Malaria Control in Emergencies

Source: Wirtz, CDC

Leading Causes of Childhood Leading Causes of Childhood DeathsDeaths

Source: WHO estimates of the causes of death in children, 2000-03 Bryce, Lancet, 26 March 2005

Major Causes of Death in emergencies for <5 Years

Sudan: Wad Kowli CampFebruary, 1985

Somalia: Gedo Region 7 Camps, January, 1980

Source: Centers for Disease Control and Prevention, Famine-Affected, Refugee, and Displaced Populations: Recommendations for Public Health Issues. MMWR, 1992;41(No. RR-13):8.

MeaslesARIMalariaDiarrheaOther

BackgroundBackground Malaria is a parasitic disease caused by Malaria is a parasitic disease caused by

one of four protozoan parasites:one of four protozoan parasites: Plasmodium falciparum Plasmodium falciparum (most severe and (most severe and

life-threatening) life-threatening) vivax, ovale, malariaevivax, ovale, malariae

300-500 million300-500 million clinical cases/year clinical cases/year

Over Over 1 million1 million deaths/year: deaths/year: 90% in sub-Saharan Africa90% in sub-Saharan Africa

Background: IIBackground: II

Complicated transmission requiring Complicated transmission requiring correct conditions for the vector, host, correct conditions for the vector, host, climate climate

Physiologically most vulnerable:Physiologically most vulnerable: Children less than five years oldChildren less than five years old Pregnant womenPregnant women

Background: IIIBackground: III

Marked antimalarial drug and Marked antimalarial drug and insecticide resistance rates:insecticide resistance rates: Few drugs available Few drugs available Available drugs costly and often have Available drugs costly and often have

complicated dosing regimenscomplicated dosing regimens

Years of vaccine research have Years of vaccine research have produced few hopeful candidate produced few hopeful candidate vaccinesvaccines

Vector: Female AnophelesVector: Female Anopheles

Parasite enters Parasite enters human host when human host when an infected an infected mosquito takes a mosquito takes a blood meal:blood meal: Bites at night (6 PM Bites at night (6 PM

to 6 AM)to 6 AM)

May rest indoors or May rest indoors or outdoorsoutdoors

Human

Mosquito

Mosquito bites infected

person

Parasites multiply in mosquito gut and migrate to salivary gland

Parasites multiply in human liver and bloodstream, causing fever &

chills

Infected mosquito bites

person

Transmission Cycle

Adapted from RBM ‘What is Malaria?’ Infosheet

Burden of Malaria in Burden of Malaria in EmergenciesEmergencies

Estimates of population of concern are Estimates of population of concern are underestimatedunderestimated

2/3 2/3 of the 21 million people of concern to of the 21 million people of concern to UNHCR live in malaria endemic areasUNHCR live in malaria endemic areas

WHO estimates WHO estimates 30%30% of malaria deaths of malaria deaths in Africa occur in wake of war, local in Africa occur in wake of war, local violence or other emergenciesviolence or other emergencies

VulnerableVulnerable Populations Populations Groups marginalized politically or sociallyGroups marginalized politically or socially

Southeast Asia- populations living on the bordersSoutheast Asia- populations living on the borders

Groups unable to access limited resources: Groups unable to access limited resources: Physically/mentally disabled, unaccompanied Physically/mentally disabled, unaccompanied

minors, elderly, those with other illnesses or minors, elderly, those with other illnesses or weaknessweakness

Groups isolated from humanitarian efforts:Groups isolated from humanitarian efforts: Fleeing Goma, Bukavu into central forest of DRC in Fleeing Goma, Bukavu into central forest of DRC in

19871987

Distribution of Malaria

Refugee and Asylum Seekers / IDP Movement

Factors Associated with Increased Factors Associated with Increased Risk of MalariaRisk of Malaria

No or poor housingNo or poor housing Location of camps/settlements often not planned Location of camps/settlements often not planned

wellwell Placing camp in well known flood plain (e.g., TZ)Placing camp in well known flood plain (e.g., TZ)

