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1950s strategy to control malaria on Zanzibar fails once more

March 29, 2013 - 09:55 -- Bart G.J. Knols

Four years ago, in 2009, I wrote an article for a Dutch newspaper (Bionieuws) with the title 'It is not yet time for a party on Zanzibar'. My article was a response to Tachi Yamada's blog on CNN 'Where have all the malaria patients gone?'. Yamada at that time was touring the spice island together with Ray Chambers and Margret Chan, and for sure their trip must have been pleasant and satisfying. After all, the renewed impetus (largely through the US Presidential Malaria Initiative) in malaria control was starting to pay off. Indoor residual spraying and massive distribution of LLINs yielded a spectacular decline in malaria prevalence. Yamada ends his commentary with a pretty strong statement...

He writes: 'Where have all the patients gone? Home, where they can live happier, healthier lives. Let them be the retort to the skeptics of development assistance'. Now, that was four years ago. Yamada has since moved on and is no longer the President of the Global Health Programme at the Bill & Melinda Gates Foundation. But his words are forever online and can be traced. In my newspaper article of 2009, in response to Yamada's commentary, I expressed my concern that Zanzibar's impressive results should not lead to euphoria since it was not much more than a repetition of the elimination activities that took place in the 1950s and early 1960s. Which ultimately collapsed and brought prevalence levels back to the pre-campaign level.

When I teach these days, I use Zanzibar as the perfect example of what I coined 'the trampoline effect'. That efforts to control can reap fruits within a short period but that inevitably the gains are lost when either funding dwindles or evolution catches up with us and resistance favours the revenge of our enemies: Anopheles and Plasmodium.

And this week, in an article published in Parasites and Vectors, we see exactly that happening. Khamis Haji and colleagues have measured what we all could have seen coming at us: That resistance to pyrethroids on Zanzibar is now full blown. Is this a surprise?: No. Could this have been foreseen?: Yes. Was it predicted?: Yes. Besides this, Haji et al. also show that the LLINs are not performing the way they should and lose effectiveness already after 6 washes. Now, let's then put Yamada's words and Haji et al.'s conclusion together here:

Yamada (CNN Commentary, 2009): 'Zanzibar -- a relatively small but striking example -- has virtually eliminated the disease over the past five years. These successes show what a combination of political will, technical resources, and financial commitment can do when applied to a strategy that works.'

Haji et al. (P&V, 2013): 'The sustainability of the gains achieved in malaria control in Zanzibar is seriously threatened by the resistance of malaria vectors to pyrethroids and the short-lived efficacy of LLINs. This study has revealed that even in relatively well-resourced and logistically manageable places like Zanzibar, malaria elimination is going to be difficult to achieve with the current control measures.'

There are some important lessons to be learned from this:

1) Bringing malaria down to really low levels can be done with the tools at hand and within a few years. Zanzibar is a good example but there are many other examples of where this has been demonstrated;

2) If you then (when prevalence is really low) stop efforts to eliminate but want to sustain the gains you will lose the fight. Since reliance on biocides (drugs and insecticides) is the sure recipe for evolution to outwin us;

3) If you then resort to using other biocides (Haji et al. tested DDT and bendiocarb) than you will be in the game for a few more years until resistance to these new chemicals takes over;

4) Keeping malaria at a very low level is difficult, hard, costly, and maybe even impossible.

So then, should we do nothing? Of course not. And, one could argue, it is easy for me (here in the Netherlands) to write about failure...what did I do to contribute to malaria control/elimination on Zanzibar?

