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

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, 2013

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

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  1. 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, 2013 Hotel Africana , Kampala

  2. 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

  3. 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

  5. Burden of Malaria in Uganda Malaria accounts for 26% of the burden of disease (BOD Uganda 1995) 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

  6. 393 1,564 Yumbe Moyo Kitgum 3 Adjumani Arua 9 Kotido Pader Gulu 591 Moroto <1 Nebbi Lira Apac Katakwi Nakapiripirit Masindi Kaberamaido 4 6 Soroti Kumi Hoima Kapchorwa Nakasongola Sironko Pallisa Kamuli Kiboga Mbale Kibaale Kayunga Luwero Tororo 287 Iganga Bugiri Kabarole Mubende Jinja Kyenjojo Busia KAMPALA Mayuge Mukono Kamwenge Kasese Waikiso Mpigi Sembabule 7 Masaka <1 Bushenyi Mbarara Rukungiri Kalangala Rakai Kanungu Ntungamo Kabale Transmission Level Kisoro very high medium- high low very low or no malaria Estimated Entomologic Infective Rate (EIR) Apac district has the highest EIR globally

  7. 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.

  8. 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

  9. 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

  10. 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”

  11. Malaria and Poverty or Poverty and Malaria ? POVERTY MALARIA

  12. 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.

  13. Anopheles Mosquitoe Mosquitoes and Malaria : From man to mosquito &vice versa Malaria parasite life cycle

  14. 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

  15. 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

  16. 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 Program Components

  17. 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

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

  19. 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

  20. Baseline epidemiological tests in children outside their home

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

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

  23. 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

  24. 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

  25. From malaria control to elimination

  26. 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!

  27. 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. THANK YOU FOR LISTENING

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