This document summarizes malaria control activities and their impact on anemia levels on Bioko Island, Equatorial Guinea between 1999-2010. It shows that after interventions including insecticide treated bed nets, indoor residual spraying, and intermittent preventative treatment for pregnant women began in 2004, marked to severe anemia in children under 5 and anemia during pregnancy significantly decreased. All cause under 5 mortality also declined in the intervention period. The interventions were highly effective in reducing malaria and anemia through integrated control efforts.

1. Impact of Malaria Control activities on Anemia on Bioko Island, Equatorial Guinea Luis Benavente1/ Immo Kleinschmidt2 1 Director, Improving Malaria Diagnostics Project, Medical Care Development International 2 London School of Hygiene and Tropical Medicine

2. Pre-intervention period March 1999 to Feb 2004 Intervention period starting March 2004 Malaria Indicator, Under 5 mortality and serology survey Annual malaria indicator surveys Baseline Malaria Indicator & under 5 mortality survey 2004 2005 2006 2007 2008 2009 2010 Year March 1999 Timelines of intervention and monitoring activities, 2004 to 2010 Malaria indicator surveys

4. Monitoring and evaluation: 18 sentinel sites

5. Elevation above sea level Lowlands, < 1000 meter Highlands 1300+m Non anemic: ≥ 11 (children 12-59mo); ≥ 11.4 ≥11.5 (children 5-11y); ≥ 11.9 ≥ 12 (children 12-14y) ≥ 12.4 Mild-moderate anemia <cut-off, > 7.9 Marked anemia 6 – 7.9 Severe anemia <6 Critical <4

10. Marked to severe anemiain children 6 months to < 5 years Bioko Island, E. Guinea

11. Impact: All cause under 5 mortality by year Pre-intervention period Intervention period

13. ANC, anemia during preg-nancy, Bioko Island 2006

14. Net use by women pregnant prev yr., found pregnant during annual survey , BIMCP 2006

15. Net use by women found pregnant during annual survey and outcomes, BIMCP 2006 P=0.052

16. Net use and maternal parasitemia in Benin N.S. N.S. Source: Huyhn et al Malaria Journal 2011, 10:72

17. Iron suppl. and anemia during pregnancy Bioko Island, 2006

18. IPT2 and parasitemia among women found pregnant (2nd- 3rd trimesters), BIMCP 2006

19. Parasitemia and anemia during pregnancy, Bioko Island 2006 Parasitemic women had five times more risk of being markedly-severely anemic. P=0.000

20. Marked-severe anemia (Hb< 8 g/dl) and parasitemia in pregnant women Bioko Island, E. G.

21. Dietary counseling: Fe-rich foods If the diet is low in Fe-rich foods, iron supplements are more important than ever

22. Anemia classification and management at community level 200 mg iron sulphate / day + folic acid Double dose of iron sulphate x 3 months Continue 200 mg FeSO4/day No symptoms: as above Symptoms: refer as below Refer to level capable to do safe transfusions

23. Credits and acknowledgements Project funded by a consortium led by Marathon Oil Corp: Noble Energy, Atlantic Methanol, Sonagas, GEP, SK of Korea, and the Government of Equatorial Guinea. PDA survey program written by D. Jituboh, C. Schwabe and A. Wolkon (CDC). Survey data collected by enumerators and supervisors, too many to name. Survey data analyzed by LB, IK, C. Schwabe, L. Segura, G. Baltazar, and M. Worges.