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PubMed2002

Malaria control reinvented: health sector reform and strategy development in Colombia.

The consequences of health sector reforms on control of malaria were analysed using Colombia as an example. One of the most complex health sector reform programmes in Latin America took place in the 1990s; it included transferring the vertical vector-borne disease control (VBDC) programme into health systems at state and district levels. A series of studies was undertaken in 1998-2000 at the national level (Ministry of Health Study), at the state level (Departamento Study) and at the health district level (District Study) using formal and informal interviews among control staff and document analysis as data collection tools. A government-financed national training programme for VBDC staff - which included direct observation of control operations - was also used to analyse health workers' performance in the postreform period (longitudinal study). The results showed that some shortcomings of the old vertical system, such as the negative aspects of trade union activity, have not been overcome while some positive aspects of the old system, such as capacity building, operational planning and supervision have been lost. This has contributed to a decrease in control activity which, in turn, has been associated with more malaria cases. Malaria control had to be reinvented at a much larger scale than anticipated by the reformers caused by a whole series of problems: complex financing of public health interventions in the new system, massive staff reductions, the difficulty of gaining access to district and state budgets, redefining entire organizations and - in addition to the reforms - introducing alternative strategies based on insecticide-treated materials and the growth of areas of general insecurity in many parts of Colombia itself. However, positive signs in the transformed system include: the strengthening of central control staff (albeit insufficient in numbers) when transferred from the Ministry of Health to the National Institute of Health, the opportunities offered by the Basic Health Plan (PAB) for new planning initiatives and intersectoral co-operation and the integration of malaria diagnosis and treatment into the general health services (associated with a decrease of malaria mortality). The potentials of the new system have not yet been fully exploited: capacity building, communication and management skills need to be improved and it require guidance from the national level.

Colombia↗
PubMed1995

Primary health care: the basis for malaria control in Hubei, China.

By 1992 malaria morbidity in Hubei, China had decreased steadily to its lowest level since 1970. Much of this achievement was through an integration of the primary health services with malaria control activities. However, in some areas malaria has been unstable due to weaknesses in the three tier health network. This has particularly been at the township and village level. The future of village doctors and appropriate measures of malaria control at the village levels are threatened by the change to a market economy. As part of the provincial health program, primary care services need to be improved in service provision, service organization and service quality.

China↗
PubMed2005

A systems approach to malaria control: an institutional perspective.

This study introduces a systems approach to malaria control. Comprising organizations from the health, environmental, agricultural, economic, political, and social sectors, the malaria control system (MCS) at hand is organized around a common goal of improving living conditions through reduced malaria. The premise is that effective malaria control strategies require the establishment of organizational linkages for information and knowledge flow in the MCS. The study first describes the systems approach. It then compares it with an existing cross-sector approach and identifies areas where the developed approach complements the existing ones. Lastly, it shows the application of the developed approach in the context of malaria control in Ghana.

Data Collection↗
PubMed2003

Roll back malaria? The scarcity of international aid for malaria control.

The WHO announced the Roll Back Malaria (RBM) movement in 1998, with the goal of halving malaria deaths by 2010, and halving again by 2015. It is widely agreed that reaching this goal requires a major increase in international aid funding for malaria control, to a budget of perhaps 1.5 - 2.5 billion dollars annually. To ascertain whether progress is being made, we compiled data self-reported by the donors to the Development Assistance Committee of OECD, and also to ourselves directly. We find that, in fact, the total amount of international aid dedicated to malaria control, from the 23 richest donor countries plus the World Bank, remains in the range of 100 million dollars annually - a figure that is virtually unchanged since the start of RBM. This lack of progress toward increasing funding very seriously threatens RBM and demands that WHO regularly audit and report on malaria control funding, with the certainty that RBM will fail to meet its deadline of 2010 if this is not done.

Animals↗
PubMed1999

Evaluation of the SPf66 vaccine for malaria control when delivered through the EPI scheme in Tanzania.