Well, below the list of activities I undertook regarding Zanzibar:

1) In 2010 I wrote an article on Zanzibar that is essentially the same as what you read here (you can read it here). In it, I show the video below:

2) In 2010 I visited Zanzibar and talked to the permanent secretary of health, Dr. Jiddawi, about my concerns. I made a case for area-wide larval source management as an add-on to the IRS/LLINs that were in place. As a means to further reduce, if not eliminate, the disease. Dr. Jiddawi was very much interested in this, and referred me to Admiral Ziemer, the man at the helm of US PMI. And so I contacted Admiral Ziemer. The result? The best I got was a response (email: 17 June 2010) from Charlene Voorhees, his assistant, who claimed: 

Dear Dr. Knols

Thanks for your note and interesting suggestion.  Dr. Soper is certainly an icon of vector control program organization and his accomplishments in Brazil and Egypt are legendary.  We note that since his feat, it appears that An gambiae (An arabiensis) has apparently not been re-introduced into either country.  Unfortunately the same can not be said for Aedes aegypti which re-invaded and spread throughout the Americas.   We are familiar with the attempts for larviciding in Stone Town in the 1980's as part of the USAID support to the Zanzibar Malaria Control Program (the second of three times that malaria was reduced on the islands).  That larval control effort failed, and as you know, other parts of Zanzibar would seem to be even more difficult with large parts of Northwest Unguja and Pemba having rice fields breeding huge populations of An arabiensis.  Eliminating these mosquito populations and preventing re-introduction would be a daunting task.  We have tremendous respect for Dr. Jiddawi and his team in Zanzibar, and the work they are doing to set up a surveillance system to prevent re-introduction of the parasite on to the island.  What more then for a surveillance system to detect the re-introduction of An gambiae (and An merus?) with the constant unregulated boat traffic around the islands and from the mainland, only 50 miles away.  Larval control may have an important role, but we are also looking for a sustained reduction in vectorial capacity through improved  housing, ITNs and were necessary, focal IRS as well as from the parasite side, rapid diagnosis and treatment.  We need to take the long-term view, now that this is the third time that malaria has been reduced in Zanzibar, to make sure we have the robust and sustained program to ensure it does not return.    
 
Sincerely,
 
Charlee
 
So much for getting US PMI interested and appreciate the concerns that (I and others at the time) raised.
 
3) Following David Smith et al. paper in Science in June 2011, we communicated several times. And although Smith appreciated the concerns raised, he did not believe that a vector elimination campaign like that staged against An. arabiensis in Egypt or Brazil would be feasible. It ended there.
 
4) In September last year I met with Dr. Jabir Uki Dahoma, Director of Preventive Services of Zanzibar, who gave a presentation on malaria in Zanzibar at the 2nd Nordic Malaria Conference in Copenhagen. He was amenable to the idea of area-wide vector control (incorporating larval source management) and would consider it...
 
Looking back at the past four years, and the developments on Zanzibar, I am now firm in my conclusion: Zanzibar will not keep malaria at a near-zero level. And Zanzibar will only be able to sustain the gains if it focuses on controlling the vector in the outdoor environment and adopts environmental and larval source management as a major component of its campaign.
 
Zanzibar has failed twice in history to get rid of its malaria. Are we tolerating a third failure? 

Comments

Mark Benedict's picture
Submitted by Mark Benedict on

The satisfaction of being proven right is far outweighed by the dismaying predictability of the outcome. As you point out, the approach that was used sowed the seeds of its own demise. While nobody underestimates the difficulty of controlling the vector, I suspect few involved in PMI are aware that tsetse was eliminated from Zanzibar and has never returned. Egypt has managed to keep An. arabiensis at bay using larval control. Nothing to see here folks. Move along.

William Jobin's picture
Submitted by William Jobin on

You are right Bart,
Zanzibar is a terrible example of the failure of the chemically-oriented strategies of WHO and the USPMI.
And like Mark, it surely gives me no pleasure to see this happening all over Africa, again, and again.

Perhaps what we need is an Exit Strategy, so that we don't have to repeat these mistakes ad infinitum.

I think in the past few decades we have had a subconscious Exit Strategy in our thinking - the mythical malaria vaccine. The hope for a vaccine has stimulated enormous amounts of research in the industrial world, and perhaps also gave comfort to those of us working in the field who see the brick wall of Resistance to Drugs and Biocides coming down the pike.

But maybe there is a better Exit Strategy than the mythical and ephemeral vaccine.

