By dr. Ridwan Gustiana Student of Liverpool School of Tropical Medicine, Msc International Public Health, Mainstreaming Humanitarian Study
Fighting malaria is one of the aims stated in the Millennium Development Goals (MDGs) by United Nations for the new millennium. International communities partnered with participating governments have, therefore, been increasing their efforts to improve policies and implement new and innovative strategies to reach the target of halving the burden of malaria disease in 2015 (UN, 2010).
There are 247 million cases of malaria occurring annually and 212 million cases are occurring in sub Saharan Africa. 3.3 billion people are at risk from malaria transmission, which is almost half of the world population. There are almost 1 million deaths because of malaria each year, 85% of them are children under five and 95% of all malaria related death happens in Africa. (Roll Back Malaria, 2010; WHO, 2010)
By definition Disaster is “serious event that cause an ecological background in the relation between humans and their environment on the scale that requires extraordinary efforts to allow the stricken community to cope, even with outside help or international aid”. Disaster can be categorized into natural disaster and man-made disaster. The natural disaster is usually linked with geological and climatic hazards while man made disasters or mostly known as Complex Humanitarian Emergencies usually linked with the breakdown of authority with resulting internal or external conflict (Spiegel,P.B. 2007).
Since the millennium, there have been more than 35 conflicts and 2,500 natural disasters, which have affected more than two billion people and caused millions of deaths (UNEP, 2010). Disaster, either natural or man made such as conflict or war, has become a major cause of population displacement.
Interestingly, most of the countries affected by disaster especially by complex humanitarian emergencies are also burdened with a high number of Malaria cases. Of 27.1 million internally displaced populations by conflict in 2009, 11.6 million of them are living in 21 countries in Africa (IDMC, 2009). There are 120 million populations at risk from both malaria is affected by complex emergency. 30% of Africa’s malaria related deaths are in countries experiencing complex emergenciesespecially the most vulnerable group, which are children under five (WHO, 2010).
This essay will critically review literature about Malaria in relation to disaster either natural disaster or man made disaster to describe the effects of disaster on Malaria situation, what is the strategies of Malaria control in disaster situation and also look at some examples and lessons learned from previous disasters.
Policies and Strategies of Malaria Control
Roll Back Malaria Partnership (RBM)
Responding to the Malaria crisis globally, as well as the MDGs, the World Health Organization (WHO), Unicef, UNDP and World Bank launched the Roll Back Malaria Partnership (RBM) in 1998. This global framework to implement the coordinated action against malaria consists of more than 500 partners who come from Malaria endemic countries, the private sectors, Non Government Organizations (NGO), Community Based Organizations (CBO), Foundations as well as research and academic institutions. The vision of the RBM Partnership is “a world free from the burden of Malaria” (Roll Back Malaria, 2010). The goals of the program are continually being evolved in response to the progress of the program and continue to be ambitious. The current targets of the program are to (1)achieve universal coverage to prevention and case management for population at risk (2) reduce by halve the disease burden between 2000 and 2010 and reduced down to 75% between 2000-2015, (3) contribute to reduce by two thirds the children mortality rate in 2015 and (4) eliminate malaria in 8-10 countries by 2015 and beyond for all countries in pre-elimination phase and to (5) eradicate Malaria worldwide in the longer term (Roll Back Malaria, 2010)
Aiming to reduce both parasite transmission from mosquito vector to humans as well as minimizing the clinical effects of the disease, in term of illness development and treating severe forms of the disease, the strategies of Malaria control is divided into two major approaches, prevention and case management. The target is to provide universal coverage for all populations at risk as stated in Global Malaria Action Plan (WHO, 2010).
The most recommended approach in malaria prevention is increasing the use of Long Lasting Impregnated Nets (LLINs) and applying Indoor Residual Spray (IRS). These two approaches have been proven effectively in reducing human vector contacts. However, to achieve significant impact in reducing the contact, the coverage must be high and sustained (WHO, 2010).
