1 Eritrea National Malaria Control Program: On the road to malaria eradication Saleh Meky Minister of Health Government of Eritrea

2 Roll Back Malaria Initiative case management, vector control, insecticide-treated nets (ITNs), information, education and communication material, training, epidemic forecasting and preparedness, operations research and monitoring, evaluation and supervision.

3 Success Eritrea as one of the four countries in the world with successful malaria control programs Together with India, Brazil and Vietnam (Source: The World Bank Rolling Back Malaria: Global Strategy and Booster Program)

4 Common elements of success Conducive country conditions Targeted technical approach Data-driven decision making –surveillance and operational research Strong leadership and commitment at all levels of government Community planning and implementation Adequate financing

5 The Eritrean Program Established in 1999 following devastating malaria epidemics ( ) Support from WHO, USAID, WB, Global Fund Introduced: –Early diagnosis and treatment at health facility and community levels –Proper management of severe malaria at zoba/subzoba level –Reduction of man-mosquito contact through ITN (national coverage) –Community awareness through the promotion of information, education, and communication –Environmental management through community participation and prevention and control of malaria outbreaks. Reduced malaria morbidity and mortality by 80% during

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7 Eritrean experience Success factors: –Targeted integrated vector management –Massive community mobilization –Organization and supervision –Evidence-based Corroborating factors: –No year round malaria transmission and –Manageable country size Once targets were exceeded more donor interest and funding

8 Country conditions Seasonal malaria and low to moderate transmission Small country –121,320 sq km –Population 4,906,585 (est World Bank). Arid environment and seasonal rainfall patterns –temporary free-standing pools of water, –clearing and levelling an attractive option.

9 Targeted integrated vector management: Nets

10 Targeted integrated vector management: Breeding sites treated, filled or drained (Average per year per zobas)

11 Targeted integrated vector management: Indoor Residual Spraying (per year, per zoba in GB,DB and SKB)

12 Massive community mobilization: information and communication malaria sessions (average per year, per zoba)

13 Massive community mobilization: population participating in site cleaning (average per year, per zoba) Community participation very significant factor in explaining breeding site cleaning

14 Evidence-based: examples 2005 RTI studies showed that the most prevalent mosquito is anopheles arabiensis (bites early in the evening and late morning, not only in the middle of the night). –Use of ITNs as a sole prevention mechanisms is insufficient –Indoor residual spraying perhaps required Sintasath et al showed that housing construction known as agudo, in the western lowland of Eritrea, increases risk of parasitemia. –Implication for housing materials

15 Areas (subzobas) with above average ITN distribution reduced –Under five malaria incidence by 4 cases per month (23% reduction per month) –Above five malaria incidence by 8 cases per month (14% reduction per month) Areas (subzobas) with above average larvae site cleaning (treatment, filling and draining) reduced –Above five malaria incidence by 9 cases per month (15% reduction per month) Effectiveness of malaria interventions on incidence (preliminary findings) Carneiro, Hassane, Legovini, Sy 2008

16 Increasing access to ITNs to 100 per 1000 population reduced malaria under five incidence by 76 cases.

17 Moving forward Securing longer term financing is a priority: –Need evidence on the economic impact of malaria interventions to motivate continued investments in malaria control –Need rigorous evaluation of the elements of the program and complementary interventions to understand what is required to eliminate malaria

18 Moving toward evidence-based eradication Impact evaluation cross-country workshop (Asmara, Feb 2008) –Capacity for evidence-based policy making –Community of practice across malaria programs in the region (15 delegations from national malaria and HIV programs) –Dissemination of Eritrean and other successful practices across the Africa region (site visits) Experimental approach to understanding what more needs to be done to eradicate malaria –Randomized evaluation of indoor residual spraying value added to the national program –Randomized evaluation of communication and community mobilization approaches

19 Thank you