are set based on each country's own abilities and resources. On a regional basis the goals of a reduction in morbidity of 50 % and in mortality of 80 % by the year 2000, in comparison to 1992 data, still seem to be realistic and achievable. The nine malaria endemic countries within the Region can be divided into three types based on the overall level of programme development as well as their capacity to collect, report, and analyse both morbidity and mortality data. The various types and their characteristics are defmed in Table 3.
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Table 3. Quality of epidemiological indicators Type coUDtry TypeZ Adequate
or
Indicator Mortality dati
Type 1 Good or adequale
Type 3 InIdequaIe or IDIIvliJable Hi'" mortality (-'y-
Malaria mortality
Low mortality Very little annual variation NO! a good indicator of control
InIermecIiaIe mortality Good indiaIor of control
areas)
DiagllOSlic capability
Microscopically confirmed cases
Microscopically confirmed cases and clinical diagnosis Adequate in part
Clinical diaposiJIfcver recording
Morbidity data
Good or adequate
inadequate in remote
Lacking or inadequate
areas Malaria incidence
measurement
.) Microscopically confirmed cases per I()()() population atrisk
Incidence based on microscopically
confirmed cases is 1Olderreported, but ..ill a valid indicator of control
b) Microscopically confirmed cases per \()()() census population
Although routine surveillance data are operationally useful, maJaria incidence is better estimated from special studies and sentinel sites
Those countries classified as types 2 and 3 do not have a fully developed network of microscopy posts and as a result many patients are diagnosed without the aid of microscopy. Where this is the case, useful indicators can be based on the number of clinical cases as long as a consistent method of collection and reporting is used. This includes clear case definitions. It is clearly desirable that the primary morbidity indicator be the incidence of microscopically conflnned cases of malarial disease. Although the meaning of "population at risk" is clear (the popUlation living at a certain time within the areas where transmission takes place), the practical estimation is not straightforward and depends on local epidemiological capacity. For planning control activities, it is obviously necessary to work on the basis of the population at risk, but it must be accepted that the meaning of this will vary somewhat between countries. National programmes should therefore report incidence rates related to total population as well as to population at risk. At regional level, incidence related to population at risk has and will be the main indicator of malaria morbidity.
Some programmes routinely use slide positivity rate (SPR) as a major indicator. It has important problems of interpretation, because it often represents a crude and variable aggregation of data from routine services and cross-sectional surveys. The most commonly used mortality indicators are: actual wmber of malaria deaths; and malaria-specific mortality rate. As with morbidity, there is a great difference between the ability of countries to collect mortality data.
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Mortality is a poor malaria control indicator in some countries because the nwnber of deaths is small, and/or the data collection is unreliable. In countries with good access to diagnosis and treatment, and good health infrastructure, malaria deaths are low and vary little from year to year. In countries with problems of access to diagnostic and treatment facilities, health information systems also are lacking, and malaria deaths are likely to be strongly underreponed. Viet Nam exemplifies an intermediate situation, where a marked mortality reduction was the earliest epidemiological result of a revitalization of the national control programme, including the application of more effective drugs. Many countries continue to use a specialized malaria surveillance system. The reason for this, in most instances, has been that the general health information system fails to collect the type and scope of information needed by the malaria control programme. In principle, integration with general health information systems can lead to information of better quality and relevance. However, the process of integration is arduous; it requires careful planning and assurance that the necessary capabilities are present. Traditionally two forms of surveillance have been practised by malaria control programmes. The routine reponing of cases detected by curative health services has been and should be the permanent core source of epidemiological information on malaria. This has often been referred to as passive case detection (PCD). Active case detection (ACD), where malaria staff actively search for cases, was long ago abandoned by most programmes because it was not in line with the concept of control and not cost effective. In some places where control activities have reduced transmission to very low levels, a form of ACD can be rational for detecting asymptomatic carriers if elimination of the infection is the goal. In many situations, for example when new, large-scale preventive measures are planned, cross-sectional surveys can have an important role for setting targets and follow-up evaluation. Such surveys should not be confused with ACD and the data should not be aggregated with routine surveillance data. 2.4 Dial:nosjs and trejl!Illellt