The current guidelines of diagnosis and treatment issued by the World Health Organization stated the importance of parasitological confirmation by using either microscopic technique or Rapid Diagnostic Test (RDT) before treatment to all patients unless inaccessible. The WHO also continue to recommend the use of Artemisinins Combine Therapy (ACT) treatment due to the wide spread resistance to Chloroquine as well as resistance to artemisinins (WHO, 2010).
SPHERE Standard: Minimum Standard on Health Services in Emergency Response
In the response to public demand on accountability as well as quality of disaster response conducted by the humanitarian organizations, Sphere Project was launched in 1997. The Sphere Project provides the principle guidelines and standards on how the global humanitarian organizations respond to disasters which written as The Humanitarian Charter and Minimum Standards in Disasters Response. the Sphere Project is based on two core beliefs, that disaster or conflict affected people have a right to life with dignity and that all possible steps should be taken to alleviate human suffering. The humanitarian charter and minimum standard were written and known as Sphere Handbook. (The Sphere Project, 2010)
There are three areas which need to be addressed in health services according to the Sphere handbook; health system infrastructures, control of communicable diseases and control of non-communicable diseases. In communicable diseases there are four major diseases which can contribute to increased mortality during disasters and especially in complex emergency.These are measles, diarrhea, acute respiratory tract infections and malaria. According to the Sphere handbook in the Minimum Standard in Health section, the disaster affected population need to have access to diagnostic and case management of Malaria and vector control. Humanitarian organizations also need to implement outbreak preparedness to reduce the risk and prevent a Malaria outbreak in the disaster setting (Sphere, 2004).
Why Malaria Control is Important in Disaster
Natural disasters such as floods, tsunamis, drought, and man made disasters such as conflict or war has forced the population to leave their homes and move to new areas within their countries as Internally Displaced Population (IDPs) or to neighboring countries as refugees. During displacement, they mostly live in the camps to receive assistance from international humanitarian organizations but exposed to various risk of diseases (Bloland P.B, 2003).
Disasters always have significant impact directly or indirectly on the public health and well-being of an affected population. One of the indirect impacts of disaster is the increased rate of infectious disease, which can lead to increase of disease morbidity and mortality. The impacts are closely related to availability and quality of water, the change of environment and sanitation, limited food supplies, health services disruption, overcrowding and population displacement. (Sphere, 2004)
A malaria epidemic is a serious threat to the disaster-affected population and likely to occur after natural disaster and complex humanitarian emergencies due to public health disruption and increased vulnerability because of mass displacement (Warring S.C, 2005). In the disaster, the risk of infectious diseases including malaria depends on other factors such as endemicity of the disease, impact on the water and sanitation system and the availability of health care services as well the effectiveness and sustainability of response to control it (Ivers, L. Ryan, E., 2006). Conflict and war has always brought massive mass displacement with disruption of social and physical infrastructure and along with security issues makes a malaria control program much more difficult to implement (WHO, 2005).
The impact of disaster not only affects displaced populations but also the affected the residents or the host populations. The host residents or host population who receive a massive influx of population will also be affected due to over burden of the current health services or other basic services. Essential materials such as food, land or water and sanitation facilities may also be disrupted in a complex emergency due to security issues which will also increase their susceptibility to disease. The emergency response therefore must be designed not only to meet the displaced population but the all populations affected – refugees, IDPs and the residents (WHO, 2005).
Effect of Disaster on the Malaria Situation
Pakistan: no progress of ongoing country malaria programme
Pakistan is the perfect example of how disaster affects the malaria situation and hampers ongoing efforts to reduce it. The ongoing conflicts in the area and the recent natural disasters have caused massive population displacement, disrupt public health services and change a large area of the country.
Increased military operations in the northwestern part, Khyber-Pukhthunkhwa (KP) and Federal Administered Tribal Area (FATA) have displaced over 2 millions Pakistanis internally (IMDC, 2010). The number of IDPs has continued to increase recently due to the large floods throughout the country in 2010 which have left 1.9 million households unoccupied (UN-OCHA 2010).
