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RF_DIS_7_A_SUDHA.
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“ROLL BACK MALARIA” |
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STRATEGY PAPER
BHUTAN
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IM RODi ( ri()\ :
“Zb "a
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,he “S'- —
>U 1, by Arunanchal Pradesh S.kta and team & Wes. Benaa!
.Slates ot India respectively.
GeographicalE die o.imin •»
a mountaim
rugged terrain svstem
■\ uh verv limited avcessibiliP The climate
i' cold and snow bound in
the north gradual changing to warm and hot m the south. The north
and the south 1S joined bv rnam nvenne valiexs.
‘hC
1S diV’ded lnT° T"enly 20i
Administrative Division
J'K”
(DistncI’ Ea-h Ozongkiag ,s administrated In
'■’.'luda cqunaicni io j Governor
^ \1 aria ( OXTROL PROGRAMME
Then rhe Nanonal Malana Eradrcar™ Programme, n,» Maiana
O'ltro! logramme rs rhe hrsr programme to be rmplememed m rhe
ear, Senrees. h was started m 1962 Then ,t was Malana
Lrad,canon Programme and the Programme was a ven,cal
Zoo I"'’', o’' I)':CeD,ral,M,',’n
“> Ae earls etahties
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the Programme was reonenled Iron. Eradication to Control
attd gradually the Malaria Contra! was completely decentralised and
ah! dl
“n'rO1 aC,'',t,eS
’"KSratKi i",°
-—aI
team, del,ven ss stem. Now all the control act, vines are earned on. be
•he Dzongldtag (Dtstnct, Health Semces Thu Has been .mplemented
M T "T r“',>"’me"da"OnS made b' Ihe 'e-etdam Ministerial
■ elmg. Global Malana Control Strategy tbllowed by the Regional
or-mg roup Meeting on Implementation ol Revised Malana
Control Strategy. 1993
REVIEW OF MALARIA CONTROL A< TB IT1ES.
POPULATION AT RISK :
More than half the population of the country is m the malarious area
with varying intensity of transmission. The Southern Districts of
Samdrupzonekhar. Sarpang. Chukha (Phuntsholmg Sub-Di\ision)
Samtse falls under the perennial malaria transmission belt. These
District also are the gateway for trade and commerce. The population
of the non-malanous area m the North and Central part have to come
the Southern District for trade and commercial activities. The
whole southern border belt is porous and enjoys free movement m
and out across me border. Thus the population of non-malanous
areas are also exposed to the risk of malaria infection.
CASE INCIDENCE :
The malaria case incidence was 518 cases in 19b?. The malaria cases
fluctuated between few hundred till 19 1. In 19 2 the case incidence
rose io 1.3"6 cases. Since, then the malaria incidence increased
steadih to a peak number of malaria case incidence of 18.368
positive malaria cases m 1984. Then m 1985 the cases came down to
.043 cases, but increased to 19.916 the following year. There was
uds and downs m the malaria case trend, and showed 22.126 positive
cases in 1991. Malaria cases increased rapid!) from 1991 onwards
and reached as high as 39.852 cases, m 1994. making it the highest no
The percentage of case load decrease
approximately about 80%.
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from
I °94 to
1998 is
Year
BSC
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1982
51.939
6.328
19S3
42.633
5.213
1984
b2.06
18.368
1985
31.“63
“.043
6 2
’986
S2.o39
19.916
30.886
630
198“
69.029
13.134
19“1
31.369
“20
1988
51.164
11.314
19“2
38.703
1.3 “6
1989
1.053
19.162
!9“3
4“,909
3.402
1990
19-9
4“.8“4
4.613
199]
6 .699
22.126
19-s
48.170
“.929
1992
“3.986
28.900
19“0
4“.699
8.035
1993
“8.321
2“.512
19—
33.611
3.328
19-8
39.518
3.483
1995
83.743
23.188
19“9
41.079
5.375
1996
76.019
15.696
1980
45.487
3.933
1997
68.153
9.029
1981
48.361
1998
58.086
6.995
o'ear
BSC
E
i: 1965
10.189
518
1966
-7.148
144
i 196"
15.329
405
1 9oS
12.913
i Otm
25.531
19“
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9.49“
* base year for comparatbt analy sis
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-l A XL 4L PARASITE 1XCIDEXCE :
The Annual Parasite Incidence rate was one of the highest m the
South East Asia region. Over the \ears the API has dropped
down considerably but still the rate of 25 per 1000 population
is not acceptable and should be aimed io be brought down to 10 or
below.
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CASE MORTALITY :
Deaths due io maiana has also shown improvement II has reduced
from 62 malaria related deaths m 1^93 io 14 deaths in 199“ and
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deaths m 190S.
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1998
1995 Y996 '199"
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Beside the Hospitals and the Health Facilities in the malarious areas,
the Health Centres of the non malarious area are also reporting
regular sporadic cases of malaria.
MALARIA DRUG POLICY :
Anti-malanal drugs is part of the Essential Drugs Programme.
Procurement, distribution and monitoring xx’ill be done by the
Essential Drug Programme. The following anti-malarial drugs are
being used m the country at present :
Pn’Tiaaiiine
First Line
Chloroauirie
Second L:ne
S-P Compound.-
Third Line
Quinine
Quinine - Tetracycline
All the ami-malarial drugs xx ill be procured and distributed through
the Essential Drugs Programme. The respectixe anti-malarial drugs
xx ill be made ax-aiiabie for use at the folloxx-mg lex-els :
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or \ iliaue Lc\ el. ;\TI\V DDCi : Chlorocuinc
: ieJ:h I nil Lex el : Cnloroquine (Both table*. <!< mectibiesi
Primaoiiine
S-P Compoi:rd>.
|-io>nnT Lexel : Chloroquine. Primaquine. S-P Compounds.
Quinine and Tetracycline
The use of different drugs and their combination will haxe to be
assessed both by In-\-ivo and In-x'itro sensitivity tests and be able to
make timelx changes m the areas of knoxxyi drug resistance. Drug
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Policy should not be static, but be able to respond to changing needs
and. therefore, may require revisions from rime to time.
DRUG RESISTANCE STATES :
Monitoring of Sensitivity of anti-malanal drug is carried out regularly
by the Anti-malanal Drugs Sensitivity Study Unit. Both in-vitro and
m-vivo test are carried out.
Recently the drug resistance studies are carried out as per the protocol
developed b\- WHO. adopted by the Workshop on Monitoring of
Therapeutic Efficac) of Anti-Malanal Drugs. Anuradhapura m Jan.
19Q7. The findings of the stud}’ by Lot Quality Assurance Sample
(LQAS) method in four sites shows that Plasmodium Falciparum has
developed resistance to Chloroquine. Similar studies using the same
protocol are being carried out for S-P Compound (SDXZPYR
compound) and result shows that Pl. falciparum parasite has
developed resistance to the 2nd. line drug.
ChoJoroquine is not used for the treatment of Pl. Falciparum Malaria
and the therapeutic efficacy of S-P Compound m Pl. Falciparum
malaria is doubtful due to development of resistance by the malaria
parasite.
Two new anti-malanal drugs has been introduced in the treatment of
Pl. Falciparum malana. They are a). Mefloquine Tablet b).
Artimisinin Denvatives. Other anti-malarial drugs will be introduced
as an when required.
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INSECTICIDE POLICY :
The Ministry' of Agriculture is the largest importer and user of vanous
insecticide, pesticide, weedicide. fungicide etc. A Policy on
Insecticide
in general has not been framed in the country,
therefore the Ministry of Agriculture has initiated a framing of a
comprehensive Policy on Insecticide in 1998 and will be pul in the
National Assembly for formal discussion and approval.
In Public Health the use of insecticide has to be justified by
investigations m regards to its environmental, ecological effects,
socio-economic factors and its applicabilny & acceptance m the
communit}’. The procurement will be done through the Unit of
Supplies & Management m the Health Division. The distribution to
Districts will be earned out by NMCP as per the requirement
placed by the individual districts.
Regular monitoring of susceptibility status of insecticide of the vector
will be earned out by the Entomological Unit of the NMCP. The
insecticide should be changed based on the results of susceptibility
tests.
ENTOMOLOGICAL STATUS:
The following are the Anopheles Species of mosquitoes detected in
the country-. An. Maculatus. An. Minimus. An. Fluvitalis. An.
Culicificies. An. Annulari. An. Barbistris. An. Majadi. An. Karwari.
An. Vaeus. An. Hvrcanus.
Due to the absence of an Entomologist not much work on entomology
could be carried out. In 1997 a BSc graduate was allotted by R.CSC
for Malaria Control Programme. He was sent to
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He has successfully completed the Post Graduate Diploma in Medical
Entomology and joined the National Malaria Control Programme as
the full time Entomologist.
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Vectors of malaria is not incriminated, but it is assumed that the
combination of Minimus. Fluvitalis and Dims are the mam vectors
responsible for the transmission of the disease. Minimus and
Fluvitalis has been found and though not incriminated, they are very
efficient in the transmission of malaria.
I ECTOR CONTROL :
A. Indoor Residual Spray :
Selective Indoor Residual Spray is still the mam stay of the
vector control measure. DDT has been in use as the
insecticide
for the indoor residual spray since the sixties. In
1994 the decision was made to change the insecticide for the
indoor residual spray. DDT was replaced by Deltamethrine, a
synthetic pyrethroid compound. From 1995 Deltamethrine has
been in use as the insecticide for In-door Residual Spray. The
change of insecticide made good impact on the reduction of
malaria cases. The encouraging trend set in, in the reduction of
malaria case load is still continuing in 1998. The life span of
Deltamethrine with uninterrupted use is understood to be four to
five years, so it is used very selectively. In the light of the fact
that vector will develop resistance within a short span of years.
Deltamethrine as In-door residual Spray is being gradually
withdrawn and impregnated mosquito net is implemented to
maintain the gams so far made by Deltamethrine spray.
In 1999 impregnated mosquito net has been implemented all over
the country replacing the indoor residual spray with
deltamethrine.
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Larval Control :
Temephos (Abate) is used as the chemical for larval control
measure. Lanai control measure is mainly used m the urban
and peri-urban areas. Othet options of larval control measures
are kept open. Biological control measure is limited due the
terrain’s system, bur can be of use in few selected places.
.Another option is to use BTI for larval control measure.
C. Thermal Fogging :
Thermal fogging with syntheuc pyrethroid has been tried on
a trial basis. The result was not encouraging and fogging has
been stopped as a vector control measure. But it is still
retained as an option in case of local and focal outbreaks. This
option is used to bring down the adult mosquito population in
confined outbreak areas. In this way the infective vector density
will be brought down breaking the malaria transmission cycle.
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7TBA' (INSECTICIDE TREATED BED NET) :
From 1997 In-door Residual Spray was withdrawn in phased manner
and in its place the use of Insecticide Treated Bed Net was
encouraged and motivated.
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In-door Residual Spray with synthetic pyrethroid was completely
stopped from 1999 in the country due to various reason. Firstly the
insecticide is costly with high recurrent expenditure and cannot be
sustained in the long run. Secondly to prevent the vectors from
developing resistance to the insecticide as the synthetic pyrethroid
group of chemical is the third generation insecticide. There are no
other new chemicals being developed.
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Now insecticide treated bed net is motivated and encouraged country
wide for use in the prevention & protection against malaria infection.
Till date more than 13,000 nos. of insecticide treated bed net has been
distributed free of cost.
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The initial cost of bed net is high as spraying, but in the long run it is
affordable and sustainable as the recurrent expenditure is cheaper by
ten times or more.
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Communities are motivated and encouraged to use insecticide treated
nei and are required to purchase their mosquito net as per their family
size & requirement. The Malaria Control Programme will procure and
provide the insecticide and the treatment of mosquito nets is carried
out by the District Malaria Staff. The expertise of treating mosquito
net will be transferred slowly to the communities themselves.
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5TRA TIFICA TIO^ OF MALARIOUS AREA :
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The malarious area of the country has been stratified as follows ;
foresi Malaria
fores: frinec Malaria
Projcci Malaria
I o\x Mountain Malaria
I rban Malaria
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Further it is stratified into the following based on the transmission
pattern ;
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a). Area of perennial transmission
c.
b). Area of seasonal transmission
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c). Area of potential transmission (Conducive factors for transmission
is present)
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d). Area of no transmission. (Where transmission cannot take place)
These areas are further stratified (Micro Stratification) into village
using the malaria caseload data. The analysed data of the monthly
malaria morbidity & mortality reports from the Health Centres is used
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for the micro stratification.
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MULTI-SECTORAL APPROACH IN THE CONTROL OF
MALARIA (INVOL VEMENT AND CO-ORDINA TION) :
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Realising the need and the importance of involvement of other sectors
in the control of malaria, a workshop was held to sensitise other
sectors in the dynamics of malaria transmission and its control in
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1995.
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The list of the sectors represented are as follows :
- Planning Commission
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- Home Affairs
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Immigration & Census
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National Budget & accounts
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Works and Housing
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- Dept, of Roads
Public Works Dept.
Public Health Engineering
- City Corporation
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National Environment Commission
Agriculture (Irrigation)
Water and Sanitation
Bhutan Chambers of Commerce & Industries
Royal Bhutan Army
Roval Bhutan Police
Under the Environmental Management, Anti-mosquito measures
(Mosquito proof drains) etc. development and implementation in
Sarpang, Gaylegphu and Samdrupzongkhar was carried out on a trial
basis. The Municipal Corporation of the Districts earned out the
works in co-ordmation with Malaria Control Programme.
The result was verj' encouraging, mosquito density had reduced m the
urban area. Drainage of wastewater and rainwater has improved
leading to improvement in hygiene, in general.
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The engineering solutions of anti-mosquito measures is planned to be
taken up in other urban areas and also in the rural areas wherever it is
found applicable and feasible.
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COMMUNITY PARTICIPATION:
Community participation is vital to the malaria control. To maintain
and sustain the good result gained from the use of synthetic
pyrethroid (Deltamethrine) as the insecticide for Indoor Residual
Spray, communities must be encouraged, involved and health
educated to cany' out preventive measures at the village and
community levels.
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The use of impregnated mosquito nets has already been introduced at ‘
the village and community level. Impregnated mosquito net use is
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seen as an affordable, maintainable and sustainable control measure
compared to the highly prohibitive cost of synthetic pyrethroid spray.
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Advocacy and IEC on malaria has been combined with the
implementation of the impregnated mosquito net . The communities
will purchase their mosquito nets, the insecticide for the impregnation
and the expertise will be provided by the programme. In a phasewise
manner the impregnation procedure and know' how' will be transferred
to the communities themselves, so that the malaria disease prevention
becomes a self-sustaining activity of the communities in general.
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GOAL :
To reduce malaria transmission to such a level that it
ceases to be a public health problem.
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OBJECTIVE :
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i.
To reduce malaria morbidity to 10 per 1000 in risk
area or to reduce API from 25 to 10 by the end of RBM
project perio<L(Five years period).
ii.
Reduce malaria mortality to under 1 per 1000 cases by
theendofRBM.
iv. To sustain and maintain the gains achieved so far by
indoor residual spray with synthetic pyrethroid.
STRATEGY :
1.
Early Diagnosis and Prompt Treatment (EDPT) and effective
case Management.
2.
Control of vectors by selective use of insecticides for control
of adult and larval stages of vector, the control method
tailored to the endemicity and intensity of transmission in
specified localities.
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Control of epidemics through the use of epidemiological
monitoring tools and emergency action thereof, and
3.
4.
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Increasing the awareness of Malaria and its transmission
dynamics through IEC activities on malaria (information,
education and communication) activities on malaria thereby,
stimulating community participation in the prevention and
protection from malaria infection and control of malaria.
5.
Multi-Sectoral involvement, especially Municipal corporation.
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PWD. Irrigation projects, and other Project
areas etc.. in the
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prevention, control and elimination of mosquito
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by Manipulation,
ground through engineering solutions
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Modification measures and environmental management.
6.
Motivation, encouragement and promotion for community
participation in the use of impregnated mosquito nets as an
self sustainable malaria prevention measure.
7.
Timely change of anti-malarial drugs through regular
monitoring of therapeutic efficacy and treatment follow
up for parasite clearance.
8.
By carrying out workshop, training, refresher courses to
update knowledge, skill for all categories of peripheral
health worker and malaria technician and share experiences.
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ACTIVITIES :
1. CAPACITY BUILDING :
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The malaria control activities is decentralised and integrated into
the general health delivery system. The activities are earned out
bv the Dzonekhag (Distnct) Health Services.
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Thouuh there is requirement of additional manpower to cany’ out
The control activities but due to non-availability. additional
Manpower could not be added. Therefore, due to the extra burden
and work placed on the existing workers the quantity and quality
of work is compromised. The additional manpower needs to be
placed through induction training of Malaria Technician. Other
necessary training and refresher courses also need to be conducted
timely to update the knowledge and skill of the existing Health
Workers. The following m country needs to be carried out.
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I. TV COUNTRY :
a). MALARIA TECHNICIAN TRAINING :
Induction training of new Malaria Technicians to fill in the
additional requirement and replacement of old workers. The
course is for a period of one year or twelve months. The
raining will be earned out by NMCP under the umbrella of
Royal Institute of Health Sciences, Health Division,
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b). IN-SERVICE TRAINING :
Timely updating of Skill and knowledge of Health Worker
is essential for quality of work and technique, and also to
encourage and motivate to work.
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The following training, refresher courses & workshop has
to be conducted.
i.
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Basic in the Techniques of Malaria Microscopy.
ii. Diagnosis and Treatment of uncomplicated
malaria.
iii. Refresher Courses.
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iv. Management of Severe and Complicated Malaria.
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II. IN COUNTRIES OF THE REGION :
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In capacity building one of the mam constraint is the
availability of Training Institutes for specialised courses m
the country. The Country has no infrastructure or the
capacity to organise the Specialised courses required for
capacity building m malaria control. The institutes and
training centres in the countries of the’ Region needs to be
explored. The specialised courses for capacity building m
malaria control is being regularly conducted in the countnes
of the region. Opportunity to get the specialised courses
needs to be taken up as priority.
a). Malariology course for Managerial Level.
b). In-vivo and In-vitro sensitivity.
c). Multi-disciplinary course on Vector control.
Parasitology & Entomology.
d). Health Education.
e). Medical Entomology course.
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2. TEC ON MALARIA :
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The IEC component of the malaria control programme has been
the weakest. Now active collaboration and co-ordination with
IECH Bureau in the Health Division in the operational research,
development, production of IEC on Malaria materials and
implementation of IEC activities in the country should be taken
on a priority basis. Support fund will be required for the
development of materials and to carry out the IEC activities.
a). Materials for IEC malaria :
Audio and visual material.
ii.
Posters, chart, flip charts etc.
b). IEC on malaria intensification:
i.
Exhibition.
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ii. Symposium.
iii. Advocacy and Sensitisation.
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iv. Malaria awareness campaigns
3. BIO-EN\aRONMENTAL MANAGEMENT :
Chemical methods of vector control though efficient are of
temporary' nature and needs to be repeated on a regular cycle. The
use of chemical is viewed by the National Environment
Commission as contamination of the environment. The Policy of
the National Environment Commission on Preservation of
Environment is restricted use of chemical in the environment' and
far as possible to do away with the use of chemical. The use of
Natural. Ecological and environmental friendly measures are
encouraged.
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Environmental
Management measures are costly to be
implemented but are of permanent nature and more reliable m
the long run. Development of resistance to environmenuU
measure is not likely unlike to the chemicals used.
Fund support used in environmental management will do away
with the dependence on chemicals for vector control.
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A.
ENVIRONMENTAL MANAGEMENT :
i. Manipulation.
ii. Modification.
iii. Other engineering solutions.
B.
BIOLOGICAL MANAGEMENT :
i.
Larvivorous fishes.
ii. Biocide.
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iii. Use of other biological methods.
4. STRENGTHENING
DISTRICT:
OF MALARIA
UNIT
IN
THE
The capability to carry out various activities in the control of
malaria is limited in the districts at the present juncture. There is
an urgent need to strengthen the district malaria team so that
they are able to carry out the basic activities related to malaria
control in their district.
Besides
the regular
activities like
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parasitology, spraying
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operation, treating of mosquito net with chemical etc the
district team also should be able to perform other basic
activities in the district such as :
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Basic entomological works.
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Able to carry out the follow up on the study of ‘Monitoring
of Therapeutic Efficacy of .Anti-malarial Drugs’.
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Assist the Drug Sensitivity study team.
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Personnel trained adequately in the skill and knowledge to be
able to earn7 out the needed activities should be developed and
placed in the districts.
ITBN USE MOTIVATION & SUSTAINANCE :
Insecticide treated mosquito nets has been found to be a
affordable and sustainable measure and as an alternative to
indoor residual spray in prevention, protection against malaria
infection. This has be expenenced m various parts of the world.
The indoor residual spray operation is expensive and the logistic
and terrain system doesn’t allow total coverage.
In the country the indoor residual spray has been gradually phased
out. The spray operation was completely phased out in 1999. The
spray was replaced by insecticide treated mosquito nets. The use
of insecticide treated mosquito net tn the prevention and
protection against malaria infection is widely encouraged,
promoted and motivated. More then 10,000(Ten thousand)
treated mosquito nets has been distributed since 1997 as
promotional activity in the community. This is aimed to get
access into the community and to get their co-operation and
participation to promote and motivate the use of treated
mosquito nets.