Early diagnosis and effective treatment of the disease is a fundamental component of malaria control. 2.4.1 Diagnosis The examination by a trained technician of a well made, correctly stained blood film is still the best and most reliable method of diagnosing malaria. The goal of most malaria programmes is to provide malaria microscopy down to the peripheral level of the health services so that treatment can be given based on the blood slide result and not solely on clinical criteria which have low sensitivity and low specificity. This is especially critical where expensive treatment regimens are needed because of drug resistance or where the mixture of parasite species requires different treatment regimens. It is also crucial for the management of patients with severe malaria. . Where microscopy is not available, it is the responsibility of malaria control programmes to ensure that health service providers are trained in clinical diagnosis. This must be adapted to local criteria, taking into account other locally imponant pathologies, such as dengue fever and typhoid fever. Every case that goes untreated due to poor clinical diagnosis may result in an unnecessary death. In most areas of the Region, where malaria transmission is not intense, the classical clinical diagnosis, "a patient who has been exposed to malaria with febrile disease (fever or a
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history of fever within the last few days) with no other explanation" will still be adequate to begin treatment. In areas with intense transmission, such as parts of Papua New Guinea and some foci in Lao PDR and Viet Nam, it is necessary to give antimalarial treatment to all young children presenting with febrile disease, irrespective of other signs and symptoms. Rapid treatment depends, in large pan, on the awareness of individuals, particularly mothers, about malaria and the potential consequences if treatment is delayed. Cambodia has addressed this problem by producing a video to educate the public on malaria symptoms and proper and economical treatment. A non-microscopic method for rapid diagnosis of falciparum malaria by immunoenzyinatic detection of a species-specific histidine-rich protein has recently been developed. A positive red-coloured antigen antibody complex can be visibly determined in ten minutes. This so-called "dipstick" method may be a tool suitable for use in peripheral services without laboratory staff. Unfortunately, the method developed so far can only detect P. Jalciparum, and it is too expensive for most programmes to use routinely. At the present stage of development, it is not a replacement for microscopy but may have some limited practical applications which include: malaria diagnosis in hospitals after laboratory hours; aparasitaemic patients suspected of having severe malaria; rapid on-site diagnosis for febrile persons during mass blood surveys so that inunediate treatment can be given; clinics located in peripheral areas of low population density; and as a means of epidemic warning in areas of low incidence. Dipstick diagnosis might also flOd a use in private clinics where people are willing to pay for good medical care. 2.4.2 Treatment For many countries in the Region, one of the most difficult questions in the field of chemotherapy remains: when is it indicated to change the first-line drug, in a situation where resistance to it is increasing? The most common situation is where the first-line drug is chloroquine, and in vivo test surveys suggest that resistance is worsening, and therefore at what level of resistance should sulfadoxine-pyrimethamine or another drug be introduced instead? Some progranunes have already gone through the series of changes in their first line regimen from chloroquine to sulfadoxine-pyrimethamine, mefloquine, and finally anemisinin. There is now growing concern that resistance to anemisinin and its derivatives might develop in areas where they are used on a large scale, especially Viet Nam. Drug susceptibility in this group of drugs has to be carefully mortitored, so that early remedial measures might be applied. Some progranunes have tended to wait too long when considering a decision to change to an alternative drug. Others have moved too quickly. While such decisions must indeed be taken prudently on the basis of a consideration of all relevant factors, the use of any drug will eventually lead to increasing resistance. The immediate need to ensure effective treatment which can prevent severe disease and death should take precedence over apprehension about future risks. It has been suggested that if the proponion of carefully assessed treatment failures is above 25 % of patients treated, it is time to stan considering whether a change may be necessary. The therapeutic efficacy of the first line treatment in use must be compared with that of the alternative(s) under consideration. However, it is necessary to compare also the following factors: - Cost A careful analysis often shows that the cost of a drug per se is not the most important factor, because the costs of re-treatment if a less effective drug is used may be considerable.
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- Side effects - Compliance
Especially those that are potentially fatal, and those which may interfere with compliance. It is necessary to assess tho: probability that the patient will take the full recommended course of treatment and the risks associated with too short a course. Compliance is low with prolonged courses of treatment, especially if there are noticeable side-effects.
- Potential development of resistance
Resistance will develop to any drug which is used, but it needs to be considered that in areas of intense transmission, its development may be particularly rapid for a drug with a long half-life.
- Characteristic Health services must be assessed for, for example, how well of health treatment guidelines can be implemented, whether vulnerable services groups are treated and how well the services can cope with treatment failures. A country with good health infrastructure and low incidence can afford to wait longer to change but has the capability to change with ease. In contrast, a country with a poor health infrastructure and high incidence cannot afford to wait but also may not be able to change drug regimens easily. In-vitro drug sensitivity testing, following the standard WHO test procedures was, in the past, considered to be critical in deciding when to change drug regimens. It is still useful as a method for quantifying resistance levels and may be useful when evaluating resistance to artemisinin but it cannot be used as a replacement for careful in-vivo studies.
