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Malaria Control in Emergencies Source: Wirtz, CDC.

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Presentation on theme: "Malaria Control in Emergencies Source: Wirtz, CDC."— Presentation transcript:

1 Malaria Control in Emergencies Source: Wirtz, CDC

2 Leading Causes of Childhood Deaths Source: WHO estimates of the causes of death in children, Bryce, Lancet, 26 March 2005

3 Major Causes of Death in emergencies for <5 Years Sudan: Wad Kowli Camp February, 1985 Somalia: Gedo Region 7 Camps, January, 1980 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. Measles ARI Malaria Diarrhea Other

4 Background Malaria is a parasitic disease caused by one of four protozoan parasites: Malaria is a parasitic disease caused by one of four protozoan parasites: Plasmodium falciparum (most severe and life-threatening) vivax, ovale, malariae Plasmodium falciparum (most severe and life-threatening) vivax, ovale, malariae million clinical cases/year million clinical cases/year Over 1 million deaths/year: Over 1 million deaths/year: 90% in sub-Saharan Africa 90% in sub-Saharan Africa

5 Background: II Complicated transmission requiring correct conditions for the vector, host, climate Complicated transmission requiring correct conditions for the vector, host, climate Physiologically most vulnerable: Physiologically most vulnerable: Children less than five years old Children less than five years old Pregnant women Pregnant women

6 Background: III Marked antimalarial drug and insecticide resistance rates: Marked antimalarial drug and insecticide resistance rates: Few drugs available Few drugs available Available drugs costly and often have complicated dosing regimens Available drugs costly and often have complicated dosing regimens Years of vaccine research have produced few hopeful candidate vaccines Years of vaccine research have produced few hopeful candidate vaccines

7 Vector: Female Anopheles Parasite enters human host when an infected mosquito takes a blood meal: Parasite enters human host when an infected mosquito takes a blood meal: Bites at night (6 PM to 6 AM) Bites at night (6 PM to 6 AM) May rest indoors or outdoors May rest indoors or outdoors

8 Human Mosquito Mosquito bites infected person Parasites multiply in mosquito gut and migrate to salivary gland Parasites multiply in human liver and bloodstream, causing fever & chills Infected mosquito bites person Transmission Cycle Adapted from RBM ‘What is Malaria?’ Infosheet

9 Burden of Malaria in Emergencies Estimates of population of concern are underestimated Estimates of population of concern are underestimated 2/3 of the 21 million people of concern to UNHCR live in malaria endemic areas 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 WHO estimates 30% of malaria deaths in Africa occur in wake of war, local violence or other emergencies

10 Vulnerable Populations Groups marginalized politically or socially Groups marginalized politically or socially Southeast Asia- populations living on the borders Southeast Asia- populations living on the borders Groups unable to access limited resources: Groups unable to access limited resources: Physically/mentally disabled, unaccompanied minors, elderly, those with other illnesses or weakness Physically/mentally disabled, unaccompanied minors, elderly, those with other illnesses or weakness Groups isolated from humanitarian efforts: Groups isolated from humanitarian efforts: Fleeing Goma, Bukavu into central forest of DRC in 1987 Fleeing Goma, Bukavu into central forest of DRC in 1987

11 Distribution of Malaria Refugee and Asylum Seekers / IDP Movement

12 Factors Associated with Increased Risk of Malaria No or poor housing No or poor housing Location of camps/settlements often not planned well Location of camps/settlements often not planned well Placing camp in well known flood plain (e.g., TZ) Placing camp in well known flood plain (e.g., TZ) Deliberate movement to areas near water Deliberate movement to areas near water Overcrowding Overcrowding Proximity of livestock Proximity of livestock Mobility: may have limited contact with health facilities Mobility: may have limited contact with health facilities Compromised immune status Compromised immune status

13 Factors II: Control strategies used in stable, non emergency setting need to be adapted May create political difficulties: May create political difficulties: Drug policies in host country may not be current Drug policies in host country may not be current Changing national malaria treatment guidelines is a laborious process: Changing national malaria treatment guidelines is a laborious process: Time is insufficient for this 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 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 Need to think of “refugee affected” area and impact on host/national population