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To sustain and further promote the use of treated mosquito nets
and to habituate families in the community, various activity aimed
at community to participate must be undertaken. Advocacy at
different levels such as;
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B.
Dzongkhag Yargay Tshokchung (DYT) members. (District
Development committee).
C.
Dungkhag
Yarkay
Tshokchung
Development Committee) members.
D.
Geog Yarkay Tshokchung
Development Committee).
E.
X'illage Elders.
F.
Families in the community.
G.
Business community (BCC1 Members) ■
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Dzongkhag (District) authorities level.
(GYT)
(Sub-divisional
Members.
(Block
Social marketing :
This is seen as an important component whereby mosquito nets
are made readily available in the market at reduced price. This
activity has already been initiated by the Dzongkhag Authorities
through the DYT (District Development Committee) Advocacy
and IEC activity.
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The Customs are requested to waver of the tax on mosquito nets.
The business community to market the mosquito net at no loss no
profit basis as a part of social service to the community m
alleviating the suffering from malaria the disease.
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Subsidised mosquito nets :
There are section of people who are unable to purchase mosquito at
the price charged in the market though it is attractive. To make it
more consumer friendly, mosquito nets at a subsidised price should
be worked out to cater to this group of individuals. This could in
the form of where there is cost sharing of mosquito net i.e. 50%
of the cost of net to be paid by the individuals. For the activity,
a). A revolving fund could be proposed and set up where the
community themselves should be made responsible to run the
activity monitored and supemsed by the programme.
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b). The programme takes up the activity of subsidised mosquito net.
Cost free mosquito net :
In the malaria endemic areas of the country' there are still
individual and families who are not able to afford to buy mosquito
nets be it at no profit no loss or subsidised rate. Their numbers are
few may run into few hundreds. Provision to take care of this
section of people with no resource should looked into. Adequate
prevention & protection against malaria infection must be
provided to this individuals and families.
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rArrfn-rfr? Wr^riTferriri rrTrf CcnW rn r-frrrTrfrrwr.wrr,r
A collaborative research program between the International Water Management Institute,
the University of Peradeniya, and the Anti-Malaria Campaign
Summary of Research Findings
A series of studies was conducted between
July 1994 and March 1998 to increase the
knowledge of malariology in the context of a
traditional Sri Lankan dry zone environment
with extensive irrigated agriculture, and to
identify and assess the feasibility of new
control interventions that could supplement the
ongoing control efforts by the government. The
main focus of the new interventions was
FIGURE I. The study area.
SRI LANKA
\ Anuradhapura
?.<\/ District
Yakalla
’ Kandy
Colombo
Village level
treatment facility
------ District Boundary
------ Road
related to water management for vector control
and community-based initiatives for diagnosis
and treatment of malaria.
Initially the studies focused on one village
but were later expanded to include the commu
nities living in seven neighboring villages with
approximately 2,500 individuals (see figure 1).
For two of the studies, the sub-basin of the
river was used as the basis for
analysis. The land in the study
area comprises homesteads, land
under small-scale reservoir
Galenbindunuwewa
based irrigation, and areas under
slash and burn cultivation
(chena). One stream crosses the
Hurulu Wewa
/ Tank
study area and serves as the
main drainage point of the
Huruluwewa watershed. In addi
tion, this stream conveys irriga
tion water from upstream irriga
tion systems to a large irrigation
reservoir downstream of the
study area.
?Q^PUra/ ------ ’X
/Ganewalpola
Kekirawa
Habarana^-
ANOPHEUNE LARVAL
ECOLOGY
//
Intensive larval sampling was
conducted in a village ecosystem
to describe the breeding habitats of the
potential malaria vectors and to document the
temporal relation between environmental
factors and larval abundance. During the dry
season, the species considered to be the major
vector of malaria in Sri Lanka, Anopheles (An.)
culicifacies, was found exclusively in small
pools when the water level in the stream was
low. However, later in the year, the large
number of pools created by the pre-monsoonal
rains within the bed of the irrigation reservoirs
and in the paddy drainage area created
opportunities for An. culicifacies breeding at a
time when the breeding potential in the stream
had been reduced by the inflow of rainwater.
Clearly, flow dynamics of the stream and the
timing of the pre-monsoonal rains were
important determinants of An. culicifacies larval
abundance. Secondary vectors were found to
have distinct breeding preferences and the
overall abundance was associated with the
availability of habitats that were created by
agricultural activities. Seepage areas below the
reservoir walls were important breeding
habitats for An. jamesii and An. nigerrimus.
Irrigation canals produced An. barbirostris, An.
peditaeniatus and An. varuna, and rice fields
and temporary pools in chena and home
gardens produced An. peditaeniatus and An.
vagus. An. varuna coexisted with An.
culicifacies in the stream but it could maintain
breeding potential at higher water levels as
well. Breeding in the rice fields and irrigation
channels was limited to some extent by the
water rotations practiced in the area to
conserve water.
When looking at the characteristics of the
breeding sites of four of the likely malaria
vectors in the area, it was found that An.
culicifacies, in contradiction of the general
belief, was able to exploit habitats that were
shaded and contained turbid water. However, it
was found that the availability of pools in the
stream and in the reservoir bed was highly
predictive of the presence of An. culicifacies
irrespective of overall habitat characteristics
such as exposure to sunlight, type of
substratum, turbidity of the water, and the
presence of vegetation and fauna.
TRANS/V\ISSION DYNAMICS
To describe the transmission dynamics of
malaria in a study village and to determine the
importance of the various potential vectors,
adult mosquitoes were sampled and the
number of human malaria cases were recorded.
An approximation of the entomological
inoculation rate was obtained by using species
specific values of abundance, circumsporozoite
rates, and the human blood index. A total of 14
different anophelines was collected. Of these, 7
different species were infected with either
Plasmodium (P.) falciparum (76%) or P vivax
(24%). The highest sporozoite rate was found in
An. barbirostris (0.015) followed by An.
culicifacies (0.011) and An. annularis (0.010).
Serotype PV247 was recorded from a vector
(An. varuna) for the first time in Sri Lanka.
Human blood was found in 10 different species.
The highest human blood index was seen in
An. culicifacies (0.095) followed by An.
nigerrimus (0.052) and An. tessellatus (0.050).
Although An. culicifacies was only the fifth
most abundant species, it had the highest
mean number of infective vectors (MIV) per
collection night—more than three times that of
the next two on the list, An. vagus and An.
peditaeniatus.
The unstable nature of malaria was clearly
demonstrated during the study period. During
late 1994 to early 1995, an outbreak of malaria
occurred with 46 percent of the village
population experiencing at least one episode of
malaria. Following this outbreak, incidence of
h
malaria remained at a low level. High monthly
MIV was associated with An. culicifacies
during the onset of the 1994 malaria outbreak.
Lower MIVs associated with low incidence of
human malaria were seen when An.
peditaeniatus, An. subpictus, An. vagus, and
An. varuna were involved in transmission.
During this malaria outbreak, close to 75
percent of all human cases was reported to be
due to P falciparum. During this period, only P
falciparum was detected in the mosquito
population. For the rest of the study period, the
balance between P. vivax and P. falciparum
remained approximately equal in both humans
and mosquitoes.
The study leaves no doubt that An.
culicifacies was the species mainly responsible
for the outbreak of malaria experienced in the
village. The adult population dynamics of An.
culicifacies was linked to the breeding
opportunities made available in the slow
flowing stream and in the reservoir bed, and
was not correlated with the main monsoonal
rains. The build-up in adult An. culicifacies
supported the increase in human malaria
cases. Seasonally highly abundant, outdoor,
dusk-biting species such as An. vagus and An.
peditaeniatus could have an impact on the
maintenance of malaria transmission. Based on
the available information, it seems likely that if
the consistent low level of An. culicifacies
breeding in the stream during the dry season
could be controlled, the adult abundance of this
species would be very low at the time when
the pre-monsoonal rains set in. A very low
abundance of An. culicifacies would make it
difficult to fully exploit the habitats generated
by the pre-monsoonal rains, especially since
these habitats will only be available for a
relatively short period. By the time the full
monsoon floods the reservoir and the drainage
areas, breeding possibilities for An. culicifacies
are greatly reduced.
RAINFALL AND MALARIA
Information on mean monthly rainfall and mean
monthly relative humidity was correlated with
the monthly malaria incidence from 1979 to 1995
for the area covered by a district hospital, which
included the villages in the smaller study area.
The analysis was done to provide more
information on the seasonality and annual
changes in incidence levels of malaria linked to
meteorological parameters and to see if a
possible predictive formula could be derived.
Aggregated data from 1979 to 1995 showed an
increase of rainfall in October with a peak in
November, and an increase in malaria incidence
in December followed by a peak in January.
However, with the same two-month time lag,
the correlation between monthly rainfall and
monthly malaria incidence was not very strong.
A better correlation was obtained when the
distribution of rainfall over a month was taken
into account. Despite the statistical significance,
the practical relevance of the relationship
between higher than average seasonal rainfall
and higher than average seasonal malaria
incidence is probably limited. Rainfall and
relative humidity alone were not sufficient to
predict increases in malaria incidence. The
entomological findings in the study area indicate
that the occasional inter-monsoonal showers
occurring during the dry season and the
distribution of the pre-monsoonal rains will be
more important for the build-up of An.
culicifacies than the rainfall during the main
monsoon season. However, a range of the
secondary vectors breeding in groundwater
pools is likely to be more directly affected by the
amount and extent of the main monsoonal rains.
This may also mean that transmission will be
initiated earlier in a riparian village than in
villages further away from waterways and, in
this way, the main monsoonal rains may have an
impact on the district-wide correlation between
rainfall and incidence of malaria.
KNOWLEDGE, ATTITUDES, AND
PRACTICES
Studies were conducted to answer a range of
questions related to the knowledge of malaria
among the communities in the study area, their
use of preventive measures, and strategy for
coping with malaria illness. Information on the
treatment-seeking behavior of the population
was collected and a qualitative assessment
was made of the rationale behind their
preference for certain types of facilities.
Methodologies were derived to estimate the
economic impact of malaria on households in a
selected village.
The surveyed community of five villages had
a high knowledge of malaria with 98 percent of
them being aware that two different types of
malaria were present in the area and with one
of the two (P. falciparum) having the potential
to develop what was locally described as
“brain malaria.” The correct treatment for
malaria was indicated by 98 percent of the
respondents although side effects of
antimalarials were often confused with
symptoms of the disease. Almost all the
respondents knew that mosquitoes were
involved in transmission. Several studies in the
area indicated that the community gave a very
high priority to the confirmation of infection by
blood-film test before taking treatment. A
survey conducted just after the main
transmission season showed that overall
malaria was ranked as the third most
important community problem, after lack of
water for cultivation and poverty.
Several surveys conducted during the study
period have shown that the community made
exclusive use of western-type facilities for
diagnosis and treatment. Approximately 85
percent of the community made use of some
form of government facility before the
introduction of a malaria treatment center in
one of the study villages. Home treatment with
paracetamol was the first medication taken in
85 percent of the households. In addition to the
drug-based treatment, special diets were often
prepared for the patients to re-establish the
"hot/cold” balance of the body and to regain
energy.
More than 90 percent of the households had
their houses sprayed with residual insecticide
under a government-funded spraying program.
In 23 percent of the households, one or more of
the members made use of mosquito nets. The
use of mosquito nets was significantly more
prevalent among the well-off families. During
the rainy season, a common preventive
measure was the burning of commercial anti
mosquito coils (54% of households) or the
roasting of traditional herbal remedies known
for their repellent effects (69%). Environmental
based control interventions were not carried
out in the area and no community involvement
in vector control took place outside the
government-funded spraying program.
ECONOMIC BURDEN TO
HOUSEHOLDS
The total direct expenditure on a single malaria
episode was approximately US$3.00, which
should be compared with a median annual
household income of approximately US$260.00
for the surveyed community. The money spent
on special diets for malaria patients was the
highest item of expenditure. The opportunity
cost to the households related to labor days
lost due to illness was estimated on the basis
of daily activity records and confirmed malaria
cases, and the application of actual wage rates
for men, women, and children. In a year with
an average malaria incidence the economically
active age group (14 to 60 years) lost 1.8
?
K
percent of working days due to malaria and 5.2
percent due to all other illnesses. This resulted
in an average annual economic loss per
household of US$15.50 for malaria and US$47.50
for all other illnesses, corresponding to 6
percent and 18 percent of annual household net
income, respectively. A few families were
greatly affected by malaria with eight families
losing more than 10 percent of labor days
during the most important agricultural season.
Children not part of the economically active age
group lost on average 2.7 percent of school
days over a one-year period due to malaria and
3.2 percent due to other illnesses. The
methodology developed to assess the economic
impact of malaria could easily be applied
elsewhere and is especially relevant under
conditions of unstable malaria where the adult
population is directly affected by the disease.
The very high knowledge of malaria, the
perceived seriousness of the disease, and the
relatively high economic cost of the disease to
the households should make the community
receptive to increased involvement in control
activities. However, the traditional reliance on
free services from the government for the
control of malaria is likely to make the
community less interested in participation in
disease control. Also, the low income of the
community makes it difficult to introduce
control measures that increase the financial
pressure on families, such as privately
purchased bed nets or user fees to cover
improved services. In monetary terms, the
absolute cost of malaria to the households is
relatively low, although high as a percentage of
income, making it more difficult to identify new
interventions with a favorable cost-benefit ratio.
RISK FACTORS FOR MALARIA
To identify the risk factors for malaria and
possible preventive measures, an epidemio-
logical study was done in a village over a oneyear period. Both environmental and
socioeconomic risk factors were studied.
Individuals living in houses where bed nets
were used had a significantly reduced risk of
getting malaria compared with families not
using mosquito nets (relative risk of 0.16, 95%
CI 0.05-0.45). Usage of traditional fumigants
was also associated with a reduced risk of
malaria. Interestingly, families using commercial
anti-mosquito pyrethrum coils had a
significantly higher risk of malaria infection
than individuals living in houses where they
were not used. Living close to the stream was
a risk factor for malaria early in the
transmission season but this did not reach
statistical significance. It was not possible to
assess the risk-related differences in
educational status and quality of house
constructions due to lack of variation in these
factors between households.
WATER MANAGEMENT AS A CONTROL
MEASURE
The association between water levels in the
stream and the breeding of An. culicifacies was
studied in great detail. The feasibility of using
water management measures to reduce the
larval abundance was also assessed.
Entomological sampling took place in the
stream on a fortnightly basis over a period of
almost three and a half years. The highest
number of immature An. culicifacies was found
in August and September when there was
virtually no flow in the stream. The. second
highest peak was observed in the period from
February to April, when the water level was
relatively low. It was found that the maximum
stream water depth in the 14-day interval
before sampling took place best explained the
number of larvae. The larval abundance was
reduced by 84 percent when the water level in
FIGURE 2. Breeding sites created in the stream when the water level drops.
Flowing
Depth
Pooling
Pooling
Flowing
Depth
the stream was increased from pooling level
(close to 0 cm) to 50 cm (see figure 2).
VILLAGE-LEVEL DIAGNOSIS AND
TREATMENT
A series of reservoirs was built early this
century across the waterway upstream of the
study area and the water levels were controlled
by water releases from these reservoirs. The
impact of different water management
scenarios was tested using a water balance
model and the established relationship
between larval abundance and stream water
depth. A range of water management options
was tested for their impact on larval
abundance using mathematical models. These
included changes in the temporal upstream
water allocations, agricultural practices, and
physical maintenance of the reservoirs, all
having the aim of making water available for
fortnightly releases into the stream during the
dry season. The results demonstrated potential
for very effective vector control by feasible
changes in irrigation management.
A village-level malaria treatment center was
established as an experiment to test new
approaches facilitating early diagnosis and
prompt treatment of malaria in rural areas. The
center was set up as a collaborative effort
between the government malaria control staff,
the researchers involved, and representatives of
the community. It was housed in a single room
in a village centrally located in the study area
and it was able to provide services to all seven
villages. The diagnosis and treatment of
patients followed the standard government
procedures. The assistants working at the
center were selected from the community and
were, after a two-week training period,
entrusted with increased responsibility. After
about 7 months, the center was fully managed
by the assistants although supervisory visits
were made by outside staff on a monthly basis.
The findings show that the village treatment
center quickly took over the role as the main
malaria facility serving the community.
However, mothers with sick young children
often preferred the government hospital since
they felt that they received a more qualified
opinion from the medical staff at the hospital.
In addition, a small number of patients
continued to make use of private facilities in
the larger towns. Overall the village treatment
center did not improve the response time in
seeking treatment for young children but the
delay for adults was reduced by 1-2 days. The
group that benefited the most was the elderly
and the handicapped in the community. The
center significantly reduced the stress and
discomfort normally experienced by them when
seeking treatment for malaria. After the
introduction of the center, people no longer
delayed seeking treatment due to financial or
time constraints, or because no person was
available to accompany the patient to the
hospital. The elimination of this small group of
people that would normally delay seeking
treatment for a considerable time is likely to
have reduced the parasite reservoir in the
community and may have influenced a
reduction in the rate of transmission. The study
indicated that the effectiveness of a village
treatment center is influenced by the degree of
initial support from key individuals in the
community, the selection procedure and
training of the staff of the treatment center, and
the history of the relationship between the
villages to be served by the center.
The wide fluctuations in the level of malaria
incidence will make it more difficult to maintain
a community interest in the treatment center,
ensure a high quality of diagnosis, and
financially sustain the center. To ensure the
long-term sustainability of village treatment
centers, it is therefore necessary to assess the
feasibility of charging a user fee and the
establishment of multi-purpose clinics.
Government policies and administrative
procedures will also need to be adjusted to
facilitate the establishment of village treatment
centers.
COST OF MALARIA CONTROL
An analysis of the cost-effectiveness of a range
of different preventive and curative
interventions was also conducted. Seen from
the government perspective, a centrally located
hospital capable of serving a relatively large
area is the most cost-effective way of treating
malaria patients. Wide use of mobile clinics and
village-level facilities is an expensive control
strategy for the government as the cost per
case treated by them is approximately twice
that of a centrally located hospital. However,
when the expenses incurred by both
government in providing treatment and
households in seeking treatment are
considered, the cost is almost the same for the
three curative options, government hospital,
village facility, and mobile clinics.
The government can implement a program of
impregnating privately purchased mosquito
nets providing protection to the households at
approximately half the cost of the ongoing
residual insecticide-spraying program.
However, for this to be effective, there is a
need to test new approaches to increase
the usage of bed nets, especially by the
rural poor. For larval control, the use of
designated water management strategies
should be explored, as this option is far
cheaper than the use of chemically based
larvicides.
iv
V
/?
- /G - /m o ) J ;
7? | \/<L-r S-j*Zy
aJ-
THIS SUMMARY IS BASED ON THE FOLLOWING PAPERS:
1. Amerasinghe, F.P, F. Konradsen, K.T.
Fonseka, PH. Amerasinghe. 1997.
Anopheline (Diptera: culicidae) breeding
in a traditional tank-based village eco
system in northcentral Sri Lanka. Jour
nal of Medical Entomology, 34: 290-297.
2.
Amerasinghe, PH., F.P. Amerasinghe, F.
Konradsen, and K.T. Fonseka. Forthcom
ing. Malaria vectors in a traditional dry
zone village in Sri Lanka.
3. Konradsen, E, P Steele, W. van der Hoek,
PH. Amerasinghe, and EP Amerasinghe.
Forthcoming. The cost of malaria control
to government and households in Sri
Lanka.
4. Konradsen, E, W. van der Hoek, PH.
Amerasinghe, and F.P Amerasinghe.
1997. Measuring the economic cost of
malaria to households in Sri Lanka.
American Journal of Tropical Medicine
and Hygiene, 56: 656-660.
5.
6.
Konradsen, E, W. van der Hoek, PH.
Amerasinghe, F.P Amerasinghe, and K.T.
Fonseka. 1997. Household responses to
malaria and their costs: A study from ru
ral Sri Lanka. Transactions of the Royal
Society of Tropical Medicine and Hy
giene, 91: 127-130.
Konradsen, E, W. van der Hoek, PH.
Amerasinghe, F.P Amerasinghe, and D.
Perera. Forthcoming. A village treatment
centre for malaria: Community response.
7.
Konradsen, E, Y. Matsuno, F.P.
Amerasinghe, PH. Amerasinghe, W. van
der Hoek. Forthcoming in Acta Tropica.
Anopheles culicifacies breeding in Sri
Lanka and options for control through
water management.
8. Matsuno, ¥., F. Konradsen, M. Tasumi, W.
van der Hoek, F.P Amerasinghe, and PH.
Amerasinghe. Forthcoming. Control of
malaria mosquito breeding through irri
gation water management.
9. van der Hoek, W., F. Konradsen, D.
Perera, PH. Amerasinghe, and F.P.
Amerasinghe. 1997. Correlation between
rainfall and malaria in the dry zone of Sri
Lanka. Annals of Tropical Medicine and
Parasitology, 91: 945-949.
10. van der Hoek, W., F. Konradsen, D.S.
Dijkstra, PH. Amerasinghe, and F.P.
Amerasinghe. 1998. Risk factors for ma
laria: a microepidemiological study in a
village in Sri Lanka. Transactions of the
Royal Society of Tropical Medicine and
Hygiene, 92, 265-269.
11. van der Hoek, W., F.P. Amerasinghe, F.
Konradsen, and PH. Amerasinghe.
1998.Characteristics of malaria vector
breeding habitats in Sri Lanka: Rel
evance for environmental management.