The importance of compliance as a major factor in treatment failures is often overlooked in the rush to carry out in-vivo or in-vitro studies. Compliance is extremely important where the drug regimen requires 5-7 days to complete and includes more than one drug. The probability that a patient will take a single dose treatment such as sulfadoxine-pyrimethamine is high; compliance with a three day regimen, such as chloroquine, is likely to be much lower and with quinine and tetracycline even lower. Quinine in combination with tetracycline which requires a full course of 21 doses and has side effects, has a compliance rate approaching zero. Control programmes need to be able to take independent, rational decisions and to communicate recommendations, not only to health care providers but also to the population at large. The latter is particularly important where self-medication is widespread. Selfmedication is often a poor substitute for a professional service, but it may be the best that is available to many risk-groups. In such situations, health education should aim at optimizing its quality. The use of primaquine varies greatly from programme to programme. It has two usages: its primary use is as an anti-relapse treatment for vivax malaria but it is also used in selected situations as an gametocytocidal drug for fa1ciparum malaria. Primaquine is the only effective drug currently available for anti-relapse treatment of P. vivax infections. To be fully effective it requires 7-14 days of treatment and patients with glucose-6-phosphate dehydrogenase (G-6-PD) deficiency may have complications ranging from transient haemoglobinuria to fatal haemolysis. Patients can be easily screened for G-6-PD deficiency using a simple test but full compliance is a major problem that has proven difficult to overcome. For individual patients who cannot take primaquine because of pregnancy, young age or G-6-PD deficiency, one year of weekly chloroquine prophylaxis may be an effective alternative.
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. ~me countries have eslabl.ished a policy of not routinely treating vivax malaria with ~nmaqume because of ~e co~phance proble~ and the fact that patients may be readily repa~ents. hav~ frequent, clinically ~rtant relapses. It also may be required on epJdenuologJcal grounds, as an adjunct to transmission reduction measures, when the
mfected. The use of prunaqume may be required on clinical grounds, when many vivax
programme aims at reducing the incidence of infection. This normally requires supervised administration preceded by G-6-PD testing. For falciparum malaria, a single dose is sufficient to kill the gametocytes, and this is not associated with important side-effects, even in patients with G-6-PD deficiency. The application of primaquine for this purpose is meaningful as an adjunct to other measures for transmission reduction when the prevalence is already low or for the control of malaria epidemics. These other measures include vector control and fully effective schizonticidal treatments. 2.5 vector control
Insecticide-treated mosquito nets are the major method of vector control in the Region. The methods for distribution, trealment, re-trealment and monitoring vary widely but problems and constraints are common to all programmes. Logistical problems, especially those associated with re-trealment, have proven to be an important issue. In looking at programmes where mOSQuito nets are being used, two basic models have emerged. First, mosquito nets as a public health intervention strategy. The aim is transmission control as well as personal protection. A high percentage of the population in a specific area are protected with nets. The second type of usage pertains to individual or family protection in which many other members of the community might not be involved. This type of net usage falls under the general category of community action in vector control which also includes sleeping in a screened bedroom, filling in or draining stagnant water pools near houses, burning mOSQuito coils, etc. These standard types of individual activity are always encouraged, even if compliance in the overall community is low. When treated nets are utilized as a public health intervention, high rates of coverage and re-trealment are required. As a general rule, a coverage rate of 80 % of the population in each community to be protected can be considered the minimum criterion. Experience has shown that areas for mOSQuito nets must be chosen carefully and covered on a phased basis. Selection is normally based on a variety of factors, the most important of which are the level of malaria endemicity and the expected level of acceptance of nets by the population. The treated nets can be expected to have the greatest impact in areas of moderate to low endemicity. Nets in high endemicity areas can provide protection to vulnerable groups such as pregnant women and young children. In areas where nets are already in use or where there is a clear demand, high rates of coverage and regular usage by a large percentage of the population can be expected. Coverage of more difficult areas will take longer and involve a greater degree of community education. Successful distribution and re-trealment of nets depends on full community partiCipation. The actual amount of time and effort put in by communities varies greatly and experience has shown that health workers should coordinate treatment activities and be present to help with measuring the insecticide. This provides one form of assurance that the nets are treated on schedule, that the insecticide is being handled safely and that an adequate dosage is applied. Two rounds of re-trealment using permethrin are considered optimal but several programmes have found this not to be practical. One round, timed just before the peak transmission period with a high percentage of nets treated, has been used by most programmes. Other insecticides, especially deltamethrin, have been successfully used for treating nets by
