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Namibia's path toward malaria elimination: a case study of malaria strategies and costs along the northern border.

Smith Gueye C, Gerigk M, Newby G, Lourenco C, Uusiku P, Liu J - BMC Public Health (2014)

Bottom Line: Indoor residual spraying is the main intervention, but coverage varies, related to acceptability, mobility, accessibility, insecticide stockouts and staff shortages.Bed net distribution was scaled up beginning in 2005, assisted by NGO partners in later years, but coverage was highly variable.Distribution of rapid diagnostic tests in 2005 resulted in more accurate diagnosis and can help explain the large decline in cases beginning in 2006; however, challenges in personnel training and supervision remained during the expenditure study period of 2009 to 2011.

View Article: PubMed Central - PubMed

Affiliation: UCSF Global Health Group, San Francisco, CA, USA. cara.smith@ucsf.edu.

ABSTRACT

Background: Low malaria transmission in Namibia suggests that elimination is possible, but the risk of imported malaria from Angola remains a challenge. This case study reviews the early transition of a program shift from malaria control to elimination in three northern regions of Namibia that comprise the Trans-Kunene Malaria Initiative (TKMI): Kunene, Omusati, and Ohangwena.

Methods: Thirty-four key informant interviews were conducted and epidemiological and intervention data were assembled for 1995 to 2013. Malaria expenditure records were collected for each region for 2009, 2010, and 2011, representing the start of the transition from control to elimination. Interviews and expenditure data were analyzed across activity and expenditure type.

Results: Incidence has declined in all regions since 2004; cases are concentrated in the border zone. Expenditures in the three study regions have declined, from an average of $6.10 per person at risk per year in 2009 to an average of $3.61 in 2011. The proportion of spending allocated for diagnosis and treatment declined while that for vector control increased. Indoor residual spraying is the main intervention, but coverage varies, related to acceptability, mobility, accessibility, insecticide stockouts and staff shortages. Bed net distribution was scaled up beginning in 2005, assisted by NGO partners in later years, but coverage was highly variable. Distribution of rapid diagnostic tests in 2005 resulted in more accurate diagnosis and can help explain the large decline in cases beginning in 2006; however, challenges in personnel training and supervision remained during the expenditure study period of 2009 to 2011.

Conclusions: In addition to allocating sufficient human resources to vector control activities, developing a greater emphasis on surveillance will be central to the ongoing program shift from control to elimination, particularly in light of the malaria importation challenges experienced in the northern border regions. While overall program resources may continue on a downward trajectory, the program will be well positioned to actively eliminate the remaining foci of malaria if greater resources are allocated toward surveillance efforts.

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Related in: MedlinePlus

Reported malaria cases from health facilities, 2001–2011. Source: Health Information System, MoHSS Note: Region populations for 2002–2004 were not available. Calculated by taking difference between 2005 and 2001 populations, dividing by 4 and adding amount to each year. Note: Based on regional names and boundaries as of July 2013. The selected study regions are shown in color. Neighboring regions are shown for comparison. PAR = population at risk; ACT = artemisinin combination therapy; LLIN = long-lasting insecticide-treated nets; RDT = rapid diagnostic test.
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Fig3: Reported malaria cases from health facilities, 2001–2011. Source: Health Information System, MoHSS Note: Region populations for 2002–2004 were not available. Calculated by taking difference between 2005 and 2001 populations, dividing by 4 and adding amount to each year. Note: Based on regional names and boundaries as of July 2013. The selected study regions are shown in color. Neighboring regions are shown for comparison. PAR = population at risk; ACT = artemisinin combination therapy; LLIN = long-lasting insecticide-treated nets; RDT = rapid diagnostic test.

Mentions: Kunene is relatively remote and sparsely populated. Because the climate is mostly dry with only sporadic rainfall [19], the environment is not particularly receptive to mosquito breeding. However, vector larvae have been found in natural springs in the north near the Namibian-Angolan border, which is demarcated by the Kunene River and does not have any official border posts. Of three districts (Khorixas, Opuwo, and Outjo), Opuwo is the northernmost, the most populated, and has the highest malaria burden: 138 (88%) of the cases in 2011 in Kunene were reported from Opuwo. Kunene has fewer malaria cases than other northern regions, and the number of cases has declined, from 11,111 in 2001 to 729 in 2009 (API = 9.64) and further to 138 in 2011 (API = 1.52; see Figure 3, reported malaria cases).Figure 3


Namibia's path toward malaria elimination: a case study of malaria strategies and costs along the northern border.