BACKGROUND: Malaria control programmes need to protect young children, who bear the brunt of malaria disease and death in Africa. The development of a vaccine is a priority if improved and sustained malaria control is to be achieved. The best use of a vaccine in Africa will be achieved if it can be delivered through the expanded programme of immunization (EPI). We conducted a trial designed to evaluate the efficacy of SPf66 vaccine for malaria control when delivered through the EPI scheme in Tanzania. METHODS: The study was a two-arm, double blind, individually randomized placebo controlled trial involving 1207 infants. The primary objective of the trial was to estimate the efficacy of three doses of SPf66 given at 1, 2 and 7 months of age in preventing clinical episodes of malaria. These were documented through a health facility-based passive case detection system. RESULTS: Among 1207 randomized children, overall compliance for third dose was 91%. SPf66 was safe, immunogenic and did not interfere with the humoral immune responses to EPI vaccines. There were 294 children among SPf66 recipients and 288 among placebo recipients with at least one malaria episode, yielding a vaccine efficacy estimate of 2% (95% CI: -16, 16; P = 0.84). CONCLUSION: This has been the first trial of a malaria vaccine among very young infants. It provides information on the safety of peptide vaccines administered at this early age as well as their capacity to induce immune responses without negatively interacting with EPI vaccines. Given the modest protection previously documented in older age groups and the lack of efficacy in younger infants, this vaccine in its current alum-based formulation does not appear to have a role in malaria control in sub-Saharan Africa. The lack of efficacy found in this trial also raises concerns about potential difficulties of inducing protective immune responses against malaria through immunization in infants.

Double-Blind Method↗
PubMed2001

Malaria control: achievements, problems and strategies.

Even if history has not always been the Magistra vitae, Cicero expected it to be, it should provide, as Baas said, a mirror in which to observe and compare the past and present in order to draw therefrom well-grounded conclusions for the future. Based on this belief, this paper aims to provide an overview of the foundations and development of malaria control policies during the XX century. It presents an analysis of the conflicting tendencies which shaped the development of these policies and which appear to have oscillated between calls for frontal attack in an all-out campaign and calls for sustainable gains, even if slow. It discusses the various approaches to the control of malaria, their achievements and their limitations, not only to serve as a background to understand better the foundations of current policies, but also to prevent that simplistic generalisations may again lead to exaggerated expectations and disillusion. The first part of the paper is devoted to the development of malaria control during the first half of the century, characterised by the ups and downs in the reliance on mosquito control as the control measure applicable everywhere. The proliferation of "man-made-malaria", which accompanied the push for economic development in most of the endemic countries, spurred the need for control interventions and, while great successes were obtained in many specific projects, the general campaigns proposed by the enthusiasts of vector control faced increasing difficulties in their practical implementation in the field. Important events, which may be considered representative of this period are, on the campaign approach, the success of Gorgas in the Panama Canal, but also the failure of the Mian Mir project in India; while on the developmental approach, the Italian and Dutch schools of malariology, the Tennessee Valley and the development of malaria sanitation, included the so called species sanitation. The projection of these developments to a global scale was steered by the Malaria Commission of the League of Nations and greatly supported by the Rockefeller Foundation. Perhaps the most important contribution of this period was the development of malaria epidemiology, including the study of the genesis of epidemics and their possible forecasting and prevention. Although the great effectiveness of DDT was perhaps the main determinant for proposing the global eradication of the disease in the 1950s, it was the confidence in the epidemiological knowledge and the prestige of malariology, which gave credibility to the proposal at the political level. The second part deals with the global malaria eradication campaign of the 1950s and 1960s. It recognises the enormous impact of the eradication effort in the consolidation of the control successes of the first half of the century, as well as its influence in the development of planning of health programmes. Nevertheless, it also stresses the negative influence that the failure to achieve its utopian expectations had on the general disappointment and slow progress of malaria control, which characterised the last third of the century. The paper then analyses the evolution of malaria control funding, which often appears out of tune with political statements. The fourth part is devoted to the search for realistic approaches to malaria control, leading to the adoption of the global malaria control strategy in Amsterdam in 1992, and the challenge, at the end of the century, to rally forces commensurate with the magnitude of the problem, while aiming at realistic objectives. After discussing the conflicting views on the relations between malaria and socio-economic development and the desirable integration of malaria control into sustainable development, the paper ends with some considerations on the perspectives of malaria control, as seen by the author in early 1998, just before the launching of the current Roll Back Malaria initiative by WHO.

Animals↗
PubMed1998

The particular and the general. Issues of specificity and verticality in the history of malaria control.

