Cost Effective Interventions For a Quick Fix in Malaria Elimination: The Katakwi Experience

Paper presented at : The UMA-UVA International One Health Conference

Dr. Lugemwa Myers (International Health Specialist)

14 th -16 th Feb, 2013Hotel Africana , Kampala

Presentation Format Malaria Epidemiology in Uganda

Burden of Disease

Move on Malaria (MoM) by PILGRIM

Approach to implementation of MoM

Results (Pre and Post intervention)

Recommendations

Global distribution of malaria

4

MALARIA DURING THE 20TH CENTURY

Source: Reproduced from a presentation by Dr Andrew Kitua, National Institute for Medical Research, Tanzania

Burden of Malaria in Uganda

Malaria accounts for 26% of the burden of disease (BOD Uganda1995) and is responsible for:

One in every 3 persons + attending OPD (33%)

One in every 4 persons admitted in hospitals (25%)

One in every 5 child deaths in hospital (20%)

Over 40,000 child deaths in a year or 140 deaths every day

Severe anaemia in children/pregnancy ↑abortions, ↑low birth weight ↑MMR ↑IMR

Low -severe economic loss& productivity, lost school days, long term disability

Masindi

Nakasongola

Kasese

Hoima

KibaaleKiboga

Luwero

Apac

MukonoKAMPALA

MubendeKabarole

Nebbi

Arua

Gulu

Adjumani

Kabale

Mbarara

Rakai

Sembabule

Masaka

Kalangala

Jinja

Iganga

Busia

Mbale

Tororo

Kapchorwa

Pallisa

Kumi

Katakwi

Moroto

Kotido

Kitgum

Soroti

Lira

Mpigi

Bushenyi

Rukungiri

Kamuli

Ntungamo

Moyo

Kamwenge

Kyenjojo

Kayunga

Kanungu

Yumbe

Pader

Sironko

Nakapiripirit

Kaberamaido

Bugiri

Mayuge

Waikiso

Kisoro Transmission Levelvery high

medium- high

low

very low or no malaria

<1

<1

4

93

7

6

287

1,564

591

393

Estimated Entomologic Infective Rate

(EIR)

Apac district has the highest EIR globally

Move on Malaria Program (MoM):

Background:

Joint effort of Pilgrim, MCP/MoH & Local District Admin. against malaria in Teso sub region

Attempt to eliminate malaria in 3-5 yrs. Design: to eliminate not to control malaria. It draws and improves on lessons from previous MoH interventions

Targets 7 districts – Katakwi, Amuria, Kumi, Bukedea, Kaberamaido, Pallisa, Soroti.

Population targeted approx 2.0 million in north-eastern Uganda

Strategy was integrated – Vector control and parasite elimination

A response to - endemic malaria and effects of 2007 floods

Launched April 2008 by Hon. Dr. S. Mallinga, MoH.

Justification for MoM: 1 High malaria incidence:

Effects of malaria:○ High morbidity/mortality

Poverty in the region: ○ High levels of poverty in the region by Ugandan Standards for

long periods

Effects of war:○ Damage to/loss of infrastructure (social, economic, moral)○ Increased poverty○ Loss of investment environment – increased deprivation of

opportunities

Geographic features favorable to mosquito breeding

Justification for MoM: 2

Epidemiological survey results on levels of malaria prevalence in age groups in Katakwi (July 2008)

○ Mean 35% general prevalence (12%-85%)○ Mean 47% for kids <15 yrs (Range 25%-85%)○ 15 % for those above >16 yrs (30-55%)○ 3,500 cases of malaria reported weekly in health centers

MOM in line with MoH’s strategic plan for Malaria

Need for an intervention:○ to halt debilitation and carnage from malaria ○ reverse onslaught of malaria, ○ eliminate malaria in 3-5 yrs from Teso Sub-region

Long Term Objective:

“Contribute to elimination of malaria in Uganda through integrated multi-

pronged interventions of vector control and case management in the Teso sub

region”

Malaria and Poverty or Poverty and Malaria ?

POVERTY

MALARIA

Main Objectives of MOM:

O.1: IRS to be carried out in at least 85% of the households in the

Teso sub-region.

O.2: Course of anti-malarial medication to be received by at least

85% of children between the ages of 4 months and 15 years,

regardless of presence or absence of parasitemia (mass drug

administration (MDA))

O.3: Course of anti-malarial treatment to be received by 85% of

population above 15 years found to have parasitemia on RDT

O.4: IPTp to at least 85% of the PW in the Teso population.