Southeast Asian Journal of Tropical
Medicine and Public Health, 29, 168-172.
The Huruluwewa malaria research project is receiving support from Danida, Norad, and the Government of japan.
Printed by ■ Graphitec (Pvt) Ltd.
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I Development of methodologies (methods
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Key recommendations /
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Need for operational
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control options and response
mechanisms;
I to identify cost-effective indicators to
forecast, prevent and detect epidemics
early;
I through existing Institutions or
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Need to improve response
capability of countries
Other RBM TRN
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I emergency funds,
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materials, etc.)
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The Development and Use of a GIS based Surveillance System for Malaria
Control for the South East Asian Region
Dr. A.R. Wickremasinghe
Senior Lecturer
Department of Community Medicine & Family Medicine,
Faculty of Medical Sciences,
University of Sri Jayewardenfepura,
Sri Lanka
Surveillance is best defined as the collection of data for action Surveillance is useful in monitoring
disease trends, identifying risk factors, estimating diseases burden in a community, planning health
services, allocating resources, monitoring and evaluation of programmes, and forecasting disease
trends In a good surveillance system it is essential that there is a two way transmission of
information for effective action to be taken
Geographic Information Systems (GIS) can be defined as a computer-assisted information
management system of geo-referenced data (1) The term GIS has come to mean, variously, an
industry, a product, a technology, and a science (2). It is seen as bounded, in a porous sense, by
computer aided design (CAD), remote sensing, and relational database management systems
(RDBMS). It has developed a great deal in the last 2 decades and can be used as an useful
component of a surveillance system. Although originally developed for use by geographers, its
applications have been constantly increasing and encompasses areas as varied as business to
health. GIS can be used to capture and store spatial and attribute data, perform spatial analyses,
and present data in map form. It can be used as a decision support system and has the potential to
be extremely useful in disease control such as in malaria control which is community based and
dependent on a number of host, vector and environmental factors.
In order to discuss the use of GIS as a component in the surveillance system for malaiia control it
is necessary that we first define the objectives of a surveillance system for malaria control and
then see how GIS can be used to achieve them. The objectives of a surveillance system include
detecting sudden changes in incidence of the disease,
assisting in planning and implementing control measures,
monitoring and evaluation of control measures, and
forecasting epidemics.
GIS can be used to achieve each of these objectives both at the macro- and micro-epidemiological
levels. For example, the mapping function of GIS can be used to identify and highlight high risk
areas. In planning and implementing control operations GIS can be used to locate cases and high
risk houses, and identify environmental risk factors that will assist in the choice of control
measures to be used and resources required for implementation of the selected control measures.
It can also be used in the monitoring and evaluation of control measures by its query ability to
detect areas where control measures have not been successful as expected The ability to
demarcate areas which are epidemic prone is perhaps the most important feature of GIS as a
component of a malaria surveillance system especially in this part of the world In summary, GIS
- —-.for malaria control as malaria itself is
can be used as an effective decision support system
ironmental and geographic .actors
influenced by many envirom----■ ■ ,„d on the qrfty of darn that is collected, the
usefulness
of
a
surveillance
system
will
The usefulness of a surveillance
~ depei
r
eliness of the information to take
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For a surveillance system to be reliable, valid and accurate data,
data that is not outdated,
.
the ability to process data quickly,
refers tQ the abi|ity of the
quickly
that
results
will
be
available
for
timely
ac
io_
y
surveillance
system to be able to
so
t^e|y^t'0.^nnrtant for a
.
....
•
•.
!
extremely
important
ro.
a
{herefore;
data measuring what is intended,
' - us<
-seful information that can be used as
be identified. Reliability of data
generate
residence of the patient where (s)he would
f
j
resources. It is essential that data th
not be meaningful and would lead to a
that COuld process the data quickly,
is being processed is not out of date and
months late and the system is not capable of
For example, in the case of malaria, if da
ab)e tQ respond as expected in
processing the data quickly, the surveillance system would
providing information for necessary action.
There are two important
’^d^o^dvLe. Th! selection of the unit
using GIS. Firstly, the spatial
should be based on
a)
b)
c)
Taking
into Niladhari (GN) area, which is the smal e d
Grama
lation ranging from 1000
on a <—
ipatial unit of analysis. A GN area compnses ^-JwllagetQ a viUage as vrl ages
s]
~ 3000. We considered it more W™
f human Sellings like in other parts of the World
to
in Sri Lanka are not totally isolated collections
but are scattered over a wide geographical area.
The second issue relates to the period of
of^info^fo^system. If the
be useful. Due consideration has to be given
probably weekly or fortnightly
=
’— - —
that is already in existence.
»»
n Donation such as climate and irrigation data from sectors other than the health sector, which
usually have their own routine information systems, is necessary for a GIS based surveillance
system which would assist in planning and implementation of malaria control programmes,
therefore for optimal utilisation of information without unnecessary duplication, there should be
close collaboration between all sectors A common spatial unit that can be used by all sectors
should be decided upon.
A substantial.amount of data required for GIS based surveillance system for malaria control can
be obtained from sectors other than health Such data is routinely collected for other purposes and
we do not have to collect these data specifically for purposes of setting up the information system
1 hese data include census information, land use, agriculture and irrigation data, climate data
including rainfall and temperature etc Some of these data will be constant for long periods of time
such as census which is estimated once a year and crop cultivation patterns which change from the
rainy season to the dry season. The frequency of the other information like rainfall, temperature
and river flow data will be required on the same basis as the malaria incidence data to develop
predictive models. Therefore, it is evident that there has to be close cooperation between the
health sector and other sectors. Setting up of such an integrated information system will not only
assist in the planning, implementation, monitoring and evaluation of health services but will also
be ot use for other development work in the area
In addition to making use of routinely collected data by other departments, ideally, specific data
will also have to be collected for an information system for malaria control These would include
data such as parasite and vector sensitivity testing and entomological data. However, if
entomology which requires a lot of resources including both human as well as financial is not
possible we could use proxy measures such as rainfall, temperature and humidity that are strongly
correlated with parameters such as vector abundance for predictive purposes
Vahd and reliable data alone are not sufficient for developing an efifcient and effective surveillance
system. The data has to be processed and analysed to give rise to a decision support system that
will provide relevant information in a timely manner Three questions we have to ask ourselves
are
Can we set up a system that would help us in deciding which option to use when9
Can we set up a system that would help us to show vulnerable areas9
‘
we set UP a system that will be able to predict disease patterns?
The answers to all the questions are in the affirmative
A GIS based surveillance system for malaria control for the South East Asian region
The Need
Malana is a major public health problem in the region and recent developments such as the spread
ofmulu-drug-res'stmrt strains of Plasmodja and development of vector resistance do not augur
well for the future of malaria control in the region Malana eradication was attempted in most of
the woT65 hn
re8,LnKn
5°,S and 6O'S but eradication P^ed futile. Malana in this part of
the world is charactensed by the presence of two species of malanal parasites, namely P nvax
and P. falciparum, the management of each of which may differ in different countries.
Epidemiologically, transmission of the disease is to a great extent determined by environmental
factors such as climatic factors, which are beyond man's control, and hence, makes the region
epidemic prone which has been witnessed in no uncertain measure throughout history. Factors
affecting transmission are common to many countnes m the region and a GIS based surveillance
system will provide a basis for developing control strategies and combatting transmission based
on exoeriences of one country being adapted to another The existence of vectors that are
common to a number of countries in the region makes a GIS based surveillance system important
to study vector control strategies in a number of different epidemiological scenarios. 3 he region is
also afflicted with a number of man made scenarios wmch favour malaria transmission such as
large scale population movements, war situations, and ;arge scale development activities. In the
case of large scale development activities, the ability ct a GIS based surveillance system to
identify these high risk areas will, in addition to reducing the morbidity and mortality due to
malaria, ensure the success of these projects in the future.
Feasibility
Due to implementation of eradication programmes in many countries of the region, there exists an
extensive infrastructure for surveillance, the potential of which can easily be exploited.
Unfortunately the existing surveillance systems are ones that were used during the eradication era
during which blanket residual insecticide spraying of houses were carried out and have not been
modified for control purposes. The modifications of the existing surveillance systems that are
needed are trivial and can easily be accomplished
The advances in computer and information technology during the last two decades provides us
with the luxury of having sophisticated computers at an affordable price, and of being able to
transfer large amounts of data and information at the cnck of a button. The availability of such
technology and computer literate personnel in all countries in the region would ensure the success
of a GIS based surveillance system.
A GIS based surveillance system is currently being de’^ eloped at the Malaria Research Unit,
University of Colombo, Sri Lanka and has shown much potential. It would not be vey difficult to
extend the programme to other countries as well.
Expected Output
The expected outputs can be summarized as follows:
Identification of high risk areas
An important output of a GIS based surveillance sy stem is the ability to identify high risk areas in
order to target control measures optimally and effectively.
Assist in choice of control programme, programme planning and implementation
As a GIS based surveillance system is expected to be i decision support system it can provide
information on the feasibility of implementing a particular control strategy depending on the
applicability and effectiveness of the control strategy and available resources, and assist in
programme planning and implementation by identifying necessary resources
Monitoring and evaluation of control programmes
As the surveillance system will analyse data it can be used to monitor and evaluate control
programmes.
Prediction of epidemics
With the development of mathematical models and their incorporation into the system it will be
possible to use the surveillance system for forecasting purposes;
Expected benefits
A GIS based surveillance system for malaria control for the region is bound to be of immense
benefit for malaria control in the region. The more important benefits are summarized below:
An uniform data collection structure
An uniform data collection structure would enable valid compansons among different countries
and regions being made. The ensuing analyses will ensure decision making with regard to
distribution of funds and resources being evidence based This would be a very important guide to
international agencies such as WHO.
Timely results
As stated earlier for any surveillance system to be effective it should provide timely results so that
necessary action could be taken. The use of sophisticated computers would drastically reduce the
time taken for manual analyses and human errors. Use of GIS would be useful in identifying high
risk areas that can be targeted for control operations.
Capacity building
Establishment of an effective surveillance system would strengthen individual member country’s
capacity to control malaria and to predict and deal with outbreaks of malaria
Fostering inter-country collaboration
The establishment of a surveillance system for the region would provide the forum and the
opportunity for member countries to share their experiences and apply control measures in an
organised and coordinated manner
Forecasting malaria epidemics
With collection of data and development of mathematical models it will be possible to forecast
future trends in disease incidence. This will be of paramount importance in being prepared for
such an eventuality, and containing and controlling unexpected outbreaks of malaria
Evidence based decision making
The proposed surveillance system will involve evidence based decision making and as a result
would ensure that limited resources are used optimally.
Reduction of malaria morbidity and mortality
As a consequence of all of the above a significant reduction in malana morbidity and mortality is
expected.
The functions of a resource network
The development and establishment of a GIS based surveillance system for malaria control can be
accomplished by a resource network. The functions of a proposed resource network for
surveillance for malaria control can be broadly categorised as follows
Developing software
The resource network should coordinate all acuities of member countries and develop suitable
software. The software, though having basic capabilities, should be amenable to individual
country requirements as well.
Training personnel
The resource network should be responsible for training of personnel in member countries on the
use and application of the surveillance system
Providing technical assistance
The network should be able to provide technical assistance on all aspects of the surveillance
system including data collection, computer hareware and software and accomodating individual
member country requirements.
Assisting control programmes
The ultimate aim of such a system is to assist control programmes Thus, the network should
provide necessary information to control programmes in order to make decisions based on sound
scientific evidence.
Conducting research
With the large volume of data that is to be collected and analysed there is an enormous potential
for operational research to be carried out. The ryetwork could act as a liaison between member
countries and facilitate and assist research projects. This will have tremendous impact for the
region as a whole as a forum will be establishes for member countries to share their experiences
and formulate a coordinated strategy for malaria control.
Developing mathematical models
As a consequence of research suitable mathematical models that can predict trends in disease
incidence can be developed. The network can assist member countries in developing such models.
How could Roll Back Malaria get involved?
Roll back malaria can establish a resource network for surveillance for malaria control in the
region and will have to be involved with the lollowing.
Developing a common data collection format
Developing software
Providing necessary equipment
Training of personnel
*.
Providing resources for conducting operational research
Developing evidence based guidelines on malaria control strategies
Providing management training for managers at all levels
Development of a GIS based surveillance system would form an integral component of the Roll
Back Malaria programme in Asia given the wealth of information such a system can provide and
be a evidence based decision support system for control programmes
References
Loslier L. Geographic Information Systems (GIS) from a Health Perspective. In GIS for
1)
Health and the Environment Proceedings of an international workshop held in Colombo,
Sri Lanka. 5-10 September 1994. Don De Savigny and Pandu Wijeyaratne (eds) IDRC,
1995.
Reader
S. The present state of GIS and future trends. In GIS for Health and the
2)
Environment. Proceedings of an international workshop held in Colombo, Sri Lanka. 5-10
September 1994. Don De Savigny and Pandu Wijeyaratne (eds) IDRC, 1995
&
LESSONS LEARNT FROM THE RECENT
EPIDEMICS WITHIN THE REGION
THE NEPAL EXPERIENCE
Dr. Mahendra Bahadur Bista
Director, Epidemiology & Disease Control Divisl
ision
Department ofHealth Services
Ministry ofHealth, Nepal
MALARIA SITUATION (I)
• Low annual malaria case load
(9,000-10,000 cases/annually)
• 90% Plasmodium vivax
10% Plasmodium falciparum
• Underreporting?
SPR > 5%, BER low
P. falciparum OUTBREAK IN
KANCHANPUR DISTRICT OF THE
FAR-WESTERN DEVELOPMENT REGION
OF NEPAL (1996)
Kanchanpur
•Affected Area: 5 Villages of Tribhuwan Basti,
Parasam VDC Sub-Health Posts
•Affected Population: 4,406
INDIA
Affected Area
INDIA
•Slides examined: 2,594
•Slides positive: 727 (88% P.
Falciparum with 8% severe
malaria)
•15 deaths reported
•Ecology: Forest fringe of
outer terai bordering with
India (UP), Lakhimpur
Khiri district
MALARIA SITUATION (II)
• Periodic focal outbreaks almost every year
resulting in few deaths
I
• Preponderance of P. falciparum (>65%) in
outbreak areas
• Inadequate response to SulfadoxinePyrimethamine treatment in epidemic foci
P. falciparum OUTBREAK IN
NAWALPARASI DISTRICT IN THE
WESTERN DEVELOPMENT REGION (1997)
• Affected Area: 3 VDCs of Pratrappur HP
•Population Affected: 18,756
•Slides Examined: 3,019
•Slides Positive: 1,045 (64% P. falciparum}
•Deaths: 2 deaths reported
Nawalparasi
Affected Area
INDIA
INDIA
•Ecology: Forest fringe;
rice ecosystem with
extensive network of
irrigation channels, and
presence of marsh land
Monthly Distribution of Malaria & P. falciparum Cases in Outbreak Area. Nawalparasi
District, 1997.
300
250
200
0)
w
ra
O
150
4k
100
50
o
Jan
Feb
Mar
May
Jun
Jul
Month
Aug
Oct
Nov
DEVELOPMENT OF TOOLS FOR
PREVENTION AND CONTROL OF
EPIDEMICS (II)
To be strengthened:
1. Rapid Response Teams (RRTs) at district and
regional levels
2. Epidemic Preparedness: buffer stock of
drugs/equipment inventory in pre-epidemic season
3. Awareness on early warning signals among health
staff and community
4. Clinical case definitions
5. Strengthening laboratory services at district level
6. Monitoring of therapeutic efflcay of anti-malarials in
use
I
IMPACT OF THE OUTBREAKS:
• Population at Risk: Impoverished marginalized
people of rural area who also suffer from other
health conditions like malnutrition, concurrent
bacterial and parasitic infections and infestations,
compromising the immune system of the
population at different levels.
• Death toll is low but politically sensitive
• Socio-economic burden on the community may
have been subtantial
CONTROL MEASURES
• Notification of the outbreak
• Parasitological &Entomological Investigation
• Immediate Vector Control (IRS)
• Decentralization of Laboratory facilities to the
focal outbreak area
• Mass Drug Administration (MDA)
• Intensified case detection and prompt
treatment
• Drug sensitivity testing
• Prompt recording and reporting
J
INSTALLATION OF SURVEILLANCE
FOR PREVENTION OF RECURRENCE
• Follow-up surveillance of epidemic
stricken areas for long term (ED/PT)
• Fever referral mechanism (severe cases
to the hospital)
• Rational anti-malaria drug use training
for health personnel
• Regular recording and reporting
• Supervision and monitoring
DEVELOPMENT OF TOOLS FOR
PREVENTION AND CONTROL OF
EPIDEMICS (I)
Existing:
1. Health Management Information
System (HMIS): Health facility based
I
2. Early Warning Reporting System
(EWARS): Sentinel, hospital based
PREDISPOSING FACTORS
• Migration to adjacent endemic areas
• Inadequate or not well organized
surveillance system
• NO IRS activities for the last 5 years
previous to the epidemics as there were NO
cases of P. falciparum in affected areas
• untimely, or lack of, treatment
• inaccurate collection of information
Ecology and physical environment
Malaria indicators used in SEA Region and the need for better standardization.
The problem
Since 1969, when the global strategy changed from eradication to
control, to today's drive for the development of an integrated health
service deliveiy strategy for children and adults, public health
surveillance practices of the malaria eradication era have remained in
place in various countries because of their wide spread use and
acceptance for more than 30 years, and their relative simplicity and
broad comparability.
As control strategies have modified, fragmented and adapted to local
requirements and circumstances emphasis has shifted from the need to
collect and analyze information at the central level for a
vertical/categorical project to the need to define and use information
that is more responsive to local needs in an integrated fashion.
There no longer is one definite single answer to all malaria problems
i.e. eradication, rather local solutions are being developed for local
problems. However this gradual and flexible approach to malaria
control has yet to adopt a minimum set of common SCDIs able to
ensure valid and meaningful comparisons between areas, countries
and regions.
Standardized data are required on morbidity, mortality, efficacy of
treatment with focus on clinical outcome of severe malaria and
treatment failure malaria cases, drug consumption and the quality and
coverage of health services and their reporting.
Core SCDIs relate to the first element of surveillance to describe and
measure the distribution ofthe disease malaria in all situations and
monitor the impact, outcomes and process of carrying out
antimalarial activities. These indicators and related case definitions
will be the focus of this presentation. Mention will be made of
others as well. Core SCDIs are the "minimum interface requirement"
in surveillance to ensure meaningful comparisons. Depending on the
level of expertise and resources available to programs much more can
and should be done depending on local needs.
Malaria indicators used in SEA Region and the need for better standardization.
Malaria Indicators and the present situation in SEA countries.
Malaria blood slide results and indicators have been at the center of
the malaria eradication strategy worldwide and still are at the center of
the malaria indicators used in SEA countries. The justification for this
is enshrined in the definition of epidemiological surveillance adopted
in malaria eradication programs.
Epidemiological surveillance consisted in "the detection of cases
through a screening mechanism of the whole population; the screening
criterion is the presence of fever, which leads to the microscopic
examination of the blood of every subject having fever or having
recently had fever". The cases found to have parasites in the blood
were submitted to follow up and radical treatment while presumptive
treatment with a single dose of chloroquine to suspicious "fever" cases
was given at the moment of taking the blood.
Based on the above two main eradication mechanisms have been
developed for blood slide collection:
Active Case Detection (ACD), that is "the process of case-finding by
visiting at monthly intervals all houses in a designated area and taking
blood specimens of any inhabitants who have, or have recently had,
fever."
Passive Case Detection (PCD) defined as; "the finding of malaria
cases through notification by medical personnel to whom fever cases
and other suspected cases are reported."
Elements of both mechanisms (+ MBS, APCD) are still being
implemented in the countries of SAE region. Blood slide results are
normally pooled together for countrywide analysis.
Ref: Table I -
MALARIA PROFILE OF SEA REGION 1970-1997
Blood Slide Results and Indicators
in
Malaria iB4i«?a<Qrs used in SEA Region and the need for better standardization.
Blood Slide Based Indicators
Ref: Table I
Malaria POP.
.Mid-year estimates
BSE
.Blood Slides Examined
I POSITIVES
.Microscopically diagnosed malaria positive slides.
Pf Cases
.Plasmodium falciparum infections (including mixed
falciparum and vivax infections)
ABER
.‘Annual Blood Slide Examination Rate (Total Blood
Slide Examined during a year over whole country
population, expressed as a % rate).
SPR
.Slide Positivity Rate (Positive per hundred slides
examined)
API
.‘Annual Parasite Incidence (Malaria positive slides
per thousand population)
Pf%
:Pf infections per hundred malaria positive slides
Much of the rationale for the above indicators rests with the
eradication strategy. In fact the laboratoiy component of the general
health services has continued to act as the guardian of eradication
gains and in so doing traditional eradication screening criterion have
been maintained, long after the eradication strategy has been
abandoned.
MALARIA PROFILE OF SEA REGION, 1971-1997 .
