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8/9/2019 Management of Malaria in Complex Emergency Situations
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MANAGEMENT OF
MALARIA INCOMPLEX
EMERGENCY
SITUATIONS
Malaria Prevention and Control Management CourseByaruhanga Emma
Mbarara-Uganda-2010
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Presentation outline
Learning Objectives
Introduction
Definition of malaria in complex emergencies
Rationale for special management of malaria in emergencies
Situations precipitating complex emergencies
Factors underlying malaria burden in complex emergencies
Strategies for management of malaria in emergencies Co-ordination of malaria control in emergency situations
M & E operational research
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Learning objectives
At the end of the session, you should be able to
understand the:
Definition of complex emergency situationsin relation to malaria
Factors influencing malaria outbreaks in
complex emergency situations
Management and control of malaria incomplex emergency situations
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Introduction
Malaria is a major communicable disease of thetropics and subtropics, killing more than one millionpeople each year.
Malaria is a disease of the poor, especially of those inremote areas with no easy access to health servicesparticularly in Asia & Africa
Malaria is also associated with conflict or theaftermath of conflicts
It is a disease that flourishes in conditions of crisis andpopulation displacement
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Definition
Complex emergencies have been defined as:
Situations affecting large civilian populations, involving
war or civil strife, food shortages and populationdisplacement
Resulting in excess mortality and morbidity from
malaria
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Situations that bring about complex emergencies
War situation between countries resulting in large
population of refugees
Internally displaced person arising from:-
Civil or political strife, tribal/ethnic conflicts
Disasters e.g. Femine, floods, cyclones, fireslandslides etc
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Factors that contribute to the malaria burden in complex
emergencies
Breakdown of health services and of malaria controlprogrammes
Movements of non-immune people or concentrationof people in high risk areas
Environmental deterioration that encourages vectorbreeding
Problems of supply of food and medicine anddifficulty of access
General lack of housing and cover/protection from
biting vectors 7
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Rationale for special Management of malaria in complex
emergencies
Conflict results in instability and lack of governance
The insecurity makes long-term planning impossible
Breakdown in systems can cause major difficulties for health
care delivery Malaria control in complex emergencies as an important
initiative to reduce the global burden of malaria
Malaria problem in complex emergency situations requirespecial attention
The strategies used in stable situations must be adapted forcomplex emergencies.
In complex emergencies malaria epidemiology is often ofepidemic nature
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Strategies for malaria management in emergency situations
Development of a plan
Situation analysis and assessment
Site Planning
Disease management
Prevention
Malaria Surveillance
Epidemic response Disease awareness & education
Coordination of malaria control efforts
Monitoring and evaluation & Operational research9
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Development of a plan
The elements of a good plan are:
Situation analysis
Define objectives for malaria control based on theseverity of the problem, human/material resources
available, level of control in the host country and the
expected future movements of refugees
Select strategies
Decide on activities
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Development of a plan (2)
The elements of a good plan cont..
Develop a work plan with responsible officer,
objectives and targets
Agree with all interested parties on organizationalframework
Develop indicators for monitoring and evaluation,and plan how they will be measured
Plan operational research, if gaps in necessaryinformation are identified
Develop a budget
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Situation analysis and assessment
Initial assessment of the situation to plan the appropriate
response, to decide upon the most effective interventions,
and to avoid costly or life threatening mistakes
Use an assessment team of experienced and qualified peoplewith a mix of complementary skills in disease control
Assess the underlying causes and establish objectives and
priorities
Assess the displaced community itself, to determine human
resources available and
Ensure their involvement in interventions
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Situation analysis and assessment (3)
Security
Military & other authorities
Access to the vulnerable
Available resources and logistics
Human
Health facilities
Drugs, etc
Funds
Logistics import practices
Legal, registration policy
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Disease management
Diagnosis Microscopic diagnosis may not be possible in the acute
phase of an emergency and clinical diagnosis is used inareas of high transmission
Confirmation is particularly important in areas where drugresistance necessitates use of expensive drugs or wheretreatment failure due to resistance can progress rapidly tosevere malaria
The recently developed rapid diagnostic tests are very useful
for screening large numbers of patientsTreatment
The treatment provided should be based on knowledge ofdrug resistance patterns in the area
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Disease management (2)
This is particularly important as displaced populations
are especially vulnerable due to low immunity (from
malnutrition or lack of previous exposure to malaria)
Management of severe malaria should be according tothe national treatment protocols
causes of treatment failure, such as non-compliance,
vomiting and poor quality drugs should always be
monitored.
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Disease management (3)Chemoprophylaxis and preventive treatment
In complex emergencies, chemoprophylaxis for malariashould be limited to pregnant Women, expatriate staff, andspecial groups such as the army
The drugs available for chemoprophylaxis in these
situations should be cautiously chosen (chloroquine,proguanil, pyremethanine /dapsone, mefloquine anddoxycycline ???)
Service delivery
A clear, understandable, treatment regimen should beestablished and communicated to all involved in healthservice delivery.
