Malaria control program

1. MALARIA PROGRAM

2. Program Planning Model
VISION and MISSION
STRATEGIC GOALS
STRATEGIC OBJECTIVES
STRATEGIES/INTERVENTIONS
ACTION PLANS
IMPLEMENTATION
EVALUATION/FEEDBACK

3. HISTORY
• Zambia has a history of malaria control dating back to the
1940s. By the mid-1980s, indoor residual spraying (IRS) in
Zambia, previously effective in urban areas along the rail line
from Chililabombwe to Livingstone, had become decentralized
and subsequently declined as the economy weakened. This
breakdown in the malaria control program was accompanied by
a temporary resurgence in malaria, with incidence tripling over a
24 year period between 1970 and 2000 and continuing to
increase several years afterwards. Since Zambia was by then
relying on case management at rural health centers as the sole
method for malaria control, the increased prevalence of
chloroquine resistance further hindered malaria control efforts.

4. HISTORY
• Zambia revitalized its malaria control program under the
guidance of the World Health Organization (WHO) Roll
Back Malaria Partnership starting in the late 1990s.
With funding from the Global Fund to Fight AIDS,
Tuberculosis and Malaria, the World Bank, PMI and
other donors, Zambia made progress in malaria control,
with dramatic declines in malaria incidence in many
parts of the country. The prevalence of malaria
parasitemia in children younger than five years of age
decreased 53% from a baseline prevalence of 22%
between 2006 and 2008.

5. HISTORY from National Elimination strategy
• Though major achievements have been made in malaria control, the
disease remains a significant cause of morbidity and mortality in
Zambia, with one in five children under age five infected with malaria
parasites. Reported malaria deaths have dramatically decreased in
Zambia over the past ten years, though more than 1,800 deaths are
still reported annually.
• In 2000, more than half of all malaria deaths were concentrated
among the poorest 20 percent of people—the highest association
with poverty of any disease of global public health importance. That
year malaria claimed more than 17,000 lives, mostly children, in
Zambia alone.

6. ZDHS 2018- KEY FINDINGS (MALARIA)
• Household possession of mosquito nets:
Although the percentage of households with at least one insecticide-treated net (ITN) increased from 12%
in 2001-02 to 78% in 2018, there remains a gap with respect to the availability of sufficient nets to cover all
household members, with only 41% of households reporting having at least one ITN for every two residents.
• ▪ Use of mosquito nets by children:
Sixty-four percent of children under age 5 in households with at least one ITN slept under an ITN the night
prior to the survey.
• ▪ Indoor residual spraying (IRS) against mosquitoes:
Sixty-one percent of households had at least one ITN for every two persons and/or IRS in the past 12
months.
• ▪ Use of intermittent preventive treatment (IPTp) by women during pregnancy:
Ninety-four percent of pregnant women received one or more doses of SP/Fansidar, 81% received two or
more doses, and only 59% received three or more doses.
• ▪ Prevalence, diagnosis, and prompt treatment of children with fever:
Sixteen percent of children under age 5 had a fever in the 2 weeks prior to the survey.
• ▪ Type of antimalarial drugs used:
Ninety-seven percent of children with fever who took an antimalarial took artemisinin-based combination
therapy (ACT).
• ▪ Haemoglobin <8.0 g/dl in children: Four percent of children age 6-59 months have haemoglobin
levels below 8.0g/dl

7. ZDHS 2018-Malaria
• The key preventive interventions deployed include insecticide-
treated bed nets, indoor residual spraying, and use of
intermittent preventive treatment among pregnant women. The
curative interventions include prompt parasitological diagnosis
and treatment with efficacious antimalarial medicines.
• Data that are useful for assessing how well malaria control
strategies are being implemented, including indoor residual
spraying of dwellings with insecticides, availability and use of
mosquito nets, prophylactic and therapeutic use of antimalarial
drugs, diagnostic testing of children with fever, and prevalence
of anaemia among children under age 5.

8. HISTORY of national malaria program
• With malaria incidence on the rise, Zambia implemented a formal,
coordinated National Malaria Control Program to fight the
disease. The national strategy laid out four proven
interventions to fight malaria: insecticide-treated nets, indoor
residual spraying, rapid diagnostic tests, and combination therapy
drugs. To ensure effective delivery, the government embraced
coordination with churches, mission hospitals, nongovernmental
organizations, and copper mining and sugar companies. It also put in
place a sophisticated tracking system to monitor progress
and adjust strategy as needed.