Mark mentions that Egypt is keeping An arabiensis under control. I think there is another factor - Aswan Dam. Now, how could a dam prevent malaria from returning to Egypt? Well Aswan produces about a Gigawatt of electricity, so many of the small villages on the banks of the Nile have affordable and reliable electricity now, since the 1960's when Aswan started generating.

That means, if they close up their houses at night, people can turn on a small electric fan to keep cool, and incidentally, blow away the "Stinky Feet Odor" which the mosquitoes need to locate their host.

So, despite enormous risks from mosquitoes and infected travellers coming into Egypt from Sudan just upstream, there has been no resurgence of malaria in Egypt since the end of the Second World War when it was successfully suppressed.

Notice that WHO certified the island of Puerto Rico as malaria free in 1961, a few years after they built their 14th hydroelectric reservoir on the island, and everyone had electricity available. This island, like Zanzibar, is subject to repeated importation of mosquitoes and infected people. But Puerto Rico has remained free from malaria since 1962. I know because my family and I lived there for 10 years, and I did field studies on all the hydroelectric reservoirs. After a while, Puerto Rico also started generating electricity with oil-fired steam plants.

Obviously the same was true in the Tennessee Valley of the USA when their 17 hydroelectric power dams were finished. They have had no malaria since 1950, over half a century. The fans work, I know, I used them.

In Turkmenistan, their last malaria death occurred at about the time that the three hydroelectric dams on the Amu Darya River were finished. They not only had fans in rural areas, they have air-conditioning! Pity the poor mosquitoes.

On the island of Mauritius, malaria disappeared about the same year that the National Electricity Board was created, to manage the abundant supply of electrical power that they had created.

That is my idea of an Exit Strategy - one that we know how to do already.

So maybe the fight against malaria should be coordinated with the creation of affordable and reliable electricity supplies, just for those cooling electric fans.

Or if you want a greener solution, how about solar panels to power small fans? Given their durability, solar panels and small electric fans might be better investments than the ephemeral and seldom used bednets.

Bill, still working on an Exit Strategy so we don't repeat Zanzibar over and over and over.....

William Jobin Director of Blue Nile Associates

Bart G.J. Knols's picture
Submitted by Bart G.J. Knols on

Thanks Bill, for your wise words. I notice with interest your comment about Puerto Rico that eliminated its malaria in 1961. Hydropower will have played a role in the elimination of malaria, as you state, but certainly there must have been activities directly directed at the vector (e.g. larval source management). Now, Puerto Rico is 9.104 km2. Compare that with Zanzibar which is 'only' 2650 km2. I cannot understand why it would be impossible to eliminate malaria from Zanzibar if similar tactics like those deployed in Puerto Rico, Egypt, and elsewhere, would be used there. We have not even tried and I think we should.

In other words, we should not find an exit strategy but an entry strategy: an approach that will make policy makers aware of what can be done but isn't tried. An approach that gets those with experience that goes beyond nets and IRS (there are numerous hands-on experts in area-wide mosquito control in US abatement districts) at the table to convince those betting on half-hearted strategies that we know are insufficient and will not lead to elimination.

It is beyond any doubt, that the world will start looking beyond nets and IRS for better solutions. Where better to find them than to look at successful historical campaigns. When this is done, those in power will start to appreciate the impact of house improvement (e.g. screening), of environmental and larval source management, and of campaigns that are run military style by well-trained and well-paid inspectors rather than by community volunteers...

It is time for change. We better before the tap of funding that is still open shuts in front of our eyes and we end up in the same situation as the early 1970s...

William Jobin's picture
Submitted by William Jobin on

Yes Bart,

You are right. The electricity was only the Exit Strategy, the final nail in the coffin. The basic anti-malaria effort in Puerto Rico was led by CDC and based on their experience in the Tennessee Valley, using ditching, drainage of coastal swamps and some spraying of larvicides.

Please remember to join us this week on our Global Health Delivery online conversations about physical and biological methods for fighting malaria in Africa. We will be online all week, and would really appreciate your comments.