In addition, since 2001 Pakistan has the highest refugee population in the world with refugees coming from neighboring countries in armed conflicts such as Afghanistan. There are over 1.7 million refugees who live in the resettlement and urban areas receiving assistance from humanitarian organization (UNHCR 2011).
The malaria situation in Pakistan recorded 4.5 million suspected cases of Malaria in 2008, which accounts for 6% of all outpatient attendances and 18% of admissions. There were 59,284 confirmed cases of malaria in 2008 of which 30% were caused by P.falciparum, the strain responsible for causing severe malaria that can lead to death of patient (WHO, 2009).
The roll back malaria program in Pakistan, which started in 1998, aimed to reduce the burden of diseases by 50% in 2010 which is unlikely to be achieved. Lack of national resources causing weak infrastructure, shortage of doctors and poor monitoring left 75% of people with malaria with no access to treatment which has lead to a high mortality rate.(IRIN, 2010).
Despite the amount of funding received by Pakistan from international donors such as Global Fund since 2001 in supporting the Roll Back Malaria Strategies, the malaria incidence remains high throughout the country. Introduction of Rapid Diagnostic Test (RDT) and Artemisinin Combine Therapy (ACT) did not resulted significant impact on the country malaria situation. An epidemiology study found that there was no reduction of disease between 2004 and 2009. The Balochistan Province and FATA, the areas affected by the conflict remains having a high incidence of malaria. Annual Parasite Incidence (API) in Balochistan is 3.9/1000 while FATA has the highest incidence 5.5/1000 (Kakar,Q. 2010).
Disaster also hampered the ongoing program in reducing the burden of disease through prevention. The Roll Back Malaria strategy, which has been implemented since 1998 by the Ministry of Health Pakistan, emphasizes the importance of preventive for the population at risk. The funding from the Global Fund provided an opportunity for the government of Pakistan with the new tools in prevention through distribution of Insecticide Treated Nets (ITN).The results from the National Demographic and Health Survey in 2006-07, which was conducted nation wide discovered that access to Malaria preventive and curative services was still very low. The survey found that only 6% of households owned mosquito nets and only 0.8% had ITN. 1.6% children under five and pregnant woman slept under a mosquito net the night before the interview but only 0.2 and 0% of children under five and pregnant woman respectively sleep under an ITN (DHS 2008; Kakar 2009).
Malaria epidemic is one of the main threats in areas affected by massive population displacement especially in complex emergencies. FATA in the Northwestern Pakistan is one area that has large numbers of refugees from Afghanistan that started arriving in 2002 and currently stands at approximately three million afghan refugees living in over 200 camps. An outbreak investigation in 2003 in the Asgharoo camp which is home to approximately 8000-10 000 refugees, found that the malaria incidence increased up to 100.4/1000 per person per year. The outbreak was associated with poor preventive measures in the camp and also failure of the health services in providing good quality malaria treatment. The substandard treatments used routinely in the camps have lead to, and exacerbated, drug resistance of Malaria (Leslie, Toby 2009).
Other Malaria epidemic in complex humanitarian emergencies were reported in Kenya between may-august 1999, Burundi September 2000-May 2001, South Sudan in June- November 2003 and two areas in Ethiopia between July 2003 –February 2004 (Checchi,Francesco 2006) . The epidemic in the Burundi was recorded as the worst epidemic ever, with 2.9 million reported cases over 6.7 million populations. Malaria related death were ranged from 1,000 to 8,900 accounted for 52% to 78% total deaths (Guthmann,Jean-Paul 2007).