_____ Blood Slides Results and Indicators
Year
1971
1972
1973
1974
1975
1976
1977
1978
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997*
Mal.Pop,
BSE
743 227 000 55 385 967
759 880 000 61 321 374
782 629 000 59 863 554
796 617 000 61 934 964
806 398 000 69 992 611
821 561 000 74 152 031
839 408 000 73 400 856
868 113 000 77 123 223
939 458 000 78 348 432
965 212 000 86 887 747
901 348 000 79 135 272
1 018 191 000 87 119 214
1 043 780 000 86 421 840
1 074 281 000 88 245 873
1 098 409 755 90 662 396
1 118 931 460
i 142 664 814 89 829 239
i 163 622 000 94 653 815
i 187 290 000 96 950 553
i 203 149 301 93 267 092
i 184 284 680 94 782 014
i 193 830 819 94 939 029
i 210 112 233 96 819 343
i 176 523 896 93 518 816
i 196 168 676 96 009 101
i 225 374 251 95 878 683
i .100 395 333 102 354 933
J*1 916 453
■' Provisional
Positives
1 688 466
1 815717
2 684 969
3 996 360
6 024 143
7 225 798
5 488 999
4 738 386
3 681 406
3 762 465
3 461 918
2 957 065
2 782 292
2 983 783
2 564 448
2 785 499
2 944 302
2 899 713
2 951 269
2 973 143
3 109 771
3 070 406
3119182
3 370 069
3 622 595
3 709 118
_ 3 131 194
Pf Cases
ABER
309 709
3.05
306 134
2.96
514 750
4.49
782 674
6.45
1 042 634
8.61
1 011 388
9.74
709 776
7.48
804 132
6.14
801 360
4.70
995 508
4.33
972 403
4.37
945 995
3.39
901 977
3.22
997 166
3.38
857 607
2.83
959 574
3.10
1 070 846
3.11
1 106 550
2.99
1 149 034
3.16
1 147 667
3.14
1 283 587
3.28
1 241 641
3.17
1 179 360
3.34
1 299 343
3.51
1 412 713
3.78
1 417413
3.62
_1 154 571
3.22
SPR
API
2.27
0.56
2.39
0.50
3.43
0.86
5.02 ■ 1.26
7.47
1.49
8.80
1.36
6.54
0.97
5.46
1.04
3.92
1.02
3.90
1.15
3.84
1.23
2.90
1.09
2.67
1.04
2.78
1.13
2.33
0.95
2.49
1.07
2.58
1.13
2.49
1.14
2.49
1.23
2.47
1.21
2.63
1.35
2.57
1.28
2.58
1.26
2.86
1.35
3.03
1.47
3.03
1.38
, 2.69
1.26
Table-1
Pt%
18.34
16.86
19.17
19.58
17.31
14.00
12.93
16.97
21.77
26.46
28 09
31.99
32.42
33.42
33.44
34.45
36.37
38.16
38.93
38.60
41.28
40.44
37.81
38.56
39.00
38.21
39.03
Table- Il
MALARIA PROFILE OF INDIA, 1971-1997
Blood Slides Results and Indicators
Year
1971
1972
1973
1974
1975
1976
1977
1978
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
Mai.Ppp,
535 000 000
547 000 000
559 000 000
568 000 000
571 000 000
575 000 000
587 000 000
609 000 000
625 000 000
643 000 000
658 000 000
678 000 000
689 000 000
710 000 000
726 000 000
737 000 000
753 550 000
766 921 000
782 259 000
800 000 000
801 660 000
824 016 000
832 616 000
861 723 000
878 957 000
9°5 712 000
884719 pon
BSE
40420000
42800000
42450000
45450000
51820000
55980000
57010000
60460000
61420000
67170000
67840000
65030000
64290000
66350000
68130000
67690000
72534799
75698256
71580000
74420000
75158681
78531151
77941025
82179407
85133349
9153645O
84905988
Positives
1322398
1428649
1930273
3167658
5166142
6467215
4740930
4144305
3064697
2898140
2701141
2182302
2018605
2184446
1864380
1792167
1663284
1854830
2017823
2018783
2117460
2099154
2207431
2511453
2988231
3035588
2457127
Pf Cases
148683
142177
265154
476922
729251
753713
461484
548567
558423
588011
589591
551057
600964
655454
545005
639912
620563
688354
740319
755240
921214
879383
852763
990508
1173599
1179561
930421
ABER
7,56
7.82
7.59
8.00
9.08
9.74
9.71
9.93
9.83
10.45
10.31
9.59
9.33
9.35
9.38
9.18
9.63
9.87
9.15
9.30
9.38
9.53
9.36
9.54
9.69
10.11
9.60
SPR
API
Pf%
3.27
.3.34
4.55
6.97
9.97
11.55
8.32
6.85
4.99
4.31
3.98
3.36
3.14
3.29
2.74
2.65
2.29
2.45
2.82
2.71
2.82
2.67
2.83
3.06
3.51
3.32
2.89
2.47
2.61
3.45
5.58
9.05
11.25
8.08
6.81
4.90
4.51
4.11
3.22
2.93
3.08
2.57
2.43
2.21
2.42
2.58
2.52
2.64
2.55
2.65
2.91
3.40
3.35
2.78
11.24
9.95
13 74
15 06
14 12
11 65
9 73
13 24
18 22
20 29
21 83
25 25
29 77
30 01
29 23
35 71
37 31
37 11
36 69
37 41
43 51
41.89
38.63
39 44
39 27
SS.Qgj
37.87
Lab°WHOySEAnfirmed Malaria P0S' ive Cases
Positive Cases(in Millions)
8
6
4
1
xxx
2
0
—
1 971
1 975
)( )
[-
1 980
1 985
Year
SEAR -±- indja
1990
1 997
-- -
"'who 77a LDab°ratory Confirmed Cases
WHO SEA Region & India, 1971-1997
Cases (in '000)
1600 i—1400 !
1200 ;
1000 !
R-
800 |
600
400
200
o L
1971
1975
1980
'
1985
Year
A India
■ SEAR
i---1---r
1990
1997
Malaria
osdiiiiiSEA Region and the need for better standardization.
Limitations of blotrf slide based indicators and related reporting
practices.
• Laboratory resources have traditionally worked independently from
the clinical needs of the patients as blood slide taking and
examination has remained divorced from the provision of prompt
and complete treatment to sick patients, with slide results often
becoming available too late for treatment. (All programs measure
backlog in slide examination in weeks not days)
• The Positive/Negative characteristic of slide results reporting
cannot differentiate on the degree of severity (SM) or drug response
(MTF) to antimalarials. This data has become essential to the stated
program objective calling for a sustained reduction in malaria
morbidity and mortality.
• Malaria deaths are clinical events and traditionally unrelated to
laboratory reporting. For this reasons mortality data in the past are
often missing or incomplete. Mortality data are now crucial and
their accurate reporting needs alternative surveillance channels.
• Only a fraction of people sick with malaria are tracked through the
laboratory reporting system. Most cases are invisible as they are
treated on clinical grounds only. They will remain so until clinical
practice and its reporting is brought into the surveillance system.
• Changes in slide collection mechanisms due to decreased outreach,
limited supervision, and selective application of ACD and PCD are
not easily reflected in the population denominator. This has created
problems in ensuring comparability across time of indicators that
were originally meant to be applied to entire populations being
brought under eradication or control operations (e.g. ABER).
• Laboratory data have become of very limited use to help define
antimalarial drug consumption and requirements as treatment
regimens have multiplied with the spread of drug resistant strains
and emphasis on morbidity control.
v
Malaria indicators used in SEA Region and the need for better standardization.
Better standardization of "core malaria indicators"
Drawing upon the latest recommendations of the 20th report from the
WHO Expert Committee on Malaria, there is renewed agreement that
a minimum set of SCDIs needs to be defined, endorsed and applied on
a routine basis to malaria control programs world wide. To do so
changes are required in the surveillance system of the countries of
SEA Region. However even if changes are few in number they are not
incremental i.e. they cannot be simply added to the present slide based
reporting system. Their adoption and implementation is a very major
change to the present surveillance system.
Core SCDIs should be moulded or built around existing health care
and surveillance systems with clinical practice and clinical outcomes
at the center of the reporting system in combination whenever
possible, with blood slide results and indicators.
Formal and explicit links need to be established, between malaria
laboratory reporting practices and reporting from health care providers
responsible for patients for whom the usefulness of recording and
reporting the disease is subordinated to successfully managing the
disease in individual patients and documenting clinical outcomes.
Malaria indicators and the RBM Initiative
SCDIs are needed at all stages of the RBM Initiative to inform policy
makers, planners, managers and all stakeholders and partners engaged
in the movement and in particular during:
• in country consultations,
• situation analysis and needs assessment at various levels
• regular annual reviews
I
Ii
VI
Malaria indicators used in SEA Region and the need for better standardization.
Core Standard Case Definitions and Indicators (SCDIs)
Case Definitions
Uncomplicated Malaria
UM
Severe Malaria
SM
Malaria Treatment Failure MTF
Impact Indicators
• Morbidity attributed to malaria
a) number of cases of UM (clinical/con firmed) among target
groups/unit population
b) number of cases of SM (clinical/confirmed) among target
groups/unit population
c) number of MTF/per number of treated patients. Reported according
to each drug used
• Mortality attributed to malaria
a) number of malaria deaths (clinical/confirmed) among target
groups/unit population
b) proportion of clinical/confirmed deaths due to malaria among
patients with SM admitted to a health facility
Outcome/Process Indicators
• Availability of antimalarial drugs (% of health facilities reporting
no rupture of stock of antimalarial drugs during last 3 months)
• Reporting coverage (% of districts regularly reporting the above to.
the national programme on a monthly basis for the last 12 months)
Additional Indicators
• API
• UseofITMN
• Performance of mothers/carers
• Protection of pregnant women
• Preparation for malaria epidemics
• Interdomiciliary spraying of insecticides
• Laboratory diagnosis
• Presence of foci of transmission
vn
Malaria indicators used in SEA Region and the need for better standardization.
Core Malaria Indicators in P. falciparum endemic areas.
Cox's Bazaar District - Bangladesh (A case study)
MALARIA RATE/1000 POPULATION (MR/1000) = Total No. of Malana Cases x 1000
Total Population
This rate per thousand population looks at the number of sick people seen at your health institution who are
diagnosed as being sick because of malaria over the total number of people living in the area served by your
health institution. The population (i.e. the denominator) of your Thana Health Complex should consider both the
Thana Population (official figure) + the Catchment Area Population = Total Population
UNCOMPLICATED MALARIA RATE (UMR)
No. of UM Cases
x 100
Total N. of Malana Cases
This rate gives you, as a percentage, the proportion of sick peocxe seen at your health institution who are
diagnosed as being sick because of Uncomplicated Malana
TREATMENT FAILURE MALARIA RATE (TFMR) =
N. of TFM Cases
x 100
Total N. of Malana Cases
This rate gives you, as a percentage, the proportion of sick people seen at your health institution who are
diagnosed as being sick because of TFM. These patients come bacx within a month after receiving a full course
of anti-malarials.
Information for action
The TFM rate is very important because it gives you an indication of now serious is the problem of drug resistant
malaria among the people living in your area. If you compare your TFM Rate month by month you will be able to
notice changes and understand if the TFM situation is stable, improving or getting worse. TFM patients can be
both Outpatients or Inpatients. In addition to calculating the TFM rate you should also check and compare your
monthly actual number of TFM cases recorded as Inpatients and Outpatients. An increase in the number of TFM
cases recorded as Inpatients is a very serious situation It tells you that your malaria patients are coming back for
additional treatment and are coming back in a serious condition that requires admission! This situation is serious
and you need additional help to investigate what is happening Inform your supervisor and seek advice from your
District Civil Surgeon Office.
SEVERE MALARIA RATE (SMR) = No. of SM Cases (inpatients) x 100
Total N. of Malaria Cases
This rate gives you, as a percentage, the proportion of very sick people admitted into your health institution who
are diagnosed as being sick because of Severe Malaria.
Infomiation for action
VMienever this rate goes up you may expect deaths due to Malana also to increase. You may be facing a new
very serious situation and this finding requires your urgent attention. Inform your supervisor and seek advice from
your District Civil Surgeon Office. Also try to find out more about those patients.
Who are those people becoming sick?
How old are they?
Where do they come from?
Is the Malaria Rate also going up?
Is this a malaria outbreak?
NOTE: You should remember that the percentage sum of the three rates always gives you a total of 100%
(for example. UMR 80% + TFMR 18% + SMR 2% = 100%)
From
(21) Malana Diagnasttc Treatment and Recording Cnans A training module for Medical Officers Tnai
Edition Malana and Parasitic Disease Control (M&PDC Unit DGHS, Dhaka 1997
I
VIII
Si
Malaria indicator$,.used in SEA Region and the need for better standardization.
I
MALARIA SURVEILLANCE DATA & INDICATORS 1995-97
COX'S BAZAAR DISTRICT (POP 1.5 M) BANGLADESH
YEAR
1995
1996
1997
Total Population
i 1,383,158
1,456?964
1,555,347
Total Slide Collected
80,141
79,225
55,976
Total Slide +ve
Slide Positivity Rate (SPR)
24,540
(30.6%)
22,577
(28.5%)
1R280
(20.15%)
Total P. falciparum Slide +ve
P.falciparum Rate (%)
15.385
(62.7%)
12,686
(56.2%)
6,665
(59.1%)
Total No. Patients (In + Outpatients) I 467.337
565,200
618,052
< 46.326
(100%)
40.4377
40.43
(100%)
(100%)
Malaria Rate MR
TMCC/1000 Population
29.2/1000
_____
Total Malaria Clinical Cases TMCC
j(100%)
■
i 37.463
l (100%)
31.8/1000 24.0/1000
1----------------------------
Uncomplicated Malaria UM
UM Rate (%)
i 32835
| (81.2%)
37,799
(81.6%)
31,214
(83.3%)
Severe Malaria SM
SM Rate (%)_______________
4,574
(11.3%)
5,389
(11.6%)
3,518
(9.4%)
Treatment Failure Malaria TFM
TFM Rate (%)
3,028
(7.5%)
3,138
(6.8%)
2,731
(7.3%)
Total Malaria Deaths
Case Fatality Rate (%)
278
(6%)
234
(4.3%)
110
(3.1%)
Ratio of Slide Collected to
Total Malaria Clinical Cases
1.98
1.71
1.49 • .
2.05
(48.7%)
3.32
(30.1%)
Ratio of Total Malaria Clinical Cases *| 1.65
I (60.7%)
TMCC to Total Slide +ve.
(Positive Predictive Value-PPV of
TMCC definitions with Total Slide
+ve as true standard. Expressed as %) [
i
IX
Malaria indicators used in SEA Region and the need for better standaidization.
Conclusion
There is a need to develop and learn a new, basic, essential, shared
epidemiological language to describe malaria trends and events in a
manner that is consistent with the stated common, primary' objectives
and interventions of malaria control programs.
This language must be able to link in a meaningful way with the slide
based reporting system.
We need:
• An alphabet
= case definitions
• A grammar
= indicators
• A single set of sounds & pictures
graphs'& charts
To talk to each other in a more meaningful way.
Malaria indicators used in SEA Region and the need for better standardization.
References:
1) Declich, S. & Carter, A.O. Public health surveillance: historical origins, methods and
evaluation. Bulletin of the World Health Organization. 1994. 72(2): 28?-304.
2) Implementation of the Global Malaria Control Strategy: report of a WHO study group on
the implementation of the global plan of action for Malaria control. 1993-2000. Geneva,
World Health Organization, 1993 (WHO Technical Report Series, No. 839).
i
3) WHO Expert Committee on Malaria. Twentieth Report (Draft). Geneva, World Health
Organization, 1998.
4i Terminology of Malaria and of Malaria Eradication. Report of a Drafting Committee.
Geneva. World Health Organization. 1963.
i
I
i
I
i
j
XI
ft
Malaria indicators used in SEA Region and the need for better standardization.
LABORATORY CONFERMED MALARIA CASES DETECTED IN BANGLADESH. 1963-1997
YR.
1
1963
1964
1965
1966
1967
1968
1969
1970
1971
1972
1973
1974
1975
1976
1977
1978
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
NOTE:
POPULATION
B.S.EXD
ABER
-VE
API
%
Pf
SPR
SFR
Pf
Sus
11'
15
110
67
62
69
136
582
647
50
22
2
3
4
5
6
7
8
9
%
To
1895000
8962000
12035000
21203000
26874000
47002000
59444000
62810000
63570000
65220000
69288000
71565000
72730000
73930000
76395000
78916000
81520000
84210000
88100000
90300000
92200000
94300000
96400000
98000000
99800000
101500000
103800000
106100000
109900000
112100000
114500000
117000000
119000000
120000000
124300000
86345
474569
975918
1715771
2485901
2988322
4880511
6107144
2212660
5311988
3259190
1884109
2929935
3537269
1414731
1391055
1374104
2634773
2338853
2808765
2516110
2552513
2823028
2685529
2771577
2704563
3152310
2444415
2081137
1919349
1635589
1661701
1461556
1146736
4.56
5.30
8.11
8.09
925
6.36
821
9.72
3.48
8.14
4.70
2.63
4.03
4.78
1.85
1.76
1.69
3.13
2.65
3.11
2.73
2.71
2.93
2.74
2.78
2.66
3.04
230
1.89
1.71
1.43
1.42
122
1.00
0.77
402
756
649
3137
4080
6244
7871
6660
2944
18384
14007
15855
31247
48844
29673
33326
49776
67707
45902
46781
42529
32977
31050
93128
35848
33824
50738
53875
63578
115660
125402
166564
152729
100864
68594
0.21
0.08
0.05
0.16
0.15
0.13
0.13
0.11
0.05
0.28
020
0.22
0.43
0.66
0.39
0.42
0.61
0.80
0.52
0.52
0.4o
0.35
0.32
0.40
0.36
0.33
0.49
0.51
0.58
1.03
1.10
1.63
1.28
1.00
0.55
0.47
0.16
0.07
020
0.16
0.21
0.16
0.11
0.13
0.35
0.43
0.84
1.07
1.38
2.10
2.40
3.62
89
279
85
357
1702
3069
2575
3307
1556
6397
8023
10726
19510
28408
12923
6717
10408
22184
15375
19059
17546
14876
16211
21064
20472
21565
35780
34061
30282
51775
54973
81015
75860
54307
42342
1.10
0.06
0.01
0.02
0.07
0.10
0.05
0.05
0.07
0.12
0.25
0.57
0.67
0.80
0.91
0.48
0.76
0.84
0.66
0.68
0.70
0.58
0.57
0.78
0.74
0.80
1.14
1.39
1.46
2.70
3.76
4.88
5.19
4.73
4.43
22.14
36.90
13.10
10.39
41.72
49.15
32.72
49.65
52.85
34.80
5728
67.65
62.44
58.16
43.55
20.16
20.91
32.76
33.50
40.74
4126
45.11
52.21
53.83
57.11
63.76
70.52
6322
47.63
44.76
43.84
48.63
49.66
53.84
61.73
955542
POPULATION
B.S. EXD.
POSITIVES
Pf
ABER
API
SPR
SFR
Pf%
Sus. Deaths
°o
1.96
1.67
1.69
1.29
1.10
1.46
1.29
1.25
1.61
2.20
3.-05
6.03
7.67
10.0
10.4
8.80
7.18
DEATHS 1
Conf |I
eT
14
103
60
156
378
383
696
742
447
457
Mid-year estimates
Blood Slides Examined
Microscopically diagnosed malaria positive slides.
Plasmodium falciparum infections (including mixed falciparum and vivax .
infections)
Annual Blood Slide Examination Rate (Total Blood Slide Examined during a year
over whole country population, expressed as a % rate).
Annual Parasite Incidence (Malaria positive slides per thousand population)
Slide Positivity Rate (Positive per hundred slides examined)
Slide Falciparum Rate (Pf. infections per hundred slides examined)
Pf Proportion (Pf infections per hundred malaria positive slides).
Laboratory confirmation of malaria not available.
Source: M&PDC Unit, DGHS
j
XII
F
!
MALARIA CLINICAL CASE DEFINITIONS
•
Patient Assessment:
The chart has a starting point at the top left comer, this is whe e you should always start when using the chart. |
specially at the beginning, when you are not familiar with its cc^tents Apply the same rules every time a patient
comes back This means that with each individual patient, no matter how many times he/she returns, always start
from the top left comer to assess the patient The patient assess—ent section takes you to four different possible
diagnosis
Other diseases
(UM)
Uncomplicated Malaria
(SM)
Severe Malaria
Treatment Failure Malaria (TFM)
Please note the following:
1
The first question to ask the patient is
"What is '-.aKtng you sick'7"
First listen to the patient's complaints, then take a routine histc^ ana perform a routine physical examination. If
you find no evidence of another disease, then ask yourself
" s maiana the reason for the patients sickness?"
2.
V\A>en you decide that the patents symptoms ana signs suggest maiana as the main reason for the
illness you must ask yourself:
is it Severe Malaria (SM)?
is it Treatment Failure Maiana (TFMP
is it Uncomplicated Maiana (UM)9
CF
CP
Severe Maiana needs urgent diagnosis and treatment Decze wnether the patient has severe maiana by
checking for any of the clinical findings in the box
unconsciousness
OR convulsion
OR unable to stand or walk
OR vomiting or severe diarrhoea
OR severe pallor (anaemia)
OR confused or abnormal behavior.
Any one or more than one of these features ts a sign of Severe Maiana. However, when recording the diagnosis,
it is important to find out whether the patient has already beer property treated for malaria in the past month. If
this is so, then, this is also a case of Treatment Failure Maiana To check carefully whether the patient has
received a complete antimalarial course in the last month, ask
"was a full course of antimalarial drugs given?",
"was correct dose for weight given?",
"was malaria treatment (i.e.chloroquine or fansidar taotets) definitely swallowed and not vomited?"