William Jobin Director of Blue Nile Associates

Submitted by Beljaev Andrei on

Bart,
I liked your post. It reminded me of my first visit in Africa (and abroad in general) in 1965.
I and my colleague Oleg Losev were in Congo with a humanitarian mission and decided to pay a visit in WHO AFRO. At that time Dr Charles was the Regional Malaria Advisor. He was very kind and spoke at length to us about tremendous achievements in malaria eradication in Africa. Successes were particularly great in two countries: Zanzibar and Mauritius. If I remember correctly, he never made any reference to the island position and size of those great countries, and I never told that I was aware of that.
I agree that the transition to the maintenance phase is the point where most of the malaria eradication/elimination ateempts failed (and will fail, as you rightly say). In Zanzibar this was the political decision of the new government to withdraw operations in 1968, if I remember correctly, with catastrophic results.
Late Mario Coluzzi never stopped to emphasize the enormous strength of the parasitic system of malaria in Afrotropica. Outside Afrotropica malaria is much less refractory in comparable climates. Therefore the successes in eliminating An.gambiae/arabiensis outside the Afrotropica (Brazil or Egypt 70 years ago) are irrelevant. I doubt that any durable interruption of malaria transmission is feasible in the Afrotropical region, except in fringe areas or islands, unless some magic bullet is invented in the future. Electricity or no electricity, larviciding or no larviciding.

Bart G.J. Knols's picture
Submitted by Bart G.J. Knols on

Dear Beljaev,
Many thanks for your contribution. Where we disagree is on the relevance of the elimination of An. arabiensis from Brazil with regard to Africa. It is argued by many that Brazil was merely an example of an invasive species that wasn't thriving well and was therefore 'easy' to eliminate. However, if you read Wilson and Soper's book 'Anopheles gambiae in Brazil' you will see that arabiensis from Senegal was doing extremely well in Brazil. It established well, spread like wildfire, and was much more competent in transmitting Brazilian falciparum than falciparum in its native Senegal. The sporozoite rates in Brazil were higher than that observed anywhere in Africa. In other words: The Brazil setting was more difficult than Senegal.

Still, the invasion was fully eliminated over an area of 54000 km2, within an amazing period of only 18 months. Imagine if a similar approach, of 4000 larval control staff doing nothing but larval source management, would be deployed in Senegal. What would happen? I am positive that elimination could be accomplished in a similar way as was done in Brazil...

Dr. Knols, thank you for highlighting some of the current challenges facing front-line malaria control programs, in Zanzibar and beyond. We agree it is “not yet time for a party in Zanzibar.” There is considerable work ahead if Zanzibar is to maintain the unprecedented low prevalence of Plasmodium falciparum documented in recent years. Eventual elimination will require an even greater commitment of resources and availability of new preventive and curative interventions.

However, it is indeed appropriate to recognize and commend the Zanzibar Ministry of Health leadership and staff for their tremendous progress to scale-up a combination of four proven malaria control strategies. Zanzibar has also worked hard to develop robust systems to monitor insecticide resistance and report weekly confirmed malaria cases from across the isles. Lauding public health accomplishments in resource constrained setting is generally not a bad idea. This was likely the intention Dr. Tachi Yamada’s blogged remarks and “euphoria” back in 2010 when he visited Zanzibar for a first-hand look at a highly successful malaria control program.

It is a bit perplexing to read your reference to Zanzibar’s “1950s strategy to control malaria” as a “repetition of the elimination activities” previously pursued. As you certainly know, three of the four malaria interventions scaled-up in Zanzibar over the past decade did not exist in the 1950s. Long-lasting insecticidal nets (LLINs), intermittent treatment of malaria during pregnancy, and artemisinin-based combination therapies (all embraced by the Roll Back Malaria Partnership) are products of research efforts completed in the 1990s. The detection, treatment, and reporting of malaria cases in the 1950s did not benefit from the availability of malaria rapid diagnostic tests (mRDTs), mobile phones, and computer servers. These mRDTs have been available at all 142 (100%) government health facilities in Zanzibar since 2008 and provide the foundation for Zanzibar’s improved malaria case management and surveillance system (http://zmcp.go.tz/reports.php). Health facilities use mobile phones to report weekly malaria summaries to a central server that processes and presents the data to ZMCP, making data-driven decisions a reality. This is malaria control in Zanzibar in 2013.

