presentation iom amfm meeting zanzibar or priorities for managing febrile illness 1 0
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OPERATIONAL RESEARCH PRIORITIES FOR MANAGING FEBRILE ILLNESS
op
Shija Joseph Shija AMFm Coordinator
Zanzibar Malaria Control Programme (ZMCP)
The National Academies, 2101 Constitution Avenue NW, Washington, DC 20037
September 17-18/2012
www.zmcp.org
Background
v Before year 2000 Zanzibar was experiencing
malaria Prevalence > 30-40% in OPD and Malaria accounted for > 50% of admitted cases,
v Two earlier attempts to eliminate the disease were not successful and high resurgence occurred once intervention were stopped.
v These engaged traditional control measures
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Integrated Strategies used by ZMCP
Major interventions: • Malaria Case management using ACTs accompanied by
improved malaria diagnosis methodologies (RDTs + Microscopes)
• Vector control (ITN/LLITN and IRS) • Malaria in pregnancy • Malaria advocacy (IEC/BCC) Supportive interventions: • SM&E • Environmental Management • Operational Research
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Malaria Case Management Objective: Improve early recognition and
effective treatment of malaria cases at all health care facilities in Zanzibar
• Screening before treatment (microscopy or Rapid Diagnostic Test)
• Treatment of malaria by using ACTs (Amodiaquine + Artesunate)- 1st Line
• Artemether-Lumefantrine (Coartem)-Alternative medicine.
• Quinine- For severe malaria/Artesunate Inject.
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Malaria Vector Control
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Malaria Vector Control
• Indoor Residual Spraying (IRS) in all eligible houses
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Vector Control
• Objective: Increase household ownership
and use of ITNs among the general population in all districts of Zanzibar
• Percentage of children under five sleeping under treated nets
• Percentage of pregnant women sleeping under treated net
• Percentage of general population sleeping under treated net
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Prevention of malaria during pregnancy
Comprises of three main interventions 1. Intermittent Preventive Therapy 2. Malaria case management in pregnancy 3. Use of Insecticide Treated nets during
pregnancy Other maternal care: HIV testing and pregnancy monitoring. Pregnant are most likely to harbor malaria parasites without showing
signs and symptoms • Most vulnerable due to weak immune system • Malaria affects both
– Unborn baby and mother
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Behavioural Change Communication
for MALARIA CONTROL
• To increase understanding about Malaria, its causes, recognition of signs and symptoms, treatment control and prevention.
• Mass media • Community groups • Malaria in School • NGOs involvement
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Supportive Interventions
SURVEILLANCE, MONITORING AND EVALUATION Zanzibar Malaria Epidemic Early Detection System (MEEDS)
disease trends morbidity and mortality
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MEEDS System in Zanzibar – 142 Gvt HFs
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Zanzibar’s recent and marked decrease in malaria prevalence posi4ons it as uniquely hypoendemic among the AMFm pilot
countries Positivity Rates: Zanzibar Malaria
Early Epidemic Detection System Epidemiology
• After IRS, LLIN, and ACT interventions in 2004, parasite prevalence fell from 25% in
2003 to less than 1% in 2010 (THMIS 2008)
• Parasite prevalence is 0.8%, ranging from 0% in Stone Town to 3.7% in northern
Pemba (THMIS 2008)
Path to Elimination
• Political will for elimination by 2015 • ZMCP target: 100% of malaria cases to
be confirmed by RDT or microscopy by 2014
• Patients access diagnosis and treatment free in public sector facilities since 2007
Source: ZMCP –MEEDS SYSTEM
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AMFm highlighted exis4ng issue of a private sector with limited diagnos4c capacity and high an4-‐malarial sales
Private Sector Landscape
• 26% of people seeking treatment for fever use the private sector (ZMCP,
2010)
• Zanzibar’s 1LB sold ~150,000 doses of ACTm into the private
sector market from June-Dec 2011 (CHAI analysis, 2012)
31%
36%
78%
3.5% 0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
Public HF (N=139) Private HF (N=171)
Microscopy
mRDTs
Availability of Diagnostics by Sector
AMFm Phase I Independent Evaluation Outlet Survey (Baseline – 2010)
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Zanzibar demonstrated important progress on key AMFm benchmarks, but needs to address a lack of diagnos4c
capacity in a low endemic environment • Goal: To ensure all people with malaria receive & use a complete dose of ACT.