Deliberate movement to areas near waterDeliberate movement to areas near water OvercrowdingOvercrowding Proximity of livestockProximity of livestock Mobility: may have limited contact with health Mobility: may have limited contact with health

facilitiesfacilities Compromised immune statusCompromised immune status

Factors II:Factors II:

Control strategies used in stable, non Control strategies used in stable, non emergency setting need to be adapted emergency setting need to be adapted May create political difficulties:May create political difficulties:

Drug policies in host country may not be currentDrug policies in host country may not be current Changing national malaria treatment guidelines Changing national malaria treatment guidelines

is a laborious process:is a laborious process: Time is insufficient for this process Time is insufficient for this process Needed drugs may not yet be registered for use in the Needed drugs may not yet be registered for use in the

host country and may be unfamiliar to workers who host country and may be unfamiliar to workers who need to use themneed to use them

Need to think of “refugee affected” area and Need to think of “refugee affected” area and impact on host/national populationimpact on host/national population

Malaria Control ObjectivesMalaria Control Objectives Enhance overall case management:Enhance overall case management:

Promote use of laboratory-based diagnosis (both Promote use of laboratory-based diagnosis (both microscopy and rapid diagnostic tests [RDTs])microscopy and rapid diagnostic tests [RDTs])

Implement treatment guidelines that use highly effective Implement treatment guidelines that use highly effective malaria drugsmalaria drugs

Understand treatment seeking behaviors of targeted Understand treatment seeking behaviors of targeted populationspopulations

Improve access to and utilization of effective Improve access to and utilization of effective malaria prevention interventions:malaria prevention interventions: Use appropriate vector control measuresUse appropriate vector control measures Ensure access to those at increased risk of malaria Ensure access to those at increased risk of malaria

(pregnant women, infants, non-immunes)(pregnant women, infants, non-immunes)

Objectives: IIObjectives: II Increase and improve knowledge, skills and Increase and improve knowledge, skills and

practice related to malaria control:practice related to malaria control: Focus on partner organization personnel, as well Focus on partner organization personnel, as well

as communityas community Ensure effective communication and Ensure effective communication and

coordination among all involved agenciescoordination among all involved agencies Promote beneficiary participation in malaria Promote beneficiary participation in malaria

control programmes:control programmes: Engage refugee communities as partners from Engage refugee communities as partners from

the beginning of a project through its durationthe beginning of a project through its duration

Objectives: IIIObjectives: III Reinforce surveillance and monitoring and Reinforce surveillance and monitoring and

evaluation of malaria control programmes:evaluation of malaria control programmes: Develop a standardized, minimum set of Develop a standardized, minimum set of

indicators to be used for surveillanceindicators to be used for surveillance Establish systems to monitor implementation of Establish systems to monitor implementation of

control interventions: use standardized data control interventions: use standardized data collection tools and case definitionscollection tools and case definitions

Use evaluations and assessments to compile Use evaluations and assessments to compile “lessons learned” and identify “best practices”“lessons learned” and identify “best practices”

Initial AssessmentInitial Assessment Malaria risk within host country:Malaria risk within host country:

Ongoing malaria control activities of host areaOngoing malaria control activities of host area Climatic conditionsClimatic conditions

Surveillance patterns: Surveillance patterns: Establishing actual numbers of casesEstablishing actual numbers of cases Multiple systems of surveillance?Multiple systems of surveillance? Differing versions of case definition: what are you Differing versions of case definition: what are you

measuring – febrile illness or malaria?measuring – febrile illness or malaria?

