Module 2: Malaria Program Development

Malaria, a life-threatening disease, is present in 108 countries and puts approximately half of the world’s population at risk.(1)  Despite being curable and preventable, this parasite-transmitted disease caused nearly 1 million deaths in 2008, 90% of which occurred in Africa where a child dies from malaria every 30 seconds.  As a disease that is transmitted exclusively through Plasmodium parasite-infected female Anopheles mosquitoes, prevention methods have focused largely on stopping mosquitoes from biting humans in the first place.

Interception of malaria transmission mainly targets three checkpoints between four factors: the parasite, the vector (Anopheles mosquitoes), the human host, and the environment.(2) Whether it’s by spraying insecticides on the walls of human living quarters with Indoor Residual Spraying (IRS), sheltering sleeping bodies under the canopy of Insecticide-Treated Nets (ITNs), larviciding mosquito-infested standing bodies of water, or promptly diagnosing and treating malaria-infected individuals, the aim is to decrease malarial transmission and - for those who contract malaria - to decrease chances of morbidity and mortality.(3)

Measuring Progress

Both domestic and international (external) groups have been striving to meet the collective global goals of eliminating and eradicating malaria, and the World Health Organization (WHO) has categorized four stages of progression: control, pre-elimination, elimination, and prevention of re-introduction.(4) Control describes the reduction of “malaria disease burden to a level at which it is no longer a public health problem”.(5) Elimination occurs when there is zero incidence of transmission of mosquito-borne malaria to human.  Prevention of re-introduction follows, and deliberate efforts are made to prevent the relapse of transmission. Ultimately, when worldwide incidences of malaria permanently reduce to zero (from a particular parasite species), eradication is achieved. At this point, intervention methods are no longer necessary in the malaria-free world.

Undoubtedly, this is a long and arduous process without a guaranteed end. To further complicate matters, not all interventions have been successful. Numerous well-intended efforts have garnered undesired results. Even lauded campaigns have been met with setbacks. For instance, the Global Malaria Eradication Program, launched in 1955 as the first global collaboration to fight malaria, was characterized by large scale deployment of diphenyltrichloroethane (DDT) to kill off mosquitoes.(6) Despite this campaign’s success in eradicating malaria in certain regions of the world, it was later recognized as a flawed program that did not fully take into account the geographical and epidemiological considerations. Thus, it met substantial technical challenges in certain parts of the world, such as sub-Saharan Africa, where no major success was achieved.  In 1969, the Global Malaria Eradication Program was discontinued.(7)

In 1978, the WHO reoriented its anti-malarial policy from eradication and elimination to control. Priorities were set to reduce malaria to a manageable level rather than to a complete wipeout. At the Global Eradication Program’s end stage, or more respectfully referred to as the “consolidation phase”(8), the WHO recognized the failures and laid out some basic requirements for future initiatives seeking to achieve and sustain malaria control:

1. Integrate malaria control into an existing functional health system

2. Maintain sustained and uninterrupted effort

3. Invest in innovation – research new tools and improve existing ones

In the last few decades, hope and visions were reignited. New medications were produced, more effective tools became available, malaria-endemic nations increased in wealth, and announcements of malaria control achievements were proclaimed (such as the WHO’s certification of malaria-free nations). Despite previous disappointment and disillusionment, governments and international donors once again sought to not only control malaria, but to eliminate and eradicate it. (9)

What Constitutes An Effective Malaria Program? 

Health professionals, public health workers, medical personnel, researchers, NGOs, and others involved in malaria control at the national and district level must be well informed about the factors that make a program effective. (10) “When marking 60 years of WHOs commitment to fighting malaria...we now know so much more about the biology of parasite-host responses, the determinants of endemicity and transmission dynamics, the social, economic, and cultural implications of malaria at household, community and national levels, and the demands made upon health systems in endemic countries. We do not yet know how to synthesize and integrate this knowledge to achieve elimination in different settings.”(11) An application of these concepts can be seen in Bioko, an island with roughly 250,000 inhabitants.

Case Study: The Bioko Island Malaria Control Project (BIMCP)

Bioko is a 779 square mile (2,017 kilometer square) island located in the Gulf of Guinea. It is 20 miles (32 kilometers) from the coast of Cameroon on the west coast of Africa. In 2003, the Bioko Island Malaria Control Project (BIMCP) was initiated in response to a growing epidemic and, astonishingly, amongst other lofty goals, it achieved the Millennium Development Goals (MDG) of decreasing childhood mortality by two-thirds. What’s more, upon retrospective statistical progress analysis, this MDG achievement was accomplished within a single year of indoor residual spraying. (12) However, it was not a solo act that brought about the success; rather, it was an integrated effort.