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some programmes. Choices have to be made, not base<! on .cost al~ne, but ~ into ~ccount the duration of effectiveness, and safety when the chemIcal IS used In a commumty settmg. Validation of coverage, re-treatment and usage rates through periodic surveys is important for evaluating the acceptance and use of nets. Con:ect utilization and num~r of nets distributed or re-treated are key factors in a successful mosquIto net programme. It IS also important that nets remain hanging or exposed in rooms and not folded or placed where mosquito contact is not possible. The quality of nets is another key factor contributing to the success of a programme. Poor quality .nets that were distributed in some countries have proven to be a major obstacle to widespread acceptance and use. Equally important are decisions on cost recovery and availability. All programmes subsidize the cost of nets but a contribution is collected that normally goes into a revolving fund that is used to purchase additional nets and insecticide. If the amount collected for each net is too high some families are prevented from acquiring nets while if the price is too low the programme can not be self-sustaining. Individual programmes or, in some cases, individual provinces or districts have set the amount collected based on the ability of families and individuals to contribute and the degree to which the cost of nets and insecticide are subsidized. There is concern that a large proportion of the mosquito nets purchased in the Region come from one supplier located in Thailand. To date, the factory has been able to provide good quality nets at a low cost but there have been delays in filling orders due to a high demand. There are other suppliers but they have not been able to match the quality and price. It would clearly be in the interest of all programmes in the Region if other suppliers could be found that are able to provide high quality nets at a reasonable cost. Sening of standards for the quality, construction size, mesh and colour of nets for malaria control programmes might encourage other manufacturers to enter the market. Where there is no organized distribution of treated mosquito nets through national malaria control programmes, the sale or distribution of nets to individuals is best accomplished through commercial outlets or nongovernmental organizations (NGO). Where this is done the goal is individual or family protection and not malaria control in a community or locality. This difference should be clearly accounted for when planning mosquito net activities. It is now recognized that a major need in the Region is for single treatment packets for net re-treatment. Low-income families, and, indeed, others, are neither able nor willing to purchase one-litre bottles of permethrin or deltramethrin. The cost is too high. Smaller quantities are essentially unavailable and efforts are being made to overcome this problem.
The role of NGOs, companies, churches, boarding schools and other centrally managed organizations or groups is to import, store and distribute nets and insecticide at a commercially sustainable price. This has meant that the cost of nets distributed through these organizations is often higher than those distributed by malaria control programmes. In the case of special groups, such as forest workers, rubber tappers, or other workers at high risk, the cost is often born by the employer. Indoor residual spraying is still a major component of some malaria control programmes. In one large programme it is done in combination with treated mosquito nets. Elsewhere, spraying is limited to well defmed areas or population groups, usually those where insecticide-treated mosquito nets have not been well accepted. DDT remains the most widely used insecticide although some programmes have begun to introduce lambda-cyhalothrin or deltamethrin in selected areas. For intensified malaria control activities in specific high incidence areas or during epidemics, backpack ultra-low-volume spray applications around houses can be used in
, ,
,
,
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combination with other measures to reduce vectorial capacity and to kill infected mosquitos. A I % ~olu~lon of a water~based formulation containing permetbrin and a synergist has been apphed m some countries. Environmental management for the control of malaria vectors is being carried out in Solomon Islands as one component of an intensified control strategy. Pipelines are being installed at the mouths of rivers and streams that are blocked by sand bars. By restoring the outward flow o~ fresh ,:"ater and inward tidal flow of salt water a mixing occurs that critically alte!"!, the breedmg habitat of the l~l vector An. faraUli. This and other techniques of environmental management or manipUlation have a considerable potential in other coastal breeding situations.