Efficacy of current treatment guidelines:Efficacy of current treatment guidelines: Used at the campUsed at the camp National or regional dataNational or regional data

Assessing the riskAssessing the risk

Resettlement areaResettlement area

Local malaria situation is clearly defined

Yes

Endemic region

No

Rapid Epi investigation

needed

Non-endemic region

People not at risk of malaria. Region could be prone to malaria outbreaks

Immune status of refugees

Little or No immunity

Coming from endemic areas

All age groups are at risk

Children and pregnant women are at risk

Source: Rutta, Norwegian People’s Aid, Ngara, TZ 2003

Health Clinics in Established Camps

Source: Manya, Kenyan MoH, Dadaab, Kenya May 2006

Phases of EmergenciesPhases of Emergencies Emergency Phase:Emergency Phase:

Focus on decreasing morbidity and mortality Focus on decreasing morbidity and mortality through prompt access to effective treatment through prompt access to effective treatment with artemisinin-based combination therapywith artemisinin-based combination therapy

If feasible, supplement with prevention, targeting If feasible, supplement with prevention, targeting groups at highest risk of severe malaria and groups at highest risk of severe malaria and deathdeath

Source: UNHCR Strategic Plan for Malaria Control 2005-7

Phases IIPhases II Stabilization phase:Stabilization phase:

Sustainability Sustainability Institute community vector-control strategies Institute community vector-control strategies

achieving high coverage:achieving high coverage: 60% of population with insecticide-treated materials 60% of population with insecticide-treated materials

(ITMs)(ITMs) 85% shelters with indoor residual spraying (IRS)85% shelters with indoor residual spraying (IRS)

Intermittent Preventive Therapy (IPTp)Intermittent Preventive Therapy (IPTp)

Source:UNHCR Strategic Plan for Malaria Control 2005-7

Phases IIIPhases III Returnee settings:Returnee settings:

Rehabilitation and reconstruction efforts should Rehabilitation and reconstruction efforts should focus on effective malaria treatment and high-focus on effective malaria treatment and high-coverage community preventioncoverage community prevention

Should have equivalent access to services as Should have equivalent access to services as that of local populationsthat of local populations

Offer long-lasting insecticide-treated nets (ITNs) Offer long-lasting insecticide-treated nets (ITNs) as part of repatriation package and adequate as part of repatriation package and adequate health education during pre-departure and transithealth education during pre-departure and transit

Source:UNHCR Strategic Plan for Malaria Control 2005-7 http://www.unhcr.org/protect/PROTECTION/456ac23a2.pdf

Challenges to malaria control in Challenges to malaria control in EmergenciesEmergencies

Increased vulnerability of displaced Increased vulnerability of displaced populations – i.e. malnutritionpopulations – i.e. malnutrition

Increased risk of epidemics - movement of Increased risk of epidemics - movement of non-immunes to high malaria transmission non-immunes to high malaria transmission areasareas

Source: BBC News, Darfur refugees coming into Chad, 2006

Housing

Source: Bloland, CDC, Dadaab, Kenya, 2005Source: Caux, UNHCR, Goz Bieda, Chad, 2006

Source: Manya, Kenyan MoH, Kakuma, Kenya, 2006

Source: Manya, Kenyan MoH, Hagadera, Kenya, 2006

Potential Breeding Sites

Source: Bloland, CDC, Kibondo, TZ1998

Source: Manya, Kenyan MoH, Dadaab, Kenya, 2006

Environmental Degradation

Challenges: IIChallenges: II Breakdown of health services or existing Breakdown of health services or existing

health facilities overwhelmed: health facilities overwhelmed: Appropriate response beyond local/national Appropriate response beyond local/national

capacitycapacity

Unstable government or no governmentUnstable government or no government

Ongoing conflict, insecurity - long term Ongoing conflict, insecurity - long term planning difficult (e.g. Southern Sudan)planning difficult (e.g. Southern Sudan)

Challenges: IIIChallenges: III Many partners - UN organizations, NGOs Many partners - UN organizations, NGOs

responsible for providing health services responsible for providing health services with local/national authorities: with local/national authorities: Often, poor or no inter-agency communicationOften, poor or no inter-agency communication

Lack of technical knowledge of malaria Lack of technical knowledge of malaria among operational agencies among operational agencies