The BIMCP used an integrative malaria-control program that included three pillar components: indoor residual spraying (IRS), case management (definitive diagnosis and treatment with artemisinin-based combination therapy, ACT), and intermittent preventive treatment of pregnant women (IPT). (13)

For indoor residual spraying (IRS), the plan was for all of the houses to be sprayed with insecticide in 6-month intervals. Progress and efficiency was monitored with a computerized spray-management system. Entomological monitoring proved to be essential. Upon tracking the effects of the first spraying, the pyrethroid knock-down resistance (kdr) was discovered in Anopheles gambiae which rendered the insecticide less effective. In response, the BIMCP switched to an alternate insecticide to circumvent the problem. Early monitoring and detection of this major hurdle allowed quick maneuvering to bring about the success of IRS in Bioka.

For case management, the BIMCP trained doctors and nurses for routine definitive diagnosis and administration of first-line malaria treatment with oral artesunate combined with sulfadoxine-pyrimethamine. Moreover, adherence to these interventions was promoted through mass media (radio, television, and printed material) and community-based interpersonal communication. The IEC strategy – information, education, and communication – was the method of choice in combining awareness with adherence.

For process monitoring, BIMCP administered prevalence surveys and ICT malaria rapid tests in both urban and rural households. Consenting individuals were asked about their IRS attitudes, the spraying status of their house (has it been sprayed in the past year?), bed net usage (who sleeps under the bed nets, and how often?), the family’s illness history and their health-seeking behavior. In addition, children 2-15 years of age were tested for Plasmodium falciparum. For those who tested positive, treatment was offered free-of-charge at a local field clinic set up specifically for this purpose. This comprehensive outcome monitoring process was essential. It consisted of both impact measures (such as malarial infection prevalence) and intervention-compliance indicators (reported household spray status and bed net use), both of which were crucial to the program’s success.

By mid-2008, five years after the implementation of the program, eight spray rounds (~100,000 structures each) were completed, and the third annual prevalence household survey was conducted. The results were astonishing. In children who were 2-5 years old, the average prevalence of P. falciparum infection fell from 48% to 18%, and moderate-severe anemia decreased from 15% to 2%. The presence of P. falciparum parasites in Anopheles gambiae mosquitoes sharply declined from 6.8% to 0.6%. Child mortality fell by two thirds. This combination of vector control, case management, and the IEC strategy adjunct with adequate adherence and comprehensive monitoring led to desirable results that could serve as guidance for similar interventions seeking effective malaria control.

Implementing Malaria Programs

For large scale programs, such as geographically-defined malaria elimination, there are many internal and external factors to consider. “WHO advises countries considering malaria elimination to undertake a rigorous scenario planning exercise that considers the epidemiological and entomological situation, programmatic capacity, financial resources, political commitment, and potential threats to success such as war and mass migration.” It is important to keep in mind that the environment is neither static nor homogenous. Large-scale control efforts must account for the changeability of the population and the variances within it. Some countries have had difficulty eliminating malaria because of frequent importing of new cases and the incapacity to pinpoint cases of untreated malaria.(14) Both experience and biostatistics models have shown that even a few infections can quickly scale up to epidemic levels in areas with potent vectors and limited protective measures.(15)

History has shown that the effort to grasp and keep an upper hand on malaria involves rigorous and thorough assessment of potential threats to malaria control. Accounting for direct and indirect factors (both natural and human influences) gives a more complete analysis of the determinants that affect transmission and treatment.(16) Weather patterns, such as rainfall and drought, are uncontrollable, but proper maintenance of irrigation systems directly impacts vector breeding habitats and is a measure to manage vector density. Atmospheric temperature and humidity are, likewise, beyond our control, but housing arrangements and human domestic behaviors can interfere with mosquito-to-human biting patterns and interrupt transmission.

Aside from the extreme of uncontrollable weather behaviors, there are other behaviors that greatly affect the outcome of a program. Cultural practices have been documented to be powerful, influential factors for the effectiveness of a program. In the end, whether or not an initiative is sustainable largely depends on the local people.