The problems faced by control programmes are not primarily technical. Inability to meet set goals is often due to poor management. Programmes are top heavy with managers but weak in the field where the work gets done. Field staff are often inadequately trained, poorly supervised, poorly paid, and lack the equipment and supplies needed to carry out their jobs. The "good old days" of malaria eradication are often looked back on as the time when there was plenty of money, staff and other resources. Those days are clearly gone, resources are now limited, new strategies are in place, and new priorities have been set. There is a clear need for senior staff to recognize or reflect on their inability to change thinking or procedures. Many still apply principles and procedures that were appropriate under malaria eradication but which do not fit with the concepts of control. In many instances beaucratic processes take precedence over accomplishments in the field. This unnecessarily impedes a programme's success. A major factor that contributed to the disruption of some malaria control programmes was the move to integrate malaria control into the general health services. This move was promoted during the 1980s as an important means of rationalizing health services while controlling costs. Vertical programmes were abolished and control activities were absorbed into the general health services. Experience has shown that malaria control activities, especially those required for prevention, are a heavy burden to place on primary health care staff, especially those at the periphery who have neither time, training nor inclination to take on work previously done by malaria workers. As a result, programmes that had undergone integration are now shifting back towards a form of vertical organization. Solomon Islands offers one example of a vertical malaria programme that has successfully decentralized management and authority while maintaining an effective control programme. There are still single purpose malaria workers and single purpose supervisors but overall responsibility has been handed over to provincial health managers. Local responsibility has allowed a greater degree of flexibility. As a result, individual provinces have introduced innovative approaches, such as using religious and women's groups to sew and distribute mosquito nets. Intersectoral cooperation is recognized as beneficial to malaria control programmes but in most situations its full potential has yel 10 be realized. Coordination of activities with the private sector and between govenunent units has been accomplished in some countries but, in most, malaria control has retained a degree of separation that has blocked any lasting linkages. The lack of adequate remuneration for malaria workers poses a major obstacle to many programmes. In many instances staff are paid such low salaries that even senior staff must have an additional source of income to live. Under such circumstances staff are not able to give their full attention to the control programme. They are, for example, understandably reluctant
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to spend long periods in the field away from their private medical practices or other jobs as it creates hardship for their families. 2.7 Trainjn~
Training is a constant requirement for malaria control programmes, to cover staff recruitment, turnover, promotion, progralnme reorientation, and the simple need for refresher courses. National training usually focuses on technical or operational aspects of individual programmes, such as microscopy, insecticide application, or epidemiological reporting. Intercountry training programmes have been organized at subregional or regional level where programme needs have overlapped. For example, a regional course for mid-level managers will be held in Malaysia during 1995. Subregional training collaboration among the three malarious countries of the south-west Pacific has also been very successful. Intercountry training involving countries in the same geographical area would seem useful and important, but language barriers hinder collaboration, especially below the top managerial level. Malaria workers are characteristically good technicians but often lack the knowledge and skills to be good managers and good trainers. Most malaria control programmes have an urgent need for managerial training, targeted at both upper and mid-level staff. Microscope maintenance training is a recognized need throughout the Region. Maintenance can be contracted out to private firms in some countries, but other countries need to have trained staff within the malaria control programme. Successful training courses have already been held in Papua New Guinea and Solomon Islands but additional courses are needed. There is a need to share resource people and resource materials, especially successful materials in which complicated subjects are simplified. For example, Vanuatu has compiled a "Malaria handbook" which provides a source of information for general health workers on all aspects of the disease, including the parasite, the vectors, diagnosis, treatment, and control interventions . Overseas training sometimes becomes an objective, rather than a means, lacking positive gain to the programme. There is a risk of drawing away the best people for long periods of time. As with other external funding, malaria programmes need to avoid becoming donordriven. It is important to ask why the training is important, rather than who is going. 2.8 Cooperation with non~oyemmental or~anjzatjons
and other partners
International attention seems to be returning to malaria control after a period of discouragement following the failure of malaria eradication and the difficulty of redefming malaria control. External or extrabudgetary support is available in the Region, and each national malaria control programme needs to be ready with a sensible and realistic plan of action for malaria control that lists the intervention measures to be taken and the criteria for their application and evaluation. In order to facilitate partner participation, malaria control programmes need to compartmentalize or segment their programme activities and costs, enabling partners to pick and choose. Briefmg materials also need to be prepared and be made available for partners. External panners are invariably looking for projects that have a strong potential for success. This is why many have generously supported treated mosquito net projects. With nets it is easy to demonstrate that they are getting right into individual households, protecting women and children. The most notable example is Rotary International's support of the mosquito net programme in Vanuatu and Solomon Islands. Based on the success in Vanuatu it may support treated mosquito nets on a worldwide basis, the way it supported the poliomyelitis eradication programme. )
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On a local basis, malaria control programmes have been successful in working with NGOs and other partners to assist with the procurement of nets and insecticide. Local sources of nets and insecticide may not be available or suppliers may not be willing, economically, to meet the "small" needs of each group. Private companies, especially those in the logging or mining industry with large work forces exposed to malaria, have two self-serving motives for cooperating on malaria control: they require a healthy workforce and need to establish good public relations with the neighbouring communities. Boarding schools, both private as well as public, represent another institution with a captive population at risk for malaria. Control programmes have successfully promoted mosquito net use in the dormitories, both as an immediate public health measure to protect students against disease, and for its follow-on effect in influencing a new generation NGOs are often a vital link between malaria control programmes and peripheral health services as well as the nonhealth sector, being able to offer an entry point to rural areas through their rural development or rural credit schemes. Extrabudgetary funds can cause problems if not properly managed. There have been instances where the national leadership of a control programme has become compromised by the outside interests of donor partners. There are also hidden costs, including the loss of good staff to training activities, to assist short-term visiting scientists, or simply to meet visitors. Other hidden expenses are high expatriate salaries and other overhead costs that often amount to a large proportion of funds pledged to the project. A fll11l commitment to refuse unacceptable funding proposals that infringe on the effectiveness of control programmes or are against national policy is the most effective way to avoid problems. Equally important are the use of what are equivalent to contracts between NGOs and malaria control programmes. This is a way to overcome problems caused by the constant turnover of staff. Disbursements and other activities to be carried out are clearly defined so that there is no confusion about the NGO's role in relation to the control programme. WHO's role in coordination of partner support is difficult to define. The situation that should normally be aimed for is for WHO to work as a close partner of the Ministry of Health, collaborating on definition of needs and assessment of the particular strengths of potential partners. In this way, advice can be offered that does not favour anyone partner but which is clearly in the best interests of the control programme.