14 Malaria Control Objectives Enhance overall case management: Enhance overall case management: Promote use of laboratory-based diagnosis (both microscopy and rapid diagnostic tests [RDTs]) Promote use of laboratory-based diagnosis (both microscopy and rapid diagnostic tests [RDTs]) Implement treatment guidelines that use highly effective malaria drugs Implement treatment guidelines that use highly effective malaria drugs Understand treatment seeking behaviors of targeted populations Understand treatment seeking behaviors of targeted populations Improve access to and utilization of effective malaria prevention interventions: Improve access to and utilization of effective malaria prevention interventions: Use appropriate vector control measures Use appropriate vector control measures Ensure access to those at increased risk of malaria (pregnant women, infants, non-immunes) Ensure access to those at increased risk of malaria (pregnant women, infants, non-immunes)

15 Objectives: II Increase and improve knowledge, skills and practice related to malaria control: Increase and improve knowledge, skills and practice related to malaria control: Focus on partner organization personnel, as well as community Focus on partner organization personnel, as well as community Ensure effective communication and coordination among all involved agencies Ensure effective communication and coordination among all involved agencies Promote beneficiary participation in malaria control programmes: Promote beneficiary participation in malaria control programmes: Engage refugee communities as partners from the beginning of a project through its duration Engage refugee communities as partners from the beginning of a project through its duration

16 Objectives: III Reinforce surveillance and monitoring and evaluation of malaria control programmes: Reinforce surveillance and monitoring and evaluation of malaria control programmes: Develop a standardized, minimum set of indicators to be used for surveillance 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 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” Use evaluations and assessments to compile “lessons learned” and identify “best practices”

17 Initial Assessment Malaria risk within host country: Malaria risk within host country: Ongoing malaria control activities of host area Ongoing malaria control activities of host area Climatic conditions Climatic conditions Surveillance patterns: Surveillance patterns: Establishing actual numbers of cases Establishing actual numbers of cases Multiple systems of surveillance? Multiple systems of surveillance? Differing versions of case definition: what are you measuring – febrile illness or malaria? Differing versions of case definition: what are you measuring – febrile illness or malaria? Efficacy of current treatment guidelines: Efficacy of current treatment guidelines: Used at the camp Used at the camp National or regional data National or regional data

18 Assessing the risk Resettlement area Local malaria situation is clearly defined Yes Endemic region No Rapid Epi investigation needed Non-endemic region People not at risk of malaria. Region could be prone to malaria outbreaks Immune status of refugees Little or No immunity Coming from endemic areas All age groups are at risk Children and pregnant women are at risk

19 Source: Rutta, Norwegian People’s Aid, Ngara, TZ 2003 Health Clinics in Established Camps Source: Manya, Kenyan MoH, Dadaab, Kenya May 2006

20 Phases of Emergencies Emergency Phase: Emergency Phase: Focus on decreasing morbidity and mortality through prompt access to effective treatment with artemisinin-based combination therapy 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 If feasible, supplement with prevention, targeting groups at highest risk of severe malaria and death Source: UNHCR Strategic Plan for Malaria Control

21 Phases II Stabilization phase: Stabilization phase: Sustainability Sustainability Institute community vector-control strategies achieving high coverage: Institute community vector-control strategies achieving high coverage: 60% of population with insecticide-treated materials (ITMs) 60% of population with insecticide-treated materials (ITMs) 85% shelters with indoor residual spraying (IRS) 85% shelters with indoor residual spraying (IRS) Intermittent Preventive Therapy (IPTp) Intermittent Preventive Therapy (IPTp) Source:UNHCR Strategic Plan for Malaria Control

22 Phases III Returnee settings: Returnee settings: Rehabilitation and reconstruction efforts should focus on effective malaria treatment and high- coverage community prevention Rehabilitation and reconstruction efforts should focus on effective malaria treatment and high- coverage community prevention Should have equivalent access to services as that of local populations 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 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