In 2008, an article titled “A new global malaria eradication strategy” appeared in the medical journal The Lancet by Richard Feachem and Oliver Sabot. It said:  “If a goal as ambitious as eradication is to be achieved, key groups—including donors, technical agencies, the scientific community, and countries where the disease is endemic—must align their energies and resources behind a common approach.”(17) Thus, accounting for human and non-human factors, both controllable and uncontrollable, are crucial in the planning stage of a program. Once the intervention is implemented, feedback on effectiveness and points of improvement is the next step. 

Case Study: Peruvian Amazonian’s Perception and Usage of Bed Nets(18)

The Mestizo communities in Peru’s Amazon region, who have traditionally used non-impregnated muslin nets, were hesitant to use the freely distributed new insecticide-treated nets (ITN) from the Peruvian Ministry of Health since 1999. Interviews with household individuals showed that usage incompliance was due to the color, size, material, and shape of the new ITNs.

Despite knowledge of the insecticide-treated bed nets as functional barriers for mosquitoes (by physically blocking their entrance and chemically killing them), some local community members refused to use them because they did not meet their needs for warmth, privacy, security, and/or aesthetic appeal. The thin material of the new polyester nets was insufficient to keep the occupants warm at night, and without the money to afford more blankets or thicker ones, some community members decided to return to using the old – but more thickly woven – non-impregnated muslin nets to avoid sleeping uncomfortably in the cold. Others were dissatisfied with the transparency of the new nets. Children were afraid to sleep under the nets at night because the see-through view of the nets made them feel unsheltered and unprotected from real or imagined malevolent ghosts, spirits, and wild jungle animals. Adults, especially those who slept with partners, felt that the thinner and paler new nets did not offer them adequate privacy from other members in the common household. Thus, the older, thicker muslin nets were preferred. The new white bed nets, though appearing cleaner and purer at first, had the drawback of dirtying easily from the pervasive dirt, soot, and dust in the dwelling quarters. Frequent washings were needed – biweekly even – and unlike the health worker’s intended 6-month wash interval, these frequent washings were not only an inconvenience to the household members, but also detrimental to the insecticide residual content. For the community members, the function of bed nets went beyond warding off mosquitoes and diseases; the nets were also a source of warmth, privacy, security, and aesthetic appeal. In instances where ITNs fail to meet these needs, an end user’s rejection of the intervention might hamper malaria-reduction progress.

From the health system’s perspective, their priorities may differ from the locals such that cost-effective, long-lasting, and operatively-potent bed nets are top choices. As in the case of these Peruvian Amazonians, understanding socio-anthropological aspects of malaria control is essential to improve ITN uptake and avoid wasted time and efforts in producing and distributing insecticide-treated nets that the locals might otherwise dislike or reject.

Measuring Program Effectiveness

It is essential to critically analyze the artificial definitions used to characterize malaria and the devised metrics used to evaluate malarial-control progress.  Not only does reassessment of malarial indicators affect the allocation of resources, but it is also an assessment of progress (or the lack of it). For example, it might be useful to distinguish between an epidemic and an outbreak; the former is recognized as a sharp increase in malarial incidence (contraction, morbidity, and mortality) beyond the “normal” occurrence, and the latter refers to a smaller caseload that may be attributed to expected seasonal and periodic variation.(19)

Humanitarian aid programs must keep the end-user in mind. Outcomes, rather than outputs, should be the metric for progress. If the efficacy of insecticide-treated nets (ITNs, or colloquially, bed nets) is being evaluated, it is useful to know not only the proportion of at-risk populations with access to ITNs (e.g., the number of ITNs distributed or the number of households with access to ITNs), but also the extent of its proper usage (i.e., the proportion of individuals who sleep under ITNs).(20) Additionally, it is important to determine if malaria-related deaths have decreased due to the distribution of the ITNs. For example, in Nigeria, some creative misuses for long-lasting insecticide nets (LLIN) were captured in photographs shown on the Malaria Matters blog. Farmers were overhanging bed nets as protective coverings for their garden patch, goat-keepers were spreading LLINs as fences for their livestock, village soccer players were pinning LLINs as goalie nets, and supermarket vendors were protecting the products on their outdoor standalone wooden shelf.(21) Well-intended interventions can have inappropriate and unexpected applications.

In the WHO World Malaria Report 2010, the following are outlined as the three crucial output measures: malaria cases, malaria deaths, and malaria transmissions. (22) If applicable and retrievable, these measures can be further broken down into the number of confirmed cases and inpatient cases for:

• All ages

• Children below 5 years of age

• Male

• Female

• Pregnant Women

• Passive (PCD) and active (ACD) case detection

• Contracted locally (introduced, indigenous, or relapse), imported, or induced.