Smith Gueye C, Gerigk M, Newby G, Lourenco C, Uusiku P, Liu J - BMC Public Health (2014)

Reported malaria cases from health facilities, 2001–2011. Source: Health Information System, MoHSS Note: Region populations for 2002–2004 were not available. Calculated by taking difference between 2005 and 2001 populations, dividing by 4 and adding amount to each year. Note: Based on regional names and boundaries as of July 2013. The selected study regions are shown in color. Neighboring regions are shown for comparison. PAR = population at risk; ACT = artemisinin combination therapy; LLIN = long-lasting insecticide-treated nets; RDT = rapid diagnostic test.
© Copyright Policy - open-access
Related In: Results  -  Collection

License 1 - License 2
Show All Figures
getmorefigures.php?uid=PMC4255954&req=5

Fig3: Reported malaria cases from health facilities, 2001–2011. Source: Health Information System, MoHSS Note: Region populations for 2002–2004 were not available. Calculated by taking difference between 2005 and 2001 populations, dividing by 4 and adding amount to each year. Note: Based on regional names and boundaries as of July 2013. The selected study regions are shown in color. Neighboring regions are shown for comparison. PAR = population at risk; ACT = artemisinin combination therapy; LLIN = long-lasting insecticide-treated nets; RDT = rapid diagnostic test.
Mentions: Kunene is relatively remote and sparsely populated. Because the climate is mostly dry with only sporadic rainfall [19], the environment is not particularly receptive to mosquito breeding. However, vector larvae have been found in natural springs in the north near the Namibian-Angolan border, which is demarcated by the Kunene River and does not have any official border posts. Of three districts (Khorixas, Opuwo, and Outjo), Opuwo is the northernmost, the most populated, and has the highest malaria burden: 138 (88%) of the cases in 2011 in Kunene were reported from Opuwo. Kunene has fewer malaria cases than other northern regions, and the number of cases has declined, from 11,111 in 2001 to 729 in 2009 (API = 9.64) and further to 138 in 2011 (API = 1.52; see Figure 3, reported malaria cases).Figure 3

Bottom Line: Indoor residual spraying is the main intervention, but coverage varies, related to acceptability, mobility, accessibility, insecticide stockouts and staff shortages.Bed net distribution was scaled up beginning in 2005, assisted by NGO partners in later years, but coverage was highly variable.Distribution of rapid diagnostic tests in 2005 resulted in more accurate diagnosis and can help explain the large decline in cases beginning in 2006; however, challenges in personnel training and supervision remained during the expenditure study period of 2009 to 2011.

View Article: PubMed Central - PubMed

Affiliation: UCSF Global Health Group, San Francisco, CA, USA. cara.smith@ucsf.edu.

ABSTRACT

Background: Low malaria transmission in Namibia suggests that elimination is possible, but the risk of imported malaria from Angola remains a challenge. This case study reviews the early transition of a program shift from malaria control to elimination in three northern regions of Namibia that comprise the Trans-Kunene Malaria Initiative (TKMI): Kunene, Omusati, and Ohangwena.

Methods: Thirty-four key informant interviews were conducted and epidemiological and intervention data were assembled for 1995 to 2013. Malaria expenditure records were collected for each region for 2009, 2010, and 2011, representing the start of the transition from control to elimination. Interviews and expenditure data were analyzed across activity and expenditure type.

Results: Incidence has declined in all regions since 2004; cases are concentrated in the border zone. Expenditures in the three study regions have declined, from an average of $6.10 per person at risk per year in 2009 to an average of $3.61 in 2011. The proportion of spending allocated for diagnosis and treatment declined while that for vector control increased. Indoor residual spraying is the main intervention, but coverage varies, related to acceptability, mobility, accessibility, insecticide stockouts and staff shortages. Bed net distribution was scaled up beginning in 2005, assisted by NGO partners in later years, but coverage was highly variable. Distribution of rapid diagnostic tests in 2005 resulted in more accurate diagnosis and can help explain the large decline in cases beginning in 2006; however, challenges in personnel training and supervision remained during the expenditure study period of 2009 to 2011.

Conclusions: In addition to allocating sufficient human resources to vector control activities, developing a greater emphasis on surveillance will be central to the ongoing program shift from control to elimination, particularly in light of the malaria importation challenges experienced in the northern border regions. While overall program resources may continue on a downward trajectory, the program will be well positioned to actively eliminate the remaining foci of malaria if greater resources are allocated toward surveillance efforts.

Show MeSH
Related in: MedlinePlus