9%
80%
30%
1% 0%
20%
40%
60%
80%
100%
Baseline Endline
Quality-Assured ACTs
Oral Artemisinin Monotherapies
Availability
Affordability
Market Share Market share of quality-‐assured ACTs increased from 2% to 61% in private for-‐profit outlets
5.99
1.17
0
2
4
6
8
Baseline Endline
(AMFm Independent EvaluaFon, 2012)
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The AMFm operational research explores shifting to diagnostics as an exit strategy from subsidized drugs in a context of high treatment seeking behavior in the private sector
Horizon 1 Horizon 3 Horizon 2
Pre
vale
nce
High
Low
Subsidize ACTs
Regulate the private sector market
Subsidize RDTs & remove ACT from
OTC
Zanzibar Today
Key Outcomes
• Affordable ACTs available throughout
the private sector
• Market for sub-optimal treatments eliminated
• Total anti-malarial market size reduced
• ACT targeting to true malaria cases with RDTs
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The AMFm opera4onal research targets ACTs to confirmed cases by leveraging the private sector supply chain to roll out diagnos4cs,
supported by strong regula4on
Wholesaler
Dispensary Pharmacy Hospital, Clinic OTC
Consumer
Diagnosis Treatment Treatment
Landscape pre-intervention:
• Large anti-malarial sales volume • Minor RDT market • Lack of regulation enables clinical diagnosis, presumptive self-treatment
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Use a structural interven4on to shiJ supply-‐side and demand-‐side dynamics of malaria case management toward diagnosis in the private sector
Intervention:
• Distribute subsidized RDTs through private sector supply chain • Remove anti-malarials from OTCs • ACTs: enforce prescription-only status
Wholesaler
Dispensary Pharmacy Hospital, Clinic OTC
Consumer
RDTs RDTs
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The interven4on aims to target ACTs to confirmed cases by leveraging the private sector supply chain, supported by
strong regula4on
Izmir Pharmacy: AMFm First Line Buyer • Roll out subsidized RDTs in private health facilities
• Distribute using the AMFm First Line Buyer and private supply chain
• Recommended retail price of 500 TZS ($.32)
Zanzibar Food and Drugs Board (ZFDB) & Zanzibar Malaria Control Program (ZMCP) • Remove all anti-malarials from over-the-counter
(OTC) shops through a series of inspections
• Enforce ACTs as Prescription Only Medicines
Rollout of RDTs
Regulatory Support
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DIRECTION: Zanzibar’s approach to channel malaria cases toward facili4es with diagnosis will inform other countries experiencing
a reduc4on in malaria endemicity
April 2012 May 2012 September 2012 March 2013
Midline Evaluation
Midline Evaluation
Potential Endline
Evaluation
Gather baseline data on diagnostic availability in the Zanzibar private sector and treatment
seeking for fever illness
Launch pilot to better target anti-malarial
treatment: • Introduce subsidized
RDTs in private HFs • Limit access to
antimalarial
Conduct follow-up evaluation (midline, Endline) to assess impact of intervention
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Process EvaluaFon – Key quesFons explored
Are an4-‐malarials effec4vely removed from OTC shops?
Are RDTs available in private facili4es and sold at the recommended retail price?
RESULTS EXPECTED: NOVEMBER 2012
2
1
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Impact EvaluaFon – Key quesFons explored
Is there an change in the propor4on of febrile pa4ents receiving a malaria diagnosis?
Does treatment seeking shiJ from the informal retail sector to facili4es with diagnos4c capacity?
RESULTS EXPECTED: NOVEMBER 2012
2
1
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