To be sure about these things, you have to ask the patient or guardian carefully. If the answer to any of the 3
questions about a previous antimalarial course is "no" then ms means the course was not completed and
therefore the return of the malaria illness is not due to treatmer* failure but due to inadequate treatment. Such a
case is recorded as severe malaria. However, if the answer tc the 3 questions is "yes", then this is a case of
treatment failure malaria and it must be recorded as T F.M even though the patient has symptoms and signs of
severe malaria and is going to be admitted. In the same way. a patient who does not have any of the symptoms
or sign of severe malaria should also be checked tc find out wr-etner he/she had a complete antimalarial dose in
the last month by asking the same questions. If any of the ans^rs is "no", then a full course was not given and
so the diagnosis is recorded as Uncomplicated Maiana (UM) H-'^ever, if the answer to all questions is "yes", this
outpatient case is recorded as Treatment Failure Malaria (TFM Always remember to ask each malaria patient
the three questions on the PATIENT ASSESSMENT section c~ -e MALARIA DIAGNOSIS AND MANAGEMENT
CHART in order to make the correct diagnosis Always checK ~e patient's health records if available, to confirm
the patient's history
I From
(21) Maiana Diagnostic Treatment and Reco'ding
and Parasitic Disease Control (M&PDC) Unit DGHS Dna-a
• -g module for Medical Officers Tnal Edition Maiar.a
r'r
XIII
Malaria indicators ttsed in
Region and the need for better standardization.
The context
Indicators are defined variables that applied to disease surveillance
data in a systematic and regular fashion, help to measure, interpret and
compare changes in the epidemiology of malaria. Indicators are tools
that allow to group data in meaningful clusters that define a
surveillance system.
The definition of epidemiological or public health surveillance has
been subject to changes since 1950, when it was first proposed by
Alexander D. Langmuir (1).
In the context of a malaria control program, public health surveillance
is the ongoing systematic collection, analysis, interpretation and
dissemination of health data required for public health action. Priority
is given to collection of data to identify those at high risk and to detect
changing disease patterns in order to plan and evaluate prevention and
control actions. These data and their indicators are required to:
• Describe and measure the distribution of the disease malaria
• Explain the distribution by its determinant factors: biological,
environmental, social, behavioral and economic
• Predict, monitor and evaluate changes in the distribution of the
disease malaria in relation to the malaria control program
objectives and interventions
Data collected locally need to relate to "Standard Case Definitions
and Indicators” SCDIs accepted globally so as to ensure that
essential comparisons are possible to assess disease trends across
borders and regions world wide.
i
Role of Advocacy,
Communication and Media
in RBM
i
Mrs Harsaran Bir Kaur Pandey
Information Officer
WHO, SEARO
5 May 1999
I
COMMUNITY LEVEL
✓ Inform/empower communities on how to
tackle Malaria
✓ Need to monitor progress
In EPI - demand was created and was
closely linked to service delivery
✓ Simplify malaria control efforts to equate
with vaccine
5 May 1999
X
I
I
I
.*Z
One Half of Malarial Deaths
can be prevented in
the next ten years
5 May 1999
4
J
%
UNDERSTANDING RBM
Malaria Eradication Programmes - are
decades old
So, What is new in RBM?
What elements spell success?
5 May 1999
5
Malaria can be tackled only with:
Combined Global Effort
Very close inter-sectoral action
✓
5 May 1999
Full community participation
6
GLOBAL - LEVEL
Make Malaria an important issue
Support research
Develop new tools
Raise funds
World Health Assembly’s concern on Malaria
WHO DG’s announcement on RBM
Four UN Agencies Joint launch
5 May 1999
7
J
NATIONAL - LEVEL
✓ Close inter-sectoral action needed
✓ Need for top political commitment at
National/Planning Commission levels (upe example)
✓ Mission mode? (e.g. Technology Missions)
✓ Make it a public/media issue
Strengthen health delivery system
Mobilize resources for the programme
5 May 1999
8
v1'
A FIVE YEAR COMMUNICATION/
ADVOCACY/MEDIA PLAN
Time Line
Programme Landmarks for double action
— Match Media Plan
5 May 1999
9
■
''s
■ — »■•» ■ ■
■]
Re-charge Health Sector to take Malaria as
a serious health problem
✓Position it as a key cause of poverty
✓Promote RBM as a social movement
✓Focus on new tools
✓ Focus on community action
5 May 1999
10
A
%
✓
✓
✓
/
ADVOCACY STRATEGY
Clarity on key messages
Explicit on intervention
Identify key audiences
Develop basic advocacy materials
(in partnership)
5 May 1999
II
MEDIA PRODUCTS
✓ Stage 1:
- Monograph on Malaria and Development or Malaria
and Poverty
- T.V. spots for Global/National release on key T.V.
networks
- Advocacy film - Create Ambassadors for Malaria
(Nelson Mandela/ Sean Connery) as anchors
- Borrow UNICEF idea of Fund raising on flights in to
Africa, Asia and Latin America
5 MayVgsf reate 111 ed 1 a/m a ,a a information/networks
12
MEDIA PRODUCTS
✓ Stage 2
- National Level:
• Prepare policy paper for Cabinet
• Documentary films
• T.V. Spots
• Radio series
• Media Workshops
5 May 1999
13
MEDIA PRODUCTS
Stage 3
- Sub-National Level
Workshops with State Information Bureaus and
State/District Newspapers
Radio. Series in local languages focusing on area
specific information tailored for local community
action
Ci eate malaria action networks
5 May 1999
14
Network of Malaria/Information
WHO
UN PARTNERS
GOVERMENTS
NGOs
COMMUNITIES
MEDIA
5 May 1999
Advocates
Questions
Carries success stories
Plays watchdog role
Monitors Progress (+/-)
Media Reports
15
O:
e
O''-'”
a
'S&
MEDIA MESSAGES
To national leaders
Z Malaria cause of suffering death and poverty
/ Can be contained using tools available
Z Ensure health system delivers
Z Empower Communities
Z Can demonstrate achievements
Communities
Z Can tackle Malaria al home
Z Can organise themselves
z NGOs can help keep programme on line
5 M;n 1999
| -"2
PU»I.1C HP ALTg SYSTEM BREAKDOWN?
• SHORTAGE OF WOIJCERS / DOCTORS
• REDUCTION IN BUDGETS
• OVERBURDENED HEALTH WORKERS
(ANMs - EXPLOITATION)
• CORRUPTION / SCAMS / MISUSE OF FUNDS
• POLITICAL INTERFERENCE
• DECISION MAKERS WITHOUT PUBLIC HEALTH
COMPETENCE / ORIENTATION
• CENTRALISED TOP DOWN PL AS N ING
• CENTRE / STATE RESPONSIBILITY
- AMBIGUITY
• INADEQUATE / UNREALISTIC PLANNING
Source Secunderabad Meeting - August 97.;
Coo
§
a
6
oS
Q-0
L Q
a oQ>
r
Ml
“3
pi
«
0<-
£
0
x
\U
s5
v- a
.3
u <x o
o
a
a. X a.
I
MARKET ECONOMY IH WEALTH
* TOP DOWN PROM TION OF
TECHNOLOGICAL FIXES'.
*
,*
market interests in decision making
INTERNATIONAL PUBL1C HEALTH
COLLABORATION / COOPERATION
Often becoming subservient to:
* AG3N3AS OF VISITING CONSULTANTS
* RESEARCH PRIORI"!-S OF COLLOBORATERS
* ‘GUINEA PIGS” for Research
* FUNDING AGENCY J 3NDITIONALITIES1
*
GRANTS TO LOANS!!
I* ILL HEALTH EFFECTS OF NEO-LIBERAL
i ECONOMIC POLICIES
(From Solidarity to exploitation!!)
Source Secunderabad meeting - August 1997 |
^ieaf>c^s
OVeMCMTS
amvwK^/vsoMBaaMHMMaHHMHHMaBKMNVV. •*- ’
QMieKO
/ £o>r/vorfc«r»e**Mh.|
*
HtAOA
£N*4*O
i
O»4T»
6W4SK
f
«i
r
MMM4&T
FJlAWtajLS
'-W*£**&*fv
*
Mc.e
i
meog
|
«MMS
I rtw^Ffe-jT 1
4
m—
K^lvO t~AMo<
I /<^0^ H6|0
f^ATiOMAL Act.»*<«•«£
AX©^
PARAMSM SHIFT
IN
MOOEL OF MALARIA CONTROL - I
(URGENT NEED)
S5W3LS?." ..r’raggst m !■ n ||—■■awocxrKi- •,
1.
BIO-TECHNOLOGY
MODEL
♦
SOCIAL/COMMUNITY
MODEL
lil'TOi'S
?•
INMVMMJAL
CASES
3.
PATIENT AS
BENEFICIARY
4.
ILLNESS
5.
MOLECULAR
BIOLOGY
♦
♦
COMMUNITY
PROBLEM
PEOPLE AS
PARTICIPANTS
HEALTH
♦
SOCM>EPH>E MJOLOGY
PARADIGM SHIFT
MODEL OF MALARIA CONTROL
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laria : A Socio-epidemiological ■
B
Perspective
■
(Recognising the 'Social Paradigmf in
Malaria Control: Beyond Technomanagerialism)
Invited Lecture at
Second Global Meet on Parasitic Diseases
at Secunderabad,
August, 1997
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Dr. Ravi Narayan,
Coordinator,
Community Health Cell,
Society for Community Health Awareness, Research and Action,
| | No. 367, Srinivasa Nilaya, Jakkasandra, I Main, I Block, Koramangala,
fw..Bangalore - 560 034, INDIA.
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Resurgence of Malaria
“The time has come for health
policy planners to move away
from narrow biomedical
approaches seking technological
fixes to a much broader social
and community-oriented
paradigm shift in research,
problem analysis and action
initiatives. In the absence of
this, malaria and the reemerging communicable
diseases will continue to
represent not only a failure of
our public health system but
also of our research methods
Source: Narayan IL, 1W7
NMJI Editorial
4
turn
mm
nn
jj
HEALTH FOR ALL
Indian Council Of Social Sciences
Research &
Indian Council Of Medical Research.
(1981)
■ Reduce:
v poverty,
z inequ ty and
z spread education
H Organise poor and
underprivileged to :
z fight for their basic rights
■ Move awayfrom :
z Counter-productive and
z Consumer^
Western ■ L^* d of
Care
■ Replace with
/ Alternative besed in the
community.
Dr. Ravi Narayan, Community Health Cell
’'BaJj^onist’1 Research
I
Participatory Reflection
mm
mm
jj
jj
jj
Alternative malaria
control strategy
REPORT
WHAT
WHO
WHEN
■ Towards an
Appropriate Malaria
Control Strategy
■ Reflections/
Recommendations
■ An Expert Group (6)
and a Reference
Group (44) from the
Voluntary / NGO
sector.
■ Apr. ‘96 - Jan.’97.
b-j
fa
Dr. Ravi Narayan, Community Health Cell
mm
mm
mm
ti
no
hh
■i al
AlternativeMalaria
Control Strategy (contd.)
WHY
HOW
■ To provide an :
y Alternative,
z Community oriented*
z Socially relevant
perspective.
[
■ Interactive &
Participatory
Individual
contributions
Group reftectiem
w Identification of
rt
through meetings
L
Dr. Ravi Narayan, Community Health Cell
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to
in
it
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RESURGENCE OF MALARIA
Causes ?
Public Health!
Agent Resistance
CRISIS
i’
and
Vector Resistance
Health Care |
System I
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Technical Problems and
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limitations
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resistance!
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INTRA-CELLULAR’
DRUGS
VACCINES
IMMUNOLOGY
BIO-TECHNOLOGY
‘BALOONIST’
\ GENOMIC IMPRINTING
I
PESTICIDES
Etc.,
+
{ KAP
COMMUNITY
DYNAMICS STUDY
+
Etc.,
ANTHROPOLOGY
MOLECULAR BIOLOGY
BEHAVIOURAL
SCIENCES
POLITICAL
ECONOMY
OPERATIONS
RESEARCH
ACTION
RESEARCH
SOCIO-EPIDEMIOLOGY
■
,„nuiiu -
,UI 1 ",l"
/
i
GOAL OF THE STR ATEG /
BRINGING BACK THE
COMMUNITY
TO THE CORE OF THE
MALARIA PROGRAMME
3
(A TASK AHEAD)
The Need For
Socio-epidemioliogy
jj
■ Studying the COMMUNITY at
risk & SOCIETAL CONTEXT not only the Agent / Vector / Environment.
■ From - TECHNO-MANAGERIAL
problem analysis and
assessment
ToSOCIO-CULTURALPOLITICAL BEHAVIOURAL
issues.
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a ■waft ■■
Dr. Ravi Narayan, Community Health Cell
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^ Tribal Population behaviour in Manstta (MP>
| &^Xs^^relatioit to bodnet use) . - ' J', ;
S
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— ■. ..
.................................. ........
•
.
.i
Community Survey
Night Mahua collection 14%
: Steep in fields
12%
Tendu leaf collection
21 %
Fishing
8%
(1,200 people out before dawn out
of 2,000)
Singh. N9 Mishra, A.K., Khan M.T. 1992
in Community Participation in Malaria Control
V.P. Sharma (Ed) MRC (KMR) 1993
i Tribal Population behaviour in Mandla (AAP) s
(in relation to bednet use)
L
L/.:.
a.
...*
..
,:"v.
?
.. .
Reasons for Nonuse
(Fatigue due to hard field 57.85%
work
9.87%
Suffocation inside net
Intoxication_
1.92%
1%
Spread on floor
; Wrapped round body
20.9%
2.8%
(Used as pillow
Singh .N, Mishra, A.K., Khan M.T. 199?
rn Community Participation in Malaria Control
V.P. Sharma (Ed) MRC (ICMR) 1993
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Rediscovering the
Community ’
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Capacity and Health Education
p
r
by involving :
I
Panchayat
Local Community Organisations
!
Voluntary Sector Projects
i
1
nr Private practitioners
I
nr ISM’s and Folk Healing traditions
nr Folk & local media
jj J
School based programmes
nr Creative , interactive - culture sensitive
. approaches
Dr. Ravi Narayan. Community Health Cell
jj J
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(from Fever programme to 'Malaria' programme)
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BE-ES31ABLISHING CLINICAL
DIAGNOSIS SKILLS
(diagnosing Malaria, excluding other
II
causes, diagnosing complications)
• RATIONAL DRUG POLICY FOR MALARIA
- rational standard regimes
- A and Rx of 'RESISTANCE'
I
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I
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A PROMOTING PERSONAL PROTECTION
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/
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ENVIRONMENT. ENVIRONMENTAL CHANGE AND THE
OPTIONS FOR VECTOR CONTROL
Felix P. Amerasinghe
Department of Zoology
University of Peradeniya
Sri Lanka
There are many historical instances of malaria associated with environmental changes
concomitant with human settlements, agriculture and irrigation. Equally, there are
instances where all of these factors have not resulted in significant increases in
malaria incidence. There does not appear to be a common link between malaria and
environmental factors. Indeed, recent studies suggest that such links as do exist are
complex and situation-specific.
In the Mahaweli project of Sri Lanka, for instance, one System (H) has been highly
malarious over nearly the past two decades, while another (System C) has not. Thus
different areas within the same overall project may react differently to development
Recent studies in the Mahi Kadana area of Gujerat, India, show higher vector
densities in irrigated than non-irrigated villages, and that vector densities are related
to irrigation water releases. In the canal-irrigated Pakistani Punjab, high water tables
and a plethora of surface water habitats have not been associated with high malaria.
Analyses of secondary health data have not been able to demonstrate any relationships
between the disease and depth to ground water or percentage of land under nee
cultivation.
Environmental Factors and their Management
Some key environmental factors relating to malaria are the sources of surface water,
climate, topography and soil. One could also consider man-made structures that
convey or store surface water (eg. reservoirs, canals, tanks) also as environmental
factors, albeit artificial.
Environmental management seeks to modify such factors in ways that reduce the risk
of generating malaria vectors. There is a mass of published literature detailing the
technical aspects of such manipulations. Yet, environmental management as a
countries
practical tool has not got off the ground in any tangible way in most
i..~r------:---- of the
*
S-;E Asian region.
To my mind, the primary problem is the enormity and complexity of the environment
per se, and the consequent lack of focus that results from recommendations relating to
its management. Added to this is a conceptual problem: malaria control agencies have
been imbued with the "magic bullet” philosophy since the advent of the "miracle of
insecticides. This has been followed by miracle drugs, miracle vaccines and the
prospect of miracle transgenic mosquitoes, all of which could be described as smart
weapons. In contrast, environmental management is very much in the nature of trench
warfare: slow, dirty, long term, and often involving co-ordination between several
agencies.
The conceptual change back to “old” methods of malaria control (albeit with modern
technology) may be difficult, but is increasingly being forced upon us. However,
much can be done to improve the focus of environmental management by developing
specific measures to address problems in specific situations. This is often described as
an ecosystems approach: one may tackle the problem at the level of a watershed, or an
irrigation command area, or a particular urban setting etc., and determine which of its
components produce vectors.
Some of the key issues that need to be focussed on are:
• What is the major vector of epidemiological importance?
• What is its main breeding habitat?
• Are there identifiable components of the ecosystem that consistently generate the
vector?
• Are these components amenable to management1
• What technical and organizational inputs are required from non-health agencies9
• Will managing these components have a local or system-wide impact ?
• To what extent can local communities be involved in the effort9
• What are the estimated costs/benefits of the intervention9
• How do these costs/benefits compare with existing vector control strategies?
In the SE-Asian region, existing data may be amenable to analyses that yield answers
to the above questions. However, it is a common experience that routinely collected
data are not of sufficient reliability on which decision-making can be based. In which
event, primary data will have to be obtained. However, such “research will need to
be geared to answer specific questions of practical applicability, rather than to indulge
in questions of purely academic interest
Case Study
A case study from Sri Lanka, in which I was fortunate to be involved, seeks to
illustrate this approach. Malaria has been a serious public health problem in much of
the north-central province for decades. A multidisciplinary team of vector biologists,
parasitologists, social scientists, economists, irrigation engineers and a malaria control
officer (representing the International Water Management Institute, University of
Peradeniya and the Anti-Malaria Campaign, Sri Lanka) have been investigating this
problem over the past 5 years in an area within this province known as the
Huruluwewa Watershed. This is an area of mixed forest and agricultural land
irrigated by an ancient tank-irrigation system, which more recently also receives
issues of water from the Mahaweli system. Some 600 farmer families (approx. 3000
persons) inhabit the area, and data shows that in an outbreak year, at least 50% of
them would suffer at least one episode of malaria. Our objective was to make a
system-wide analysis of the factbrs contributing to malaria, with a view to
implementing environmental management, if appropriate
Briefly, our studies established conclusively that, despite the involvement of several
anopheles species in malaria carriage. Anopheles culicifacies was the only vector of
real epidemiological importance. We then established that a stream, which also served
as an irrigation conveyance canal, was the primary breeding habitat. At the level of an
index study village, distance of houses from the stream was a significant risk factor
for malaria. At a system-wide level, villages further away from the stream had lowei
densities of the main vector, and concomitantly lower malaria. Thus, we were in a
position to convince irrigation engineers that manipulation of the stream could
potentially impact on malaria throughout the watershed. Detailed analyses ot water
dynamics of the entire watershed area that influenced water flows in the stream
followed, resulting in data that were used to model various water management
practices that could reduce vector breeding in this key habitat The most v.able one
was a redistribution of existing water flows in order to mamtam a water depth
sufficient to discourage the breeding of the vector. Costs analyses also ^ere done not
only of the water management measures, but also of other vector control
such as indoor residual spraying, bednets and stream larvciding as weB;as theco^s
of curative measures (hospital, mobile clinics, village-level treatment centres) in the
area We are now in a position to meet challenges relating to all aspects o
e
environmental management proposed, and to mobilize state agencies in the next
phase: implementation
This is a test case, but one that potentially has wider applicability both within ana
outside of Sri Lanka, since small irrigation schemes (both old and new) are common
throughout the region. What needs to be emphasized here is th^ vague ccncepts o
the benefits of environmental management will not convince either ma ari
other agencies to participate in such ventures. Hard data from sharply focussed tudies
are often the only way to proceed, first to interest non-health sectors to get involved,
and finally to convince policy makers and implementers that viable altematis es .
supplemets to insecticidal control are available
Ajnera^inghefl^pe& N.G. Indrajith. 1994. Post irrigation breeding patterns ol
surface water mosquitoes in the Mahaweli Project, Sri Lanka and comparisons with
preceding developmental phases. Journal ofMedical Entomology 31.
Mutuwatte, L.P. et al. 1997. Water-related environmental factors and malaria
transmission in Mahi Kadana, Gujerat, India. International Irrigation Management
Ik199&°irrigatio£ water relaeses and Anopheles cultctfactes
ground water and malaria prevalence, Punjab, Pakistan. International Irrigation
Management Institute. Working Paper No. 40. 39 pp.
a
Amerasinghe, F.P. et al. 1997. Anophelme (Diptera: Cuhcidae) breeding
traditional tank-based village ecosystem in north central Sri Lanka. Jounta of
ftom
Sri L»ka tart™ «/
respond.«
and
• -Jy
Koyal Soe^ of Tropical Med.aoe a.,d
SX; KH .Tim Measuring .he econom.c cost of malaria to households in
Sri Lanka American Journal of Tropical Medicine and Hygiene 56: 63 6f66^.