Malaria Control in a Disaster Situation
Even in stable environments Malaria control programs need long term and continuous efforts in reducing the burden of disease. The strategies in prevention as well as case management need good quality program management in order to reach their goals. Effective emergency response which includes malaria control in the disaster situation require good coordination among all institutions, accurate and timely assessment, good planning, comprehensive and effective implementation as well as continuous monitoring and evaluation to overview progress (WHO, 2005, Sphere 2004). However there are usually many challenges faced by institutions in implementing malaria programs in times of disaster. These challenges include poor health infrastructures, capacity of human resources, logistics, security, funding and the coordination which can contribute to failure in controlling the disease during the emergency phase (WHO,2005).
The Main Aspects
The main components which need to be addressed in implementing effective malaria control in a disaster situation are (1) emergency public health surveillance system, (2) good quality of curative services, (3) combination of preventive measure (4)community participations and (5) continuous monitoring evaluation to evaluate impact of the interventions (Bloland,P. B. 2003, WHO 2005). These are the main aspects which need to be in place in order to monitor the malaria situation, treat the infected population and also protect the affected population from becoming infected.
Emergency Public Health Surveillance System
Public health surveillance is the “continuous, systematic collection, analysis and interpretation of health-related data needed for the planning, implementation, and evaluation of public health practice” (WHO, 2011). It is a fundamental aspect in fighting any communicable disease which involves routine case counts of disease and demographic data of patients (Bloland,Peter B. 2003). The purpose of malaria surveillance is to monitor trends, provide early warning of outbreaks and as a tool to monitor the effectiveness of malaria control intervention (WHO, 2005). However, because malaria is one of several important threatening communicable diseases in disaster, the emergency surveillance system should be integrated with other diseases, such as Measles, Diarrhea, and Upper Respiratory Tract Infection (Sphere, 2004).
The effectiveness and the success of an emergency surveillance system rely on data collection, reporting and sharing between different institutions that carry out the malaria control program in the area. The health worker should understand the importance of the surveillance to ensure data collection of disease. Data reporting, however, is a major constraint in surveillance system because it needs infrastructure and logistical support which is usually affected by the disaster and needs heavy reconstruction. One idea which can be taken from the earthquake disaster response in Sichuan, China in 2008 is the reporting system using mobile phone through short message system (known as SMS or text message). This innovation ensures a quick and effective reporting system, although it would be better if the system was already in place as part of disaster preparedness (Yang,Changhong, 2009).
Data sharing between organizations can take place during coordination meetings or using internet soon as the infrastructures were established. The coordination between humanitarian organizations itself, however, is a challenge, especially when the number of organizations involved in the disaster response is very large.
One example of an effective surveillance system was establishment of IDPSS (internally displaces population surveillance system) during the Haiti 2010 disaster response by Haitian Ministry of Public Health, Pan American Health Organization and CDC. Although challenges due to logistic, coordination, geographic distribution of NGO, turnover of health care provision, inadequate infrastructure and dynamic situation exist as usual, the IDPSS continue to be improved with time. Within 6 months of the operation the IDPSS have 177 members, representing 60 different NGOs and coordinating agencies. The IDPSS provide weekly surveillance reports and continuously improve the quality of the data as more information is collected and with improvements in logistics and infrastructure (CDC, 2010).
Malaria surveillance is great tools in outbreak or epidemic early identification in disaster prone area. One of example of successful malaria outbreak surveillance system is implemented in South Africa. the system is using the binomial threshold which has proved effective in identifying outbreak in a low and unstable malaria transmission settings(Coleman,Marlize 2008).
The malaria outbreak surveillance system using binomial thresholds achieved its primary goal of identifying outbreaks early facilitating appropriate local public health responses aimed at averting a possible large-scale epidemic in a low, and unstable, malaria transmission setting
Malaria cases need to be treated effectively because malaria falciparum can become a life-threatening condition within a few hours to a day. Treatment should use standard medication recommended by the ministry of health or current international guidelines (WHO,2005; Sphere, 2004) and should also consider the referral system (Bloland. P.B, 2003). A substandard medication can lead to the failure of treatment which can lead to an epidemic, and furthermore can lead to drug resistance. A malaria epidemic which occurred in refugee camp in Pakistan is a good example of how substandard medication can cause a malaria epidemic and drug resistance (Leslie,Toby 2009).