Several ideas have currency through long periods of malaria control history and important issues in controlling many communicable diseases have often been fought out over malaria. Health administrators view complex problems of malaria control through these apparently simple ideas. The most important concepts concern the need for specific methods to combat particular features of the spread of malaria and how far this is reflected by the development of specific health services. This paper follows these ideas through the last century and argues that the dead hand of history has played too large a role in determining malaria control generally, and especially over the last two decades, while the whole period provides an illuminating commentary on conceptualization in tropical health and its evolution. The two decades following discovery of the mosquito transmission of malaria saw increasingly specific knowledge about the vectors and approaches to preventing breeding. This required "odd" health workers who poured oil on water and did fresh-water biology and later special engineers who could design reservoirs and irrigation systems hostile to anopheline breeding and apply "species sanitation". The expertise required lay outside the health sector. Later, the DDT phase focused on a single highly specialized control technique, total coverage house spraying, and led on to attempted eradication, whose activities were vertically grouped. Malaria eradication became autonomous within the health department. It became the archetypal vertical programme whose funding levels and early successes made it a model to be emulated. But the need for active case surveillance to be integrated with general health services was a major reason for failure in some countries. The subsequent reaction to failed eradication emphasized horizontal or general health services, and these are very relevant to current pre-occupations with morbidity and mortality reduction by early diagnosis and prompt treatment. The future needs a complex mixture of interventions that cut across traditional views of either specificity or of the horizontal/vertical split in programmes, and development of effective control with imperfect tools requires a more sophisticated analysis of control methods and organizations than is provided by a simple vertical/horizontal debate.

Africa↗
PubMed2004

Measuring the effects of an ever-changing environment on malaria control.

The effectiveness of malaria control measures depends not only on the potency of the control measures themselves but also upon the influence of variables associated with the environment. Environmental variables have the capacity either to enhance or to impair the desired outcome. An optimal outcome in the field, which is ultimately the real goal of vaccine research, will result from prior knowledge of both the potency of the control measures and the role of environmental variables. Here we describe both the potential effectiveness of control measures and the problems associated with testing in an area of endemicity. We placed canaries with different immunologic backgrounds (e.g., naïve to malaria infection, vaccinated naïve, and immune) directly into an area where avian malaria, Plasmodium relictum, is endemic. In our study setting, canaries that are naïve to malaria infection routinely suffer approximately 50% mortality during their first period of exposure to the disease. In comparison, birds vaccinated and boosted with a DNA vaccine plasmid encoding the circumsporozoite protein of P. relictum exhibited a moderate degree of protection against natural infection (P < 0.01). In the second year we followed the fate of all surviving birds with no further manipulation. The vaccinated birds from the first year were no longer statistically distinguishable for protection against malaria from cages of naïve birds. During this period, 36% of vaccinated birds died of malaria. We postulate that the vaccine-induced protective immune responses prevented the acquisition of natural immunity similar to that concurrently acquired by birds in a neighboring cage. These results indicate that dominant environmental parameters associated with malaria deaths can be addressed before their application to a less malleable human system.

Animals↗
PubMed1990

Malaria control: present situation and need for historical research.

A rapid review is made of the history of malaria control, calling attention to differences between the evolution of the technical concepts, the formulated strategies and their implementation. Particular emphasis is placed on the discussion of the present situation of the world malaria problem and the difficulties faced by many endemic countries in adopting a malaria control strategy, based on primary health care, while their services are vertically organized for the performance of routines, which are irrelevant for disease control. The present malaria control strategy recognizes local variability, but it is possible to identify a limited number of types of situations, likely to respond to similar approaches. The definition not only of the control approaches but also of their conditions of applicability will become more precise as experiences are accumulated and adequately documented from different types of epidemiological situations. It is postulated that historical research on the malaria control and public health approaches, with proper attention being given to their socioeconomic and political context, in the countries which succeeded in controlling endemic malaria, will make an important contribution to such a definition.

Africa↗
PubMed2001

Efficacy and cost-effectiveness of environmental management for malaria control.

Roll back malaria (RBM) aims at halving the current burden of the disease by the year 2010. The focus is on sub-Saharan Africa, and it is proposed to implement efficacious and cost-effective control strategies. But the evidence base of such information is scarce, and a notable missing element is the discussion of the potential of environmental management. We reviewed the literature and identified multiple malaria control programmes that incorporated environmental management as the central feature. Prominent among them are programmes launched in 1929 and implemented for two decades at copper mining communities in Zambia. The full package of control measures consisted of vegetation clearance, modification of river boundaries, draining swamps, oil application to open water bodies and house screening. Part of the population also was given quinine and was sleeping under mosquito nets. Monthly malaria incidence rates and vector densities were used for surveillance and adaptive tuning of the environmental management strategies to achieve a high level of performance. Within 3-5 years, malaria-related mortality, morbidity and incidence rates were reduced by 70-95%. Over the entire 20 years of implementation, the programme had averted an estimated 4173 deaths and 161,205 malaria attacks. The estimated costs per death and malaria attack averted were US$ 858 and US$ 22.20, respectively. Over the initial 3-5 years start-up period, analogous to the short-duration of cost-effectiveness analyses of current studies, we estimated that the costs per disability adjusted life year (DALY) averted were US$ 524-591. However, the strategy has a track record of becoming cost-effective in the longer term, as maintenance costs were much lower: US$ 22-92 per DALY averted. In view of fewer adverse ecological effects, increased sustainability and better uses of local resources and knowledge, environmental management--integrated with pharmacological, insecticidal and bednet interventions--could substantially increase the chances of rolling back malaria.