Physical and transport barriers - delays in Physical and transport barriers - delays in access to suppliesaccess to supplies

Security concerns prevent consistencySecurity concerns prevent consistency

Operational research - many gaps in Operational research - many gaps in knowledge, few funds availableknowledge, few funds available

Lack of data on malaria burden in emergenciesLack of data on malaria burden in emergencies

Lack of information on drug or insecticide Lack of information on drug or insecticide resistanceresistance

Challenges: IV

Clinical DiagnosisClinical Diagnosis Common approach for diagnosis in Common approach for diagnosis in

endemic countriesendemic countries Current or recent history of malaria = Current or recent history of malaria =

feverfever Sensitive, but results in over-diagnosis Sensitive, but results in over-diagnosis

and over-treatment:and over-treatment: Increased drug pressure, which enhances Increased drug pressure, which enhances

likelihood of developing antimalarial drug likelihood of developing antimalarial drug resistanceresistance

Adverse drug reactionsAdverse drug reactions Increased costIncreased cost Misdiagnosis of non-malarial feverMisdiagnosis of non-malarial fever

Diagnostics Diagnostics Low to Moderate

Transmission

Prompt parasitological confirmation of diagnosis

recommended before treatment

High Stable Transmission

Probability of fever caused by malaria high in children under

age 5 – treat with clinical diagnosis.

Older children/adults (pregnant women) obtain parasitological

diagnosis before treatmentSuspected severe malaria:

parasitological confirmation if available, if not, treat on clinical

grounds

MicroscopyMicroscopy Considered gold Considered gold

standard for standard for diagnostics:diagnostics: Can identify species and Can identify species and

level of parasitemialevel of parasitemia Often not used in Often not used in

emergenciesemergencies overwhelming load of overwhelming load of

patientspatients lack of electricitylack of electricity inadequate inadequate

supplies/trainingsupplies/training

Credit: Wirtz, CDC, TZ, 2006

Rapid Diagnostic Tests (RDTs)Rapid Diagnostic Tests (RDTs)

Detect specific antigens Detect specific antigens (proteins) produced by (proteins) produced by malaria parasitesmalaria parasites

Rapid, easy to use, Rapid, easy to use, results in 20 minutesresults in 20 minutes

Cost ~ $0.70Cost ~ $0.70 Prone to deterioration Prone to deterioration

through heat and humiditythrough heat and humidity Difficult to see results in Difficult to see results in

situations of low situations of low parasitemiaparasitemia

Late readingsLate readings

Credit: R Gerrets, NYU, Mukuranga, TZ, 2005

Case ManagementCase Management Gold standard for treatment of uncomplicated Gold standard for treatment of uncomplicated

malaria is an artemisinin-based combination malaria is an artemisinin-based combination therapy (ACT):therapy (ACT): New Emergency Health Kit (NCHK) contains New Emergency Health Kit (NCHK) contains

Artemether/Lumefantrine co-formulated in a Artemether/Lumefantrine co-formulated in a single tab (Coartem®):single tab (Coartem®): Requires fatty food with doseRequires fatty food with dose

Other combinations available:Other combinations available: Sulfadoxine-pyrimethamine (SP) and Amodiaquine Sulfadoxine-pyrimethamine (SP) and Amodiaquine

(AQ)(AQ) Artesunate (AS) with SPArtesunate (AS) with SP AS/AQ (co-formulated, single dose, “Coarsucam”)AS/AQ (co-formulated, single dose, “Coarsucam”)

Severe MalariaSevere Malaria Pre-referral therapy: artesunate Pre-referral therapy: artesunate

suppositoriessuppositories

Requires rapid referral to in-patient unitRequires rapid referral to in-patient unit

Quinine (QN) drug of choice but requires a Quinine (QN) drug of choice but requires a higher level of care:higher level of care: Kakuma 2007 outbreak: insufficient skills in in-Kakuma 2007 outbreak: insufficient skills in in-

patient unit to use QN loading dose as patient unit to use QN loading dose as recommendedrecommended

