management of malaria in complex emergency situations

8/9/2019 Management of Malaria in Complex Emergency Situations

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MANAGEMENT OF

MALARIA INCOMPLEX

EMERGENCY

SITUATIONS

Malaria Prevention and Control Management CourseByaruhanga Emma

Mbarara-Uganda-2010


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Presentation outline

Learning Objectives

Introduction

Definition of malaria in complex emergencies

Rationale for special management of malaria in emergencies

Situations precipitating complex emergencies

Factors underlying malaria burden in complex emergencies

Strategies for management of malaria in emergencies Co-ordination of malaria control in emergency situations

M & E operational research

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Learning objectives

At the end of the session, you should be able to

understand the:

Definition of complex emergency situationsin relation to malaria

Factors influencing malaria outbreaks in

complex emergency situations

Management and control of malaria incomplex emergency situations

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Introduction

Malaria is a major communicable disease of thetropics and subtropics, killing more than one millionpeople each year.

Malaria is a disease of the poor, especially of those inremote areas with no easy access to health servicesparticularly in Asia & Africa

Malaria is also associated with conflict or theaftermath of conflicts

It is a disease that flourishes in conditions of crisis andpopulation displacement

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Definition

Complex emergencies have been defined as:

Situations affecting large civilian populations, involving

war or civil strife, food shortages and populationdisplacement

Resulting in excess mortality and morbidity from

malaria

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Situations that bring about complex emergencies

War situation between countries resulting in large

population of refugees

Internally displaced person arising from:-

Civil or political strife, tribal/ethnic conflicts

Disasters e.g. Femine, floods, cyclones, fireslandslides etc

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Factors that contribute to the malaria burden in complex

emergencies

Breakdown of health services and of malaria controlprogrammes

Movements of non-immune people or concentrationof people in high risk areas

Environmental deterioration that encourages vectorbreeding

Problems of supply of food and medicine anddifficulty of access

General lack of housing and cover/protection from

biting vectors 7


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Rationale for special Management of malaria in complex

emergencies

Conflict results in instability and lack of governance

The insecurity makes long-term planning impossible

Breakdown in systems can cause major difficulties for health

care delivery Malaria control in complex emergencies as an important

initiative to reduce the global burden of malaria

Malaria problem in complex emergency situations requirespecial attention

The strategies used in stable situations must be adapted forcomplex emergencies.

In complex emergencies malaria epidemiology is often ofepidemic nature

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Strategies for malaria management in emergency situations

Development of a plan

Situation analysis and assessment

Site Planning

Disease management

Prevention

Malaria Surveillance

Epidemic response Disease awareness & education

Coordination of malaria control efforts

Monitoring and evaluation & Operational research9


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Development of a plan

The elements of a good plan are:

Situation analysis

Define objectives for malaria control based on theseverity of the problem, human/material resources

available, level of control in the host country and the

expected future movements of refugees

Select strategies

Decide on activities

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Development of a plan (2)

The elements of a good plan cont..

Develop a work plan with responsible officer,

objectives and targets

Agree with all interested parties on organizationalframework

Develop indicators for monitoring and evaluation,and plan how they will be measured

Plan operational research, if gaps in necessaryinformation are identified

Develop a budget

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Situation analysis and assessment

Initial assessment of the situation to plan the appropriate

response, to decide upon the most effective interventions,

and to avoid costly or life threatening mistakes

Use an assessment team of experienced and qualified peoplewith a mix of complementary skills in disease control

Assess the underlying causes and establish objectives and

priorities

Assess the displaced community itself, to determine human

resources available and

Ensure their involvement in interventions

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Situation analysis and assessment (3)

Security

Military & other authorities

Access to the vulnerable

Available resources and logistics

Human

Health facilities

Drugs, etc

Funds

Logistics import practices

Legal, registration policy

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Disease management

Diagnosis Microscopic diagnosis may not be possible in the acute

phase of an emergency and clinical diagnosis is used inareas of high transmission

Confirmation is particularly important in areas where drugresistance necessitates use of expensive drugs or wheretreatment failure due to resistance can progress rapidly tosevere malaria

The recently developed rapid diagnostic tests are very useful

for screening large numbers of patientsTreatment

The treatment provided should be based on knowledge ofdrug resistance patterns in the area

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Disease management (2)

This is particularly important as displaced populations

are especially vulnerable due to low immunity (from

malnutrition or lack of previous exposure to malaria)

Management of severe malaria should be according tothe national treatment protocols

causes of treatment failure, such as non-compliance,

vomiting and poor quality drugs should always be

monitored.

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Disease management (3)Chemoprophylaxis and preventive treatment

In complex emergencies, chemoprophylaxis for malariashould be limited to pregnant Women, expatriate staff, andspecial groups such as the army

The drugs available for chemoprophylaxis in these

situations should be cautiously chosen (chloroquine,proguanil, pyremethanine /dapsone, mefloquine anddoxycycline ???)

Service delivery

A clear, understandable, treatment regimen should beestablished and communicated to all involved in healthservice delivery.

