SUCCESS STORY SUCCESS STORY in in

THE CONTROL OF MALARIA THE CONTROL OF MALARIA IN ERITREA IN ERITREA

National Malaria Control Program/DPCDepartment of Health Services

Ministry of Health

Intercontinental Hotel18-22 Feb. 2008, Impact Evaluation

Asmara, ERITREAERITREA

Kill Mosquito! Kill Malaria

Eritrea: General Country BackgroundEritrea: General Country Background

Population: 3.6 Population: 3.6 millionmillion

Area: 124,320 Area: 124,320 sq. kmsq. km

Population Population <16 years old<16 years old: : 50%50%

Rural:UrbanRural:Urban – – 80:2080:20

Malaria Epidemiology of EritreaMalaria Epidemiology of Eritrea

3 epidemiologically distinct strata:3 epidemiologically distinct strata: Coastal plains (0-1000m)Coastal plains (0-1000m) Western lowlands (700-1500m)Western lowlands (700-1500m) Highlands (1500-2000m and above)Highlands (1500-2000m and above)

67% (2.3 million) of population live in 67% (2.3 million) of population live in malaria risk areasmalaria risk areas

Parasite distribution: Parasite distribution: P. falciparumP. falciparum (90%), (90%), P. P. vivaxvivax (10%) (10%)

Main vector: Main vector: Anopheles arabiensisAnopheles arabiensis

Malaria Epidemiology……Malaria Epidemiology……

2 main malaria transmission seasons:2 main malaria transmission seasons: September – November (central, southern, western September – November (central, southern, western

lowlands)lowlands) January – March (coastal plains)January – March (coastal plains)

Malaria is seasonal, focal, and unstable. (Risk Malaria is seasonal, focal, and unstable. (Risk for malaria epidemics is high)for malaria epidemics is high) Displaced populations due to border conflictDisplaced populations due to border conflict High population mobility/movementHigh population mobility/movement Low immunityLow immunity Drug resistanceDrug resistance

MALARIA CONTROL STRATEGIESMALARIA CONTROL STRATEGIESCASE MANAGEMENT

IVM

EPIDEMIC PREVENTION

CAPACITY BUILDING

HEALTH PROMOTION

OPERATIONAL RESEARCH

M & E

IMPACT ON MALARIA

REDUCTION IN MALARIA MORBIDITY & MORTALITY

2005-2009 CRBMSP 2005-2009 CRBMSP OBJECTIVESOBJECTIVES

malaria morbidity by 30% malaria morbidity by 30%

malaria mortality by 50%malaria mortality by 50%

AVOID MALARIA EPIDEMICS AVOID MALARIA EPIDEMICS TOTALLY!!! TOTALLY!!!

ITN distribution has been markedly scaled up since its ITN distribution has been markedly scaled up since its inception in 1995inception in 1995

0

200

400

600

800

1000

1200

1400

1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007

Thousands

ITN

s d

istr

ibu

ted

Cu

mu

lati

ve

0

50

100

150

200

250

300Thousands

Mal

OP

D C

ases

Bed net distribution by zone, 2004-2007

ANSEBA

NORTHERN RED SEA

GASH BARKADEBUD

ANSEBA

DEBUBDEBUB

SOUTHERN RED SEA

Anseba.shpDebub.shpGashbarka.shpMaekel.shpNorthenredsea.shpSouthernredsea.shp

100 0 100 200 300 400 500 Kilometers

NEritrea Map by ZONES

23%

16%

26%

5%

22%

7%

Bed net Bed net re-impregnation ratere-impregnation rate increased from increased from 10.1%10.1% in 1999 to in 1999 to 95 95 %% in 2007 in 2007

10.117.2

53.358.5

76.583.5

93.3 94 95

0

10

20

30

40

50

60

70

80

90

100

Re-im

pre

gnation R

ate

1999 2000 2001 2002 2003 2004 2005 2006 2007

ITNs ownership and usageITNs ownership and usage (RBM evaluation 2004)(RBM evaluation 2004)

