EritreaNational Malaria Control Program: On the road to malaria eradication Saleh Meky Minister of Health Government of Eritrea
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.
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)
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
The Eritrean Program • Established in 1999 following devastating malaria epidemics (1997-1998) • 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 1999-2005
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
Country conditions • Seasonal malaria and low to moderate transmission • Small country • 121,320 sq km • Population 4,906,585 (est. 2007 World Bank). • Arid environment and seasonal rainfall patterns • temporary free-standing pools of water, • clearing and levelling an attractive option.
Targeted integrated vector management:Breeding sites treated, filled or drained(Average per year per zobas)
Targeted integrated vector management:Indoor Residual Spraying(per year, per zoba in GB,DB and SKB)
Massive community mobilization:information and communication malaria sessions (average per year, per zoba)
Massive community mobilization:population participating in site cleaning (average per year, per zoba) • Community participation very significant factor in explaining breeding site cleaning
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. 2005 showed that housing construction known as agudo, in the western lowland of Eritrea, increases risk of parasitemia. • Implication for housing materials
Effectiveness of malaria interventions on incidence(preliminary findings)Carneiro, Hassane, Legovini, Sy 2008 • 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)
Increasing access to ITNs to 100 per 1000 population reduced malaria under five incidence by 76 cases.
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
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