First line treatment may need to be changed if drugresistance studies show that national policy is ineffective.

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Disease management (4) On-site training of health workers is needed to improve case

management Accessibility to the service delivery points is important-

appropriate type of health systems ( mobileclinics/community health workers)

In the acute phase, cash incentives may be needed to carryout control interventions, but food-for-work is an option

Delivery of services should be integrated with primary health

structures or networks (e.g. using local NGOs or community

based organizations) Delivery systems should be diversified and community

participation encouraged to improve efficiency and coverage.

In the post-emergency phase the commercial sector mayprovide sustainable supply of nets and

insecticide (sachets or tablets for home-treatment). 18


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Prevention

Acute phase

The choice of intervention for disease prevention in the acute phasewill vary according to effectiveness, feasibility, cost and speed ofsupply.

The key local factors influencing choice are:

Type of shelter available (permanent housing, tents, plasticsheeting)

Human behavior (Culture, sleeping practices, mobility)

Vector behavior (Biting cycle, indoor or outdoor resting)

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Prevention (2)

Insecticide treated mosquito nets (ITN) & Items and subsequentre-treatment are suitable

ITN may also be appropriate for those who regularly travelcross-border to insecure areas.

Indoor spraying of residual insecticide (house spraying) hasbeen the method of control most often used in chronic refugeesituations

Environmental control may be difficult during the acute phaseexcept on a local scale, and impact is often limited. To reduce thenumber of vector breeding sites: Drain clean water around water tap stands & rain water drains

Larvicide vector breeding sites if these are limited in number (seek expertadvice)

Drain ponds, but may not be acceptable if used for washing

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Prevention (3)

Post-emergency phase

Emergency needs change and mortality is brought under control

beneficiary involvement and skills improvement

displaced people living in plastic shelter or tents construct local stylehuts

Establishing wider use of self protection methods

Some cost recovery could be introduced for new nets as peoples livelihoods

Re-treatment process needs to be established on a cost recovery basis

Free or reduced cost distribution is essential for some vulnerable (widows withyoung children, orphans etc.)

Environmental control may be possible during rehabilitation of irrigation and watersupply sources

House spraying should become increasingly focal; prioritization of camps forspraying

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Malaria Surveillance

Malaria surveillance is essential to assess the impact of the disease on the displacedpopulation in a complex emergency.

The information sources or indicators available will depend on whether the regioncannot, could, or does support malaria transmission

Minimal information required in order to assess the impact of malaria and toprepare a response:

Species of Plasmodium (which species are present, in what ratio, and inwhich seasons?)

Mortality- what evidence is there for excess mortality or for malaria

being the cause? Morbidity-what is the incidence of fever and incidence of malaria?

what is the evidence for an increase in incidence of malaria?

which age groups are affected (14yr)?

pregnancy outcomes (low birth weight, stillbirth, prematurity)

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Surveillance and epidemic investigation

Investigate any outbreak should be prepared in advance

Epidemic preparedness measures for malaria should be taken jointly withother disease of epidemic potential

To respond appropriately to the outbreak, the following minimalinformation is required:

Population Who is affected? Where are they from? How are they living?

Disease Number with acute febrile illness Number with confirmed uncomplicated malaria Number with microscopically confirmed severe malaria Number of malaria deaths

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Surveillance and epidemic investigation(2)

Number of maternal deaths due to malaria

Proportion of children with anaemia

Proportion of pregnant women with anaemia

Drug resistance; the proportion of treatment failures

Management

Number of health facilities Available staff and expertise

Access of population to the health facilities

Availability of drugs and supplies

Malaria policy and treatment guidelines 24


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Epidemic response

The main aim of the response must be to reduce mortality and

disease burden.

Three strategies for intervention may include:

1. Mass treatment of fever cases

2. Case detection and treatment by outreach services

3. Passive case detection

In a severe outbreak the majority of fever cases may be due tomalaria.

Health services should reach as deeply into the community as

possible and make full use of community health workers if

available. 25


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Disease awareness & education

Simple messages are needed that:

Improve understanding of disease

Encourage appropriate treatment-seeking behavior

Make the connection between protection against mosquitoesand prevention of disease

Improve mosquito net retention and correct use

Emphasize who needs protection most (usually children and

pregnant women) Health messages may be delivered through community health

workers (CHWs), posters, leaflets, and the mass media.

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Training

Who to train?

Policy makers

Health co-ordinators : National/local/expatriateNGO staff

Clinical workers

Front line preventive health workers

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Coordination

Reduce security risk

Improve efficiency

Prevent duplication of activities Provide common logistic systems

Mediate or improve agency negotiating power with authorities

or factions

Coordination might be provided under a UN umbrella agencyor by a special coordination body which agencies subscribe to

and within such fora it is possible to establish sector

committees to address specific health issues.

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M & E Operational research

Monitor input and process indicators

Evaluate outcomes and impact

Undertake operational research to inform themanagement of emergency operation

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management of malaria in complex emergency situations

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