Van der Hoek, W. et al. 1998. Risk factors for malaria a microepidemiolog
study in a village in Sri Lanka. Transadions of the Royal Society’ oj 1 topical
—-7in sri
water management. Water Resources: Development 15: 93-105.
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I
MALARIA PROBLEMS IN INDONESIA
Challenges for Roll Back Malaria
Thomas Suroso
MEETING ON IMPLEMENTATION OF COLLABORATIVE
ACTIVITIES ON “ ROLL BACK MALARIA “
NEW DELHI, 4-6 MAY 1999
C :\mydoc\covermal .doc
CONTENTS
Page
1. INTRODUCTION
2
2. CURRENT MALARIA SITUATION
2
3. PROBLEMS AND CONSTRAINTS
3
4. FUTURE PLAN
4
5. SUMMARY
4
ANNEXES
C:\mydoc\crmal.doc
1
MALARIA PROBLEMS IN INDONES IA
I. INTRODUCTION
Malaria control in Indonesia was conducted as early as 1919. The control activities
included anti larvae measure (source reduction, larvivorous fish, irrigation works) and
prevention of transmission (using bednet or mosquito proof housing etc) in limited areas.
Quinine was widely used for malaria treatment as well as to control malaria epidemics.
Between 1952 and 1958 malaria control programme with insecticide residual spraying
was implemented in large areas of Java-Bali and certain areas of economic importance of
other islands.
In 1959 malaria eradication programme (MEP) was launched in Java and Bali, the most
densely populated islands of Indonesia, where 70 % of the total population lived. During
the MEP, the other islands were on the preparation phase for eradication. The MEP
Java-Bali was terminated in 1965 and the control policy has been revised turned back to
malaria control programme (MCP).
The two anti malaria programme in Indonesia was successfully reduced malaria problem
in Java-Bali. The malaria incidence in Java-Bali which was estimated 400 per thousand
population in 1950, was significantly reduced to 0.023 in 1968. However, following
termination of the MEP, malaria incidence increased up to 1.83 per thousand population
in 1973.
During 1974-1997 the Malaria Control Programme had been continued to control malaria
foci in Java and Bali and in the priority areas of the other islands i.e. : transmigration
areas and development areas such as forestry, agriculture, mining and tourist area.
II. CURRENT MALARIA SITUATION
In Java-Bali, the annual parasite incidence (API) tend to decrease following the
intensified MCP start than 1974. API was reduced from 1.83 per 1000 population in
1973 to 0,12 per 1000 population in 1997. However since 1995 API tend to increase.
At present, in Java-Bali where 65 % of the total country population live, malaria
transmission is absent. Malaria incidence has been kept below one case per 1000
population since the last 8 years.
C:\mydoc\crmal.doc
2
In the outer islands (Sumatera, Kalimantan, Sulawesi. Nusa Tenggara, Maluku, West
Irian) the malaria prevalence remain high and malaria foci with high endemicity are
scattered , mainly in the eastern part of the country
In urban areas and many cities of the outer islands mainly the capital of provinces, there
is no malaria vectors found, except in the eastern part of the country i.e. Province of Irian
Jaya and East Timor.
In outer islands, the parasite rate in the priority areas since 1988 is almost stable. Malaria
epidemics/outbreaks in year 1997 occurred in 11 areas, mostly in transmigration areas,
where non immune people entered malarious areas.
In Barelang Binkar where development program for industries and tourisms is
intensively and extensively conducted, malaria elimination programme has been
implemented in collaboration with the private companies. Malaria transmission
continuous to occur in these islands, with the highest peak occurs during the end of rainy
season, due to the increasing number of potential breeding places of An. sundaicus.
Two main factors causing malaria transmission were :
♦ Many workers come from endemic area and live together with non immune people.
♦ The increase of breeding places because of environmental change (construction of
factory, resettlement, building, roads and other public works).
In Irian Jaya, where the potential malaria vectors are: A.punctulatus group, malaria is
endemic in most of the province area. In 1997 during the.El Nino, prolonged drought and
forest bums caused malaria transmission the highland (2000 m asl) and outbreaks in
several localitis causing a high number mortality.
In copper mining area (Tembagapura), intensive malaria control has been implemented
successfully by the private company (PT Freepon Indonesia). Malaria transmission
occurs through out the year
III. PROBLEMS AND CONSTRAINTS
The problems for malaria control in Indonesia are as follows :
1. Lack of health personnel both in quantity and quality to carry out all malaria control
activities at all administrative level from the central down to the village level.
2. Shortage of supplies, equipment and budget to support activities of malaria control.
3. Lack of management capability particularly in district level.
4. Poor inter sectoral collaboration and community involvement.
5. Lack of awareness on malaria among health providers, community and decision
makers/adm i ni strato rs.
C:\mydoc\crmal.doc
The constraints for malaria control in Indonesia are :
1. Environmental changes due to development projects, climatic changes or others.
2. Population movement due to improvement of transportation facilities and economic
reasons.
3. Anti malarial drug resistance.
IV. FUTURE PLAN
To overcome the problems and constraints in the control of malaria in Indonesia, the
malaria control strategy has been revised and improved.
The strategy consist of
4 components as follows :
1. The capacity building of District level in malaria control management.
2. Decentralization of the management of malaria control program to District and HC
level
3. Building linkages and develop collaboration with related institutions including private
sectors and NGO's.
4. Promotion of community involvement in malaria prevention.
The above control strategies has been intensively implemented since 1997 in 6 provinces
(South Sumatera. West Java, Central Java. South Kalimantan. Central Sulawesi and East
Nusatenggara Provinces) under the intensified CDC Project supported by ADB.
As a follow up of the Intercountry Consultative Meeting of National Malaria Control
Programme Management, held in Pattaya. February 1999. 3 areas with different malaria
problems has been proposed for RBM pilot project i.e. transmigration in Kalimantan,
collaborative malaria control with private sectors in development project in BarelangBinkari and promotion of community involvement and inter sectoral collaboration in
refractory malaria area at the border of Central Java and Yogyakarta Provinces.
C:\mvdoc crmal.doc
V. SUMMARY
During the last five years, resurgence of malaria occurred in some foci in Java-Bali,
where as in outer islands malaria cases increased and several outbreaks were reported
from areas of environmental changes due to development project and climatic change.
Existing malaria problems include the lack of health personnel in quality and
quantity, shortage of supplies, equipment and fund, also lack of inter sectoral
collaboration, community participation and diminishing awareness to malaria.
Malaria Control Policy has been revised to improve and strengthening the strategy to
overcome problems and constraints include : building linkages and capacity,
promotion of community participation and, decentralization to intensify the malaria
control programme.
Three areas of different malaria problems have been proposed for pilot project to
implement the RBM approach (development project area, transmigration area and
refractory malaria foci).
C:\mydoc\crmai.doc
5
EXISTING MALARIA
SURVEILLANCE SYSTEMS AS
A DECISION SUPPORT MECHANISM
IN INDONESIA
Thomas Suroso
MEETING ON IMPLEMENTATION OF COLLABORATIVE
ACTIVITIES ON “ ROLL BACK MALARIA “
NEW DELHI, 4-6 MAY 1999
C:\mydoc\covsearo.doc
Parasite rates IN PRIORITY AREAS IN 7“
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TABLE OF CONTENT
I.
INTRODUCTION
IL
EXISTING SURVEILLANCE IN INDONESIA
III.
PARTICIPATION OF COMMUNITY & SECTORS OTHERS
THAN HEALTH
IV.
PROBLEMS
V.
FUTURE PLAN
VI.
SUMMARY
C:\mydoc co\searo.doc
EXISTING MALARIA SURVEILLANCE SYSTEM AS
A DECISION SUPPORT MECHANISM IN INDONESIA
I.
INTRODUCTION
During the period of 1959-1968, when malaria eradication programme was implemented,
the roll of PCD in malaria surveillance through hospitals was quite small, because most
of the malaria cases could be detected through ACD by surveillance agents. At this time,
the information on malaria status in outer island was collected mainly through malaria
surveys.
In 1968 malaria eradication programme in Java-Bali was terminated. Since then the
malaria control policy has been revised, and turned back to malaria control programme.
The activities of malaria control are integrated into the general health service. Therefore
malaria surveillance is carried out on the basis of the general health service system.
In 1977. 15.000 surveillance agents and malaria microscopist were recruited as
government servants. Since then, there has been no recruitment of this filed personnel.
The number of surveillance agents and microscopist has gradually decreased. Priority of
malaria surveillance was given to villages high incidence of malaria,. The shortage
by hiring
number of malaria surveillance agents and malaria microscopist were fulfilled
1
was
no
longer
daily workers, who work and paid on monthly basis. Malaria surveillance
conducted on a total coverage basis.
IL
THE EXISTING SURVEILLANCE IN INDONESIA
A. MALARIA CASE SURVEILANCE
Based on the activities malaria surveillance and control, Indonesia could be divided into
two areas :
(1) . Java-Bali, Barelang-Binkar and Timika and
(2) . Other areas
1. JAVA-BALI, BARELANG-BINKAR & TIMIKA
In this areas ACD is carried out by malaria surveillance agent through regular household
visit. The frequency of the visits depends on the seriousness of malaria incidence and
other purposive consideration.
C:\mydoc searo.doc
1
In the islands of Java, Bali, Batam and Bintan two weekly visit is applied in HCI areas
(Villages with malaria cases more 5 per 1000 population), in MCI areas ( villages with
malaria cases between I up to 5 cases per 1000 population.) is conducted monthly,
whereas in LCI the visit is perform on three monthly visit.
In Barelang and Binkar islands, all of the areas are covered by ACD, as there is no
shortage in the number the surveillance agents. In Bintan Beach International Resoil
active malaria surveillance is conducted by the health division of the project, using
worker-supervisors as the surveillance agent.
In Java-Bali and Barelang-Binkar, blood films collected by the surveillance agent from
fever cases and sent to the Health Centers for microscopic examination.
In Timika, Irian Jaya Province, where intensive malaria control is organized by PT.
Freeport Indonesia, daily house to house visit is performed by surveillance team.
In addition to the above active case finding, all clinical malaria cases detected by health
centers and hospitals are to be bled for slide examination.
In all areas where ACD is conducted, all microscopic confirmed malaria cases are to be
visited by senior surveillance agent for epidemiological investigation to classify the
malaria cases into indigenous, imported, relapse or unclassified. Follow up actions is
made by the HC based on the result of the investigation.
2. OTHER AREAS
Malaria surveillance in other areas of Indonesia is mainly based on the clinical finding in
health centers and hospitals. This is due to the lack of microscopist and microscope in
many of the health centers.
In the health centers with no laboratory facilities, all clinical malaria cases are treated
with standard malaria treatment (Chloroquine 10 tablets and primaquine 3 tablets).
In hospitals and health center where laboratory for malaria confirmation is available,
treatment of malaria cases is given according to the species of malaria parasite.
In transmigration and other priorities areas (industries, mining, forestry, tourism and other
development projects), malaria prevalence is measured by conducting malariometric
survey to children under ten years old, every year during the expected highest malaria
transmission. Spleen examination is usually conducted to measure malaria endemicity at
the beginning of each development project.
Malariometric survey in transmigration areas and the surrounding villages are conducted
yearly by the district health offices together with the health centers, to monitor malaria
prevalence. Whereas in the development projects and areas of 2 km radius outside the
C:\mydoc\searo.doc
2
project is the responsibility of the private companies usually provide clinic with
doctors/nurses and. anti’malarial drugs. Report on the clinic attendants is usually sent to
the District Heaidi Office.
B. VECTOR SURVEILLANCE
Activities of vector surveillance include :
1. Monitoring potential breeding places of An. sundaicus (and An. subpictus ).
In west coast of Sumatera, south coast of Java. Bali and Lombok islands, monitoring
Anopheles sundaicus breeding places is usually conducted every month during
the malaria transmission season in each of the malaria foci.
Larva control measure such as larviciding or cleaning algae on the water surface are
immediately conducted to eliminate Anopheles sundaicus larvae and prevent malaria
transmission and outbreak.
In Bintan resort of Riau Province , larva monitoring and elimination is conducted
weekly to prevent malaria transmission in these tourism areas by Malaria Division of
Bintan Beach International Resort.
Similarly in Timika, intensive monitoring and elimination of larva is conducted
regularly by PT.Freeport Indonesia.
2. Monitoring insecticide for detecting early resistance of malaria vectors is conducted
in areas with high suppression of insecticide residual spraying.
3. Monitoring fluctuation the vector density7 on a monthly basis is conducted in selected
localities of malarious areas in several provinces.
C. MONITORING ANTI MALARIAL DRUG EFFICACY:
Monitoring anti malaria drug efficacy aims to detect resistance of anti malarial drugs to
P.falciparum . At present the monitoring has been done in 3 provinces of Indonesia :
Central Java, Yogyakarta and East Nusa Tenggara Provinces this will be expanded to 4
other provinces i.e. West Java, South Sumatera, Central Sulawesi and South Kalimantan
Provinces.
III.
PARTICIPATION OF COMMUNITY & OTHER SECTORS
In outer islands and in malaria foci Java-Bali, cadres in malarious areas is provided by a
simple anti malaria drug (chloroquine) in their home to treat fever cases (Drug post). In
addition, the cadres also take part in the regular activities of POSYANDU by reporting
fever cases with chills and give anti malarial drugs. The cadres is guided and supervised
by the health center.
C:\mydoc\searo.doc
In Java and
toahof villages in malaria potential areas (receptive areas) are requested
to inform health center if any fever case coming from outer islands for blood
examination
Transmigraticr: Department provides facilities for sub-health center including anti
malarial drugs m each transmigration areas and operational cost for vector control.
Most of the "vale sectors in development project provide health facilities including anti
malarial drugs and other facilities for personal protection such as distribution of bet-net
and provision mosquito screen housing to prevent malaria transmission.
All hospitals and clinics of private and public are requested to sent monthly report to the
District Heal± Office.
IV.
1
PROBLEMS
Shortage :: microscopist/laboratory technician and lack of microscope at the health
center in : cter island.
2. Diminishing number of surveillance agents has caused limited areas covered by
malaria surveillance.
3. Limited quantity and quality of the entomologist at the province and assistant
Entomologist at the district level as well as mosquito collectors in the field level.
4. Lack of legislation concerning the obligation of private sectors in the prevention and
control c: malaria.
5. Lack of sense of emergency on malaria among health providers from central down to
the healtn center have caused unproper recording, weak analysis, delayed reporting
and dela\ ed response to anticipate malaria problem.
6. Lack hea_’_h education activities to increase community involvement.
7. Lack of experience staff in malaria control at all administrative level.
8. No laborziory facilities for cross checking at the District level.
C: m\doc sei-
4
V.
FUTURE PLAN
To improve the quality and coverage of the malaria surveillance , the following activities
has been planned as follows :
1. Training of microscopist /laboratory technician at the health center and provision of
microscope to health center in outer islands.
2. Training entomologist and assistant entomologist.
3. Training of Health staff at the Province, District and HC on malaria surveillance.
4. Improve waging and recruitment system of malaria surveillance agent in Java-Bali.
5. To strengthen and develop various components of surveillance system within the
health sector (village midwife, sub-health center, private practice) and other sectors
including private companies and the community.
6. Establishment of regulation for private sectors in malaria prevention and control.
7. To intensify information and develop health education program on malaria control.
8. To develop Vector Control Field Station (VCFS)
In six Provinces under ICDC Project, the VCFS are being constructed to support the
Malaria Control Program in providing reliable and accurate data for control activities.
VCFS will carry out surveys and operational studies to solve the malaria and other
vector borne diseases problems. VCFS will be established 6 provinces under ICDC
project (South Sumatera, West Java, Central Java, South Kalimantan, Central
Sulawesi and Eats Nusa Tenggara provinces).
The VCFS will also involve in various training on malaria and other vector borne
diseases to health staff of District Health Office and Health Center.
VI. SUMMARY
Since 1968 when Malaria Eradication Program (MEP) in Java-Bali was terminated the
malaria control including surveillance activities has been integrated into general health
services. However, up to the present, active case finding is still implemented in high case
incidence of Java-Bali, and in Barelang-Binkar where the control program aims at
elimination of malaria and in Timika where malaria transmission is extremely high and
the vector is difficult to be controlled. Whereas, in other areas of Indonesia, malaria
surveillance was conducted mainly based on the clinical malaria case finding.
In transmigration area malariometric survey is conducted by District Health Officers once
a year during the expected highest transmission. Whereas in the development projects
such as mining, forestry, tourism etc. malaria case finding and management is handled by
the private companies clinic.
C:\mydoc\searo.doc
5
At present malaria surveillance in Indonesia has not achieved a total coverage as a
consequences of limited number of surveillance agent in Java-Bali, and lack ot
microscopist and laboratory facilities at the health center in the outer islands.
To improve coverage and quality of malaria surveillance, several steps have been planned
and conducted :
1. Improvement of policy and strengthen malaria surveillance system.
2. Training of microscopist and entomologist, provisions of microscope at the health
center.
Training on malaria surveillance to the health staff from the province down to the
health center level.
4. Develop and improve cross check system for microscopi work.
5. Strengthen and develop various component of surveillance system whit in health
sector, other sector and the community.
6. Development of vector control field station in six provinces.
C: mydoc\searo.doc
6
WORLD HEALTH ORGANIZATION
ORGANISATION MONDIALE DE LA SANTE
MEETING ON ‘IMPLEMENTATION OF COLLABORATIVE
ACTIVITIES ON ROLL BACK MALARIA, NEW DELHI,
4-6 MAY 1999’
TENTATIVE PROGRAMME
Tuesday, 4 May 1999
0800 - 0830 hrs
Registration
0830-0930
Inauguration - as per enclosed programme
0930- 1000
Introduction of participants
Election of Office Bearers
Announcement of administrative arrangements
i
3
1000-1030
The Roll Back Malaria concepts, mechanisms and approaches
(Dr David Nabarro)
1030-1100
WHO / UNICEF partnership for rolling back malaria
(Dr Rudolf.Knippenberg)
1100-1120
Rolling Back Malaria in SEA Region through Health Sector
Development (Mr David Peters)
1120-1140
A brief overview of the malaria situation : The main types of malaria
situation, the main problems in the region and the progress made
(Dr V.S. Orlov)
1140- 1200
Challenges for Rolling Back Malaria
■ The malaria problem in India (Dr Shiv Lal)
1200- 1220
Challenges for Rolling Back Malaria
■ The malaria problem in Indonesia (Dr Thomas Suroso)
1220- 1330
Lunch break
1330- 1350
Provision of health care for malaria (early treatment) in decentralised
health systems (MrRajiv Misra)
1350- 1410
Anti-malarial drug resistance patterns and monitoring systems in South
Asia: a review of the situation in the region and an outline of the issues
(Dr V.S. Orlov)
1410-1430
The role of combination therapy for malaria
(Dr Francois Nosten)
1430-1500
Cost effectiveness studies on bed nets / house spraying in
South Asia : The rational use of insecticides, monitoring of
Resistance and national policies on insecticide use
(Dr V.P. Sharma)
1500- 1530
Tea/Coffee break
u
1530- 1610
Environmental changes and scope for transmission control
(Dr F.P. Amerasinghe and Mr Robert Bos)
/Z
1610-1630
The role of the private sector in prevention and treatment of
malaria: success stories, opportunities and potential mechanisms
(Dr Mohammad Asri)
I 3
1630- 1650
Involving donor agencies in country level action: a moderated
discussion (Moderator: DFID)
1650- 1710
Roll Back Malaria in the Community (Dr Ravi Narayan)
G>
7
/O
i
'
♦
4
Wednesday, 5 May 1999
/5
0800 - 0820
The role of media in advocacy for RBM, and the scope for social
and political mobilization (Mrs Harsaran Bir Kaur Pandey)
I C
0820 - 0840
Malaria indicators used in the SEA region, and the need for better
standardization (Dr R.M. Montanari)
0840 - 0900
Lessons learnt from the recept epidemics with the region
(Dr M.B. Bista)
I
0900 - 0920
Existing malaria surveillance systems as a decision support mechanism
in Indonesia (Dr Thomas Suroso)
1^1
0920 - 0940
The use of GIS as a component of the surveillance system
Dr A.R. Wickremasinghe)
0940- 1000
Epidemic malaria in chronic emergencies (Dr Francois Nosten)
1000- 1030
Tea / Coffee break
1030- 1050
Presentation of the Roll Back Malaria Technical Support Network on
Malaria Epidemics (Dr Charles Delacollete)
1050- 1130
Coordination of malaria control in border areas: status and needs
(Dr Shiv Lal)
1130- 1230
Formation of Working Groups
1230- 1330
Lunch Break
1330- 1500
Group Work
1500- 1530
Tea / Coffee break
1530- 1630
Group Work
2)
I
Thursday, 6 May 1999
i
J____
0800- 1000
Preliminary presentations by Groups
1000- 1030
Tea / Coffee break
1030- 1230
Group discussion as per enclosed details
1230- 1330
Lunch break
1330- 1500
Group Work
1500- 1530
Tea/Coffee break
1530- 1630
Adoption of Recommendations
1630- 1700
Closure of Meeting
o
Malaria Journal
BiOlWed Central
Case study
A community-based health education programme for
bio-environmental control of malaria through folk theatre
(Kalajatha) in rural India
Susanta K Ghosh*1, Rajan R Patil4-2, Satyanarayan Tiwari1 and
Aditya P Dash3
Address: ’National Institute of Malaria Research (ICMR), Epidemic Diseases Hospital, Old Madras Road, Bangalore - 560 038, India, Community
Health Cell, Kormangala, Bangalore - 560 034, India, ’National Institute of Malaria Research (ICMR), 22-Sham Nath Marg, Delhi - 110 054, India
and “Integrated Disease Surveillance Programme (WHO, UNDP), UN House-II, 256, Forest Park, Bhubaneswar, Orissa - 751009, India
Email: Susanta K Ghosh* - ghoshmrc@vsnl.net; Rajan R Patil - rajanpatil@yahoo.com ; Satyanarayan Tiwari - satyanarayan_01@yahoo.com;
Aditya P Dash - apdash2@rediffmail.com
* Corresponding author
Published: IS December 2006
Malaria Journal 2006, 5:123
doi: 10.1186/1475-2875-5-123
Received: 13 December 2006
Accepted: 15 December 2006
This article is available from: http://www.malariajOurnal.eom/content/5/l/l23
© 2006 Ghosh et al; licensee BioMed Central Ltd.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (h.ttp;//cr€atlY€CQmrnQns19rg/llC€n$€$/by/2.Q).