In a malaria endemic disaster area, diagnosis of malaria can also become very difficult, due to unspecific symptoms and damage to the healthcare infrastructure. Although presumptive clinical diagnosis can sometimes be used, especially during the acute phase, laboratory-based diagnosis should be used whenever possible. The introduction of Rapid Diagnostic Test (RDT) was a breakthrough in increasing the quality and effectiveness of malaria diagnosis in disaster situation (Hashizume,M. 2006).
The main priority of malaria control in the emergency phase of disaster response is case management. However prevention becomes important in reducing the risk of new transmissions and outbreaks during displacement. There are various ways prevention can be implemented such as using antimalarial drugs, environment control to control breeding places of the vector and personal protection such as repellent. The most common method used in prevention is distribution of Insecticide Treated Nets (ITNs) or Indoor Residual Spray (IRS). The methodology of prevention, however, should consider effectiveness and sustainability of the strategy while also considering the most vulnerable group (WHO, 2005).
High coverage of IRS and ITN in the affected population is needed to provide effective prevention measure. Both of the methodology also needs to be combined with health education to ensure community understand the benefit and know how they will be protected by the intervention. The availability of Long Lasting Insecticide-treated Nets (LLIN, a factory based treated nets, are increasing and become the choice of ITNs used in disaster area. The WHO, however, approved only two brands of LLINs which is provides challenges logistically during disaster, when the number needed can become very high within short time depending the magnitude of the disaster (WHO, 2005.
Even the best strategies of disease control, both preventive and curative intervention, will not be successful without involvement of the community. During emergency phase of a disaster, delivery of aid or services is usually very much carried out vertically. The strategies of intervention were decided without reviewing what the target population understands about the situation and the importance of the intervention.
In curative services, the success of treatment depends how fast the community seek health services which highlight the importance of community participation as well as health education. This is due to the fact that late or failure to seek treatment from health facilities is usually caused by lack of awareness about the disease (WHO,2005). Therefore, it is recommended to understand the perception of febrile illness and health seeking behavior in the target population during provision of malaria treatment in disaster response (Bloland, P.B, 2003).
It would be quite difficult to involve or educate the disaster affected population during the early emergency phase in malaria prevention, as they may be overwhelmed by situation. The prevention strategies, however, should consider community participation at some level. The strategy should first begin with an understanding of community perception as well as behavior in preventing malaria. For example, the distribution of ITN would not be useful if the target population did not sleep under it. Understanding the socio-culture of the target population also plays a great part in choosing the best strategies of preventing malaria (Bloland, P.B, 2003).This would allow better design of the strategy to meet the objective and also would increase the sustainability of the program even in complex emergency situation. (Howard,Natasha 2010)
Monitoring and Evaluation
Monitoring and evaluation throughout the malaria control program is very important. The purpose is to oversee the progress of the program and to see whether improvements or modification of the strategies should be made. Operational research can become a great tool in monitoring and evaluating the progress and achievement of such a program. There are a few ethical considerations, however, that should be looked at before initiating research in the disaster situation, such as the burden of displaced population or NGO participating in the research especially during acute phase. (Bloland, P.B, 2003)
There are a few examples of operational research which can become a good tool in monitoring and evaluation such as malaria prevalence survey, therapy efficacy assessment, entomological survey, behavior research and malaria in pregnancy. Lot Quality Assurance Sampling (LQAS) is one of the methodologies of surveying which is feasible, effective and valid to be used to evaluate malaria indicators even in a wide catchment and low transmission area (Rabarijaona,L. 2001;Biedron,Caitlin 2010).
Other aspect: Coordination
Disaster response usually involves many institutions, depending on the magnitude of the disaster with a major disaster involving international organizations, UN agencies, Government institutions and local organizations. Coordination, therefore, has to be conducted between all institutions involved in the response to ensure its effectiveness.
