Transcript No Slide Title - Save the Children

Malaria Control in Emergencies
Source: Wirtz, CDC
Leading Causes of Childhood
Deaths
Source: WHO estimates of the causes of death in children,
2000-03 Bryce, Lancet, 26 March 2005
Major Causes of Death
in emergencies for <5 Years
Somalia: Gedo Region
7 Camps, January, 1980
Sudan: Wad Kowli Camp
February, 1985
Measles
ARI
Malaria
Diarrhea
Other
Source: Centers for Disease Control and Prevention, Famine-Affected, Refugee, and Displaced
Populations: Recommendations for Public Health Issues. MMWR, 1992;41(No. RR-13):8.
Background

Malaria is a parasitic disease caused by
one of four protozoan parasites:

Plasmodium falciparum (most severe and
life-threatening) vivax, ovale, malariae

300-500 million clinical cases/year

Over 1 million deaths/year:

90% in sub-Saharan Africa
Background: II

Complicated transmission requiring
correct conditions for the vector, host,
climate

Physiologically most vulnerable:
 Children less than five years old
 Pregnant women
Background: III

Marked antimalarial drug and
insecticide resistance rates:
Few drugs available
 Available drugs costly and often have
complicated dosing regimens


Years of vaccine research have
produced few hopeful candidate
vaccines
Vector: Female Anopheles

Parasite enters
human host when
an infected
mosquito takes a
blood meal:

Bites at night (6 PM
to 6 AM)

May rest indoors or
outdoors
Transmission Cycle
Parasites multiply in human liver and
bloodstream, causing fever & chills
Human
Infected mosquito bites
Mosquito bites infected
person
person
Mosquito
Parasites multiply in mosquito gut and
migrate to salivary gland
Adapted from RBM ‘What is Malaria?’ Infosheet
Burden of Malaria in
Emergencies

Estimates of population of concern are
underestimated

2/3 of the 21 million people of concern to
UNHCR live in malaria endemic areas

WHO estimates 30% of malaria deaths
in Africa occur in wake of war, local
violence or other emergencies
Vulnerable Populations

Groups marginalized politically or socially


Groups unable to access limited resources:


Southeast Asia- populations living on the borders
Physically/mentally disabled, unaccompanied
minors, elderly, those with other illnesses or
weakness
Groups isolated from humanitarian efforts:

Fleeing Goma, Bukavu into central forest of DRC in
1987
Distribution of Malaria
Refugee and Asylum Seekers / IDP Movement
Factors Associated with Increased
Risk of Malaria


No or poor housing
Location of camps/settlements often not planned
well






Placing camp in well known flood plain (e.g., TZ)
Deliberate movement to areas near water
Overcrowding
Proximity of livestock
Mobility: may have limited contact with health
facilities
Compromised immune status
Factors II:
Control strategies used in stable, non
emergency setting need to be adapted

May create political difficulties:
Drug policies in host country may not be current
 Changing national malaria treatment guidelines
is a laborious process:




Time is insufficient for this process
Needed drugs may not yet be registered for use in the
host country and may be unfamiliar to workers who
need to use them
Need to think of “refugee affected” area and
impact on host/national population
Malaria Control Objectives

Enhance overall case management:




Promote use of laboratory-based diagnosis (both
microscopy and rapid diagnostic tests [RDTs])
Implement treatment guidelines that use highly effective
malaria drugs
Understand treatment seeking behaviors of targeted
populations
Improve access to and utilization of effective
malaria prevention interventions:


Use appropriate vector control measures
Ensure access to those at increased risk of malaria
(pregnant women, infants, non-immunes)
Objectives: II

Increase and improve knowledge, skills and
practice related to malaria control:
Focus on partner organization personnel, as well
as community
 Ensure effective communication and
coordination among all involved agencies


Promote beneficiary participation in malaria
control programmes:

Engage refugee communities as partners from
the beginning of a project through its duration
Objectives: III

