Zanzibar Malaria Control Program, ZMCP

Digital Library of the Tanzania Health Community

MALARIA SITUATION IN ZANZIBAR 
 
Developing the 2nd Global Malaria 
Action Plan (GMAP2) 
 Whitesands Hotel  
September 4-5th, 2014 
Dar-es-salaam, Tanzania 
United Republic of Tanzania 
Introduction 
ZANZIBAR 
Unguja 
Unguja Pemba 
Unguja 
Zanzibar: 
•  1.3 m pop 
•  2,500 km2 
•  Transmission  
•  Perennial 
•  High seasonality 
•  Vectors 
•An. Arabiensis 
• An. gambiae s.s 
• Parasite 
•P. falciparum ( 83%) 
•P. malariae& Pf (17%) 
 74.2  
 6.3  
 45.8  
 36.0  
 45.4  
 12.5   1.0  
colonial era
(<1960)
eradication
campaign
(1960-1969)
after
eradication
campaign
(1970-1985)
during IRS
project (1986-
1989)
pre RBM scale
up (1990-1999)
early RBM years
(2000-2005)
after RBM scale
up (2006-2010)
History of malaria in Zanzibar: 
Household malaria prevalence 1927-2010 
0%
10%
20%
30%
40%
50%
1
9
9
9
2
0
0
0
2
0
0
1
2
0
0
2
2
0
0
3
2
0
0
4
2
0
0
5
2
0
0
6
2
0
0
7
2
0
0
8
2
0
0
9
2
0
1
0
2
0
1
1
P
o
s
it
iv
it
y
 r
a
te
 
< 5 years 5+ years
• Evidence from that past 5 years shows 
that in Zanzibar malaria has been 
controlled and the country is now in a 
pre-elimination phase 
• Health Facility Data confirm that since 
2006 SPR is largely below 5% (threshold 
for pre-elimination) 
• Repeated surveys data from 2006 
onwards show an overall prevalence rate 
of <1% 
• Still evidence of increased seasonal 
transmission in some foci (hot spots) 
every year 
• Evidence of some localized outbreaks 
(2010) 
Pre 
elimination Control 
Malaria Control Phases in Zanzibar 
Malaria positivity rate 1999-2011 
MEEDS Results: Annual Malaria Confirmed Cases and positivity 
rate, 2008-14 (157 HF) 
0
500
1,000
1,500
2,000
2,500
3,000
0
1,000
2,000
3,000
4,000
5,000
2008 2009 2010 2011 2012 2013 2014
R
ai
n
fa
ll 
(m
m
) 
C
o
n
fi
rm
e
d
 M
al
ar
ia
 C
as
e
s 
<5 yrs 5+ yrs rainfall
0
500
1,000
1,500
2,000
2,500
3,000
0.0
1.0
2.0
3.0
4.0
5.0
2008 2009 2010 2011 2012 2013 2014
R
ai
n
fa
ll 
(m
m
) 
M
al
ar
ia
 P
o
si
ti
vi
ty
 R
at
e
 (
%
) 
<5 yrs 5+ yrs rainfall
Confirmed malaria cases 
Malaria positivity rate (%) 
Where are the cases in 2013 
Unguja Pemba 
North B: Distribution of followed-up cases in 2013 (n=218)  
Timeliness of notified cases by months and by district (n=1974) 
0%
20%
40%
60%
80%
100%
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
P
ro
p
o
rt
io
n
 o
f 
ca
se
s 
 
Within 24 hours 24-48 hours  More than 48 hours Target (90%)
24% 
26% 
50% 
0%
20%
40%
60%
80%
100%
C
H
A
K
EC
H
A
K
E
N
O
R
TH
 A
C
EN
TR
A
L
SO
U
TH
U
R
B
A
N
W
ES
T
M
K
O
A
N
I
N
O
R
TH
 B
W
ET
E
M
IC
H
EW
EN
I
P
ro
p
o
rt
io
n
 o
f 
ca
se
s 
Within 24 hours 24-48 hours  More than 48 hours
0500
1000
1500
2000
2500
3000
3500
4000
4500
2008 2009 2010 2011 2012 2013 2014
# 
o
f 
co
n
fi
rm
e
d
 c
as
e
s 
Passively detected Active detection - MCN
20% 
(510) 
37% 
(130) 
Annual Malaria Confirmed Cases from 157 HFs through MEEDS and 
MCN, 2008-14 
Timeliness of cases follow-up by months and by district (n=1974) 
0%
20%
40%
60%
80%
100%
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
%
 f
o
llo
w
e
d
-u
p
 c
as
e
s 
 