79 73

0

20

40

60

80

100

Own any net Own ITN

Per

cen

t 59

<5 slept underITN

39.3

50.4

>5 slept underITN

Preg motherslept under ITN

Malaria OPD by yearMalaria OPD by year

0

20000

40000

60000

80000

100000

120000

2000 2001 2002 2003 2004 2005 2006 2007

Ma

lari

al

OP

D c

as

es

MalOPDU5 MalOPD A5

Malaria OPD Cases – 6-year TOTAL data

SELA

ARETA

AFABET

KARORA

GULUJ

FORTO

GHELAELO

DEBUB-DENKALIA

DIGHE

FORO

NAKFA

ASMAT

GOGNE

KERKEBET

SHIEB

MULKI

LAELAY GASH

MENSURAHAYCOTA

ADOBHA

MAKELAY KEYHI BAHRI

GHINDAE

AREZA

HABERO

SENAFE

HAGAZ

DBARWA

HALHAL

MAY-MINETSORENA

DAHLAK

ASSAB

MOGOLO

SHAMBUKOTESSENEY

100 0 100 200 300 400 500 600 Kilometers

N

Very Low (53-461 cases)Low (462-1207 cases)Moderate (1208-2167 cases)High (2168-3516 cases)Very High (3517-5868 cases)

Malaria IPD Cases by yearMalaria IPD Cases by year

0

500

1000

1500

2000

2500

2000 2001 2002 2003 2004 2005 2006 2007

<5

Mal

aria

IP

D C

ases

0

1000

2000

3000

4000

5000

6000

7000

8000

9000

10000

Tota

l Mal

aria

IPD

Cas

es

<5Mal IPD Total Mal IPD

Malaria Mortality by yearMalaria Mortality by year

5030

4532 28

2 9 9

176

85

129

8570

35

6

2516 32

020406080

100120140160180200

1999 2000 2001 2002 2003 2004 2005 2006 2007

# of

mal

aria

dea

ths

<5MalDeaths TotMalDeaths

MalariaMalaria case fatality rate case fatality rate

5.97

2.31 2.351.76

1.34 1.110.720.22

2.393.63

1.07 1.19 1.250.64 0.690.80

0.37 0.470.00

1.00

2.00

3.00

4.00

5.00

6.00

7.00

1999 2000 2001 2002 2003 2004 2005 2006 2007

Mal

aria

CF

R

<5 MalariaCFR Total Malaria CFR

Satellite Estimated Rainfall Values (1995-2007)

0

50

100

150

200

250

300

350

400A

ug-9

5

Aug-9

6

Aug-9

7

Aug-9

8

Aug-9

9

Aug-0

0

Aug-0

1

Aug-0

2

Aug-0

3

Aug-0

4

Aug-0

5

Aug-0

6

Aug-0

7

Avera

ge

Month

ly R

ain

fall

(mm

)

SELANAKFAASMATHABEROKERKEBETFORTOSHIEBDIGHEHAGAZGELEBKERENELABEREDMENSURAMASSAWAGHINDAEADI-TEKELEZANAGORDATLOGO ANSEBASEREJ EKAFOROGOGNEGHELAELOMOGOLOBERIKHHAYCOTANORTH WEST ASMARATESSENEYNORTH EAST ASMARAGHALA NEFHISOUTH EAST ASMARASOUTH WEST ASMARADEKEMHARESEGHENEYTIDBARWABARENTUADI-KEIHAREZALAELAY GASHGULUJMENDEFERAMAY-AYNEESENAFEKUDO-BOUERTSORENAADI-QUALAMAY-MINEASSABADOBHAKARORAMULKISHAMBUKOHALHALHAMELMALODAHLAKAFABETARETAMAKELAY KEYHI BAHRIDEBUB-DENKALIA

Environmental Management (Source reduction)Environmental Management (Source reduction)

0

20000

40000

60000

80000

100000

120000

140000

160000

2003 2004 2005 2006 2007

Sites Avoided Sites treated Pop. participated

Eritrea has sustained the use of Eritrea has sustained the use of multiple vector control methodsmultiple vector control methods

Bed nets

Indoor Spraying

Larviciding

Source Reduction

Drainage

Quality control of malaria diagnosisQuality control of malaria diagnosis(Cross-checking BF Slides from HFs(Cross-checking BF Slides from HFs))

  