3. CONCLUSIONS AND RECOMMENDATIONS
3.1
Conclusions
There has been considerable progress since the meeting in Kunming. Both national managers and WHO malaria staff atthia meeting expressed confidence that with continued political support from governments in the region, technical and financial support from WHO and funds from other partners the ambitious targets set at the Kunming meeting can and will be realized. Programmes have undergone major changes over the past decade with the switch from eradication to control. Many governments within the Region reduced levels of funding and placed a lower level of priority on malaria control. Managers have had to make the shift from eradication to control while at the same time being faced with fewer resources. After many years, programmes are now beginning to reorganize and focus their efforts to apply resources
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in selected priority areas. Donor partners have seen this change and are putting more and more resources at the disposal of malaria control programmes. Malaria control is therefore entering a crucial period during which programmes will have to demonstrate that they can achieve significant reductions in the burden of malaria. There may not be another such chance. Problems encountered in implementing the intensified control programmes discussed and presented at the meeting in Kunming are, by and large, common to all programmes in the Region. Although emphasis has continued to be focused on antimalarial interventions, malaria control is very dependent on social and economic development. China and Malaysia are two rapidly developing countries with strong economies that have well-developed malaria control programmes showing tremendous success. The Philippines and Vietnam are two countries that, in the past, had strong and successful programmes but which are only now able to show progress against malaria again after many years. Lao PDR and Papua New Guinea, on the other hand, are still in the process of strengthening their programmes. Small island countries, such as Solomon Islands and Vanuatu fall into yet another category, where, because of their size, they have been able to quickly and effectively reorganize their programmes. A wide range of teclmical and operational issues were discussed during the meeting but the lack of effective management constantly came out as the single most important problem to be overcome. With this in mind the recommeodations were made. 3.2 (1)
Recommendations
Programme management should be decentralized so that important decisions can be made at the local level. This leads to flexibility and innovation within the programme, better supervision and stronger community support. (2) Training of staff to effectively take on management roles should be a priority for all programmes in the Region. (3) Each country should improve its malaria information system as part of the general health information system so that the collection and analysis of malaria mortality and morbidity data is improved. (4) Malaria microscopy should be extended into the peripheral health services SO that all patients can be treated based on a parasitological diagnosis. Where this is not possible, clinical diagnosis must be the basis for deciding to treat. (5) Epidemiological indicators for malaria morbidity should be based on microscopic diagnostic data where possible. National programmes without adequate microscopic diagnostic capabilities will need to use a consistent and clear clinical diagnosis supplemented by prevalence surveys and/or sentinel sites. (6) Malaria morbidity should be reported as an annual incidence rate calculated using population at-risk as well as total census population denominators. (7) Realistic targets for annual reduction in incidence rates should be set by each national programme keeping in mind the regional target of a 5 %-10 % reduction per year through to the year 2000. This is to achieve a 50 % reduction based on 1992 incidence. (8) Decisions about drugs and regimens to be used in health services should be guided primarily by the principle that effective treatment must be available so that severe malaria and death can be prevented. The main indicator is therapeutic efficacy. Although it is not possible
