Tanzania Daily News (Dar es Salaam)
Anthony Tambwe
28 May 2011
Afew years ago,Othman Mrushid would show up each morning at his clinic in a tiny rugged Matemwe village,Unguja,Zanzibar, to find a group of shivering villagers waiting for his services. After checking the patients, majority would be suffering from malaria. It used to be a daily routine.
How things have changed! Malaria was ravaging his community. Unlike then, nowadays at times only one patient shows up at his clinic. Yet in 2002, his bare concrete floors and light bulbs clinic treated about 3,063 cases of malaria. By 2005, that number had been cut almost by a half, to 1,740. Since 2006 to last year, there were just 31 cases, and so far this year, there have been very few cases, less than 10.
The adage that prevention is better than cure has proved true in the isles, making the significant reduction of malaria cases a case study. Concerted efforts and a well funded strategy by the government and the international community has made this possible.
A combination of insecticide- treated bed nets, widespread home spraying, rapid diagnostic kits, lifesaving drugs and public education has transformed malaria from a major killer to a rare affliction.
In 2005, 20 percent of young children who showed up in health care facilities in the Isles tested positive for malaria. Today, there is only one percent. In 2004, 416,911 malaria cases counted among a population of just over one million. By 2009, that had plunged to less than 14,000.
“Malaria has been a big, big problem in public health. It was the number one disease,” said Mahdi Ramsan, a doctor who has worked in Zanzibar for over 10 years and runs a program sponsored by an American research institute.
“In a very, very short time,we are seeing results that are really great. Our challenge now is to keep the morbidity down.” In 2005 nearly about 200,000 homes in Zanzibar were sprayed in three waves,and over 230,000 nets were given out. Also 100,000 rapid diagnostic kits were stocked in clinics.
Sheila Shiba, 39, who lives in a two roomed structure at Matemwe village in Unguja, was one of the beneficiaries of the drive. “My house was sprayed three times,” she says. Her children sleep together in a bed protected by a blue net draped over the posts and tucked under a thin mattress.
Shiba’s 10 year old son, Said Omar, used to suffer from fever, headaches and other malaria symptoms three to five times a month. But since 2005, after starting to use the treated bed net, he has not experienced any malaria attack.
For Mariam Mussa, 34, a small trader and mother of three in Tunguu village south of Unguja, she is also grateful malaria menace has been under control. “I thank God the last time one of my children had malaria was in May 2009.In the past we used to have malaria frequently,” she says.
Othman, the head of Mboni Clinic, is relieved. He has been treating Matemwe villagers and their neighbors of malaria for about 30 years. He used to use an old microscope but today he has a blood test kit, which can tell within minutes if a patient has malaria. One red mark means negative, two mean positive. He marks each one in a book, and the last few pages all carry the same handwritten notation . ‘Negative’ “We had so many people,” he recalled.
“Every day there were so many patients,” he says with a distant look, and adding that the number has drastically decreased changing the community in a farreaching way. Days wasted without working or schooling due to malaria attack has become a thing of the past.
How Zanzibar cut down Malaria Zanzibar switched to ACTs in 2004, after it was realised malaria had grown resistance to chloroquine, previously the most commonly used drug. At Wete District Hospital,Sheikh Makame recalls that once he was so sick with malaria that he could not even move a finger.
“But when I was brought here and given ACT, I recovered fast. That’s why I’ve brought my child who is also suffering from malaria.”
The man at the helm of Zanzibar’s Malaria Control Programme (ZMCP), Abullahi Ali, says they want to distribute a further 70,000 treated bed nets, taking the total figure to 300,000.
Zanzibar’s strategy to fight malaria was closely modelled on the World Health Organization’s Roll Back Malaria initiative.
Efforts to combat the disease have seen the prevalence rate come down from 35 percent before 2008 to below one percent, but health officials are worried the gains could be reversed.
“Despite the achievements in reducing malaria, lack of funds for awareness [raising], indoor residual spraying and surveillance, is a challenge.Also, we have a problem with people’s resistance to behavioural change, particularly in keeping the environment clean and in the use of mosquito nets,” said Mwinyi Msellem, head of the diagnostic unit at ZMCP.
As malaria prevalence heads towards zero, the population is also losing its natural immunity to the disease, meaning that population screening will become increasingly important, said Msellem. The prevalence was below one percent according to 2007 Roll Back Malaria Indicator Survey.
ZMCP interventions have only been able to reach 60 percent of 280,000 household and hope to reach 95 percent in the near future. Along with past interventions, emphasis is on new case monitoring and research. “When you get this kind of success you have to increase surveillance,” he noted.
Early epidemic detection system: Phone messages becomes handy
A Malaria Early Epidemic Detection System has also been established to monitor new cases at 52 of Zanzibar’s 150 health facilities.
“Weekly, they [the health entres] send text messages to our server, indicating the number of patients, those tested for malaria and the number diagnosed with malaria,” said Msellem.
Comparisons are then drawn against previous weekly reports. “If an increase is noted, we have to investigate and check breeding grounds,” he said. The health centres reported 1,671 confirmed malaria cases in 2009, of which 618 were children under five.
According to the Ministry of Health and Social Welfare, health centres have been showing 2-3 percent malaria prevalence, with no change noted since the short March- May rains.
New challenges as Malaria prevalence heads to zero
Challenges are, however, merging in disease monitoring,behaviour change and funding.
Among the problems is difficulty of getting monitoring data from the health facilities, he said. Mobile phone technical errors sometimes also interfere with data collection.
“Each district also needs its own surveillance and response team and there is a need for more trained personnel,”he said. “To set up this system you also need a lot of money.
“Refusal to test and be treated for malaria has also been noted as cases decline,raising the risk of onward transmission or even death.This is because some people believe malaria has already been eliminated, said ZMCP.
ZMCP officials say they need about USD 10.5 million (over 12bn/-) to move towards eliminating the disease in the islands.
“We have been recording admirable success in combating malaria in the islands through multiple interventions. We have managed to reduce the prevalence from 41 per cent in 2001 to 0.4 per cent this year,” ZMCP Manager,Mr Abdullah Suleiman said However, he said that sustaining the achievements remain the biggest challenge.
“Although the disease is down, the situation remains fragile. Sustainable commitment by the government, including having its own funds for the anti-malaria programme and awareness of the need to keep the environment
clean, is important to control mosquitoes,” said Heri Tungaraza, a doctor at Lugalo Hospital.ZMCP’s Msellem also said the likelihood of donors and the government withdrawing support due to the recorded success is a major concern.
“As malaria prevalence heads towards zero, the population is also losing its natural immunity to the disease, meaning that population screening will become increasingly important,” said Msellem.
“We need to sustain control measures to avoid resurgence… Malaria prevalence was reduced to 1-2 percent in the 1970s, and then people relaxed… If we do not have proper strategies and do not work together – yes there is a fear of sliding back, “he informed.
Malaria prevalence was below one percent, according to the Roll Back Malaria Indicator Survey done two years ago. A 2009 study by University of Dar es salaam on ‘Aid and healthcare’, notes that Africa has the highest disease urden, yet the lowest financing on health.
It also notes that in the recent past, many initiatives including the Presidential Emergency Plan for AIDS Relief (PEPFAR) and the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFTAM) have been created to fast-track the race to achieve Millennium Development Goals MDGs by 2015. This may not be sustainable.
Elsewhere in Tanzania, Kagera region has managed to cut the disease by almost 50 percent in the last 3 years, but for nationwide the battle remains an uphill task.
Panos Eastern Africa provided the writer with support to travel to Zanzibar for this story.
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