Adolescent↗
PubMed2003

Malaria control in complex emergencies: the example of East Timor.

Malaria control in complex emergencies forms part of the World Health Organization's Roll Back Malaria (RBM) initiative. The underlying principle is a partnership with other UN agencies and non-governmental organizations, with the RBM programme providing support to its implementing partners through a Technical Support Network. This innovative approach was applied for the first time in 1999-2000, following the return of stability and security to East Timor. The RBM programme assessed the malaria situation during the acute emergency phase and identified programme priorities. Two non-governmental organizations were subsequently invited to operate as implementing partners. Individual proposals were developed and funding obtained, but no overall organizational and planning framework was established. Implementation commenced quickly, addressing aspects of prevention, diagnosis and treatment. As East Timor progressed into the transitional phase towards independence, the programme was not realigned to the changing context. Absence of monitoring and evaluation was a significant factor contributing to the resulting continuation of emergency malaria control activities well into the transitional phase. East Timor's example of malaria control in complex emergencies provides important lessons: (i). partnership roles and responsibilities should be clearly defined from the beginning of the programme, (ii). planning, monitoring and evaluation should be instigated from the start with the aim to develop long-term strategies and policies, (iii). expert support is necessary to guide implementation at all stages, (iv). the flexibility to react to changing priorities should be ensured as the context of the emergency and the available health structure changes, and (v). the implementation process, and alternatives for continuation of activities once the RBM complex emergency partnership has terminated, should be clarified to all partners involved.

Antimalarials↗
PubMed1991

Prospects for malaria control in urban and rural Kinshasa.

Malaria is a major cause of paediatric illness and death in Kinshasa, and all 3 million inhabitants are at risk. In view of the increasing chloroquine-resistance of Plasmodium falciparum, the early treatment of fever cases as the sole malaria control measure is no longer acceptable. The prospects for vector control are determined by the effectiveness, the acceptability and the practicability of the various methods in the local conditions of Kinshasa. Pronounced differences in the level of endemicity exist between the various parts of the town. These differences, and the ecological and socio-economic factors that underlie them, must be taken into account when estimating the potential of a control method. The reduction of man-vector contact through personal protection with impregnated bednets is the only realistic goal at this moment, but even a very marked decrease of the inoculation rate will produce little apparent effect in the highly endemic (semi-)rural districts at the periphery of town. In the urbanized center of Kinshasa, where the moderate to low intensity of transmission is more susceptible to a critical reduction, the same method may have an impact on malaria morbidity. Moreover, the big nuisance from non-vector mosquitoes in the urban area is an important motivating factor for the acceptance and the use of bednets. A mass effect, on the other hand, only is to be expected in isolated villages. Field trials are needed to evaluate the short- and long-term effect on malaria transmission and on its' clinical expression, as well as on the build-up of natural immunity, in the epidemiologically distinct areas. However, the final outcome of a large scale implementation of malaria control with impregnated mosquitonets will equally depend on health education, on the availability of bednets at low cost, on the creation of the appropriate structures for the (re)impregnation and distribution of the nets, and finally on the sustainability of the whole effort.

Democratic Republic of the Congo↗
PubMed1999

Overview of malaria control in the Americas.

The malaria endemic countries of the Americas have adopted in 1992 the WHO Global Malaria Control Strategy whose difficulties of implementation have been compounded to a major reform in the health sector, as the countries adjust to conform to financial scarcity and new economic policies. Most countries of the Region have reoriented its control program from eradication of malaria to the elimination of malaria mortality and morbidity. The Region has advanced towards these objectives having already reduced its mortality by 60% and is now in the final stages of applying new tools to control transmission and rapidly advance to reduce the incidence of malaria in the Americas.

Americas↗
PubMed1999

Malaria control priorities and constraints.