23 Challenges to malaria control in Emergencies Increased vulnerability of displaced populations – i.e. malnutrition Increased vulnerability of displaced populations – i.e. malnutrition Increased risk of epidemics - movement of non-immunes to high malaria transmission areas Increased risk of epidemics - movement of non-immunes to high malaria transmission areas Source: BBC News, Darfur refugees coming into Chad, 2006

24 Housing Source: Bloland, CDC, Dadaab, Kenya, 2005 Source: Caux, UNHCR, Goz Bieda, Chad, 2006 Source: Manya, Kenyan MoH, Kakuma, Kenya, 2006Source: Manya, Kenyan MoH, Hagadera, Kenya, 2006

25 Potential Breeding Sites Source: Bloland, CDC, Kibondo, TZ 1998 Source: Manya, Kenyan MoH, Dadaab, Kenya, 2006 Environmental Degradation

26 Challenges: II Breakdown of health services or existing health facilities overwhelmed: Breakdown of health services or existing health facilities overwhelmed: Appropriate response beyond local/national capacity Appropriate response beyond local/national capacity Unstable government or no government Unstable government or no government Ongoing conflict, insecurity - long term planning difficult (e.g. Southern Sudan) Ongoing conflict, insecurity - long term planning difficult (e.g. Southern Sudan)

27 Challenges: III Many partners - UN organizations, NGOs responsible for providing health services with local/national authorities: Many partners - UN organizations, NGOs responsible for providing health services with local/national authorities: Often, poor or no inter-agency communication Often, poor or no inter-agency communication Lack of technical knowledge of malaria among operational agencies Lack of technical knowledge of malaria among operational agencies Physical and transport barriers - delays in access to supplies Physical and transport barriers - delays in access to supplies

28 Security concerns prevent consistency Security concerns prevent consistency Operational research - many gaps in knowledge, few funds available Operational research - many gaps in knowledge, few funds available Lack of data on malaria burden in emergencies Lack of data on malaria burden in emergencies Lack of information on drug or insecticide resistance Lack of information on drug or insecticide resistance Challenges: IV

29 Clinical Diagnosis Common approach for diagnosis in endemic countries Common approach for diagnosis in endemic countries Current or recent history of malaria = fever Current or recent history of malaria = fever Sensitive, but results in over-diagnosis and over-treatment: Sensitive, but results in over-diagnosis and over-treatment: Increased drug pressure, which enhances likelihood of developing antimalarial drug resistance Increased drug pressure, which enhances likelihood of developing antimalarial drug resistance Adverse drug reactions Adverse drug reactions Increased cost Increased cost Misdiagnosis of non-malarial fever Misdiagnosis of non-malarial fever

30 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

31 Microscopy Considered gold standard for diagnostics: Considered gold standard for diagnostics: Can identify species and level of parasitemia Can identify species and level of parasitemia Often not used in emergencies Often not used in emergencies overwhelming load of patients overwhelming load of patients lack of electricity lack of electricity inadequate supplies/training inadequate supplies/training Credit: Wirtz, CDC, TZ, 2006

32 Rapid Diagnostic Tests (RDTs) Detect specific antigens (proteins) produced by malaria parasites Detect specific antigens (proteins) produced by malaria parasites Rapid, easy to use, results in 20 minutes Rapid, easy to use, results in 20 minutes Cost ~ $0.70 Cost ~ $0.70 Prone to deterioration through heat and humidity Prone to deterioration through heat and humidity Difficult to see results in situations of low parasitemia Difficult to see results in situations of low parasitemia Late readings Late readings Credit: R Gerrets, NYU, Mukuranga, TZ, 2005

33 Case Management Gold standard for treatment of uncomplicated malaria is an artemisinin-based combination therapy (ACT): 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®): New Emergency Health Kit (NCHK) contains Artemether/Lumefantrine co-formulated in a single tab (Coartem®): Requires fatty food with dose Requires fatty food with dose Other combinations available: Other combinations available: Sulfadoxine-pyrimethamine (SP) and Amodiaquine (AQ) Sulfadoxine-pyrimethamine (SP) and Amodiaquine (AQ) Artesunate (AS) with SP Artesunate (AS) with SP AS/AQ (co-formulated, single dose, “Coarsucam”) AS/AQ (co-formulated, single dose, “Coarsucam”)