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Abstract_____________________________ __________ ________________________________________
Background: Health education is an important component in disease control programme.
Kalajatha is a popular, traditional art form of folk theatre depicting various life processes of a local
socio-cultural setting. It is an effective medium of mass communication in the Indian sub-continent
especially in rural areas. Using this medium, an operational feasibility health education programme
was carried out for malaria control.
Methods: In December 2001, the Kalajatha events were performed in the evening hours for two
weeks in a malaria-affected district in Karnataka State, south India. Thirty local artists including ten
governmental and non-governmental organizations actively participated. Impact of this programme
was assessed after two months on exposed vs. non-exposed respondents.
Results: The exposed respondents had significant increase in knowledge and change in attitude
about malaria and its control strategies, especially on bio-environmental measures (p < 0.001).
They could easily associate clean water with anopheline breeding and the role of larvivorous fish in
malaria control. In 2002, the local community actively co-operated and participated in releasing
larvivorous fish, which subsequently resulted in a noteworthy reduction of malaria cases.
Immediate behavioural changes, especially maintenance of general sanitation and hygiene did not
improve as much as expected.
Conclusion: This study was carried out under the primary health care system involving the local
community and various potential partners. Kalajatha conveyed the important messages on malaria
control and prevention to the rural community. Similar methods of communication in the health
education programme should be intensified with suitable modifications to reach all sectors, if
malaria needs to be controlled.
Page 1 of 7
(page number not for citation purposes)
Malaria Journal 2006, 5:123
Background
The threat of malaria
Malaria is a major public health threat to the developing
world, indirectly affecting the economic development.
Nearly 40% of the world's population is at risk and 80%
of the burden exists in sub-Saharan Africa. Almost all the
remaining cases exist in tropical and subtropical Asia,
Latin America and Melanesia [ 1]. In India, less than two
million cases with few hundred deaths are recorded every
year [2,3], but the estimated number is 15 million with
about 19,500 deaths [4]. Karnataka state, south India con
tributes approximately 7-10% of India's annual malaria
burden [5].
The need for health education in malaria control
programme
Unlike HIV/AIDS, sufficient emphasis has not been given
to health education in malaria control programmes. This
has resulted in poor community acceptance and involve
ment in the various control strategies undertaken [6].
WHO under the Roll Back Malaria (RBM) initiative recog
nizes the need for community participation and inter-sec
toral co-ordination involving various like-minded
partners for effective programme implementation [7].
Community being the stakeholder, it is essential that
information about diseases and their control methodolo
gies should be made available to them [8].
There is no standard format for delivering health educa
tion messages. Many conventional methods such as post
ers, pamphlets, hoardings and electronic media, have
limited effects on the rural community due to their low lit
eracy rate. In such situation, Kalajatha (folk theatre) as a
medium of mass communication has been experimented
to assist the malaria control programme.
Background to the study
Each year, nearly 50% of malaria cases in Karnataka were
reported from the districts of Tumkur, Hassan, Chickmagalur and Chitradurga [5]. Anopheles culicifacies is the
primary malaria vector, which breeds mainly in wells,
streams and irrigation ponds |9|. The traditional method
of malaria control using indoor residual spraying with
insecticides even with synthetic pyrethroids did not pro
duce the expected result. A kind of frustration was prevail
ing in the local community. In a silk producing area of
Kolar district, local farmers were reluctant to the use of
DDT spaying because of the perceived deleterious effect
on silk worms. In this area, bio-environmental control of
malaria especially larvivorous fish is very effective in con
trolling An. culicifacies [ 10,11 ]. Tumkur was one of the five
districts in India selected for situational analysis under
RBM. The expert committee recommended the need for
health education in malaria control [12]. Based on this.
http.7/www.malariajournal.com/content/5/1/123
the present programme was initiated with the following
objectives:
i. to assess the operational feasibility and communication
efficacy of Kalajatha in health education programme for
bio-environmental control of malaria.
ii. inter-sectoral co-ordination and involvement of all
potential partners in health education.
Methods
Population and the area served
The Kalajatha programme was organized in Primary
Health Centre (PHC) Mathigatta under Chikkanayakanahalli taluka, Tumkur district which was badly affected by
malaria [5]. This taluka (secondary revenue division) has
264 villages covering an area of 112,998 hectares with a
population of 215063 in 2001. The villages are adminis
tered by 28 Gram Panchayats (village elected representa
tion). Health care services are provided through eight
PHCs. PHC Mathigatta has 58 villages with a population
of 28253. The literacy rate was 63%. The male to female
sex ratio was 0.97. Infant mortality rate was 50 per 1,000
live births. The birth rate is double the death rate. Agricul
ture, horticulture, and animal husbandry are the main
economic activities, which engage almost 80% of the
workforce. Coconut is the main cash crop. Agriculture
provides only seasonal employment and the returns are
low. Non-agricultural economic activities are poorly
developed. The annual rainfall ranges from 600 to 800
mm while temperature is between 13°C and 39°C. The
peak malaria transmission period is in the months May
and June.
The partners and planning
The National Institute of Malaria Research (NIMR) and
Community Health Cell (CHC), Bangalore, jointly initi
ated the programme. An inter-sectoral co-ordination com
mittee was formed involving ten governmental and non
governmental organisations for smooth functioning. The
district health committee headed by the District Commis
sioner approved the proposal of the Kalajatha pro
gramme. NIMR and CHC, Departments of Health,
Education, Child and Women's Welfare, Rural Develop
ment and Panchayat Raj, Tumkur Science Forum, local
political and religious leaders actively participated in this
programme.
Thirty local artists (15 males and 15 females) from differ
ent occupational background were selected. A local script
writer wrote 8 songs, two dramas and 4 rupakas (musical
dramas). The scripts were based on various aspects of
malaria namely signs and symptoms of sickness, treat
ment, health facilities, processes of transmission, role of
anopheles mosquitoes and names of the malaria vectors,
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Malaria Journal 2006, 5:123
breeding grounds of mosquitoes especially the vectors, its
control strategies focusing especially on larvivorous fish
(Poecilia reticulata and Gambusia affinis} and environmen
tal management. Other control strategies like insecticidetreated nets, adopting measures for maintaining general
hygiene, keeping cleanliness in and around houses, and
the role of the community were also included in the script.
These were then translated into skits using local dialects,
musical styles and theatre traditions. In the beginning, the
artists underwent orientation training on the entire proc
esses. Two troupes consisting of 15 artists each were
formed. Before the actual performances, they rehearsed
the events in the evening for two weeks in a religious trust
of Kuppur Mutt (Figure 1). Each troupe was equipped with
a set of musical instruments and a performing wardrobe.
The Kalajatha events
The Kalajatha events were performed in December 2001.
One week before the events, wide publicity was given
through the local village administration (Gram Panchayat)
and the community consent was obtained from the village
headmen or Panchayat presidents (Figure 2). The Minister
in-Charge of the district and the local elected legislative
assembly members inaugurated the programme (Figure
3). The events were performed in the evenings so that
maximum number of people could witness. Every day,
each troupe visited two villages and spent two hours in
each village. Villagers voluntarily attended the pro
grammes (Figure 4). Local health officials and Gram Panchayats provided all the necessary logistics and hospitality.
A valedictory function was held at the end, which was pre
sided over by the Director of Health Services, Karnataka
(Figure 5). Local media covered the events and helped in
spreading the key messages.
Il III
fl
M4
Figure 2
Public awareness campaign for the Kalajatha programme.
Local high school children, teachers and Gram Panchayat
members took part in the campaign.
Impact assessment
Two months after the events, impact was assessed in five
villages of PHC Mathigatta (exposed) and in another five
villages of PHC Dasaudi (non-exposed) chosen at ran
dom. Semi-structured interviews based on eight question
naires were conducted with individual households. In
each village, households were selected randomly and con
sidered as one unit. All the individuals in the house
I
111^ ;
;.
J
Pr -■
ILk
J
Figure I
Rehearsal of the Kalajatha programme in the evening at the
Kuppur Mutt (religious trust). A trainer was directing the art
ists.
-j
Figure 3
Inauguration of the Kalajatha programme, December 2001.
The Minister-in-Charge of Tumkur district, local Gram Pan
chayat members, Head, Kuppur Mutt, district health officials,
members from NIMR, CHC, Bangalore and others were
present.
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Malaria Journal 2006, 5:123
http://www.malariajournal.eom/content/5/1/123
(17 children and 120 adults) respondents respectively
were interviewed. The exposed respondents significantly
gained new knowledge about malaria, its symptoms,
transmission and control methodologies (P < 0.001).
They could easily associate clean water with anopheline
breeding and recall the names and the role of larvivorous
fish guppy (Poecilia reticulata) and Gambusia affinis in con
trol of malaria vectors. However, immediate behavioural
changes especially in maintenance of general hygiene
were not observed. The budget breakdown of the events is
summarized in Table 2. The per capita cost for conducting
the programme was INR 3.0 (US $ 0.064; 1 US $ = 47
INR).
IB"- ■
Figure 4
A glimpse of the Kalajatha programme performed by the art
ists. The artists are presenting the various sings and symp
toms of malaria.
present at that time were interviewed. Children below
eight years were excluded. Responses between the exposed
and the non-exposed respondents were analyzed follow
ing Fisher Exact and %2 tests, wherever applicable.
Results
Data on the Kalajatha responses are shown in Table 1. Of
the total 87 households interviewed 48 were from PHC
Mathigatta (exposed) and 39 from PHC Dasaudi (non
exposed). In the exposed households, 152 (23 children
and 129 adults) and in the non-exposed households 137
Figure 5
Sharing the experience of the Kalajatha programme in the
valedictory function. The Director, Health and Family Wel
fare Services; Head, Kuppur Mutt, members from NIMR,
CHC and local Gram Panchayat members and other local
health officials participated in the function.
Discussion
There are many forms of theatres for delivering health
messages. Street theatre, folk theatre forum theatres etc.
are being used in many countries. In the Indian sub-con
tinent Kalajatha is a very lively and highly powerful tradi
tional art of dance and drama (folk theatre) which
delivers key messages of the life processes in local dialects
and cultural settings. This is slightly different from street
theatre. Street theatre is utilized for mobilizing people to
participate in controlling tuberculosis, HIV/AIDS, polio,
diarrhoeal diseases and also malaria [13-16]. Puppet
shows and street theatre is being used extensively in HIV/
AIDS control programme [ 17,18]. In Africa and in North
America, in both rural and urban settings, forum theatre is
an effective means of health promotion. Projects on
women's health, care for patients with mental disorders,
and AIDS prevention show the usefulness of this medium
for community action programmes [19]. Theatre was used
for mobilizing and sensitizing the community for tsetse
control in Uganda [20]. In a cross-sectional study, an
impact of IEC campaign for tuberculosis and health seek
ing behaviour was assessed in Delhi and was used as pro
gramme performance indicator [211.
Attempts were made to explore this strong medium for
bio-environmental control of malaria under the primary
health care system. The performances were very lively and
motivating and many spectators even offered to act along
with the actors. In some events many had reacted and also
agitated for not providing the proper treatment and cor
rect information to the community earlier. The biggest
information delivered to the community was that Anoph
eles and Aedes mosquitoes breed in clear water as against
the general belief of polluted water where Culex mosqui
toes generally breed. Use of biocontrol agents, source
reduction of opportunistic breeding of vector mosquitoes,
treatment, health education, environmental manage
ment, maintenance of cleanliness and personal hygiene
are important components of bio-environmental control
strategy. This method is very effective in Indian situations
122]. Besides this, various other methods of malaria con-
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Malaria Journal 2006, 5:123
Table I: Responses of the Kalajatha events performed in December 2001
Respondents
Questionnaires
Exposed
Any new learning
17 children and 102 adults responded that they had learnt new information about
malaria
2
Signs and symptoms of malaria
3
Knowledge of malaria
transmission
4
5
S. No
Non-exposed
P
None responded correctly
<0.001*
6 children and 93 adults could describe the three stages of malaria; chill, fever and
sweat
None could tell correctly
<0.001*
9 children and 57 adults specified correctly
Only 4 school children
<0.001b
Name of the malaria vectors
11 children and 61 adults. Children clearly specified female Anopheles mosquito
Only 4 school children
Breeding grounds of malaria
vectors
19 children and 102 adults clearly specified clear water sources
3 children and 10 adults
specified clear water
<0.001b
<0.001b
6
Larvivorous fish in malaria
control
19 children and 137 adults clearly specified
Only 13 adults specified
< 0.001b
7
8
Names of larvivorous fish
8 children and 18 adults correctly responded
None responded
<0.001*
Any physical improvement/
changes after the events
All responded positively to change in their attitude towards cleanliness and
hygiene. However, no change in practice was observed
Negative response
* Fisher Exact test; b Chi-square test; % Effectiveness could not be found due to some responses were 0 (none) in the non-exposed respondents.
trol including insecticide treated nets were also incorpo
rated in the messages, but the focus was on larvivorous
fishes since they are, at the moment, the main interven
tion in malaria control in the area.
The present study set an example of inter-sectoral co-oper
ation between various heterogeneous groups. Apart from
the impact, the process was itself a model of governmental
and non-governmental partnership which was timely
especially when the government is seeking examples of
public-private partnership in health education activities.
The education department deputed five teachers while the
Child and Women's Welfare Department deputed ten
Angamuadi (female resident staff) workers for one month.
Fifteen members from the local community, with various
occupational backgrounds ranging from carpenter to bar
ber, and having artistic acting and singing talent came
together as a team. The Government of Karnataka through
the Department of health partially funded the pro
gramme. Politicians and ministers played their role by
accepting the invitation to inaugurate the programme
thereby providing wider visibility to the health education
programme. Religious leaders contributed by offering free
accommodation and hospitality for the period of one
month as a token of solidarity in the fight against malaria.
The press and radio helped in wider dissemination of
health education messages and analyzing the malaria sit
uation of the district. Female artists were involved in the
team, which resulted in good responses from the women
community. Currently, all the developmental pro
grammes including health are directly executed by the
Panchayat Raj Institution. The local Gram Panchayat mem
bers provided maximum support to this programme. Sub
sequently these members played a major role in
disseminating the messages and generated awareness in
the entire area. In the following year (2002), the commu
nity co-operated actively in a WHO funded project in
releasing larvivorous fish for malaria control. The mid
term report revealed that in Chikkanayakanahalli taluka
malaria cases have declined from 10,136 in 2001 to 66
(up to September 2006) (23].
The present study was aimed to sensitize and mobilize
and its impact on the community using folk theatre to
control malaria especially on bio-environmental meas
ures for which no comparable baseline data were availa
ble. The data between the exposed and non-exposed
respondents indicated that there was no perceived infor
mation on the present campaign. In rural areas many fes
tivals and socio-cultural programmes are performed that
Table 2: Budget breakdown of the Kalajatha programme
Item
Grant provided by the State Health Department, Government of Karnataka towards honorarium for 30 artists; local transport from their houses to
the PHC head quarter; wardrobes; event management and incidental expenditures for two organisers from Community Health Cell
Approximate amount received in kind:
Kuppur Mutt for in-house one-week training of the artists
Taluka Health Office for providing transport facility from PHC to the respective villages for 15 days
Gram Panchayats for providing refreshments
National Institute of Malaria Research, Bangalore
Total amount spent to cover 58 villages (population 28253) was INK 85000.00 Per capita cost was INR 3.0 (US$ 0.064); I US$ = INR 47.
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Malaria Journal 2006, 5:123
Table 3: General steps, in chronological order for conducting a Kalajatha programme
Target: Local community suffering from a specific disease for which they can contribute in the control programme.
Partners and planning: Select the problematic area. Identify the related partners. Form a co-ordination committee involving all potential
partners. Arrange funding for the programme. Identify the artists. Conduct the programme in an appropriate season and time. Give wide publicity
and seek political and religious support. Rehearse the programme.
Content: Compose music and drama based on the local dialects and tradition carrying the key messages of the disease and its control
methodologies. Emphasis should be given on their specific role in the control programme.
Logistics: Materials for event management e.g. wardrobe, light and sound systems, refreshments, honorarium and transport etc. for the artists
should be made available in time.
Precautions: Prior consent of the community should be obtained. Other programmes should not coincide in the same area. An orientation
workshop is necessary for the collaborating partners before launching the programme. Co-ordination should be maintained at all levels and time.
may have some counter effects on such events. Such issues
were taken into consideration while organizing the Kala
jatha events.
Conclusion
Health education aims at behavioural changes in individ
uals and the community. Kalajatha was found to be a very
effective medium in promoting health education and pos
sibly behavioural changes to the rural community. The
immediate behavioural changes especially on mainte
nance of general hygiene was not observed. However, the
first essential step towards achieving behaviour change
communication in the community was achieved by pro
viding correct and scientific information on malaria con
trol and prevention through the innovative and
traditional medium that the rural community best identi
fied. Implementation of control measures by the authori
ties would enhance the community's acceptance and
bring about major behavioural changes so as to avoid
mosquito borne diseases [24]. Efforts were made to con
vey the correct messages to the community, because
wrong messages may have disastrous after-effects. Many
still believe two kinds of environmental modifications
which are effective against malaria and are unfortunately
frequently included in health education posters as anti
malaria measures. These are (a) cutting grass and bush
clearance which was shown to be completely ineffective
[25]; (b) clearing of garbage to prevent rainwater accumu
lation that supports breeding of Aedes mosquitoes which
need to be controlled for dengue outbreaks, but these
mosquitoes do not transmit malaria.
Webber [26] has rightly advocated 'a multiplicity of sim
ple methods, carried out by many people who are likely to
be more successful in the long term than more complex
methods. It will be the community who will finally con
trol malaria, but health authorities must advise and assist
them in the ways of achieving this'. In the study area bio
control of malaria programme is being maintained rou
tinely. People still refer to the Kalajatha events and the
messages delivered to them earlier. Thus this made indel
ible marks in the people's mind for a long period. This
programme is now utilized for other diseases also. A
detailed account has been described in Table 3 for carry
ing out a Kalajatha programme with suitable modifica
tions. Based on the results described in the present paper,
the State Health Department is conducting such events for
the prevention of HIV/AIDS.
Authors' contributions
SKG and RRP conceived and ananged the entire pro
gramme. SNT assisted in conducting the events. APD
reviewed and edited the paper. All authors helped write,
read and approved the final manuscript.
Acknowledgements
We would like to thank Dr. Ravi Narayan and Dr. CM Francis and other
members of the CMC. Bangalore team for guidance and encouragement;
the teachers from government schools and the Tumkur Science Forum in
helping us with detailed field arrangements; the Deputy Commissioner, the
District Health Officer, the District Malaria Officer of Tumkur District, the
Taluka Health Officer, Chikkanayakanahalli taluka, the PHC Medical Officer,
Mathigatta, the Indian Council of Medical Research, New Delhi for their
support. A special acknowledgement to the students of the Indian Institute
of Management, Bangalore for data collection and all the artists of Kolajotho
for active participation. We are grateful to the Director, Health and Family
Welfare Services, Government of Karnataka for providing financial assist
ance and his keen interest in the programme. Special thanks to Prof C.F.
Curtis, London School of Hygiene and Tropical Medicine, London for
reviewing and valuable suggestions.
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Page 7 of 7
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INT J TUBERC LUNG DIS 14(10):1215-1221
©2010 The Union
---------------- 2010---------------THE YEAR OF THE LUNG
Series editor: John F. Murray
UNRESOLVED ISSUES
In this month’s 2010: Year of the Lung series, readers are privileged to have
the views of two groups of experts from different parts of the world who
agree that extreme poverty and all its accompaniments—malnutrition, over
crowding or homelessness, addiction, and lack of access to health care—is
the major driving force underlying the presence and spread of tuberculosis,
including the current increases in tuberculosis caused by multiple drug
resistant and extensively drug-resistant strains. Doctors Benatar and Upshur
reach this conclusion by taking an historical route from the distant past to
the present and suggest ‘a new mind set’ for the future. By contrast, Doctors
Keshavjee and Farmer review the more recent treatment strategies that have
worked and those that have failed, and propose ways to ‘put boots on the
ground’ to finally control this eminently treatable scourge. Tuberculosis will
continue to flourish as long as the poverty that fosters it remains uncontrolled.
Moreover, experience has taught us how to mobilize resources in ways that
have proved effective in controlling drug-resistant strains in previous highburden, low-income regions. The time has come to apply these lessons.