Within 48 hrs 48 hours to 1 week  More than 1 week Target (90%)
0%
20%
40%
60%
80%
100%
W
ET
E
M
K
O
A
N
I
C
H
A
K
EC
H
A
K
E
N
O
R
TH
 A
C
EN
TR
A
L
W
ES
T
M
IC
H
EW
EN
I
N
O
R
TH
 B
U
R
B
A
N
SO
U
TH
%
 f
o
llo
w
e
d
-u
p
 c
as
e
s 
Within 48 hrs 48 hours to 1 week  More than 1 week
24% 
22% 
54% 
Travel history by district and by month in 2013 (n=722 - 27%) 
 -
 20
 40
 60
 80
U
R
B
A
N
N
O
R
TH
 A
N
O
R
TH
 B
W
ET
E
C
EN
TR
A
L
W
ES
T
M
K
O
A
N
I
SO
U
TH
M
IC
H
EW
EN
I
C
H
A
K
EC
H
A
K
Ep
ro
p
o
rt
io
n
 in
  (
%
) 
Secondary cases (%) Index cases (%)
0
20
40
60
80
100
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
p
ro
p
o
rt
io
n
 in
 (
%
) 
secondary cases (%) index cases (%)
monthly travel hx 
travel hx by district 
Overall history of travel among malaria cases investigated 29% 
MCN-Achievements 
• Additional of  DMSOs   - (2 per district – trained and equipped) 
• Remarkable case follow up > 70%:  76% of detected cases have been followed -up  
• Community willingness and involvement in malaria outreach services 
• Data cleaning processes and reinforcement for preventive measures is at early 
implementation stages (including adding controls) 
• Information dissemination through Quarterly reports 
• Initiates village mapping for focal and intensive implementation of various 
interventions (ACDs, IRS etc) 
• Assist in Decision making at Programme level (focusing resources) 
 
Malaria Confirmed Cases by Week, 2008-12 
Confirmed malaria cases 
Malaria positivity rate (%) 
0
50
100
150
200
250
300
0.0
2.0
4.0
6.0
8.0
10.0
12.0
1 6 11 16 21 26 31 36 41 46 51 4 9 14 19 24 29 34 39 44 49 1 6 11 16 21 26 31 36 41 46 51 4 9 14 19 24 29 34 39 44 49 2 7 12 17 22 27 32 37
2008 2009 2010 2011 2012
ra
in
fa
ll 
(m
m
) 
p
o
si
ti
vi
ty
 r
a
te
 (
%
) 
< 5 yrs 5+ yrs Rainfall
0
50
100
150
200
250
300
0
50
100
150
200
250
300
350
400
1 6 11 16 21 26 31 36 41 46 51 4 9 14 19 24 29 34 39 44 49 1 6 11 16 21 26 31 36 41 46 51 4 9 14 19 24 29 34 39 44 49 2 7 12 17 22 27 32 37
2008 2009 2010 2011 2012
ra
in
fa
ll 
(m
m
) 
n
u
b
er
 o
f 
m
a
la
ri
a
 c
a
se
es
 
< 5 yrs 5+ yrs Rainfall
Introduction cont.. 
Revised-STRATEGIC PLAN 
• Vision: Zanzibar free of malaria  
 
• Mission: To provide quality, affordable and cost effective 
anti-malarial interventions to all people in Zanzibar 
 
• Mediam Term: To consolidate the malaria control 
achievements towards pre- elimination  by 2018 
 
• Long term Goal: Malaria elimination in Zanzibar 
Objectives: 
• Obj 1:  All suspected malaria cases will have a confirmatory test using the 
recommended parasitological test by 2015 
 
• Obj 2:  All confirmed malaria cases will be treated with an effective antimalarial 
medicine. In addition an anti-gametocytocidal drug will be added to the treatment 
for its transmission blocking effect by 2017 
 
• Obj 3:  Maintain universal coverage (100%) prevention measures up to 2018 
 
• Obj 4:  Expand malaria surveillance; conduct active case detection and investigate 
100% of confirmed malaria cases up to 2018 
 
• Obj 5:  Establish functional coordination structures for malaria elimination at 
National, district and Shehia levels by 2018  
 
• Obj 6:  Conduct Operational Research to evaluate and optimize ongoing activities 
and monitor resistance to anti-malarials and insecticides up to 2018  
 