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to set an exact figure, when treatment failure rates reach 25" it is time to start considering whether a change may be necessafY. (9) Mothers make the important decisions about when and where a child gets treatment. They should therefore be the target of intensified health education progranunes that stress the signs and symptoms of malaria as well as proper treatment. . (10) Malaria control programmes should also provide education and treatment guidelines to private health care providers, especially in countries where a majority of patients seek treatment outside government health facilities. . (11) Insecticide-treated mosquito nets should continue to be an important part of preventive control strategies. It is essential that coverage and usage of nets be carefully monitored to ensure that they have a maximum impact on malaria transmission. When the aim is reduction of transmission, coverage with insecticide-treated nets should exceed 80% to be effective. (12) Individual and family use of treated nets should be encouraged, even if usage in the overall community is low. Pregnant women, infants and young children are priority groups for coverage. (13) Distribution and re-treatment of nets should be a collaborative effort involving both health workers and the community. There is a need for single treatment packets for net re-treatment. (14) Private organizations and nongovernmental organizations should be encouraged and supported to organize malaria control activities within their areas of responsibility. This may mean that control programmes provide such organizations with supplies, equipment and technical support. (15) External or extrabudgetafY support is available in the Region, and each national malaria control programme should be ready with a sensible and realistic plan of action that lists priority areas, the intervention measures to be taken and criteria for their application and evaluation. (16) Governments should take a clear stand to refuse unacceptable funding proposals that infringe on the effectiveness of control programmes or that are against national policy. (17) Microscope maintenance training is a recognized need throughout the Region. Successful training courses have already been held in Papua New Guinea and Solomon Islands but additional courses should be organized.
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ANNEXl
LIST OF PARTICIPANTS
1. TEMPORARY ADVISERS Mr Bernard Bakore'e Chief Antimalaria Officer Honiara Solomon Islands Dr Mey Bouth Denis Vice-Director National Malaria Centre Phnom Penh Cambodia Dr Ho Keong Bin Deputy Director Vector-Borne Diseases Control Programme Ministry of Health Kuala Lumpur Malaysia Dr Leonard I. Onega Medical Ofticer Chief Research Section Malaria Control Service Department of Health Manila Philippines Dr Khamliene Pholsena Director Institute of Malariology, Parasitology and Entomology Vientiane Lao People's Democratic Republic Mr George K. Taleo National Malaria Supervisor Department of Health Pon Vila Vanuatu
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Dr I.e Khanh Thuan Director Sub-Institute of Malariology. Parasitology and Entomology Ouinhon Viet Nam
2, WHO REPRESENTATIVE Dr G. Cuboni WHO Representative in the Socialist Republic of Viet Nam Hanoi Viet Nam
3, WHO MALARIA FIELD STAFF Dr S. Bjorge WHO Consultant/Malaria Honiara Solomon Islands Dr Jeffrey Hii WHO Consultant/Malaria Phnom Penh Cambodia Dr S. Hoyer Malaria Scientist Vientiane Lao People's Democratic Republic Dr K. \chimori Malaria Scientist Port Vila Vanuatu Dr M. Macdonald Malaria Scientist. Phnom Penh Cambodia I I
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I
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Annex
I
Dr K. Palmer Malaria Scientist Honiara Solomon Islands Dr J. Rozendaal Malaria Scientist Pon Moresby Papua New Guinea Dr A. Schapira Malaria Scientist Hanoi Viet Nam Dr R. Velayudhan Malaria Scientist Honiara Solomon Islands
4. SECRETARIAT Dr L.S. Self Malaria Adviser World Health Organization Regional Oftice tor the Western Pacitic Manila Philippines Dr Sima Huilan Director. Drug Policy. Environmental Health and Health Technology World Health Organization Regional Oftice for the Western Pacific Manila Philippines
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THE DETAILED PROGRAMME OF THE MALARIA MEETING ON INTENSIFIED CONTROL MEASURES MANILA, PHILIPPINES 24-27 OCTOBER 1995 Chairman: Dr Ho Keong Bin. Malaysia Vice-Chairman: Dr Mey Bouth Denis, Cambodia
Tuesday. 24 October 1995 OSOO - Registration
0900 0930
Opening Ceremony Coffee break .
