Malaria Elimination in Zanzibar

Introduction Dramatic declines in malaria morbidity and mortality over the last decade (prevalence remained <1%) Varying malaria transmission pattern: – Seasonal (10 wks), - hot-spots (7), - importation in urban areas (>70%) Risk factors: importation, low net usage, age 5-25 years old seem to be more affected Robust malaria surveillance systems including early epidemic detection, Case investigation, active case detection and Entomological surveillance in place

General idea on malaria Interventions Universal coverage with integrated vector control interventions: LLIN ownership (80%, THMIS 2012), targeted IRS over 90% coverage, and Larviciding is piloted, environmental management Universal access to malaria case management: Diagnostics available in 100% of public and private facilities, effective anti-malarials (ACTs) in public and private HFs Malaria quality assurance and quality control for microscopy and mRDT Universal malaria surveillance system: MEEDS and MCN is in place

Key points for this presentation Malaria Epidemiological Indicators – Prevalence, morbidity and mortality Malaria Performance Indicators – Case management (Diagnosis & treatment) Malaria Prevention Indicators – Use of LLINs, Indoor Residual Spraying and Larviciding Malaria Surveillance Indicators

Malaria Epidemiological Indicators Indicator ProgressTarget 2012/132013/14 Malaria prevalence rate 0.4%0.3% Malaria incidence rate/1,000 pop Number of deaths attributed to Malaria (Facility based) 274 Number of malaria cases reported (at health facility and community) 2,956 (84%) 3,026 (89%) 3,383 Data sources: Malaria Cross-Sectional Survey in Zanzibar 2013 Routine HMIS (DHIS2) 2013/14 ZAMEP Report

Remarks: Low prevalence contributed by combined interventions including IRS, LLINs, larviciding and strengthened Case management Malaria is noted to increase this year: extended rainfalls, increased hotspots areas, low LLINs use in some Shehias

Programme performance Indicators Indicator ProgressTarget 2012/132013/14 Proportion of suspected malaria cases tested by RDT/microscopy 100% Number of confirmed malaria cases treated with an effective anti Malaria medicine 2,9563,0263,383 Malaria case fatality rate (health facility) Data source: 2013/14 ZAMEP Report Remarks: ZAMEP Strategic plan is recommending parasitological confirmation of all suspected malaria cases The target was meant to cover both Public and Private facilities In recent years, management of malaria cases has been improved reflecting reduced fatality rate

Malaria Prevention Indicators Indicator ProgressTarget 2012/132013/14 Number of LLINs distributed through continuous distribution NaNA Number of LLINs distributed through mass distribution NA % Children under-five years of age slept under LLINs night prior the survey 50.7 (THMIS 2012) Not available 75% Number of people protected by IRS in the targeted areas 259,432339,135358,877 Data sources: IRS Operation Report 2013/14 ZAMEP Annual Report 2013/14 Remarks: Continuous distribution of LLINs started in 2014/15, no data available to show the progress of implementation for this reporting period Mass distribution is planned to be implemented in August 2015 Low coverage of IRS - Refusal rate in West district contributed to low performance

Malaria Surveillance Indicators Indicator ProgressTarget 2012/132013/14 Number of mapped breeding sites in Uzi and Kisiwa Panza Islets and treated with larvicides NA33 Percentage of confirmed Malaria cases reported through case based surveillance and investigated within 48 hours NA54%90% Data source: ZAMEP Annual Report 2013/14 Remarks: The MCN system started in 2013/14, no retrospective data for 2012/13 reporting 54% is used as a baseline to monitor reporting trends in the future.

Malaria Finances – 2013/14 Source of fundsPlanned finances (TSh) Funds received (TSh) Expenditure RGoZ (2013/14)60,000,00012,000,000 (20%)12,000,000 PMI/USAID (2013/14) 1,349,575,5501,251,583,846 (93%)1,251,583,846 GFATM (2013/14)6,496,192,9526,434,165,728 (99%)5,141,211,727 Total 7,905,768,5027,697,749,574 (97%)6,404,795,573 GF disbursement included two years LLINs procurement VPP

Key challengesPossible solution mRDT performance in detecting malaria parasites in low malaria settings like Zanzibar is technically questionable Strengthen sensitive malaria diagnostic services in public and private facilities -> Workforce, -> Infrastructure development, -> Equipment and supplies -> Intensive continuous field monitoring Inadequate mechanisms to preventive imported malaria cases More evidence importation risk is required to help designing strategies to control importation Management of malaria admissions is currently becoming critical Intensive follow-up, implementation of routine DAQ, establishment of routine death audits Low coverage of LLINs utilization among the population A need to raise Ownership AND community sensitization through all available channels be effectively utilized No significant change in malaria trends over the last 5 years (both morbidity and mortality) Need to use focalized approach for intensive implementation of anti-malarials interventions. (-> high seasonality, -> hotspot) Malaria program financially is heavily reliant on two donors (PMI and GF) The Government should increase domestic financing by implementing malaria financial sustainability plan strategy prepared by ZAMEP and CHAI. This will decrease donor’s dependent and guarantee sustainability for the program. Key challenges and possible solution

Maintain high coverage of LLINs through Continuous Distribution – CD Strengthening malaria diagnosis by distributing more microscopes to HFs and by introducing more sensitive diagnostic methods including Polymerase Chain Reaction - PCR for QA Introduce anti–gametocytocidal drug (primaquine) Conduct IRS in high malaria incidence shehias Increasing community awareness and behavioral change towards malaria elimination through multiple channels Scale-up surveillance system to Universal coverage (public+private) and maintain high coverage of performance indicators Priorities for 2014/15