Reinforce surveillance and monitoring and
evaluation of malaria control programmes:
Develop a standardized, minimum set of
indicators to be used for surveillance
 Establish systems to monitor implementation of
control interventions: use standardized data
collection tools and case definitions
 Use evaluations and assessments to compile
“lessons learned” and identify “best practices”

Initial Assessment

Malaria risk within host country:



Surveillance patterns:




Ongoing malaria control activities of host area
Climatic conditions
Establishing actual numbers of cases
Multiple systems of surveillance?
Differing versions of case definition: what are you
measuring – febrile illness or malaria?
Efficacy of current treatment guidelines:


Used at the camp
National or regional data
Assessing the risk
Resettlement area
Local malaria situation is clearly defined
No
Yes
Endemic region
Non-endemic region
Immune status of refugees
Little or No
immunity
All age groups are at
risk
Coming from
endemic areas
People not at risk of
malaria. Region could be
prone to malaria
outbreaks
Children and pregnant
women are at risk
Rapid Epi
investigation
needed
Health Clinics in Established
Camps
Source: Rutta, Norwegian People’s Aid, Ngara, TZ 2003
Source: Manya, Kenyan MoH, Dadaab, Kenya May 2006
Phases of Emergencies

Emergency Phase:

Focus on decreasing morbidity and mortality
through prompt access to effective treatment
with artemisinin-based combination therapy

If feasible, supplement with prevention, targeting
groups at highest risk of severe malaria and
death
Source: UNHCR Strategic Plan for Malaria Control 2005-7
Phases II

Stabilization phase:
Sustainability
 Institute community vector-control strategies
achieving high coverage:

60% of population with insecticide-treated materials
(ITMs)
 85% shelters with indoor residual spraying (IRS)


Intermittent Preventive Therapy (IPTp)
Source:UNHCR Strategic Plan for Malaria Control 2005-7
Phases III

Returnee settings:
Rehabilitation and reconstruction efforts should
focus on effective malaria treatment and highcoverage community prevention
 Should have equivalent access to services as
that of local populations
 Offer long-lasting insecticide-treated nets (ITNs)
as part of repatriation package and adequate
health education during pre-departure and transit

Source:UNHCR Strategic Plan for Malaria Control 2005-7
http://www.unhcr.org/protect/PROTECTION/456ac23a2.pdf
Challenges to malaria control in
Emergencies


Increased vulnerability of displaced
populations – i.e. malnutrition
Increased risk of epidemics - movement of
non-immunes to high malaria transmission
areas
Source: BBC News, Darfur
refugees coming into Chad, 2006
Housing
Source: Caux, UNHCR, Goz Bieda, Chad, 2006
Source: Manya, Kenyan MoH, Hagadera, Kenya, 2006
Source: Bloland, CDC, Dadaab, Kenya, 2005
Source: Manya, Kenyan MoH, Kakuma, Kenya, 2006
Environmental Degradation
Source: Bloland, CDC, Kibondo, TZ
1998
Potential Breeding
Sites
Source: Manya, Kenyan MoH, Dadaab, Kenya, 2006
Challenges: II

Breakdown of health services or existing
health facilities overwhelmed:

Appropriate response beyond local/national
capacity

Unstable government or no government

Ongoing conflict, insecurity - long term
planning difficult (e.g. Southern Sudan)
Challenges: III

Many partners - UN organizations, NGOs
responsible for providing health services
with local/national authorities:

Often, poor or no inter-agency communication

Lack of technical knowledge of malaria
among operational agencies

Physical and transport barriers - delays in
access to supplies
Challenges: IV

Security concerns prevent consistency

Operational research - many gaps in
knowledge, few funds available

Lack of data on malaria burden in
emergencies

Lack of information on drug or insecticide
resistance
Clinical Diagnosis



Common approach for diagnosis in
endemic countries
Current or recent history of malaria =
fever
Sensitive, but results in over-diagnosis
and over-treatment:
Increased drug pressure, which enhances
likelihood of developing antimalarial drug
resistance
 Adverse drug reactions
 Increased cost
 Misdiagnosis of non-malarial fever