Data sources can vary from routine surveillance systems, household surveys, or registration systems. Monitoring and evaluation of malaria-control programs serves the purposes of assessing and documenting the outcomes of the interventions. Moreover, this establishes a database of credible information that notes any progress and setbacks, achievements and failures. “Monitoring, which measures process indicators, should be carried out at district, as well as at provincial, national, regional and global levels. Apart from ensuring that activities are being implemented in the agreed manner, it allows decision-makers to stay aware of all problems and constraints which may slow down progress and provide the information they may need to refine their planning.”(23) Subsequently, evidence-based effective measures must be scaled up for high and equitable coverage, with priority given to those who are most in need.(24) To maintain the sustainability of good health, health networks must be formally established and ensured of functionality. Standardized impact indicators are useful for tracking the progress and efficacy of malarial preventative and curative measures.

Footnotes

(1) World Health Organization. “Media Centre Factsheet No.94: Malaria”.

(2) Ibid

(3) World Health Organization. “Malaria: Vector control of malaria.”

(4) World Health Organization. World Malaria Report 2010. “Chapter 3: Financing malaria control”.

(5) World Health Organization. World Malaria Report 2010. “Chapter 2: Goals, policies, and strategies for malaria control and elimination.”

(6) Feachem R. & Sabot O. “A new global malaria eradication strategy.” Lancet. 2008: 371: 1633-35.

(7) Tanner M. & de Savigny D. “Malaria eradication back on the table”. Bulletin of the World Health Organization. 2008: 86: 81-160.

(8) World Health Organization. Global malaria control and elimination: report of a technical review. World Health Organization 2008: 7.

(9) World Health Organization. Global malaria control and elimination: report of a technical review. World Health Organization 2008: 7.

(10) World Health Organization HIV/AIDS, Tuberculosis, and Malaria (HTM), Roll Back Malaria. Prevention and control of malaria epidemics: tutor’s guide. World Health Organization: 2003.

(11) Tanner M. & de Savigny D. “Malaria eradication back on the table.” Bulletin of the World Health Organization. World Health Organization 2008: 86.2. 

(12) Snow R. & Marsh K. “Malaria in Africa: progress and prospects in the decade since the Abuja Declaration.” Lancet. 2010: 376(9735): 137-9. 

(13) Kleinschmidt I., Torrez M. et al. “Factors influencing the effectiveness of malaria control in Bioko island, Equatorial Guinea.” Am. J. Trop. Med. Hyg. 2007: 76(6): 1027-32. 

(14) World Health Organization (WHO). WHO Global Malaria Programme: Q & A on malaria elimination and eradication. November 2010.

(15) Feachem R. & Sabot, O. “A new global malaria eradication strategy.” Lancet. 2008: 371: 1633-35.

(16) World Health Organization HIV/AIDS, Tuberculosis, and Malaria (HTM), Roll Back Malaria. Prevention and control of malaria epidemics: tutor’s guide. World Health Organization: 2003.

(17) Feachem R. & Sabot, O. A new global malaria eradication strategy. Clinton Foundation HIV/AIDS Initiative. Lancet 2008: 371: 1633-35.

(18) Harvey S., Olotegui M., et al. “The whole world will be able to see us: determining the characteristics of a culturally appropriate bed net among mestizo communities of the Peruvian Amazon.” Am J Trop Med Hyg. 2008: 79(6): 834-8.

(19) World Health Organization HIV/AIDS, Tuberculosis, and Malaria (HTM), Roll Back Malaria. Prevention and control of malaria epidemics: tutor’s guide. World Health Organization: 2003.

(20) World Health Organization. World Malaria Report 2010. “Chapter 2: Goals, policies, and strategies for malaria control and elimination.”

(21) Brieger B. (Jul. 16, 2010). “Creative mis-uses of LLINs.” Tropical Health Matters. http://malariamatters.org/creative-mis-uses-of-llins/.

(22) World Health Organization. World Malaria Report 2010. “Chapter 2: Goals, policies, and strategies for malaria control and elimination.”

(23) World Health Organization. “Malaria: Surveillance, monitoring, and evaluation.” https://apps.who.int/iris/bitstream/handle/10665/272284/9789241565578-eng.pdf.

(24) American Medical and Research Foundation (AMREF). Malaria Prevention and Control Strategy: 2006-2010.