P. falciparum prevalence in Zanzibar was 0.5% in 2012 (http://www.measuredhs.com/pubs/pdf/AIS11/AIS11.pdf). The previous malaria control initiatives in Zanzibar did not reduce prevalence to levels quite this low. In addition to the new interventions, the Zanzibar Malaria Control Programme is far more strategic with malaria control than in the 1950s. Monitoring for vector resistance to insecticides has become a routine programmatic activity, allowing ZMCP and partners to make strategic shifts in the insecticides used for IRS. After pyrethroid resistance was detected in Zanzibar, U.S. President’s Malaria Initiative (PMI) supported ZMCP’s decision in 2012 to shift to carbamate as an insecticide alternative. The complete and timely surveillance data have also allowed ZMCP to switch to a more focal application of IRS since they know over 80% of their confirmed malaria cases arise from the population catchment areas surrounding just a handful of health facilities.

Are the current vector control strategies in Zanzibar missing the exophilic, exophagic vectors that persist? Probably. Khamis and colleagues’ recent publication highlights the increasing prominence of An. arabiensis in Zanzibar. If ongoing entomologic monitoring determines An. arabiensis is indeed the culprit, ZMCP is certainly now in a better position to deal with the issue. The most serious vector (An. gambiae s.s.) has been dealt with by existing vector control strategies (IRS and LLINs) and parasitemia is low. Thus, ZMCP’s vector control staff can (finally) shift attention to the outdoor feeding An. arabiensis. Perhaps the approach you propose: larviciding, will be a useful adjunct where larval habitats are few, fixed, and findable as recommended by the World Health Organization Global Malaria Programme (http://www.who.int/malaria/publications/atoz/interim_position_statement_larviciding_sub_saharan_africa.pdf.)

PMI is not opposed to alternative vector control strategies as you imply. Please review the annual Malaria Operational Plans available on the PMI website (www.pmi.gov). PMI provided financial support ($900,000 between FY07-09) for a pilot project to implement larviciding with Bacillus thuringiensis israeliensis (Bti) in selected parts of Dar es Salaam over three consecutive years. PMI support for this intervention only ceased when the project’s surveillance data began to show lower malaria prevalence in the control areas where larviciding had not been implemented.

Finally, your statement concerning the “renewed impetus” in malaria control in Zanzibar as “largely thru the US President’s Malaria Initiative” is not quite accurate. PMI has indeed been a major financial and technical contributor to malaria control in Zanzibar since 2006, $29 million through FY2012, but other donors such as the Global Fund have also contributed significantly to Zanzibar, $12 million since 2003 (http://portfolio.theglobalfund.org/en/Country/Index/ZAN). Multiple donor contributions have resulted in a strong financial and technical partnership that strives to address the concerns you have expressed. We welcome your thoughts on how PMI can strengthen vector control (or malaria control in general). However, PMI is committed to supporting evidence-based interventions.

Rear Adm. Tim Ziemer
U.S. Global Malaria Coordinator

Submitted by Robert Novak on

Dear All, I had the opportunity to meet face to face with Tim Ziemer on 2 occasions very early in his first year and second year as head of PMI At that time my IMM group gave him a detailed proposal on monitoring malaria and making management decisions based on evidence and location. Tim Ziemer was cordial but his minions primarily the MD epidemiologist that surrounded him vetoed our proposal. USAID was totally and I mean totally committed to Bed nets and bed nets only. All else was considered irrelevant. I told Zemier at that time that without a monitoring system on the ground malaria will continue to be a problem. We as a group continually talk about the tools, nets, IRS and ignore the basic most fundamental concept of IPM, IVM and IMM, that data about the parasite and the vector within a specific landscape provide the necessary information to apply the tools to manage. In every situation, beginning with the Panama Canal and Gorgus through WW1 and 2 has this strategy worked and worked effectively. We tried to give these very important examples to Zemier but he was not interested. Remember Tim Zemier was not a public health naval officer but a operational commander and helicopter pilot. He I assume got the position because of his administrative and organizational skills.
If any of you are interested their will be a Symposium devoted to the operational philosophy of IVM at the upcoming Society of Vector Ecology International Congress in CA this September. In fact Bart will introduce the topic at the plenary session. For more information go to the SOVE web page