Intermittent Preventive Intermittent Preventive Therapy (IPT)Therapy (IPT)

Pregnant women at higher riskPregnant women at higher risk severe maternal anemia, maternal death, low birth severe maternal anemia, maternal death, low birth

weight and higher infant mortality ratesweight and higher infant mortality rates IPTp recommends at least two doses of SP (targets IPTp recommends at least two doses of SP (targets

ANC visits):ANC visits): Monthly doses - HIV+ womenMonthly doses - HIV+ women Requires good record keepingRequires good record keeping

Infants (IPTi): Infants (IPTi): A few trials with promising resultsA few trials with promising results Not currently recommended but may be promising Not currently recommended but may be promising

interventionintervention

Insecticide Treated Nets Insecticide Treated Nets (ITNs)(ITNs)

Individual-level protection Individual-level protection Community-level protection Community-level protection PortablePortable Requires re-treatment every Requires re-treatment every

6 months unless long-lasting 6 months unless long-lasting ITNs used (LLITNs)ITNs used (LLITNs)

Can target most vulnerable Can target most vulnerable populations in areas of high populations in areas of high transmissiontransmission

Disadvantages: expensive Disadvantages: expensive start-up costs, need start-up costs, need distribution strategy, high distribution strategy, high level of resale, retreatment level of resale, retreatment requirements, incorrect userequirements, incorrect use

Credit: Williams, CDC, Kakuma, Kenya, Jan 20006

Indoor Residual Spraying Indoor Residual Spraying (IRS)(IRS)

Logistically feasible Logistically feasible Target specific areas Target specific areas

where malaria is where malaria is unstableunstable

Community level effect Community level effect requires 85% requires 85% coveragecoverage

Timing important Timing important Every six monthsEvery six months Resistance increasing Resistance increasing Should pre-stock Should pre-stock

materialsmaterials

Credit: Wirtz, CDC, Lugufu, TZ, 2006

Other Preventive MeasuresOther Preventive Measures Insecticide treated clothing, top sheets and Insecticide treated clothing, top sheets and

blankets: Afghan campsblankets: Afghan camps

Hammock nets: Cambodia and VietnamHammock nets: Cambodia and Vietnam

Larviciding: works best when breeding sites Larviciding: works best when breeding sites are limited and relatively permanentare limited and relatively permanent

Aerosol spraying: not generally Aerosol spraying: not generally recommendedrecommended

Insecticide Treated Plastic Insecticide Treated Plastic Sheeting (ITPS)Sheeting (ITPS)

Insecticide treated plastic sheeting (ITPS):Insecticide treated plastic sheeting (ITPS): Combined shelter and malaria control toolCombined shelter and malaria control tool Major effect on mosquito mortality in trials:Major effect on mosquito mortality in trials:

Proportion killed depended on surface area coveredProportion killed depended on surface area covered Mode of action and efficacy more closely Mode of action and efficacy more closely

resembles IRS than ITNs:resembles IRS than ITNs: Confers limited personal protection inside home but, Confers limited personal protection inside home but,

applied at community level, works as a control by applied at community level, works as a control by decreasing mosquito longevitydecreasing mosquito longevity

Currently at trial levelCurrently at trial level

Current IssuesCurrent Issues

Which interventions can be targeted to Which interventions can be targeted to those most in need: IRS versus ITNs?those most in need: IRS versus ITNs?

Cost-effectiveness of strategiesCost-effectiveness of strategies

Chronic shortages of food and non-food Chronic shortages of food and non-food item distribution: impact on resale of ITNsitem distribution: impact on resale of ITNs

Current Issues: IICurrent Issues: II

Substandard medicationsSubstandard medications

Overall, lack of effective monitoring and Overall, lack of effective monitoring and evaluation in malaria controlevaluation in malaria control

Thank You!

Credit: O’Reilly, CDC, Kibondo, TZ, 2006