   20042004 20052005 20062006 20072007

False False PositivePositive 3.52%3.52% 0.5%0.5% 1.1%1.1% 0.40.4

False False NegativeNegative 1.17%1.17% 0.37%0.37% 0.9%0.9% 0.40.4

MisclassificationMisclassification 7.44%7.44% 2.57%2.57% 5%5% 5.95.9

* Source: Eritrea Health Profile, 2000

22

Top 10 causes of <5 inpatient deaths

2000

1. ARI2. Diarrhea3. Malaria4. Anemia5. Septicemia6. TB7. HIV/AIDS8. Heart failure9. Burns10. Soft tissue

injury

2005

1. ARI2. Anemia &

malnutrition3. Diarrhea4. Septicemia5. Slow fetal growth,

Malnut etc6. HIV/AIDS7. Perinatal

respiratory problem8. Intrauterine

Hypoxia/Birth Asphyxia

9. Malaria10. Heart diseases

2007

1. ARI2. Anemia &

malnutrition3. Diarrhea4. Septicemia5. Perinatal

respiratory problem

6. Slow fetal growth, Malnut etc

7. Intrauterine Hypoxia/Birth Asphyxia

8. HIV/AIDS9. Malaria10. TB, all types

* Source: Eritrea Health Profile, 2000

23

Top 10 causes of ADULT inpatient deaths

2005

1. HIV/AIDS2. ARI3. TB4. Other liver

diseases5. Hypertension6. Diabetes

Mellitus7. Anemia &

malnutrition8. Septicemia9. Heart diseases10. Malaria

2000

1. Malaria2. TB3. Anemia &

malnutrition4. ARI5. HIV/AIDS6. Diarrhea7. Hypertension8. Other liver diseases9. Diabetes Mellitus10. Septicemia

2007

1. ARI2. Anemia &

malnutrition3. HIV/AIDS4. Diarrhea5. Septicemia6. TB, all types7. Perinatal resp.

problem8. Hypertension9. Other liver

diseases10. Diabetes

MellitusSource: NHMIS

Achievements of Selected Country Specific and Abuja Achievements of Selected Country Specific and Abuja TargetsTargets

Indicator forIndicator for Abuja Abuja Target Target

Targets Targets 20042004

Achievement Achievement (survey)(survey)

MortalityMortality

To reduce malaria mortality compared to 1999To reduce malaria mortality compared to 1999 60% 60%

80% 80% 85%85%

To reduce malaria case fatality rate compared to To reduce malaria case fatality rate compared to 19991999

60%60% 80%80% 85%85%

Proportion of target groups with severe malaria Proportion of target groups with severe malaria correctly managed by health personnel correctly managed by health personnel

80%80% 59%59%

The proportion of target groups reporting early to The proportion of target groups reporting early to health facilities when sick from malaria health facilities when sick from malaria

90%90% 30%30%

MorbidityMorbidity

To reduce malaria morbidity compared to 1999To reduce malaria morbidity compared to 1999 60%60% 80%80% 86.5%86.5%

Proportion of nurses & health/assistants trained Proportion of nurses & health/assistants trained on malaria case managementon malaria case management

90%90% 28%28%

Proportion of CHAs trained on malaria case Proportion of CHAs trained on malaria case managementmanagement

90%90% 100%100%

Vector ControlVector Control

Indicator forIndicator for Abuja Target Abuja Target Targets Targets 20042004

Achievement Achievement (survey)(survey)

Proportion of the population Proportion of the population residing in the malarious residing in the malarious areas of the country will have areas of the country will have ITNsITNs

60%60% 50%50% 79%79%

Proportion of the already Proportion of the already selected malarious villages selected malarious villages will be covered by insecticide will be covered by insecticide residual house spraying (IRS)residual house spraying (IRS)

10%10% 95%95%

Number of sentinel sites Number of sentinel sites establishedestablished

30 sites in six 30 sites in six zoneszones

22 by end 22 by end 2005 (for 2005 (for malaria malaria

incidence & incidence & vector vector densitydensity

26 26 sites in sites in six zones, six zones,

NOW NOW

Technical Technical AreaArea

Abuja Target (by 2010)Abuja Target (by 2010) EritreaEritrea Achievement Achievement (2004 survey)(2004 survey)

Vector control Vector control via via insecticide insecticide treated nets treated nets (ITNs)(ITNs)

6060%% of those at risk for malaria, of those at risk for malaria, particularly children under five years particularly children under five years and pregnant women, will benefit and pregnant women, will benefit from a suitable combination of from a suitable combination of personal protection and community personal protection and community protective measures such as ITNsprotective measures such as ITNs

48.348.3%% ITNs for ITNs for children <5 yrs children <5 yrs (65.4% in 2001)(65.4% in 2001)

