SUCCESS STORY in THE CONTROL OF MALARIA IN ERITREA

2. National Malaria Control Program/DPC Department of Health Services Ministry of Health Intercontinental Hotel 18-22 Feb. 2008, Impact EvaluationAsmara, ERITREA SUCCESS STORY in THE CONTROL OF MALARIA IN ERITREA

3. Kill Mosquito! Kill Malaria

4. Eritrea: General Country Background • Population: 3.6 million • Area: 124,320 sq. km • Population <16 years old: 50% • Rural:Urban – 80:20

5. Malaria Epidemiology of Eritrea • 3 epidemiologically distinct strata: • Coastal plains (0-1000m) • Western lowlands (700-1500m) • Highlands (1500-2000m and above) • 67% (2.3 million) of population live in malaria risk areas • Parasite distribution: P. falciparum (90%), P. vivax (10%) • Main vector: Anopheles arabiensis

6. Malaria Epidemiology…… • 2 main malaria transmission seasons: • September – November (central, southern, western lowlands) • January – March (coastal plains) • Malaria is seasonal, focal, and unstable. (Risk for malaria epidemics is high) • Displaced populations due to border conflict • High population mobility/movement • Low immunity • Drug resistance

7. MALARIA CONTROL STRATEGIES CASE MANAGEMENT IVM M & E EPIDEMIC PREVENTION CAPACITY BUILDING HEALTH PROMOTION OPERATIONAL RESEARCH IMPACT ON MALARIA REDUCTION IN MALARIA MORBIDITY & MORTALITY

8. 2005-2009 CRBMSP OBJECTIVES malaria morbidity by 30% • malaria mortality by 50% • AVOID MALARIA EPIDEMICS TOTALLY!!!

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

10. Bed net distribution by zone, 2004-2007 23% 22% 5% 26% 16% 7%

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

12. ITNs ownership and usage (RBM evaluation 2004) 100 79 73 80 59 50.4 60 Percent 39.3 40 20 0 Own any net Own ITN <5 slept under >5 slept under Preg mother ITN ITN slept under ITN

13. Malaria OPD by year

14. Malaria OPD Cases – 6-year TOTAL data N K A R O R A A D O B H A S E L A N A K F A A F A B E T A S M A T H A B E R O K E R K E B E T H A L H A L F O R T O S H I E B H A G A Z D I G H E D A H L A K G H I N D A E M E N S U R A H A Y C O T A M O G O L O F O R O G O G N E D B A R W A T E S S E N E Y M U L K I S H A M B U K O A R E Z A T S O R E N A G H E L A E L O G U L U J S E N A F E M A Y - M I N E L A E L A Y G A S H A R E T A M A K E L A Y K E Y H I B A H R I V e r y L o w ( 5 3 - 4 6 1 c a s e s ) L o w ( 4 6 2 - 1 2 0 7 c a s e s ) M o d e r a t e ( 1 2 0 8 - 2 1 6 7 c a s e s ) D E B U B - D E N K A L I A H i g h ( 2 1 6 8 - 3 5 1 6 c a s e s ) A S S A B V e r y H i g h ( 3 5 1 7 - 5 8 6 8 c a s e s ) 1 0 0 0 1 0 0 2 0 0 3 0 0 4 0 0 5 0 0 6 0 0 K i m l o e t e r s

15. Malaria IPD Cases by year

16. Malaria Mortality by year

17. 7.00 5.97 6.00 5.00 4.00 3.63 2.39 3.00 2.35 2.31 Malaria CFR 1.76 2.00 1.34 1.11 0.72 1.25 1.19 1.07 1.00 0.22 0.80 0.69 0.47 0.64 0.37 0.00 1999 2000 2001 2002 2003 2004 2005 2006 2007 <5 MalariaCFR Total Malaria CFR Malaria case fatality rate

19. 160000 140000 120000 100000 80000 60000 40000 20000 0 2003 2004 2005 2006 2007 Sites Avoided Sites treated Pop. participated Environmental Management (Source reduction)

20. Eritrea has sustained the use of multiple vector control methods Bed nets Source Reduction Indoor Spraying Drainage Larviciding

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

22. 2000 ARI Diarrhea Malaria Anemia Septicemia TB HIV/AIDS Heart failure Burns Soft tissue injury Top 10 causes of <5 inpatient deaths 2005 • ARI • Anemia & malnutrition • Diarrhea • Septicemia • Slow fetal growth, Malnut etc • HIV/AIDS • Perinatal respiratory problem • Intrauterine Hypoxia/BirthAsphyxia • Malaria • Heart diseases 2007 • ARI • Anemia & malnutrition • Diarrhea • Septicemia • Perinatal respiratory problem • Slow fetal growth, Malnut etc • Intrauterine Hypoxia/BirthAsphyxia • HIV/AIDS • Malaria • TB, all types * Source: Eritrea Health Profile, 2000

