1. ADAPTIVE DESIGN OF URBAN MALARIA CONTROL PROGRAMS Marcia Caldas de Castro 1 Deo Mtasiwa 2 Burton Singer 1 Marcel Tanner 3 Juerg Utzinger 1 Yoichi Yamagata 4 1 Office of Population Research Princeton University 2 Dar es Salaam, Tanzania City Council 3 Swiss Tropical Institute 4 Japan International Cooperation Agency

2. i.Environmental management is the central focus, with several interventions/surveillance methods acting simultaneously. ii.Tuning the package of interventions to minimize the number of malaria cases per year is an adaptive process involving ongoing performance evaluation of each of the tools and the outcome measure (interventions are adjusted over time in response to these evaluations). CHARACTERISTICS OF SUCCESSFUL MALARIA CONTROL PROGRAMS

3. iii.3-5 years were required before a given package of interventions exhibited high level performance. iv.Diagnosis of malaria cases, anti-malarial drugs, bed-nets, and the use of chemical insecticides (following the discovery of DDT) were necessary but not sufficient (for success) components of the program. v.Program staff contained people knowledgeable about entomology, hydrology, epidemiology/ecology, and clinical aspects of malaria. vi.The implementation strategy, including the mix of tools employed, was highly idiosyncratic to the particular locality.

4. a) Roan Mine

5. A.Gambie and A.Funestus larval habitats  A.Gambie –Open and un-shaded natural or man-made pools of standing water, near rivers and tributaries –Open water tanks and nature wells loosely overgrown with grass  A. Funestus –Shaded banks of rivers and tributaries –Swamps and flooded areas with partial shade

6. Biting pattern

7. Reduction of Average Monthly Malaria Rate and Total Malaria Cases after the Implementation of Malaria Control Program - (1930-1933)

8. Average Monthly Malaria Incidence Rate and Annual Malaria Cases at the Roan Antelope Mine between 1944 and 1949

9. b) Nkana Kitwe Mine

10. Reduction of Malaria Incidence at Nkana-Kitwe Mine between 1935-1943

11. Reduction of Malaria Incidence at Nkana Mine between 1944-1950

12. Malaria, Rainfall, and Anopheles Statistics at the Roan Antelope Mine between 1944-1949

13. Urban Malaria: Dar es Salaam, Tanzania

14. Dar es Salaam Africa Area Study

15. Urbanization in Dar es Salaam Source: http://mshand.geog.gla.ac.uk/DAR/Tanzania.htm

16. - Land Use - Vegetable Production Source: http://www.cityfarmer.org/daressalaam.html

17. History of Malaria Control in Dar es Salaam 1902 - 1961 •1902-1912 – German Colonial Government Drainage, soil modification, bednets •1912-1918 – German ordinances for controlling breeding sites; proscribed urban agriculture (potatoes and other ridge-and-furrow type cultivation •1918-1961 – British Protectorate Continued drainage works, stronger legal measures  1920 – Sanitation Branch established East Africa Malaria Unit established  1951 – Tanganyika Malaria Service

18. History of Malaria Control in Dar es Salaam Post colonial period •1961+ – Urban mosquito control integrated into general health services •1971 – Integrated malaria control experiment Dar es Salaam City Council & WHO East Africa Aedes Research Unit •1980 – Reduction in size of central malaria control unit – Consequential to adverse economic conditions (1970s high inflation) •1988-1996 – JICA – Malaria control initiative Japan-Tanzania bilateral project

19. - Breeding Sites - Aerial Observation Misimbazi Creek

20. Breeding Sites - Aerial Observation Temeke

21. - Breeding Sites - Aerial Observation Regent State & Kijito-Nyama

22. Breeding Sites Malaria Risk Mapping Dar es Salaam, 1993

23. Breeding Sites Malaria Risk Mapping

27. Interventions Strategy Indoor Residual House Spraying (IRHS) and Larvicide Kisarawe Pagu Kajungeni Selected schools

28. Effect of Interventions - IRHS

29. Effect of Interventions - Larvicide

30. Effect of Interventions Both IRHS and larvicide X no intervention

31. Total Length of Drain Cleaned (cumulative - meters) Dar es Salaam Tanga

32. - Program Implementation - Based on successful programs in the past i.Environmental management is the central focus, with several interventions/surveillance methods acting simultaneously. ii.Tuning the package of interventions to minimize the number of malaria cases per year is an adaptive process involving ongoing performance evaluation of each of the tools and the outcome measure (interventions are adjusted over time in response to these evaluations).

33. iii.3-5 years were required before a given package of interventions exhibited high level performance. iv.Diagnosis of malaria cases, anti-malarial drugs, bed-nets, and the use of chemical insecticides (following the discovery of DDT) were necessary but not sufficient (for success) components of the program. v.Program staff contained people knowledgeable about entomology, hydrology, epidemiology/ecology, and clinical aspects of malaria. vi.The implementation strategy, including the mix of tools employed, was highly idiosyncratic to the particular locality.