ZANZIBAR CITY, 25 April 2010 (IRIN) - Efforts to combat malaria in Zanzibar have seen the prevalence rate come down from 35 percent before 2008 to below 1 percent, but health officials are worried the gains could be reversed.

"Despite the achievements in reducing malaria, a lack of funds for awareness[-raising], indoor residual spraying and surveillance, is a challenge. Also, we have a problem with people's resistance to behavioural change, particularly in keeping the environment clean and in the use of mosquito nets," said Mwinyi Msellem, head of the diagnostic unit at the Zanzibar Malaria Control Programme (ZMCP).

As malaria prevalence heads towards zero, the population is also losing its natural immunity to the disease, meaning that population screening will become increasingly important, said Msellem. Malaria prevalence was below one percent, according to the Roll Back Malaria Indicator Survey of 2007.

ZMCP interventions include case management through the treatment and training of health workers, and integrated vector control through the use of insecticide-treated bednets, environmental hygiene and indoor spraying. The programme hopes to cover 95 percent of the island's estimated 280,000 households in this way as against 60 percent at present.

The prevention of malaria in pregnancy has also been a key malaria control intervention although the use of prophylaxis medication by pregnant women is low at 40 percent against a target of 85. "Most pregnant women attend clinics when they are close to delivery so they just get the last dose," he said. Two doses are recommended.

Along with past interventions, emphasis is on new case monitoring and research. "When you get this kind of success you have to increase surveillance," he noted.

Early epidemic detection system

A Malaria Early Epidemic Detection System has also been established to monitor new cases at 52 of Zanzibar's 150 health facilities. "Weekly, they [the health centres] send text messages to our server indicating the number of patients, those tested for malaria, and the number diagnosed with malaria," said Msellem. Comparisons are then drawn against previous weekly reports.

"If an increase is noted, we have to investigate and check breeding grounds," he said. The health centres reported 1,671 confirmed malaria cases in 2009, of which 618 were children under five.

According to the Ministry of Health and Social Welfare, health centres have been showing 2-3 percent malaria prevalence, with no change noted since the short March-May rains.

Emerging challenges

Challenges are, however, emerging in disease monitoring, behaviour change and funding.

Among the problems is difficulty getting monitoring data from the health facilities, he said. Mobile phone technical errors sometimes also interfere with data collection.

"Each district also needs its own surveillance and response team and there is a need for more trained personnel," he said. "To set up this system you also need a lot of money."

Refusal to test and be treated for malaria has also been noted as cases decline, raising the risk of onward transmission or even death. This is because some people believe malaria has already been eliminated, said ZMCP.

Mariam Mussa, 34, a small trader and mother of three in Tunguu village south of Unguja, one of Zanzibar's constituent islands, said: "I thank God that the last time one of my children had malaria was in May [2009]. In the past we used to have malaria frequently."

"Situation remains fragile"

"Although malaria is down, the situation remains fragile. Sustainable commitment by the government, including having its own funds for the anti-malaria programme and awareness of the need to keep the environment clean, is important to control mosquitoes," Juma Muchi, a doctor, told IRIN.

The likelihood of donors and the government withdrawing support due to the recorded success is a major concern, according to ZMCP's Msellem. "We need to sustain control measures to avoid a resurgence... Malaria prevalence was reduced to 1-2 percent in the 1970s, and then people relaxed... If we do not have proper strategies and do not work together - yes there is a fear of sliding back."

"Maintaining the gains in fighting malaria is probably the biggest challenge facing Zanzibar now," said Asha Abdallah, the Minister of Employment, Youths, Children, and Women.

Source http://www.irinnews.org/Report.aspx?ReportId=88920