Submitted by Manuel Lluberas (not verified) on

Malaria control in Zanzibar or any other country is achievable. In fact, malaria has been eradicated or reduced to a point where it is no longer a serious health or economic burden in a large number of countries. Almost without exception, eradication was reached by combining the political will of the country with active vector population suppression methods and techniques and involving the local population to make their immediate environment less conducive to the proliferation of mosquito populations. More significantly, every country that achieved eradication did so more than two decades ago, long before the establishment of many of the current anti-malaria initiatives and without the benefit of a vaccine. While much has been said about the expenditures related to malaria control and the funding shortfalls many programs face, there has been very little regarding their evaluation. Continued reliance on passive methods like mosquito nets -purported to be a mosquito control intervention- without implementing active mosquito control methods beyond IRS that include larviciding and adulticiding with ULV sprays where appropriate will only guarantee malaria’s existence. Examples of well organized, systematic and integrated mosquito control methodologies that attack the vector from different fronts and include good medical surveillance and treatment systems that have been instrumental in eradicating or reducing malaria to a point where it does not overwhelm diminishing available public health resources are plentiful and include the United States. Well into the Twenty First Century, public health entomologists continue to press the active mosquito control issue and wonder why the methods that eradicated malaria from so many countries -and has kept it out- continue to be overlooked and neglected by the agencies and organizations that promoted and implemented them so aptly early in the Twentieth Century. Delaying implementation of active mosquito control will continue to claim lives at a rate equivalent to six or seven 747 Jumbo jets full of children under five and pregnant women crashing every day.

William Jobin's picture
Submitted by William Jobin on

Hello Tim and other folks at PMI,

Congratulations on expanding the PMI. I am aware of some of the diplomatic and administrative challenges you have overcome, having helped start PMI in Angola in 2005, along with Manuel Lluberas, Joaquim Canelas, Martinho Somandjinga and Felix Januario.

In order to improve technical aspects of the fight against malaria, we started a group last year called African Malaria Dialogues, including several entomologists and water engineers with African experience. Since Bart Knols has now provided a forum for us in MalariaWorld, I offer the following comments in response to your recent note, based on our Dialogues. I hope you will find these helpful:

1.REALISM. I understand your first point about encouraging the folks in Zanzibar. But it is worrisome that the donor community is getting the impression that this fight against malaria will soon be over. Realistically, it will be 40-50 years before we can think about relaxing.

2.EVIDENCE-BASED STRATEGY. Your use of a comparison area in Dar for testing the value of larviciding is an important technique for field evaluations of new control methods, but a very tricky process. We have found that 3-4 replicates of such paired evaluations would be advisable, to deal with the large variability in field situations, before you make up your mind about larviciding with B. thuringensis.

3.WATER MANAGEMENT BY CDC. Based on experience of the US Army and Public Health Service in controlling malaria while building the Panama Canal, CDC then assembled a group of entomologists and engineers after the First World War who developed water management techniques to successfully control malaria in the new reservoirs of the TVA. Using environmental methods, they suppressed malaria along the Tennessee River by the end of the Second World War, before DDT and chloroquine were in use. Their methods were then successfully expanded to the entire southern USA, and also to Puerto Rico. Your current strategy should take advantage of these classical methods.

4.CLASSICAL CONTROL METHODS. Don’t ignore the steady line of successes since 1900, using direct physical attacks on the larvae, drainage, water management, screened housing, and larviciding. These classical methods led to the first declaration by WHO in 1962 of the elimination of malaria from a tropical area - Puerto Rico. I remember it because I was there working with CDC, and saw the permanent impact of the simple things they did, like ditching swamps. The advantage of these classical methods is that they do not rely on chemicals; thus are not prone to the insecticide-resistance trap. Draining the Pontine Marshes west of Rome in 1930, and turning them into the most productive agricultural area in Italy, was the foundation for suppressing malaria in all of Italy and throughout the Mediterranean area. Similar measures were used successfully in Malaysia and Indonesia before the Second World War.