Diagnostics
Low to Moderate
Transmission
Prompt parasitological
confirmation of diagnosis
recommended before treatment
High Stable Transmission
Probability of fever caused by
malaria high in children under age 5
– treat with clinical diagnosis.
Older children/adults (pregnant
women) obtain parasitological
diagnosis before treatment
Suspected severe malaria:
parasitological confirmation if available,
if not, treat on clinical grounds
Microscopy

Considered gold
standard for
diagnostics:


Can identify species and
level of parasitemia
Often not used in
emergencies



overwhelming load of
patients
lack of electricity
inadequate
supplies/training
Credit: Wirtz, CDC, TZ, 2006
Rapid Diagnostic Tests (RDTs)






Detect specific antigens
(proteins) produced by
malaria parasites
Rapid, easy to use,
results in 20 minutes
Cost ~ $0.70
Prone to deterioration
through heat and humidity
Difficult to see results in
situations of low
parasitemia
Late readings
Credit: R Gerrets, NYU, Mukuranga, TZ,
2005
Case Management

Gold standard for treatment of uncomplicated
malaria is an artemisinin-based combination
therapy (ACT):

New Emergency Health Kit (NCHK) contains
Artemether/Lumefantrine co-formulated in a
single tab (Coartem®):


Requires fatty food with dose
Other combinations available:
Sulfadoxine-pyrimethamine (SP) and Amodiaquine
(AQ)
 Artesunate (AS) with SP
 AS/AQ (co-formulated, single dose, “Coarsucam”)

Severe Malaria

Pre-referral therapy: artesunate
suppositories

Requires rapid referral to in-patient unit

Quinine (QN) drug of choice but requires a
higher level of care:

Kakuma 2007 outbreak: insufficient skills in inpatient unit to use QN loading dose as
recommended
Intermittent Preventive
Therapy (IPT)
Pregnant women at higher risk
severe maternal anemia, maternal death, low birth
weight and higher infant mortality rates
 IPTp recommends at least two doses of SP (targets
ANC visits):



Monthly doses - HIV+ women
Requires good record keeping
Infants (IPTi):
A few trials with promising results
 Not currently recommended but may be promising
intervention

Insecticide Treated Nets
(ITNs)






Individual-level protection
Community-level protection
Portable
Requires re-treatment every
6 months unless long-lasting
ITNs used (LLITNs)
Can target most vulnerable
populations in areas of high
transmission
Disadvantages: expensive
start-up costs, need
distribution strategy, high
level of resale, retreatment
requirements, incorrect use
Credit: Williams, CDC, Kakuma, Kenya,
Jan 20006
Indoor Residual Spraying
(IRS)
Logistically feasible
 Target specific areas
where malaria is
unstable
 Community level effect
requires 85%
coverage
 Timing important
 Every six months
 Resistance increasing
 Should pre-stock
materials

Credit: Wirtz, CDC, Lugufu, TZ, 2006
Other Preventive Measures

Insecticide treated clothing, top sheets and
blankets: Afghan camps

Hammock nets: Cambodia and Vietnam

Larviciding: works best when breeding sites
are limited and relatively permanent

Aerosol spraying: not generally
recommended
Insecticide Treated Plastic
Sheeting (ITPS)

Insecticide treated plastic sheeting (ITPS):
Combined shelter and malaria control tool
 Major effect on mosquito mortality in trials:



Mode of action and efficacy more closely
resembles IRS than ITNs:


Proportion killed depended on surface area covered
Confers limited personal protection inside home but,
applied at community level, works as a control by
decreasing mosquito longevity
Currently at trial level
Current Issues

Which interventions can be targeted to
those most in need: IRS versus ITNs?

Cost-effectiveness of strategies

Chronic shortages of food and non-food
item distribution: impact on resale of ITNs
Current Issues: II

Substandard medications

Overall, lack of effective monitoring and
evaluation in malaria control
Thank You!
Credit: O’Reilly, CDC, Kibondo, TZ, 2006