John F. Murray, Series Editor
e-mail: johnfmurr4@aol.com
Tuberculosis and poverty: what could (and should) be done?
S. R. Benatar,*1 R. Upshur*
* Faculty of Health Sciences, University of Cape Town, Observatory, South Africa,f Joint Centre for Bioethics, University
of Toronto, Toronto, Ontario, Canada
HISTORICAL BACKGROUND
* _
Four eras can be identified within the history and tra
jectory of tuberculosis (TB) in the world. In each of
these eras, different sets of circumstances have con-
Previous articles in this series, Int J Tuberc Lung Dis 2010 Editorials:
Murray J F. 2010: The Year of the Lung. 14(1): 1-4; Castro K G, Bell
B P, Schuchat A. Preventing complications from 2009 influenza A
(HIMl) in persons with underlying lung diseases: a formidable
challenge for 2010 Year of the Lung. 14(2): 127-129; Barker K. Ca
nadian First Nations experience with MINI: new lessons or peren
nial issues? 14(2): 130; Annesi-Maesano I. Why hasn't human ge
netics told us more about asthma? 14(5): 521-523; Billo N E. Good
news: asthma medicines for all. 14(5): 524; Goodman P C. Com
puted tomography scanning for lung cancer screening: an update.
14(7): 789-791; Price K A, Jett J R. Advances in treatment for non
small cell lung cancer. 14(7): 792-794; Kumaresan J, Enarson D A.
Inequities in lung health: challenges and solutions. 14(8): 931934. Unresolved issues: Lal loo, U G. Drug-resistant tuberculosis:
reality and potential threat. 14(3): 255-258. Review articles: Mur
ray J F. The structure and function of the lung. 14(4): 391-396;
Daley C L, Griffith D E. Pulmonary non-tuberculous mycobacterial
infections. 14(6): 665-671. Perez-Padilla R, Schilmann A, RiojasRodriguez H. Respiratory health effects of indoor air pollution.
14(9): 1079-1086.
tributed to the amelioration or aggravation of the
burden of this disease (Table I).1
We are now at a crucial and determining point in
our global experience with tuberculosis, and we may
well ask what the fifth era will hold for humanity. We
face the spectre of either having to deal with more
drug resistance or collectively making a concerted ef
fort to face, realistically, the global challenges posed by
tuberculosis. The persistence of poverty will ensure
ongoing complexity in providing effective treatment.
As severe poverty is the result of a global political
economy deliberately structured by humans, we have
the potential to control the scourge of tuberculosis.
WHAT IS POVERTY?
Poverty means being deprived materially, socially and
emotionally. It includes lack of economic resources,
lack of education, lack of access to basic life resources
such as food, water and sanitation, and lack of con
trol over one’s life and reproductive partners. Absolute
Correspondence to: Solomon R Benatar, Faculty of Health Sciences, University of Cape Town, Obsiiervatory 7925, South
Africa. Tel: ( + 27) 21 406 611. e-mail: solomon.benatar@uct.ac.za; solly.benatar@utoronto.ca
1216
The International Journal of Tuberculosis and Lung Disease
Table 1
Four eras of tuberculosis
100 -T ~
iiar
4174'
■5'^
90 --
First era: eighteenth century Europe
• Tuberculosis accounted for 20% of all deaths, and killed about
500 people per 100000 population every year in the United
Kingdom. The cause of the disease was unknown then and
there was no specific treatment.
• With improved living conditions associated with the industrial
revolution, the annual death rate in the United Kingdom fell
progressively to 200/100000 by 1882 (the year in which Koch
discovered the tubercle bacillus), and further to 50/100000 by the
time the first anti-tuberculosis drugs were introduced in the 1940s.
• These trends made clear the social underpinnings of the
disease—an insight that needs to be more consciously
appreciated and acted upon today.
* Second era: mid 1900s
• Development of effective treatment regimens.
• Sophisticated medical skills allowed development of drugs and
the clinical trials required to show the effectiveness of short
course chemotherapy.
• Medical, managerial and political skills facilitated widespread
application of such regimens in the United Kingdom and other
countries, leading to a further fall in mortality to about
5/100000 in wealthy nations.
* Third era', late 1900s and early 2000s
• Recrudescence of tuberculosis and the rise of multi- and
extensively drug-resistant strains. This is the saddest era and the
beginning of a reversion to the inability to treat the disease
effectively.
• The possibility of drug resistance was recognised immediately
upon the discovery of effective tuberculosis chemotherapy, yet
warnings for great vigilance and care with regard to resistance
went largely unheeded (World Health Organization 2010 report1)• The emergence of drug resistance is also an indictment of
political and global health institutions that have shamefully
neglected to make the resources available to implement curative
regimens worldwide.
• So, since the 1960s and 1970s, when it was potentially possible
to eliminate tuberculosis globally, the global economy has
fostered widening disparities in wealth and in health globally,
and in the process ignored the global challenge of tuberculosis.
Current era
• Beginning in the 1980s, the HIV pandemic has resulted in the
life-time incidence of active tuberculosis, rising from 5% in
those who had been infected but remained HIV-negative, to
over 50% in those who are HIV-positive.
• As a result the global annual load of new cases of tuberculosis
increased from 6.6 million in 1990 to 9.3 million in 2007. As
long as HIV continues to spread, so will HIV-related tuberculosis.
• The added complication of MDR- and XDR-TB (up to 100 times
as costly to treat per patient, with much longer and more toxic
regimens) is now making tuberculosis potentially unbeatable in
poor countries where the incidence and prevalence are highest.
HIV = human immunodeficiency virus; MDR = multidrug-resistant; XDR =
extensively drug-resistant; TB = tuberculosis.
poverty is defined as a condition of life severely lim
ited by malnutrition, illiteracy, disease, squalid sur
roundings, high infant mortality and low life expec
tancy. Poverty brings not only material disadvantage
but also social exclusion, which in turn is associated
with discrimination across a wide range of social ac
tivities that adversely affect health and wellbeing.
Relative and absolute poverty have been constant
characteristics of the human condition. With rapid in
creases in the wealth of the elite over the past 50 years,
relative poverty has become more pronounced. At
the beginning of the twentieth century the wealthiest
20 per cent of the world’s population were nine times
richer than the poorest 20 per cent. This ratio has
* Revised in online publication, November 2010.
80 ■:
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$1.45
$2.00
$2.50
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Poverty Line (USD Dollars a day at 2005 Purchasing Power Parity)
Numbers inside bars are world population at that indicator, in billions
■ Below the poverty line
s Above the poverty line
Source- World Bank Development Indicators 2008
Figure 1 Percentage of people in the world at different levels
of poverty. From Shah.3 © Copyright 1998-2009, under a Cre
ative Commons License.
grown progressively—to 30 times by 1960, 60 times
by 1990 and to 140 times by 2009.2
Absolute poverty remains a problem, and its ex
tent has increased. The number of extremely poor
people in the world more than doubled between 1975
and 1995. Over half of the world’s population live on
less than $900 a year, and more than a quarter of the
world’s population live (on less than $1 a day) under
conditions of absolute poverty (Figure I).3 Of the
4.4 billion people in developing countries, over half
lack access to sanitation, over 30 per cent lack access
to clean water and essential drugs, and almost a quar
ter are inadequately nourished. Five per cent of the
world’s population (who live in the United States) ac
count for 50% of annual global health expenditure.
Annual per capita expenditure on health care ranges
from over $6500 in the United States (17% gross do
mestic product [GDP]) down to less than $15 in the
poorest countries in Africa (<3% GDP). While no
tions of poverty that go beyond economic consider
ations have been suggested, these will not be further
discussed here.4
POVERTY AND HEALTH
Absolute wealth and relative wealth both affect health.
Among industrialised countries it is not the richest
that have the best health but those with the smallest
income differentials between rich and poor.5 Despite
the non-linearity of the relationship between wealth
and health above annual per capita gross national
products (GNPs) of $5000, the existence of this rela
tionship and the effect of wide income differentials
underscore the need to see health and disease as inti
mately linked to social and economic conditions.
Poverty directly accounts for almost one third of
the global burden of disease. Poverty leads to poor
health, which in turn aggravates poverty and reduces
*
TB and poverty
1217
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Poverty
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Figure 2 Top: World map of poverty with size of areas in proportion to degree of poverty. Bottom: World map of tuberculosis with
size of areas in proportion to extent of tuberculosis. From WorldMapper, maps 228 and 174.6 © Copyright SASI Group (University
of Sheffield) and Mark Newman (University of Michigan). This image can be viewed online in colour at http://www.ingentaconnect.
com/content/iuatld/ijtld/2010/00000014/00000010/artOOOOl
human productivity. Ninety-five per cent of TB cases
and 98% of TB deaths are in developing countries
(Figure 2).6 TB has a direct bearing on the economies
of poor countries, as 17% of those who die from this
disease are in the economically productive age group
of 15-49 years. Poor adherence to treatment is a ma
jor problem.
Some of the reasons for poor adherence and loss
to follow-up involve the competing priorities faced
by poor populations: the need to earn money on a
daily basis, duties towards family members, and sub
stance misuse as a coping strategy for impoverishment.
Overcoming these problems requires a level of social
support that is rarely available in overburdened and
understaffed health systems.7
Diagnosis: social, not medical failure
We can argue from the above that the correct answer
to why the burden of morbidity and mortality from
tuberculosis is increasing in many poor countries, and
why multidrug-resistant TB emerged, lies more in the
failure of how human society is structured and func
tions than from failures of medical practice.4’5’8 When
living conditions for millions of people remain at the
1218
The International Journal of Tuberculosis and Lung Disease
level of pre-industrial revolution England/Europe and
health care services are so inadequate that easily af
fordable treatment cannot be provided for all who
need it in good time and for the full duration re
quired, we should not be surprised that the burden of
suffering from tuberculosis can only get worse.9
How is poverty conceptualised in current policies
responding to tuberculosis?
It is instructive to examine how poverty is understood
and discussed in current documents from major global
policy actors. Are interventions to remedy poverty
viewed as important in their own right as a means to
control tuberculosis? Is poverty alleviation seen as an
adjunct to new biomedical interventions? If poverty
is a causal determinant of tuberculosis, then it should
be considered as an important focus for intervention
studies.
While current policy documents tend to acknowl
edge poverty as a core determinant of health, recent
policy documents have not explicitly stated that alle
viation of poverty should be part of the response to
control tuberculosis.
For example, in the World Health Organization
(WHO) 6-step approach to addressing poverty in na
tional tuberculosis programmes (see Table 2),10 pov
erty is seen as a barrier to successful implementation
of tuberculosis programmes, rather than a cause of
tuberculosis amenable to direct influence. The Stop
TB action plan (see Table 3) mentions mobilisation
of resources, but does not explicitly address the issue
of poverty.11
Table 2 Addressing poverty in TB control: options for
national TB control programmes8
Step 1 Identify the poor and vulnerable groups in the country/
region served by the national TB programme.
Step 2 Determine which barriers prevent access of the vulnerable
groups to services that provide TB diagnosis and treatment.
Step 3 Assess potential actions to overcome the barriers to access.
Step 4 Review the situations and population groups requiring
special consideration.
Step 5 Explore possibilities for harnessing additional resources.
Step 6 Evaluate the impact of pro-poor measures.
TB = tuberculosis.
Table 3
Stop TB action plan9
1 Strengthen quality of basic TB and HIV/AIDS control
2 Scale up programmatic management of MDR-TB and XDR-TB
3 Strengthen laboratory services
4 Expand MDR-TB and XDR-TB surveillance
5 Develop and implement infection control measures
6 Strengthen advocacy, communication and social mobilisation
7 Pursue resource mobilisation at all levels
8 Promote research and development of new tools
TB = tuberculosis; HIV = human immunodeficiency virus; AIDS = acquired
immune-deficiency syndrome; MDR = multidrug-resistant; XDR = extensively
drug-resistant.
The Beijing call to action against multidrug-resistant
and extensively drug-resistant tuberculosis recognises
poverty as a cause, yet omits any mention or discus
sion of interventions designed to alleviate poverty as
a means of controlling tuberculosis.12 The May 2009
World Health Assembly resolution on the prevention
and control of drug-resistant tuberculosis also neglects
any mention of poverty.13 So, current major policy
documents lack a systematic and explicit focus on pov
erty in relation to the control of tuberculosis, thus
implicitly relegating it to secondary status.
WHAT COULD BE DONE?
Global poverty fuels TB. To create communities that
work towards health for all and therefore contribute to
humans flourishing in the long run, the causes of pov
erty and the social determinants of health must be ad
dressed on an equal footing with medical approaches.
The onus is on the global community to change per
ceptions and create conditions where, through solidar
ity, a united approach can be developed to alleviate a
grave threat to human health. This will require ad
dressing the root causes of poverty, which are so inti
mately linked to the social determinants of health, as
an explicit goal of TB control strategies.
A new mind-set about ourselves and how we live
Efforts to address many pressing global problems,
such as tuberculosis, are dominated by a develop
ment agenda that we know has been failing for many
decades.14’15 It is not surprising that the new poverty
agenda that surfaced in the 1990s, and was embod
ied in the Millennium Development Goals (MDGs)
20 years later, ‘stresses the importance of market-led
growth itself as the most important method to ad
dress poverty’.16 While global institutional efforts have
been stepped up in support of the international devel
opment targets,17 current global economic trends are
sustaining privilege, poverty and abuse of our envi
ronment, while fostering inequality, intensifying star
vation and promoting violence. Such global trends
are devastatingly unsustainable and threatening to
global health.4’8’9
The state of global health calls for new ways of
thinking and acting. Among many shifts in metaphors
that could encourage such progress is a shift from the
idea of sustainable development to developing sus
tainability.14 Like many others, we share the view
that the dominant development paradigm (based on
individual rights—mainly civil and political—and the
acquisition/consumption of increased quantities of
goods and services) does not itself create a harmoni
ous world community, nor does it develop sustain
ability. In its place, a new paradigm of development
has been proposed to facilitate progress towards the
goals of sustainability through promotion and re
spect of rights, and by protecting basic needs.14’18’19
TB and poverty
As we have argued elsewhere, an expanded dis
course on ethics and human rights, more broadly
conceived, could act as a wedge to new ways of think
ing about ourselves and how improved health and se
curity could be achieved for a greater proportion of
the world’s people.20
Endeavours to bring bioethics and human rights
activities closer together in the quest for better global
health provides an opportunity to reflect both on
the content of the Universal Declaration of Human
Rights (UDHR)—and of subsequent supportive cove
nants and declarations— and on the extent to which
these aspirations have not yet been met.21 Pessimism
and optimism have been expressed regarding the ful
filment of these declarations to date, and what may
be achieved in the future. The despair of some at the
extent of the continuing and even escalating human
rights abuses and violations throughout the world—
even in highly privileged societies—is countered by
the hope of others that with the development of in
ternational law and other human rights instruments,
coupled with intensified educational efforts, the im
pact of the UDHR will spread more widely.21 The Gen
eral Comment on the Right to Health by the United
Nations Committee on Economic, Social and Cul
tural Rights is viewed as a significant milestone.22
MAKING PROGRESS
In seeking to pursue an ambitious agenda for improv
ing global health there are two main questions to be
asked and answered. First, what resources are required
in the short term to achieve immediate beneficial ef
fects? Second, how can the global political economy
be changed to result in longer term and more endur
ing amelioration of poverty?
What resources are required in the short term
and are these available?
The poorest 1 billion people in the world live on less
than $1 dollar per day and have health care packages
in the region of $15 per year. It has been calculated
that a tax of 1 cent on every $10 earned by the wealth
iest 1 billion in the world could provide the addi
tional $35 billion required per year to give the poor
est 1 billion people a $50 annual per capita health
care package.*
If $35 billion per year sounds a lot, we should recall
that annual global military spending was $780 billion
in the late 1990s, and that the annual cost of provid
ing basic education for all in the world at that time
was estimated at $6 billion, while that of providing
access to reproductive health services for all women
in the developing countries was about $12 billion. It
is of somewhat morbid interest that industrialised
* Jeffrey Sachs during a video conference presentation at the Cana
dian Conference on International Health, Ottawa, October 2009.
1219
countries spend on average 5.3% of GNP on the mil
itary (global military expenditure in 2007 amounted
to US$1,339 trillion), but only about 0.3% on eco
nomic aid to developing countries.23 Between 1998
and 2007, world military expenditure increased by
45%.24 Most recently, up to $17 trillion has been
raised worldwide to rescue financial institutions from
their fraudulent activities that led to the currently
evolving global financial disaster. This is 22 times
more than the $750 billion required over 5 years to
achieve the MDGs,25 and it has not yet been possible
to raise this amount!
Two more statistics are revealing of potential re
sources. First, in 2007, about $100 billion was pro
vided to developing countries in the form of Official
Development Assistance, of which much is used to
pay donor country staff who assist in delivering aid.
In the same year, developing countries paid $590 bil
lion in debt repayment—mostly interest on debt.26
(In addition to this there is extraction of mineral and
other wealth, as well as active recruitment of trained
professionals). Second, annual farming subsidies of
about US$350 billion in industrialised countries and
trade protectionism cost developing countries about
US$100 billion annually in lost export earnings.27 Al
lowing farmers in developing countries to sell their
products at a fair price and not in competition with
massive subsidies could largely eliminate the need for
‘development’ aid. Recent acknowledgment that the
efforts of the Canadian International Development
Agency (CIDA) have been less successful than desired
and that the agenda should be liberated and rein
vented provides welcome recognition of the limita
tions of so-called development aid:28
The Canadian International Development Agency
(CIDA) has failed to make a foreign aid differ
ence in Africa. Since its inception in 1968, CIDA
has spent $12.4 billion in bilateral assistance to
sub-Saharan Africa, with little in the way of de
monstrable results. CIDA is ineffective, costly and
overly bureaucratic. Approximately 81% of CIDA’s
1500 employees are based in headquarters in Ot
tawa. Field staff has little authority to design and
implement projects or to allocate funds. This topheavy system has perpetuated a situation where
our development assistance is slow, inflexible, and
unresponsive to conditions on the ground. (Segal
H, Stollery P. Overcoming 40 years of failure: a
new road map for sub-Saharan Africa. 2007.
Quoted in reference 25.)
These facts and interpretations are not intended to
imply that the wealthy, productive and fortunate in
the world bear the total burden of blame for the eco
nomic activities that polarise the world. Failure of de
velopment is the result of complex interactions, many
of which are not discussed widely.29 Political reali
ties within developing countries, including corrup
tion, ruthless dictatorships, ostentatious expenditure
1220
The International Journal of Tuberculosis and Lung Disease
by elites and under-investment in education and health,
have contributed greatly to the suffering of billions.30
However, it is vital for privileged people to be cog
nisant of the extent to which these deficiencies in
many developing countries have been facilitated by
the policies of wealthy nations in pursuit of their own
interests (characterised by ongoing, often fraudulent,
extraction of natural and human resources). Insight
into how favoured lives are sustained by overt and
covert exploitation of unseen others could allow
those of us who live comfortable lives anywhere in
the world to appreciate that we do not have a mo
nopoly of entitlement to the benefits of progress.31’32
We should be capable of understanding that there is
no real shortage of resources to improve the lives and
health of the poorest in our world.
Changing the global political economy
While the concept of poverty can be broadened be
yond a narrow definition of income to include other
dimensions of human development,4 both the issues
and the strategies of current anti-poverty programmes
are rooted in market-oriented policies—reflecting and
reinforcing the dominant neo-liberal discourse.8 Thus
the first issue to be acknowledged is that alleviating
poverty is not about charity or so-called official de
velopment assistance, but rather about fostering in
dependence. Whether or not current policies can be
changed, and how this may be done to make the world
a better place, is now a topic being addressed by
many.33-36 The proposal for a ‘Social Offsets’ fund to
supplement the biomedical approach to neglected trop
ical diseases is an example of a practical first step to
wards promoting new ways of alleviating poverty.37
Recent research in development economics has
emphasised the importance of randomised interven
tions to build an evidence base for effective responses
to poverty.38 On this view, poverty is a condition that
can be approached via the rigorous application of
scientific method in the same way the modern evi
dence base has been built for medications.39 Medica
tions are typically evaluated in randomised controlled
trials. Where are the controls in randomised poverty
interventions? This means that poverty is not a back
ground condition over which little influence can be
exerted, but a condition that interventions can di
rectly address. It is time to put interventions dedi
cated to alleviating poverty on an equal footing with
interventions to evaluate new medications. The di
rect effect of poverty reduction interventions on rates
of tuberculosis, then, should be seen as a major re
search priority.
CONCLUSIONS
In the absence of measures that could begin to reduce
poverty, improve living conditions and enable the
poorest in our society to achieve their potential as
productive working citizens, the problems of tuber
culosis, HIV/AIDS and other infectious diseases will
surely get steadily worse in many countries. As these
diseases know no boundaries and as they have pro
foundly adverse social and economic effects, we shall
all pay the price—and a heavy one it will be for both
individuals and society.
We can either begin to gear ourselves now towards
the mind-set required to face the challenge of allevi
ating poverty and improving health, and in the pro
cess achieve meaningful social progress beyond only
political emancipation and enrichment of privileged
elites, or we can ‘continue with business as usual’
and pay the price later—losing much that has been
gained and forgoing future gains. We are free to
choose, and we shall be condemned to live with our
choices. Whether or not we can avoid the errors made
40 years ago will mark the extent of our resolve as a
species to eradicate tuberculosis as a disease that is
potentially totally under human control.
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