5. THE PEACE CORPS AND FAITH-BASED INITIATIVES. You have made a very wise addition to your program by bringing in the Peace Corps, and the faith-based initiatives such as those in Nigeria and Mozambique. They can easily organize community work parties to do local ditching and filling of mosquito breeding areas, permanently eliminating mosquito populations around their homes.

6.THE RESISTANCE TREADMILL. You seem pleased to have found bendiocarb as a replacement for the pyrethroids in Zanzibar. But please realize that you are now on a treadmill, and will need another chemical in 3-4 years, as soon as the mosquitoes go resistant to bendiocarb. In Sudan we went through 5 insecticides before getting off the treadmill. In Turkey and Pakistan they went through 8 insecticides before their programs collapsed. The new insecticides are seductively effective, but each new one will cost more, and will probably have greater human toxicity. This is a very serious hazard when used in bednets.

7. AFRICAN MALARIA DIALOGUES Our group meets quarterly, and last met in January in the Boston area, including about 25 faculty and students from several universities and 8 African countries. It was hosted by Prof. el Fatih el Tahir of MIT, who has several grad students now working on engineering and hydrologic approaches to malaria control in Africa, probably the only place you will find such a broadly based group. Prof. Fatih is now adapting the TVA techniques to African reservoirs, starting in Ethiopia. We will meet again on 21 May in the Boston area and invite you to come. Also we plan to meet sometime later this year in Washington DC and would like very much to have your entire staff participate.

8. HISTORICAL EVIDENCE. There is a wealth of documentation of the success of the classical approaches we mentioned, which you should get for your entomology and engineering advisors to evaluate. I recommend to you the following references, most of which can be obtained on Amazon.com, or from WHO Geneva:

a. “Malaria control on impounded waters”, 1947 by CDC-USPHS.
b. “Manual of larval control operations in malaria programmes”, 1973 by WHO Geneva, Offset publication No.1
b. “Manual on environmental management for mosquito control”, 1982 by WHO Geneva, Offset publication No.66
c. “The Conquest of malaria”, 2007 Snowden, by Yale University Press
d. “Case history of malaria vector control through the application of environmental management in Malaysia”, 1988 Singh and Tham, by WHO/VBC/88.960

Finally I have recently summarized these documents in my recent monograph “Improving the US Presidential Malaria Initiative,” 2012 by Boston Harbor Publishers.

If you have trouble getting these documents, please let me know and I will gladly send you copies.

Bill
Coordinator for African Malaria Dialogues

William Jobin Director of Blue Nile Associates

Clive Shiff's picture
Submitted by Clive Shiff on

This certainly has elicited a string of predictable advisory notes, but I would like to draw attention to some points made by Tim Zeimer, and these include the new devices available. In several publications we at Macha in Zambia have shown the value of collecting data from the positive case diagnosed from all clinics/rural health centres each week. Computed this information clearly shows where and when outbreaks occur. With a good local infrastructure that can respond to such the existence of such foci, it is possible to MANAGE the malaria load in the population. Overall, it is necessary to have the local people trained in outbreak epidemiology, trained in ensuring data are collected and transmitted regularly to the central NMCP, and a disease management programme integrated into the health system.
In Israel we talked the larval control to a standstill, it can help, but it will never eliminate the vector species. In the US we still have mosquitoes in spite of excellent mosquito abatement long term programmes, so let us recognize that all aspects of vector and parasite control need to be integrated and delivered to a local health system that can keep vigilant.
We have the tools (we being the Zanzibari people) so how can this be managed. I have my idea, that they should be managed by Zanzibar with assistance from WHO. management is NOT the job of any donor, so the next step is to invite WHO to discuss with the Government of Zanzibar how to recruit, set up and fund the Health Dept so that this integrated service can operate in perpetuity. What do others think

Clive Shiff