1000 - Content and objectives of meeting
lOIS - Epidemiology: Indicators for monitoring and evaluation of control programmes 1100 - Detection of malaria parasites: with and without microscope 1200 Lunch break
\330 - Treatment and clinical diagnosis: Treatment policy. drug selection. drug resistance, clinical symptoms 1430 Coffee break
1500 - Treatment and clinical diagnosis (continuation) 1600 Informal get-together (hosted by Regional Director)
Wednesday. 25 October 1995 OSOO - Vector control: Residual sprays, insecticide-treated mosquito nets, other measures
0930 1000
Coffee break Management: Supervision, vehicles, tinancial aspects
1100 - Training: National courses, fellowships, intercountry collaboration 1200 Lunch break
1330 - Nongovernmental organizations and donor agencies: Role of NGOs and donors
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1430 1500
Coffee break Integration: Collaboration with other health programmes, new horizons in health
Thursday, 26 October 1995 0800 - Group Discussions: Operational constraints, ways to overcome constraints, achievable targets by end 1997, recommendations 0930 1000 Coffee break Discussions with the Regional Director
1200 - Lunch break . 1330 Continuation of group discussions
1430 - Coffee break 1500 - Continuation of group discussions Friday, 27 October 1995 0800 0930 1000 1200 1330 Presentation and !inalization of group discussions Coffee break Drafting of recommendations Lunch break Finalization of recommendations
1430 - Closing ceremony
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ANNEX 3
OPENING REMARKS OF THE REGIONAL DIRECTOR FOR THE MALARIA MEETING ON INTENSIFIED CONTROL MEASURES MANILA, 24-27 OCTOBER 1995
I am pleased to welcome all of you here to the Regional Office. The last time that most of us were together was in November 1993 at the opening of our malaria meeting in Kunming, China. Dunng that meetmg. we sat down with colleagues from the malarious countries of the South-East Asia Region to discuss common problems and to tormulate plans tor intensified malaria control strategies. An important outcome was that Regional targets were set for the year 2000. These were the reduction of malaria morbidity by 50% and mortality by 80% using 1992 figures as the base. At the time. those targets might have seemed to be overly optimistic. Today, there are some countries within the Region only two years later. that are well on the way to reaching them. On the other hand, there are other countries that have not yet put into place their revised malaria control plans. Two of the malarious countries in the southwest Pacitic have begun implementing intensified comrol programmes. V4Iluatu has made great progress towards its goal of covering the population of the entire country with insecticide-treated mosquito nets as part of its integrated control strategy. Solomon Islands has launched an innovative and aggressive programme to control malaria in Honiara and Guadalcanallsland. The intensitied plan of action tor 1995-1996 aims to reduce the incidence of malaria greatly. to improve the quality of life of the people. and to instill contidence that something can be done to overcome the burden of malaria. This approach. in line with the Region's move to implement the concepts of New horizons in health. retlects increased attention to muitisectoral and multidisciplinary approaches. and emphasizes that each person has the potential to make a long-term difterence in his or her own health status. In Cambodia. the malaria control programme is striving hard to implement field activities leading to reductions in deaths and sickness due to malaria. Malaysia has achieved good control in specitic areas, and on a countrywide basis has reduced the number of deaths due to malaria. Viet Nam has markedly reduced malaria mortality by the widespread use of the Chinese herbal plant Qinghaosu or artemisinin. Progress is being made in these countries but a lot more needs to be done. The problems that we face in the field are not mainly technical. We have a number of methods at our disposal that can be effective. when applied in the right place, at the right time in the technically correct manner. Our inability to meet the set goals is partly due to poor management of what resources we had. Programmes are top heavy with managers but weak in the tield where the work gets done. Field staff are often inadequately trained and poorly supervised. and more eft'or! is needed to overcome operational Held problems. A meaningful analYSis of mortality data has been difticult. One problem has been unreported malaria deaths. As the malaria infrastructure tor diagnosis and treatment in remote areas improves, detectable changes in preventing mortality may become apparent. In some situations. it may be easier to show gains in malaria control by analYSing mortality data as opposed to morbidity data. The people or communities themselves should understand the importance of prompt and adequate treatment of suspected malaria. especially for high-risk groups such as young children and pregnant women. I have brought you together here in the Western Pacific Regional Oftice for discussions and deliberations that will yield practical recommendations and plans which have a reasonable chance of being implemented. It would be better to have a short list of practical. action-oriented plans or
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Annex 3
recommendations rather than a long list retlecting various interests and viewpoints or a wish list of what would be ideal. Please give some attention to identifying specitic activities to be implemented under the 1996-1997 WHO regular budget allocation and also from extrabudgetary sources. Malaria is a complex disease requiring a simple control approach. The immediate goal is to achieve, at the country level, a reduction in the number of cases and deaths due to malaria. I am contident that with your continued etl'orts and dedication, this can be achieved. I also should mention that we are here to share information and learn from each other. which will be an important way of reinforcing our progress. I wish you all a successful meeting.
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