Can Zanzibar eliminate malaria? “Only the health ministry can decide”

25 Jun 2010

Paul Chinnock

Source: The Malaria Elimination Group (see original article)

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A market scene in Zanzibar: Will it be realistic to take on the challenges of malaria elimination? [Credit: Karen Fasimpaur.]

Malaria elimination is defined as reducing to zero the incidence of locally acquired infection in a specific geographic area [1]. In many countries where there is malaria (particularly Africa), elimination is regarded as too ambitious a goal and the focus has been on reducing case numbers and improving control. But in one part of Africa – Zanzibar – switching to the goal of elimination is now under serious consideration.

The Malaria Elimination Group (MEG) – which is based at the University of California, San Francisco (UCSF) – reports that the Zanzibar Malaria Control Programme (ZMCP) has completed an assessment to determine the technical, operational and financial feasibility of eliminating the disease. This follows major reductions that have been made in Zanzibar’s malaria burden in recent years [2]. The Zanzibar islands are, however, a part of Tanzania and the malaria burden on the Tanzanian mainland is still high.

The ZMCP’s feasibility assessment resulted in a series of evidence-based recommendations, which MEG describes as, “…the first robust analysis on the feasibility of elimination, therefore forming a strong foundation from which strategic decisions and programmatic shifts in Zanzibar can be made”. Many local and international experts provided technical advice to the feasibility assessment, including the Clinton Health Access Initiative and MEG members. Financial support was provided by the UCSF Global Health Group through a grant from ExxonMobil.

The final report and recommendations [3] on a way forward were recently presented to the senior leadership of the Zanzibar Ministry of Health and Social Welfare (MOHSW). To quote from the report’s conclusions:

“Overall, this assessment presents a mixed picture of the prospects of malaria elimination on Zanzibar. On the one hand, it shows that it is possible to completely eliminate malaria from the islands with currently available interventions. At the same time, it concludes that it will be operationally and financially challenging to prevent the reintroduction of malaria following elimination if importation risk remains high. In that way, Zanzibar’s elimination ambitions are tied to the fate of malaria control on the mainland …. This suggests that the MOHSW should engage in active dialogue with the relevant mainland Ministries of Health as it pursues further exploration and/or planning of malaria elimination. Yet even if importation is reduced through such collaboration, Zanzibar should expect to be able to only modestly reduce its annual expenditure on malaria.”

The report goes on to emphasize that an elimination programme could only succeed with strong political will:

“Whether this will can and should be generated and therefore whether malaria elimination should be pursued is a decision that can only be taken by the MOHSW.”

Meanwhile, however, the ZMCP is said to have already begun implementing several of the recommended strategies, most notably those to enhance surveillance capacity.

It has often been pointed out that Zanzibar has many characteristics that distinguish it from mainland Africa; most of the one million population live on two islands, income levels are higher than the African average and standards of primary health care and education are relatively high. These characteristics would make elimination easier to achieve than on the mainland. Nevertheless, malaria elimination in Zanzibar would be a considerable achievement and might serve as an example to control programmes in the rest of sub-Saharan Africa and elsewhere.

Reference

1. [No authors listed] (1998). Global Disease Elimination and Eradication as Public Health Strategies. Proceedings of a conference. Atlanta, Georgia, USA, 23-25 February 1998. Bull World Health Organ;76 Suppl 2:5-162. Available online: http://whqlibdoc.who.int/bulletin/1998/supplement2/bulletin_1998_76(supp2).pdf

2. WHO (2009). World Malaria Report 2009, Geneva, World Health Organization. Ch4, pp 32-33. Available online: http://www.who.int/malaria/world_malaria_report_2009/mal2009_rep_chap4_v2.pdf

3. Zanzibar Malaria Control Programme (2009). Malaria Elimination in Zanzibar: A Feasibility Assessment. Available online: http://www.malariaeliminationgroup.org/sites/default/files/MalariaEliminationZanzibar.pdf

Malaria Elimination Group (MEG)

The MEG is a group of 48 international experts convened by the UCSF Global Health Group to elaborate the scientific, technical, operational, financial, and programmatic issues that countries need to consider when pursuing or embarking on malaria elimination. The MEG website hosts a collection of resources and information specifically on malaria elimination from the latest peer-reviewed journals to reports and news from recent events occurring around the world.