34 Severe Malaria Pre-referral therapy: artesunate suppositories Pre-referral therapy: artesunate suppositories Requires rapid referral to in-patient unit Requires rapid referral to in-patient unit Quinine (QN) drug of choice but requires a higher level of care: Quinine (QN) drug of choice but requires a higher level of care: Kakuma 2007 outbreak: insufficient skills in in- patient unit to use QN loading dose as recommended Kakuma 2007 outbreak: insufficient skills in in- patient unit to use QN loading dose as recommended

35 Intermittent Preventive Therapy (IPT) Pregnant women at higher risk severe maternal anemia, maternal death, low birth weight and higher infant mortality rates severe maternal anemia, maternal death, low birth weight and higher infant mortality rates IPTp recommends at least two doses of SP (targets ANC visits): IPTp recommends at least two doses of SP (targets ANC visits): Monthly doses - HIV+ women Monthly doses - HIV+ women Requires good record keeping Requires good record keeping Infants (IPTi): A few trials with promising results A few trials with promising results Not currently recommended but may be promising intervention Not currently recommended but may be promising intervention

36 Insecticide Treated Nets (ITNs) Individual-level protection Individual-level protection Community-level protection Community-level protection Portable Portable Requires re-treatment every 6 months unless long-lasting ITNs used (LLITNs) Requires re-treatment every 6 months unless long-lasting ITNs used (LLITNs) Can target most vulnerable populations in areas of high transmission 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 Disadvantages: expensive start-up costs, need distribution strategy, high level of resale, retreatment requirements, incorrect use Credit: Williams, CDC, Kakuma, Kenya, Jan 20006

37 Indoor Residual Spraying (IRS) Logistically feasible Logistically feasible Target specific areas where malaria is unstable Target specific areas where malaria is unstable Community level effect requires 85% coverage Community level effect requires 85% coverage Timing important Timing important Every six months Every six months Resistance increasing Resistance increasing Should pre-stock materials Should pre-stock materials Credit: Wirtz, CDC, Lugufu, TZ, 2006

38 Other Preventive Measures Insecticide treated clothing, top sheets and blankets: Afghan camps Insecticide treated clothing, top sheets and blankets: Afghan camps Hammock nets: Cambodia and Vietnam Hammock nets: Cambodia and Vietnam Larviciding: works best when breeding sites are limited and relatively permanent Larviciding: works best when breeding sites are limited and relatively permanent Aerosol spraying: not generally recommended Aerosol spraying: not generally recommended

39 Insecticide Treated Plastic Sheeting (ITPS) Insecticide treated plastic sheeting (ITPS): Insecticide treated plastic sheeting (ITPS): Combined shelter and malaria control tool Combined shelter and malaria control tool Major effect on mosquito mortality in trials: Major effect on mosquito mortality in trials: Proportion killed depended on surface area covered Proportion killed depended on surface area covered Mode of action and efficacy more closely resembles IRS than ITNs: Mode of action and efficacy more closely resembles IRS than ITNs: Confers limited personal protection inside home but, applied at community level, works as a control by decreasing mosquito longevity Confers limited personal protection inside home but, applied at community level, works as a control by decreasing mosquito longevity Currently at trial level Currently at trial level

40 Current Issues Which interventions can be targeted to those most in need: IRS versus ITNs? Which interventions can be targeted to those most in need: IRS versus ITNs? Cost-effectiveness of strategies Cost-effectiveness of strategies Chronic shortages of food and non-food item distribution: impact on resale of ITNs Chronic shortages of food and non-food item distribution: impact on resale of ITNs

41 Current Issues: II Substandard medications Substandard medications Overall, lack of effective monitoring and evaluation in malaria control Overall, lack of effective monitoring and evaluation in malaria control

42 Thank You! Credit: O’Reilly, CDC, Kibondo, TZ, 2006

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