23. 2005 HIV/AIDS ARI TB Other liver diseases Hypertension Diabetes Mellitus Anemia & malnutrition Septicemia Heart diseases Malaria Top 10 causes of ADULT inpatient deaths 2000 • Malaria • TB • Anemia & malnutrition • ARI • HIV/AIDS • Diarrhea • Hypertension • Other liver diseases • Diabetes Mellitus • Septicemia 2007 • ARI • Anemia & malnutrition • HIV/AIDS • Diarrhea • Septicemia • TB, all types • Perinatal resp. problem • Hypertension • Other liver diseases • Diabetes Mellitus * Source: Eritrea Health Profile, 2000 Source: NHMIS

24. Achievements of Selected Country Specific and Abuja Targets

25. Vector Control

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

28. 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.

29. What are the Contributory Factors towards the overall reduction in malaria incidence in Eritrea? • High ITN coverage, re-treatment and utilization • Introduction of combination therapy of CQ+SP as first line drugs since 2002 • Early diagnosis and timely case management • Quality control (cross-checking of BF slides from Health Facilities) • Training of Health Workers during pre-service and in-service periods. • Training of new Health cadres/Public Health Techicians (>100) who work at district level for malaria and environmental health. • High levels of community awareness and participation in environmental vector control (KAP survey showed population awareness >99%)

30. What are the Contributory Factors towards the overall reduction in malaria con… • Effective and functional partnership of country and RBM partners • Government commitment and follow-up of malaria control activities • Technical and financial support received through RBM initiative • Effective planning and implementation of program activities at central and zonal levels • The HAMSET project provides a mechanism in which other health programmes can successfully deliver their interventions to the grass roots in the society;

31. Lessons Learned • Effective Programme Management at NMCP HQ & Zonal levels – motivated & proactive team. • The presence of malaria teams at national, zonal, sub-zonal levels. • Availability of CHAs at the community level facilitate early Rx. • Availability of New Young Health cadres/PHTs (>above 100) in all sub-zones/districts of the country. • Epidemic preparedness and control system in place. • Sentinel sites (26) for following up trends of malaria morbidity and mortality established • Quarterly, semi-annual and annual meetings carried out (zoba and national level)

32. Lessons learned… • Stakeholders Involvement HAMSET project • In support of the principles of National Health Policy • The diseases are multi-sectoral in origin arising from an interaction of factors across several sectors

33. Lessons Learned… • Stakeholders Involvement… • Communities: Eritrea has strong societal cohesion which is reflected very well seen. • Organizations like NUEWS, NUEYS, PFDJ and the leadership at the community among others are strong and efficient. • This process leads to Ownership & Involvement of the Community & they demand for the service if weak or not available in the community.

34. Recommendations and Conclusion • Most of the Abuja targets were/are met in Eritrea on schedule mainly because, among others, the government has set even higher targetsfor itself • Both mortality and morbidity have declined dramatically move to pre- malaria elimination phase. • Impact assessment need to be conducted to determine the individual contributions of the different control strategies.

35. Recommendations and conclusion… • Meanwhile, the implementation of these strategies that seem to be working should continue & further strengthened for the sustenance of achievements. • A need to consider Malaria Elimination and technical support expected to come soon from RBM funding partners.

36. Priority Actions &The Way Forward • Conduct Mid- Term evaluation of the Second Country RBMSP (2005-2009). • Intensify the research component of the program. • Strengthen the surveillance system of malaria. • Strengthen the capacity & skill of PHTs in the country. • Aim and plan for Elimination of malaria considering the drastic reduction of malaria in the last 7 years. • Address the risk of other vector-born diseases considering the ecological/environmental changes taking place in the country (construction of dams, irrigation schemes etc).

37. THE CURRENT COUNTRY RBM PARTNERS FINANCIAL, TECHNICAL & Implementing Partners • The MoH & the Gov’t of Eritrea - the MAIN driving forces • WHO • UNICEF • WHO/PHARPE (Italian corporation) • World Bank – since 1998 and then as HAMSeT since 2001 • GFATM Rd 2 and Rd 6 • JICA • Ministries: MoA, MoE, MoI, MoLWE, Local Government, Ministry of Finance, Dep. of Environment among others Associations & CBOs • Youth and Women Associations, Eritrean Confederation of workers • PFDJ, Zonal, sub zonal and village administrators • ESMG/PSI since 2004 • Faith-based organizations

38. Malaria is still a BIG PROBLEM which seeks a BIG SOLUTION !!!!!! SO MUCH DONE BUT SO MUCH TO BE DONE

39. KILL MOSQUITO KILL MALARIA

40. YEKENYELEY !!!! SHUKREN !!!! THANK U 4 LISTENING !!!! Awet Nhafash !!!