Mosquitoes and Malaria : From man to mosquito &vice versa

Malaria parasite life cycle Anopheles Mosquitoe

Strategic Integrated Interventions:

STRATEGY: Integrated malaria interventions to break transmission, infection and morbidity of malaria (Elimination not Control focusing on both vector and parasite)

Break Parasite Transmission - Vector Control IRS for all human residences ITNs/LLINs – 3 per household (where funds allow)

Stop/Limit Infection/Morbidity - Case Management …MDA Management of severe malaria Mass Treatment of Infected persons with ACTs (Arco & Duo

Cotexcin)(pre-morbid stage) Intermittent Treatment of malaria in pregnancy (IPTp).

Mobilize population to fight malaria Information - technical/social facts about malaria –BCC/IEC

Field activities (IRS+”MDA” commenced 02/11/08)

Entomological Survey Conducted prior to commencement of program including Bio

assays Standard WHOPES techniques used

Epidemiological Survey Baseline data collection from both community and HFs

conducted prior to commencement of program Trained HWs on use of RDTs Examined all spray persons prior to engagement

Program Components

System for supply of logistics, insecticide and equipment established

Trained and deployed 300 spray operators and wash persons

All spray personnel underwent medical exam for fitness and a sample of bio-specimens tested for traces of insecticide

Environmental monitoring conducted to assess compliance with set standards

Case detection in Above 5 &Rx and mass Rx in the Under 5yr olds +IRS

RESULTS of interventions:

Vector Control Planned to spray 64,400 h/h, achieved 55,900 h/h (87%) Planned to protect 147,900 people, achieved 172,260 (110%) Desired to distribute ITNs for children <5yrs & pregnant

mothers – not covered

Case Management Planned to provide 520 doses of IPTp, achieved 750 (144%) Planned to treat/manage 85% cases of severe malaria,

achieved 3,436 cases (100%) Planned MDA of 4 months - <15 yrs against malaria, achieved

64,513 (89%) Planned MST among >16 yrs olds. Tested 24,419 and

treated 3,446 +ves (100%) seen

Jan Feb Mar April May Jun Jul Aug Sept Oct Nov Dec

2006 6939 6932 6356 8532 7734 5815

2007 6183 5410 6100 5128 6251 5856 7486 6269 4561 8311 8803 4560

2008 5477 6827 5983 7643 8903 11351 13968 7590 7558 8100 8469 3582

2009 1957 1214 1952 1594 5136

0

2000

4000

6000

8000

10000

12000

14000

16000

Mal

aria

Rep

ort

ed C

ases

Months

Malaria OPD Trends in Katakwi (Jun 2006 - May 2009)

2006

2007

2008

2009

Oct -Nov. 2008 MOM Implementation

Weekly Malaria cases (Pre & 6 months after intervention)Note the dramatic decline(90%) in cases after IRS + “MDA”

Impact of MOM in Katakwi:

More accurate and professional diagnosis of malaria using RDTs from MOH

Ninety two (92)% reduction in reported cases of malaria at community level (from 47%-4.9%)

Ninety (90) % reduction of OPD attendance in HFs

Decongestions of health centers and reduced workload among health workers in the district

Increased knowledge of ICON CS10% efficacy against malaria causing mosquitoes through bio assay

Increased hope, confidence and expectation of better conditions among the population

Baseline epidemiological tests in children outside their home

Case finding in the above 16 year olds and treatment and MDA in the under 16 near one of the typical village habitats

An enthusiastic woman taking a spray person to spray her houseNote the empty pediatric ward at Katakwi HCIV after IRS+”Chemotherapy”

Community sensitization before MOM with IRS+”Chemotherapy”

Dr. Myers from MoH and Pilgrim officials addressing members of one of the villages in Katakwi on the objectives of the intervention.

Immunization, De-worming, IPTi, Vit A supplement, causes and prevention of malaria featured during the sensitization

Disease Elimination: What will it take? Resources:

Resources for all the activities by MOM were raised from various donors - Three Loaves Fund - >$ 900,000 GoU NMCP/MOH - >$ 25,000 World Concern & Agathos Foundation - >$ 400,000 International Mid Wives Association - - >$ 40,000 Katakwi Local Govt - >$ in kind

Malaria activities cost US$ 0.5 m !!! US$0.5m x112=US$ 66m (Equivalent to UgX180b) vs US$ 658m

lost p.a

From malaria control to From malaria control to eliminationelimination

Summary and Conclusion:

By integrating IRS, Case mgt.& general drug admin, Pilgrim piloted the impact of integrated approaches to the fight against malaria

Integrated approaches, implemented effectively and efficiently, may be the answer to malaria elimination and eradication

Preliminary results show rapid decline in mosquito population/bites and in malaria cases at OPDs of clinics in Katakwi (over 90%)

Malaria can be eradicated quicker than we all thought!

Isaiah Chapter 33:34“ And the inhabitants* shall not say, I am sick, the people that dwell

therein shall be forgiven their inequity*”

Koran: Sula 5: When you treat one person, you treat the whole nation.

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