9. RESULTS OF PROGRAM
• Routine monitoring and evaluation show that Zambia’s efforts have
paid off, and malaria-specific health indicators have
improved. Between 2006 and 2012, the share of children under
five with malaria parasites in their blood dropped from 22
percent to 15 percent. At the same time, the share of children
under five with severe anemia—another metric because malaria
parasites destroy red blood cells—decreased from 14 percent
to 9 percent. Most important, by 2008 the number of malaria
deaths reported by health facilities had plunged by 66
percent compared to the toll in 2000.

10. Commentary……
• The experience of Zambia, one of the first African countries to scale
up malaria control, yields important lessons on the delivery of a
multifaceted, comprehensive national malaria program. It stressed
both prevention and treatment and included a monitoring and
evaluation system that enabled data-driven decision making. The
country’s success shows that with leadership, tools, support, and
partners, even low-income countries can successfully take on the
malaria menace.

12. National Malaria Elimination Strategic Plan 2017-
2021
• A strategy to move from accelerated burden reduction to malaria
elimination in Zambia.
• This document is intended to serve as a framework for a coordinated
and collaborative approach to malaria elimination in Zambia. It is also
meant to serve as a basis for the development of detailed and costed
plans of action at the national level adapted to the provincial, district,
and local realities and the response to the specific needs of each
location in Zambia.

13. National Malaria Elimination Strategic Plan
2017-2021
• The country’s last two iterations of the National Malaria Strategic Plan
(NMSP) aimed to reduce transmission through multiple strategies,
including the distribution of long- lasting insecticide treated mosquito
nets (LLINs), increased indoor residual spaying (IRS), case
management using confirmatory diagnostic tests, and treatment with
artemisinin-based combination therapy (ACT). Due to these
successful interventions and strong political support, Zambia will
continue to implement cost-effective malaria interventions in pursuit
of a malaria-free nation.

14. MISSION
To provide equitable access to
cost-effective, high-quality
health services as close to the
family as possible.

15. National Malaria Elimination Strategic Plan
2017-2021
•The vision for this new strategy is to attain
a malaria-free Zambia.
•The goal is to eliminate local malaria
infection and disease in Zambia by 2021 and to
maintain malaria-free status and prevent
reintroduction and importation of malaria into
areas where the disease has been eliminated.

16. In order to achieve this goal, the following
objectives must be pursued:
• Increase the implementation rate of interventions from 36 percent in
2015 to 95 percent by 2018.
• Reduce malaria incidence from 336 cases per 1,000 population in
2015 to less than 5 cases per 1,000 population by 2019.
• Increase the malaria-free health facility catchment areas (HFCAs)
from 0.5 percent in 2015 to 100 percent in 2021.
• Reduce malaria deaths from 15.2 deaths per 100,000 in 2015 to less
than 5 deaths per 100,000 population by 2021.
• Achieve 100 percent malaria-free status by 2021.
• Maintain 100 percent malaria-free status, following 2021.

17. Interventions
• Vector Control
• Case Management
• Malaria in pregnancy
• Parasite Clearance
• Health Promotion
• Enhanced Surveillance
• Monitoring and Evaluation
• Research

18. Vector Control
• Long-lasting insecticide-treated nets (LLINs)-Studies have shown that
when used widely in a community, LLINs can significantly reduce
severe malaria and resulting side effects. Mass campaigns have been
conducted every 3 years to ensure universal coverage. Most recently,
10 million nets were distributed nationwide in 2017
• Indoor residual spraying (IRS) - IRS activities are conducted annually
in Zambia to support malaria control activities. These activities
routinely include district-level planning and budgeting for targeted
areas, assessment of spray structures, training of spray teams, and
supervision and monitoring of spray activities.

19. Case Management
• Universal coverage with early diagnosis and effective treatment is a key
strategy in reducing malaria morbidity and mortality. Achieving universal
coverage of case management should consider three channels of service
delivery: public, private, and community-based. In areas where malaria
incidence remains high, coverage should be maximized through all three
channels, with efforts made to improve the quality of services delivered.
• The detection of malaria infection is based on blood examination by RDTs
or microscopy.
• Treatment for malaria is based on WHO and national treatment guidelines.
The current first-line therapy for the treatment of uncomplicated P.
falciparum malaria in Zambia is a quality-assured ACT (artemisinin-based
combination therapies).