To ensure the effectiveness of health services response during humanitarian crises, the Word Health Organization launched a health cluster approach to coordinate the responses conducted by all humanitarian organization in the health sector. The goal of the health cluster in a humanitarian crises is “To reduce avoidable mortality, morbidity and disability, and restore the delivery of, and equitable access to, preventive and curative health care as quickly as possible and in as sustainable a manner as possible”. The expected outputs of the cluster approach other than coordinating all humanitarian organizations is also to map health personnel, health services available, and also health services in the disaster areas as well as sharing up to date information and needs available to all stakeholders (WHO, 2011).
The coordination meeting in malaria control could be used to share the surveillance data, discuss gaps and sharing resources to meet the objectives of the program. The coordination during malaria control should involve the authority of the country/area, as they are responsible in terms of policies changes.
Lesson Learned from Previous Malaria Program in Disaster
The Indian Ocean Tsunami caused by an undersea earthquake with the epicenter on the west coast of Sumatera Indonesia was the biggest and deadliest natural disaster in history. The death toll reached approximately more than 200 000 and displaced more than 1.5 million people. Indonesia, Sri Lanka, India and Thailand were the worst affected countries. The disaster prompted a worldwide humanitarian response involving US $14 Billion of funding. The tsunami also caused huge infrastructure and environmental damage to the coastal area, which needed years of reconstruction and rehabilitation. (Wikipedia, 2011)
A study in Nicobar and the Andaman Islands, India, on the impact and malaria control program post tsunami discovered that there was an increase in breeding places for malaria mosquito vectors, increasing the risk of exposure to the displaced population. The study also found in the Andaman Islands the number of malaria cases doubled post disaster from 305 cases in 2004 to 720 cases in 2005, with a six fold increase of Falciparum Malaria. In Nicobar however, the malaria case numbers increased seven fold from 440 cases in 2005 to 3234 in 2005, with a huge increase of Malaria falciparum from 76 cases to 1808 cases. The highest peak of cases occurred during the first 3 months post disaster, January to March 2005, and the incidence of Malaria continued to be high throughout the 3 years post disaster compared with pre disaster incidence. Malaria, however, was controllable due to good planning and timely prevention conducted by humanitarian organizations and the government, where high coverage and high utilization of long lasting Impregnated bed nets were found among the displaced population combined with other malaria control interventions (Kumari,R. 2009).
The similar situation also found in Simeleu Island, Aceh where sustained high coverage of bed nets distributed by the government and humanitarian organizations contributed to the reduction of malaria cases and provided the opportunity to eliminate malaria in the island (Sudomo,M. 2010).
During post conflict response in East Timor in 2006, the routine malaria control program was disrupted. The malaria situation, however, is now under control due to good intervention during the crisis regarding treatment, ITN distribution, vector control, and surveillance and health promotion. The crisis also provided the opportunity for the countries health authority to implement policy change which emphasized the use of Rapid Diagnostic Test (RDT), and Artemisinins combine therapy for treatment (Martins,Joao S. 2009)
Disasters, both natural or man made can increase the incidence of malaria and can hamper the efforts in the ongoing fight against of Malaria due to disruption of the public health system, mass displacement and environmental change. Complex humanitarian emergency possibly has the worst effect on malaria prevalence and incidence due to various reasons, particularly sustained instability and security situation. Malaria epidemic is commonly related with the complex humanitarian emergencies which need some degree of preparedness. However, natural disasters can also lead to serious increases of Malaria especially disasters such as floods or tsunamis that lead to an increase of breeding places for malaria carrying mosquitoes.
Malaria during disaster, however, can be controlled with an effective program involving public health surveillance, good case management, sustained prevention, and involvement of operational research. Coordination between different agencies involved in the program, however, is needed to avoid overlap and to strengthen the program to meet the objectives.
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