Cost Effective Interventions For a Quick Fix in Malaria Elimination: The Katakwi Experience
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Transcript of Cost Effective Interventions For a Quick Fix in Malaria Elimination: The Katakwi Experience
Cost Effective Interventions For a Quick Fix in Malaria Elimination: The Katakwi Experience
Paper presented at : The UMA-UVA International One Health Conference
Dr. Lugemwa Myers (International Health Specialist)
14 th -16 th Feb, 2013Hotel Africana , Kampala
Presentation Format Malaria Epidemiology in Uganda
Burden of Disease
Move on Malaria (MoM) by PILGRIM
Approach to implementation of MoM
Results (Pre and Post intervention)
Recommendations
Global distribution of malaria
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MALARIA DURING THE 20TH CENTURY
Source: Reproduced from a presentation by Dr Andrew Kitua, National Institute for Medical Research, Tanzania
Burden of Malaria in Uganda
Malaria accounts for 26% of the burden of disease (BOD Uganda1995) and is responsible for:
One in every 3 persons + attending OPD (33%)
One in every 4 persons admitted in hospitals (25%)
One in every 5 child deaths in hospital (20%)
Over 40,000 child deaths in a year or 140 deaths every day
Severe anaemia in children/pregnancy ↑abortions, ↑low birth weight ↑MMR ↑IMR
Low -severe economic loss& productivity, lost school days, long term disability
Masindi
Nakasongola
Kasese
Hoima
KibaaleKiboga
Luwero
Apac
MukonoKAMPALA
MubendeKabarole
Nebbi
Arua
Gulu
Adjumani
Kabale
Mbarara
Rakai
Sembabule
Masaka
Kalangala
Jinja
Iganga
Busia
Mbale
Tororo
Kapchorwa
Pallisa
Kumi
Katakwi
Moroto
Kotido
Kitgum
Soroti
Lira
Mpigi
Bushenyi
Rukungiri
Kamuli
Ntungamo
Moyo
Kamwenge
Kyenjojo
Kayunga
Kanungu
Yumbe
Pader
Sironko
Nakapiripirit
Kaberamaido
Bugiri
Mayuge
Waikiso
Kisoro Transmission Levelvery high
medium- high
low
very low or no malaria
<1
<1
4
93
7
6
287
1,564
591
393
Estimated Entomologic Infective Rate
(EIR)
Apac district has the highest EIR globally
Move on Malaria Program (MoM):
Background:
Joint effort of Pilgrim, MCP/MoH & Local District Admin. against malaria in Teso sub region
Attempt to eliminate malaria in 3-5 yrs. Design: to eliminate not to control malaria. It draws and improves on lessons from previous MoH interventions
Targets 7 districts – Katakwi, Amuria, Kumi, Bukedea, Kaberamaido, Pallisa, Soroti.
Population targeted approx 2.0 million in north-eastern Uganda
Strategy was integrated – Vector control and parasite elimination
A response to - endemic malaria and effects of 2007 floods
Launched April 2008 by Hon. Dr. S. Mallinga, MoH.
Justification for MoM: 1 High malaria incidence:
Effects of malaria:○ High morbidity/mortality
Poverty in the region: ○ High levels of poverty in the region by Ugandan Standards for
long periods
Effects of war:○ Damage to/loss of infrastructure (social, economic, moral)○ Increased poverty○ Loss of investment environment – increased deprivation of
opportunities
Geographic features favorable to mosquito breeding
Justification for MoM: 2
Epidemiological survey results on levels of malaria prevalence in age groups in Katakwi (July 2008)
○ Mean 35% general prevalence (12%-85%)○ Mean 47% for kids <15 yrs (Range 25%-85%)○ 15 % for those above >16 yrs (30-55%)○ 3,500 cases of malaria reported weekly in health centers
MOM in line with MoH’s strategic plan for Malaria
Need for an intervention:○ to halt debilitation and carnage from malaria ○ reverse onslaught of malaria, ○ eliminate malaria in 3-5 yrs from Teso Sub-region
Long Term Objective:
“Contribute to elimination of malaria in Uganda through integrated multi-
pronged interventions of vector control and case management in the Teso sub
region”
Malaria and Poverty or Poverty and Malaria ?
POVERTY
MALARIA
Main Objectives of MOM:
O.1: IRS to be carried out in at least 85% of the households in the
Teso sub-region.
O.2: Course of anti-malarial medication to be received by at least
85% of children between the ages of 4 months and 15 years,
regardless of presence or absence of parasitemia (mass drug
administration (MDA))
O.3: Course of anti-malarial treatment to be received by 85% of
population above 15 years found to have parasitemia on RDT
O.4: IPTp to at least 85% of the PW in the Teso population.