50.450.4%% ITNs for ITNs for pregnant women pregnant women (40% in 2001)(40% in 2001)

Prevention Prevention and control and control of malaria of malaria in pregnant in pregnant womenwomen

6060%% of pregnant women at risk of of pregnant women at risk of malaria are covered with a suitable malaria are covered with a suitable combination of personal and combination of personal and community protective measures such community protective measures such as ITNsas ITNs

50.450.4%% ITNs ITNs

► Burundi ► Comoros► Djibouti ► Eritrea► Ethiopia ► Kenya ► Rwanda ► North Sudan► South Sudan►Tanzania►Zanzibar► Uganda

NO NEED TO TALK & EXPLAIN MUCH !!! BECAUSE …………….

• The MoH with its PARTNERS Has already made very notable and undisputable successes.

• The Impacts made on malaria morbidity and mortality are evident enough to talk of the success of the program.

• The Achievements & impacts made, however, need to be sustained, documented and try to find out which Intervention or Interventions was or were effective in the drastic reduction of Malaria in Eritrea.

High ITN coverage, re-treatment and utilizationHigh ITN coverage, re-treatment and utilization

Introduction of combination therapy of CQ+SP as first line drugs since 2002Introduction of combination therapy of CQ+SP as first line drugs since 2002

Early diagnosis and timely case management Early diagnosis and timely case management

Quality control (cross-checking of BF slides from Health Facilities)Quality control (cross-checking of BF slides from Health Facilities)

Training of Health Workers during pre-service and in-service periods. Training of Health Workers during pre-service and in-service periods.

Training of new Health cadres/Public Health Techicians (>100) who work at Training of new Health cadres/Public Health Techicians (>100) who work at district level for malaria and environmental health.district level for malaria and environmental health.

High levels of community awareness and participation in environmental High levels of community awareness and participation in environmental vector control (KAP survey showed population awareness >99%)vector control (KAP survey showed population awareness >99%)

What are the Contributory Factors What are the Contributory Factors towards the overall reduction in malaria towards the overall reduction in malaria

incidence in Eritrea?incidence in Eritrea?

What are the Contributory Factors What are the Contributory Factors towards the overall reduction in malaria towards the overall reduction in malaria

con…con… Effective and functional partnership of country and RBM Effective and functional partnership of country and RBM

partnerspartners Government commitment and follow-up of malaria Government commitment and follow-up of malaria

control activitiescontrol activities Technical and financial support received through RBM Technical and financial support received through RBM

initiativeinitiative Effective planning and implementation of program Effective planning and implementation of program

activities at central and zonal levelsactivities at central and zonal levels The HAMSET project provides a mechanism in which The HAMSET project provides a mechanism in which

other health programmes can successfully deliver their other health programmes can successfully deliver their interventions to the grass roots in the society; interventions to the grass roots in the society;

Effective Programme ManagementEffective Programme Management at NMCP HQ & Zonal at NMCP HQ & Zonal levels – motivated & proactive team. levels – motivated & proactive team.

The presence of malaria teams at national, zonal, sub-zonal The presence of malaria teams at national, zonal, sub-zonal levels.levels.

Availability of Availability of CHAsCHAs at the community level facilitate early Rx. at the community level facilitate early Rx.

Availability of Availability of New Young Health cadres/PHTs (New Young Health cadres/PHTs (>above 100) in >above 100) in all sub-zones/districts of the country.all sub-zones/districts of the country.

Epidemic preparedness and control system in place.Epidemic preparedness and control system in place.

Sentinel sitesSentinel sites ( (2626) for following up trends of malaria morbidity ) for following up trends of malaria morbidity and mortality establishedand mortality established

Quarterly, semi-annual and annual meetings carried out (zoba Quarterly, semi-annual and annual meetings carried out (zoba and national level)and national level)

Lessons Learned Lessons Learned

Lessons learned…Lessons learned…

Stakeholders InvolvementStakeholders InvolvementHAMSET projectHAMSET project

In support of the principles of National In support of the principles of National Health PolicyHealth Policy

The diseases are multi-sectoral in origin The diseases are multi-sectoral in origin arising from an interaction of factors arising from an interaction of factors

across across several sectorsseveral sectors

Lessons Learned…Lessons Learned…

Stakeholders Involvement…Stakeholders Involvement… Communities: Eritrea has strong societal cohesion Communities: Eritrea has strong societal cohesion

which is reflected very well seen.which is reflected very well seen.