20. Malaria in pregnancy
• The national programme's policy on malaria in pregnancy includes the
provision of:
• Free Intermittent Preventive treatment in pregnancy (IPTp) with at least
four doses of Sulfdoxine-Pyrimethamine (SP) during pregnancy
• Free long-lasting insecticide-treated nets (LLINs)
• Free prompt diagnosis and treatment of clinical malaria
• This malaria control package is implemented as part of routine antenatal
care (ANC). Because pregnant women are particularly susceptible to
malaria, it is important for them to start receiving antenatal care early in
their pregnancy so that they can readily access malaria prevention and
treatment services

21. Health Promotion
• Health promotion cuts across and facilitates all the
elimination components. Advocacy and social behavioural
change communication will form the anchor in health
promotion utilising household and community settings in
order to increase and sustain malaria elimination efforts.
Involvement of policy- and decision-makers in health
increases acceptance, uptake, and utilisation of health
services. Further, community engagement will play a big role
in enhancing sustainability of key malaria elimination
interventions.

23. Social Behavioural Change Communication (SBCC)
• The purpose of social and behaviour change communication is to increase
knowledge, awareness, and risk perception of individual and to mobilise
communities to create long-term changes towards desired behaviours and to
sustain enabling behaviours around the key malaria elimination interventions.
• interpersonal and dialogue-based communication, and social mobilisation to
systematically accelerate change in the underlying drivers of risk to malaria,
vulnerability, and impact.
• Social and behaviour change communication approaches have been
demonstrated to have an impact in behaviour change, raising awareness, and
influencing social norms leading to change in deeply rooted practices, including
refusals to participate in key malaria interventions like
IRS, misuse and abuse of LLINs, and late treatment-
seeking behaviour/self-medication.

24. Enhanced surveillance
• Active surveillance occurs when a positive malaria case triggers a
follow-up visit at the patient’s home and at neighbouring homes to
test and treat for malaria. Residents of each household are screened
for fever, travel history, and other risk factors. The Community Health
Worker records case investigations in handwritten registers, which are
reviewed at monthly health facility meetings.

25. Enhanced surveillance
Action required for this component includes:
 Registering each index case and determining the likelihood of local acquisition
of the infection (as opposed to acquisition during travel);
 Visiting each affected household and neighbourhood;
 Screening all residents of each household and neighbours for fever, travel
history, or other risk factors;
 Testing everyone in the household and some (or all) in the neighbourhood;
 Treating any confirmed infections and possibly providing presumptive
treatment for a wider group if indicated;
 Enhancing other malaria prevention strategies including LLIN ownership and
use, IRS, or other interventions.

26. Monitoring and Evaluation
• Monitoring the operational aspects of the programme and measuring impact or
process indicators to ensure that the activities are yielding the desired results and
moving the programme towards achieving its operational targets and objectives.
• Monitoring changes in epidemiological indicators resulting from the activities
implemented.
• Appropriately interpreting results and informing policy and strategy revisions,
when needed, to help ensure progress.
• Documenting progress towards malaria elimination—information on coverage
and quality of interventions, mapping out residual and new active malaria foci,
maintaining relevant eco-epidemiological data, and ensuring first-line treatment
efficacy is particularly important. This type of information is usually collected
through a national information system for disease surveillance and health
management.

27. AN EXAMPLE OF A
SUCCESSFUL
PROGRAM

36. The research project
• Mapped out the catchment area, population, # of households
• Vigorous community engagement over long period of time ( meetings
over many months with stakeholders such as tradional chiefs, village
headmen, village elders, women’s groups, tradional healers, church
leaders, teachers)
• Once the Community clearly understood the purpose of the study,
we commenced screening and treatment of those found malaria
positive, whether or not they had symptoms

43. Project observations
• Remarkable reduction in malaria morbidity and mortality in the
Macha area, but malaria is still not eliminated
• Eliminate or actually eradicate malaria in Macha area- efforts were
sustained and elimination was achieved