• Obj 7:  By 2018, 90% of Zanzibar population will have correct knowledge and good 
practices towards malaria elimination continuum 
Coverage 
0% 
24% 
37% 
74% 
69% 
55% 
71% 
35% 
33% 
31% 
9% 
0% 
16% 
2% 
2002 2004 2005 2007 2008 2009 2010
3% 
18% 
37% 
73% 
64% 
50% 
72% 
31% 
20% 
29% 
12% 
17% 
4% 
2002 2004 2005 2007 2008 2009 2010
3% 
21% 
26% 
60% 
52% 
58% 
25% 
28% 
29% 
11% 
20% 11% 
2002 2004 2005 2007 2008 2009 2010
Un-treated nets LLINs/ITNs 
Under fives Pregnant women All ages 
Indicators 2009 2010 2011 2012 
LLINs utilization  52 58 72 - IRS 
IRS coverage 96 93 88 95 
  % of health facilities with no stock out of nationally 
recommended antimalaria drugs continuously for one 
week during the last 3 months 
100 100 79 100 
  % of households having at least three ITN 37.2 
  % pregnant women on anti-malarial chemoprophylaxis 
according to national policy 
49.2 
Impact 
Indicators 2009 2010 2011 2012 
Malaria positivity rate 2868 (2.0%) 2454 (1.5%) 3161 (1.2%) 2145 (1.1%) 
Malaria incidence per 1000 population 2.3 1.9 2.4 1.6 
  Mortality attributed to malaria (all ages) 0 0 3  (1.2%) 
  Mortality attributed to malaria (under five ) 0 0 1 (0.7%) 
Malaria Prevalence from Household Surveys, 2002-10 
0
5
10
15
20
25
2002 2003 2004 2005 2006 2007 2008 2009 2010
I
P
T
p 
P
re
va
le
n
ce
 (
%
) 
A
C
T
s 
L 
L 
I
N
s 
I
R
S 
R
D
T 
current “Malaria Prevalence in Zanzibar is < 1%.” 
Progress: strengths 
• Malaria prevalence and incidence has significantly 
declined and has been maintained at low levels for 
over five years, feasible for malaria elimination 
 
• Mortality attributed to malaria is almost inexistence 
( 2009:0, 2010: 0, and 2011:3: cases)  
 
• Robust surveillance system in place; Re- & Pro-Active 
Case Detection, and follow up of index cases on 
going 
 
• Intensive vector control activities in place 
 
• Production of Surveillance reports from 2008 to date 
 
Weaknesses 
• Low proportion of domestic financing for 
malaria activities – ?sustainability 
 
 
• Lack of external quality assurance scheme 
 
• Lack of Death audit scheme 
 
• No short-term and medium term forecasting 
for early warning of epidemics 
 
 
Priorities 
In September 2011, a comprehensive Malaria Programme 
Review was conducted in all thematic areas. Key issues and 
recommendations (programmatic and operational) were 
raised to improve programme performance 
  
High priority 
1. Surveillance guidelines in line with malaria elimination 
strategies 
 
2. Geographical reconnaissance to facilitate recognition of 
areas for targeted interventions 
 
3. Death Audit Scheme 
4. Introduction of more sensitive diagnostic tool 
5. Introduction of targeted LSM to complement IRS&LLINs 
6. Therapeutic efficacy of ACT 
 
 
Priorities cont.. 
Less but important (could be done as time goes on) 
1. To estimate malaria importation rate  
 
2. No Insecticide Resistance Management Plan in place following an 
emergence of Pyrethroid resistance (in pipeline) 
• Maintaining the delivery of commodity  
• 824,882 LLINs required in 2015 
–  536,123 RDTs required in 2015 
• Keep up strategy for LLINs (172,000LLINs required) 
Priorities cont... 
• Conduct periodic comprehensive Malaria Programme Review 
• Conduct Intervention coverage survey every year 
• Conduct household survey to determine the prevalence of G6PD-Deficiency, 
2013 (Glucose-6-Phosphate Degedrogenase Deficiency) 
• Monitoring vector species, densities, and behaviour 
• Monitor quality of IRS using bioassay test 
• Monitoring efficacy and durability of LLINs 
• Regular monitor the vector susceptibility to insecticides 
• Regular monitor and evaluate BCC interventions and strategies 
• Monitor the pharmacovigilance activities on all antimalarial medicines 
• Conduct mid-term and end-term programme evaluation based on new 
malaria elimination strategy 
• Continue implementing surveillance systems 
Critical to achieve impact 
 • Strengthen the QC/QA system for malaria 
diagnostic tests in public and private sector 
• Introduce primaquine for gametocytes clearance  
• Timely, replacement of LLINs after every three 
years   
• Implementation of LLINs Keep-up strategy 
• Mobilization of resource from both domestic and 
external sources (timely) 
• The rest nice to do – facilitate program operation 
 
 
New and revised approaches 
• Establish  functional Malaria Elimination Multi-sectoral 
Committees at all levels including private sectors 
 
• Empower district health management teams to conduct 
surveillance activities - active case detection   
 
• Introduce malaria screening on arriving passengers in 
major ports 
 
• Update the Malaria Community Strategy in line with 
malaria elimination 
 
• Incorporate IEC/BCC in the curriculum of health 
professionals training institutions and train mobile 
populations such as travelers, fishermen, and seasonal 
workers on the importance of malaria elimination 
Acknowledgments 


Malaria Situation in Zanzibar: Developing the 2nd Global Malaria Action Plan (GMAP2)

http://ihi.eprints.org/2869/1/Zanzibar_GMAP2.pdf

Malaria Situation in Zanzibar: Developing the 2nd Global Malaria Action Plan (GMAP2)

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