Each year, there are still between 300-500 million clinical cases of malaria and over one million deaths due to the disease, 90% of which occur in Africa south of the Sahara. In all continents, malaria risk is highest in remote rural areas where poverty abounds, population densities are low and the quality and coverage of the health services are poor or in existent. A sustained impact on the malaria burden can only be achieved through the cost-effective use of current tools, by including malaria in health sector development and inter-sectorial action, by mobilizing malaria control within communities and by investing in new and more effective tools. This paper highlights some of the constraints faced by countries in controlling malaria and outlines the priority activities that are being carried out to address these constraints within both communities and the health services. It aims to be set the scene for the papers of this Centenary book which address some of these issues in more detail.

Bedding and Linens↗
PubMed2006

Malaria control in Henan Province, People's Republic of China.

We analyzed malaria prevalence and evaluated the effect of malaria control measures in Henan Province, People's Republic of China between 1993 and 2004. Data relating to malaria epidemics, malaria control measures and their effects, and vector surveillance between 1993 and 2004 were collected and analyzed. Mean malaria incidence during this period was 2.96/100,000. After integrated vector control measures and appropriate treatment of malaria cases were carried out, the number of malaria cases in Henan Province decreased from 4,815 in 2000 to 2,112 in 2004. The parasite-positive rate and the density of Anopheles anthropophagus were also reduced. Malaria control measures were effective and malaria incidence decreased in Henan. However, there are still more cases in this province than in 1992. Local malaria outbreaks and epidemics have occurred in areas where Anopheles anthropophagus and An. sinensis are present. Thus, malaria control measures should be strengthened.

Animals↗
PubMed2004

Integrated urban malaria control: a case study in dar es salaam, Tanzania.

The rapid growth of cities in sub-Saharan Africa, much of it driven by rural-urban migration, is associated with complex transformations of these ecosystems and an intricate set of challenges for malaria control. Urban malaria transmission is substantially less intense and much more focal than in rural and peri-urban settings. However, the danger of epidemics is higher and the presence of substantial non-immune populations places people of all ages at comparable levels of risk. The limited number of breeding sites in urban centers suggests that prevention strategies based on vector control, with emphasis on environmental management, should be a central feature of urban malaria control programs. We focus on malaria in the city of Dar es Salaam, Tanzania. Following a brief review of the 100-year history of malaria control in this urban center, we describe and evaluate a control program that operated from 1988 to 1996 as a consequence of a bilateral agreement between the governments of Tanzania and Japan. We present an innovative urban malaria risk mapping methodology based on high-resolution aerial photography with ground-based validation. This strategy clarifies that remote sensing technology at a level of resolution of one meter is essential if this kind of information is to play a role in guiding the detailed specification of intervention strategies for urban malaria control. The Tanzania-Japan multiple-intervention malaria control program, adaptively implemented over time, is described and evaluated with implications for urban malaria control in sub-Saharan Africa more generally.

Animals↗
PubMed2002

The economic payoffs of integrated malaria control in the Zambian copperbelt between 1930 and 1950.

It has long been suggested that malaria is delaying the economic development of countries that are most severely affected by the disease. Several studies have documented the economic consequences of malaria at the household level, primarily in communities engaged in subsistence farming. A missing element is the appraisal of the economic impact of malaria on the industrial and service sectors that will probably become the backbone of many developing economies. We estimate the economic effects of integrated malaria control implemented during the colonial period and sustained for 20 years in four copper mining communities of the former Northern Rhodesia (now Zambia). Integrated malaria control was characterized by strong emphasis on environmental management, while part of the mining communities also benefited from rapid diagnosis and treatment and the use of bednets. The programmes were highly successful as an estimated 14,122 deaths, 517,284 malaria attacks and 942,347 work shift losses were averted. Overall, 127,226 disability adjusted life years (DALYs) were averted per 3-year incremental period. The cumulative costs of malaria control interventions were 11,169,472 US dollars (in 1995 US dollars). Because the control programmes were so effective, the mining companies attracted a large reservoir of migrant labourers and sustained healthy work forces. The programmes averted an estimated 796,622 US dollars in direct treatment costs and 5,678,745 US dollars in indirect costs as a result of reduced work absenteeism. Within a few years of programme initiation, Northern Rhodesia became the leading copper producer in Africa, and mining generated the dominant share of national income. Copper production and revenues, which increased dramatically during malaria control interventions, amounted to the equivalent of 7.1 billion US dollars (in 1995 US dollars). Integrated malaria control in copper mining communities was a sound investment. It had payoff for public and occupational health, generally, and without it copper extraction and social and economic development would have been impossible.

Absenteeism↗