Organizations like Organizations like NUEWSNUEWS, NUEYS, PFDJ and the , NUEYS, PFDJ and the leadershipleadership at the community among others are at the community among others are strong and efficient.strong and efficient.

This process leads to This process leads to Ownership & Involvement of Ownership & Involvement of the Community & they demand for the service if the Community & they demand for the service if weak or not available in the community.weak or not available in the community.

Recommendations and ConclusionRecommendations and Conclusion

Most of the Abuja targets were/are met in Eritrea Most of the Abuja targets were/are met in Eritrea on schedule mainly because, among others, the on schedule mainly because, among others, the government government has set even higher targetshas set even higher targets for itselffor itself

Both mortality and morbidity have declined Both mortality and morbidity have declined dramatically move to dramatically move to pre- malaria elimination pre- malaria elimination phasephase..

Impact assessmentImpact assessment need to be conducted to need to be conducted to determine the individual contributions of the determine the individual contributions of the different control strategies.different control strategies.

Recommendations and conclusion…Recommendations and conclusion… Meanwhile, the implementation of these Meanwhile, the implementation of these

strategies that seem to be working should strategies that seem to be working should continue & further strengthened for the continue & further strengthened for the sustenance of achievements.sustenance of achievements.

A need to consider Malaria Elimination and A need to consider Malaria Elimination and technical support expected to come soon technical support expected to come soon from RBM funding partners.from RBM funding partners.

Priority Actions &The Way ForwardPriority Actions &The Way Forward Conduct Mid- Term evaluation of the Second Country RBMSPConduct Mid- Term evaluation of the Second Country RBMSP (2005-2009).(2005-2009).

Intensify the research component of the program.Intensify the research component of the program.

Strengthen the surveillance system of malaria.Strengthen the surveillance system of malaria.

Strengthen the capacity & skill of PHTs in the country.Strengthen the capacity & skill of PHTs in the country.

Aim and plan for Elimination of malaria considering the drastic Aim and plan for Elimination of malaria considering the drastic reduction of malaria in the last 7 years.reduction of malaria in the last 7 years.

Address the risk of other vector-born diseases considering the Address the risk of other vector-born diseases considering the ecological/environmental changes taking place in the country ecological/environmental changes taking place in the country (construction of dams, irrigation schemes etc).(construction of dams, irrigation schemes etc).

THE CURRENT COUNTRY RBM THE CURRENT COUNTRY RBM PARTNERSPARTNERS

FINANCIAL, TECHNICAL & Implementing PartnersFINANCIAL, TECHNICAL & Implementing Partners The MoH & the Gov’t of Eritrea - the MAIN driving forcesThe MoH & the Gov’t of Eritrea - the MAIN driving forces WHO WHO UNICEF UNICEF WHO/PHARPE (Italian corporation) WHO/PHARPE (Italian corporation) World Bank – since World Bank – since 1998 1998 and then as HAMSeT since 2001and then as HAMSeT since 2001 GFATM Rd 2 and Rd 6 GFATM Rd 2 and Rd 6 JICA JICA Ministries: MoA, MoE, MoI, MoLWE, Local Government, Ministries: MoA, MoE, MoI, MoLWE, Local Government,

Ministry of Finance, Dep. of Environment among othersMinistry of Finance, Dep. of Environment among others

Associations & CBOsAssociations & CBOs Youth and Women Associations, Eritrean Confederation Youth and Women Associations, Eritrean Confederation

of workersof workers PFDJ, Zonal, sub zonal and village administratorsPFDJ, Zonal, sub zonal and village administrators ESMG/PSI since 2004ESMG/PSI since 2004 Faith-based organizationsFaith-based organizations

SO MUCH DONESO MUCH DONE

BUTBUT

SO MUCH TO BE DONESO MUCH TO BE DONE

Malaria is still a BIG PROBLEM whichMalaria is still a BIG PROBLEM which

seeks a BIG SOLUTION !!!!!!seeks a BIG SOLUTION !!!!!!

KILL MOSQUITO KILL MALARIA

YEKENYELEY !!!!YEKENYELEY !!!!

SHUKREN !!!!SHUKREN !!!!

THANK U 4 LISTENING !!!!THANK U 4 LISTENING !!!!

Awet Nhafash !!!Awet Nhafash !!!