First line treatment may need to be changed if drugresistance studies show that national policy is ineffective.
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Disease management (4) On-site training of health workers is needed to improve case
management Accessibility to the service delivery points is important-
appropriate type of health systems ( mobileclinics/community health workers)
In the acute phase, cash incentives may be needed to carryout control interventions, but food-for-work is an option
Delivery of services should be integrated with primary health
structures or networks (e.g. using local NGOs or community
based organizations) Delivery systems should be diversified and community
participation encouraged to improve efficiency and coverage.
In the post-emergency phase the commercial sector mayprovide sustainable supply of nets and
insecticide (sachets or tablets for home-treatment). 18
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Prevention
Acute phase
The choice of intervention for disease prevention in the acute phasewill vary according to effectiveness, feasibility, cost and speed ofsupply.
The key local factors influencing choice are:
Type of shelter available (permanent housing, tents, plasticsheeting)
Human behavior (Culture, sleeping practices, mobility)
Vector behavior (Biting cycle, indoor or outdoor resting)
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Prevention (2)
Insecticide treated mosquito nets (ITN) & Items and subsequentre-treatment are suitable
ITN may also be appropriate for those who regularly travelcross-border to insecure areas.
Indoor spraying of residual insecticide (house spraying) hasbeen the method of control most often used in chronic refugeesituations
Environmental control may be difficult during the acute phaseexcept on a local scale, and impact is often limited. To reduce thenumber of vector breeding sites: Drain clean water around water tap stands & rain water drains
Larvicide vector breeding sites if these are limited in number (seek expertadvice)
Drain ponds, but may not be acceptable if used for washing
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Prevention (3)
Post-emergency phase
Emergency needs change and mortality is brought under control
beneficiary involvement and skills improvement
displaced people living in plastic shelter or tents construct local stylehuts
Establishing wider use of self protection methods
Some cost recovery could be introduced for new nets as peoples livelihoods
Re-treatment process needs to be established on a cost recovery basis
Free or reduced cost distribution is essential for some vulnerable (widows withyoung children, orphans etc.)
Environmental control may be possible during rehabilitation of irrigation and watersupply sources
House spraying should become increasingly focal; prioritization of camps forspraying
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Malaria Surveillance
Malaria surveillance is essential to assess the impact of the disease on the displacedpopulation in a complex emergency.
The information sources or indicators available will depend on whether the regioncannot, could, or does support malaria transmission
Minimal information required in order to assess the impact of malaria and toprepare a response:
Species of Plasmodium (which species are present, in what ratio, and inwhich seasons?)
Mortality- what evidence is there for excess mortality or for malaria
being the cause? Morbidity-what is the incidence of fever and incidence of malaria?
what is the evidence for an increase in incidence of malaria?
which age groups are affected (14yr)?
pregnancy outcomes (low birth weight, stillbirth, prematurity)
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Surveillance and epidemic investigation
Investigate any outbreak should be prepared in advance
Epidemic preparedness measures for malaria should be taken jointly withother disease of epidemic potential
To respond appropriately to the outbreak, the following minimalinformation is required:
Population Who is affected? Where are they from? How are they living?
Disease Number with acute febrile illness Number with confirmed uncomplicated malaria Number with microscopically confirmed severe malaria Number of malaria deaths
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Surveillance and epidemic investigation(2)
Number of maternal deaths due to malaria
Proportion of children with anaemia
Proportion of pregnant women with anaemia
Drug resistance; the proportion of treatment failures
Management
Number of health facilities Available staff and expertise
Access of population to the health facilities
Availability of drugs and supplies
Malaria policy and treatment guidelines 24
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Epidemic response
The main aim of the response must be to reduce mortality and
disease burden.
Three strategies for intervention may include:
1. Mass treatment of fever cases
2. Case detection and treatment by outreach services
3. Passive case detection
In a severe outbreak the majority of fever cases may be due tomalaria.
Health services should reach as deeply into the community as
possible and make full use of community health workers if
available. 25
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Disease awareness & education
Simple messages are needed that:
Improve understanding of disease
Encourage appropriate treatment-seeking behavior
Make the connection between protection against mosquitoesand prevention of disease
Improve mosquito net retention and correct use
Emphasize who needs protection most (usually children and
pregnant women) Health messages may be delivered through community health
workers (CHWs), posters, leaflets, and the mass media.
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Training
Who to train?
Policy makers
Health co-ordinators : National/local/expatriateNGO staff
Clinical workers
Front line preventive health workers
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Coordination
Reduce security risk
Improve efficiency
Prevent duplication of activities Provide common logistic systems
Mediate or improve agency negotiating power with authorities
or factions
Coordination might be provided under a UN umbrella agencyor by a special coordination body which agencies subscribe to
and within such fora it is possible to establish sector
committees to address specific health issues.
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M & E Operational research
Monitor input and process indicators
Evaluate outcomes and impact
Undertake operational research to inform themanagement of emergency operation
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