Mosquitoes and Malaria : From man to mosquito &vice versa
Malaria parasite life cycle Anopheles Mosquitoe
Strategic Integrated Interventions:
STRATEGY: Integrated malaria interventions to break transmission, infection and morbidity of malaria (Elimination not Control focusing on both vector and parasite)
Break Parasite Transmission - Vector Control IRS for all human residences ITNs/LLINs – 3 per household (where funds allow)
Stop/Limit Infection/Morbidity - Case Management …MDA Management of severe malaria Mass Treatment of Infected persons with ACTs (Arco & Duo
Cotexcin)(pre-morbid stage) Intermittent Treatment of malaria in pregnancy (IPTp).
Mobilize population to fight malaria Information - technical/social facts about malaria –BCC/IEC
Field activities (IRS+”MDA” commenced 02/11/08)
Entomological Survey Conducted prior to commencement of program including Bio
assays Standard WHOPES techniques used
Epidemiological Survey Baseline data collection from both community and HFs
conducted prior to commencement of program Trained HWs on use of RDTs Examined all spray persons prior to engagement
Program Components
System for supply of logistics, insecticide and equipment established
Trained and deployed 300 spray operators and wash persons
All spray personnel underwent medical exam for fitness and a sample of bio-specimens tested for traces of insecticide
Environmental monitoring conducted to assess compliance with set standards
Case detection in Above 5 &Rx and mass Rx in the Under 5yr olds +IRS
RESULTS of interventions:
Vector Control Planned to spray 64,400 h/h, achieved 55,900 h/h (87%) Planned to protect 147,900 people, achieved 172,260 (110%) Desired to distribute ITNs for children <5yrs & pregnant
mothers – not covered
Case Management Planned to provide 520 doses of IPTp, achieved 750 (144%) Planned to treat/manage 85% cases of severe malaria,
achieved 3,436 cases (100%) Planned MDA of 4 months - <15 yrs against malaria, achieved
64,513 (89%) Planned MST among >16 yrs olds. Tested 24,419 and
treated 3,446 +ves (100%) seen
Jan Feb Mar April May Jun Jul Aug Sept Oct Nov Dec
2006 6939 6932 6356 8532 7734 5815
2007 6183 5410 6100 5128 6251 5856 7486 6269 4561 8311 8803 4560
2008 5477 6827 5983 7643 8903 11351 13968 7590 7558 8100 8469 3582
2009 1957 1214 1952 1594 5136
0
2000
4000
6000
8000
10000
12000
14000
16000
Mal
aria
Rep
ort
ed C
ases
Months
Malaria OPD Trends in Katakwi (Jun 2006 - May 2009)
2006
2007
2008
2009
Oct -Nov. 2008 MOM Implementation
Weekly Malaria cases (Pre & 6 months after intervention)Note the dramatic decline(90%) in cases after IRS + “MDA”
Impact of MOM in Katakwi:
More accurate and professional diagnosis of malaria using RDTs from MOH
Ninety two (92)% reduction in reported cases of malaria at community level (from 47%-4.9%)
Ninety (90) % reduction of OPD attendance in HFs
Decongestions of health centers and reduced workload among health workers in the district
Increased knowledge of ICON CS10% efficacy against malaria causing mosquitoes through bio assay
Increased hope, confidence and expectation of better conditions among the population
Baseline epidemiological tests in children outside their home
Case finding in the above 16 year olds and treatment and MDA in the under 16 near one of the typical village habitats
An enthusiastic woman taking a spray person to spray her houseNote the empty pediatric ward at Katakwi HCIV after IRS+”Chemotherapy”
Community sensitization before MOM with IRS+”Chemotherapy”
Dr. Myers from MoH and Pilgrim officials addressing members of one of the villages in Katakwi on the objectives of the intervention.
Immunization, De-worming, IPTi, Vit A supplement, causes and prevention of malaria featured during the sensitization
Disease Elimination: What will it take? Resources:
Resources for all the activities by MOM were raised from various donors - Three Loaves Fund - >$ 900,000 GoU NMCP/MOH - >$ 25,000 World Concern & Agathos Foundation - >$ 400,000 International Mid Wives Association - - >$ 40,000 Katakwi Local Govt - >$ in kind
Malaria activities cost US$ 0.5 m !!! US$0.5m x112=US$ 66m (Equivalent to UgX180b) vs US$ 658m
lost p.a
From malaria control to From malaria control to eliminationelimination
Summary and Conclusion:
By integrating IRS, Case mgt.& general drug admin, Pilgrim piloted the impact of integrated approaches to the fight against malaria
Integrated approaches, implemented effectively and efficiently, may be the answer to malaria elimination and eradication
Preliminary results show rapid decline in mosquito population/bites and in malaria cases at OPDs of clinics in Katakwi (over 90%)
Malaria can be eradicated quicker than we all thought!
Isaiah Chapter 33:34“ And the inhabitants* shall not say, I am sick, the people that dwell
therein shall be forgiven their inequity*”
Koran: Sula 5: When you treat one person, you treat the whole nation.
THANK YOU FOR LISTENING