MALARIA CONTROL IN GHANA

GROUND-BREAKING CEREMONY OF BIOLARVICIDE FACTORY

DR (MRS) CONSTANCE BART-PLANGE

PROGRAM MANAGER. 6TH AUGUST 2013

OUTLINE OF PRESENTATION• INTRODUCTION/INTERVENTIONS

• PROGRESS MADE

• CHALLENGES AND LESSONS LEARNT

• CONCLUSION

INTRODUCTION• MALARIA DATES BACK TO PREHISTORIC TIMES:

• KILLED MORE PEOPLE THAN THE GUN IN WORLD WAR II

• Mid-19th century: malaria endemic in most countries of the world including the Arctic Circle

• 1945: Efforts to reduce malaria with DDT begins

o Result: positive impact on malaria mortality and morbidity

o 1992: Dramatic increase led to the adoption of the Global Malaria Control Strategy

o 1998: Roll Back Malaria Partnership was launched to coordinate global efforts in combating malaria

• . 

Determinants of malaria

Environment Stagnant waters,

Agent=Anopheles mosquito which carries

The parasite

Host-manCattle, monkeys etc

Malaria Disease burden is the interaction of the three determinants

• Diverse species-3500 different types of mosquitoes

• AGENTS FOR YELLOW FEVER, ELEPHANTIASIS, MALARIA, ENCEPHALITIS, WEST NILE FEVER, DENGUE

• About 40 species known to be vectors of malaria Globally

• IN GHANA: ONLY SIX (6) IDENTIFIED SO FAR

MOSQUITOES: AGENTS OF DIFFERENT DISEASES

SIX ANOPHELES MOSQUITO TYPES SEEN IN

GHANA

• Anopheles gambiae complex:

o An gambiae ss-whole country-most imp

o Arabiensis-northern part

o Melas-swampy areas

• Anopheles funestus group• Anopheles hargreavesi• Anopheles coustani• Anopheles rufipes• Anopheles nili

LIFE CYCLE OF MOSQUITO- FROM EGG-LARVAE-PUPAE-ADULT: 7 days at 31oC and 20 days at 20oC

Females lay eggs in batches of about 50 – 200 and they continue to lay eggs throughout

their life

LARVAE TO PUPA

Adult Mosquito• Both male and female mosquitoes feed on nectar

• FEMALE MATES ONCE ONLY IN ITS ENTIRE LIFE

• After mating, the female mosquito searches for a blood meal for the development of her eggs

• TAKES BLOOD EVERY TWO-THREE DAYS TO LAY ITS EGGS

• WILL LAY EGGS UP TO 7 TIMES

• The average LIFE SPAN of female Anopheles under optimum conditions is 28 days

• Males live shorter than the females.( 14 days)

Habitat preference of ANOPHELES• Anopheles gambiae prefer small water

collection that are open to sunlight

• Anopheles funestus prefer edges of streams, swamps and marshes

• Anopheles pharoensis prefer swamps and vegetated water bodies

• Anopheles culicifacies; adenesis prefer domestic breeding site such as barrels and water collections in domestic utensils

Mosquito Larvae Habitats

MALARIA PARASITES IN GHANA

oP. falciparum (About 90%)

oP. malariae (about 9%)

oP. ovale (about 1%)

CHARACTERISTICS P. FALCIPARUM

P. MALARIAE

P.OVALE

PREPATENCY(INFECTION TO DETECTION IN BLOOD FILM)

5.5 DAYS 15 DAYS 9 DAYS

ASEXUAL CYCLE IN BLOOD

48 HOURS 72 HOURS 48 HOURS

NO OF MEROZOITES PER HEPATIC SCHIZONT

30, 000 15,000 15,000

DURATION OF UNTREATED INFECTION

1-2 YEARS UP TO 50 YEARS

1-5 YEARS

Epidemiology of Malaria: IN GHANA

Malaria is endemic with slight seasonal variation:

oHypo-endemic in Greater Accra Region- 4% o hyper-endemic in the Upper West Region-51%

omeso-endemic in the rest of the country (18-22%)

• Overall parasite prevalence under 5 years is 27.5% (MICS 2011)

Malaria within the Ghana health System

• Malaria is an important public health problem and considered high Priority in the country

• It is captured in MOH’s Medium Term Health Strategic Plan

• There exists a government policy which has exempted the payment of duty/taxes on ITNs; insecticides for IRS

• The National Malaria Strategic Plan 2008 -2015 INCLUDES LARVICIDING AS ONE OF THE KEY INTERVENTIONS

IN LINE WITH Global Malaria Action

Plan Targets

GHANA MALARIA PROGRAM HAS SET THESE GOALS IN STRATEGIC PLAN 2008-2015

By 2015: Using the year 2000 as baseline:

oReduce Malaria cases by 75%

oReduce malaria attributable deaths by 75%

GHANA-NMCP Targets on CURE- BY 2015

• All health facilities will provide prompt and effective treatment

• All communities will have access to community – based treatment for uncomplicated malaria;

• 90% of caretakers/parents will recognise early symptoms/signs of malaria and act correctly

• 90% of children under five years of age with fever will receive an appropriate ACT within 24hrs of onset;

• Reduce malaria cases in pregnant women from 16.1% to 8% and deaths from 9.0% to 4.5%

GHANA-NMCP Targets ON PREVENTION- BY

2015 • ALL households will own at least one ITN

• 80% of the general population; 85% chn under-five years & pregnant women sleep under ITNs

• 90% of all structures in targeted districts protected thro Indoor Residual Spraying

• Limited Larviciding using chemicals and biological agents to be carried out coupled with focused spraying.

SNAP-SHOT OF INTERVENTIONS PUT IN

PLACEA, PREVENTIVE INTERVENTIONS:

• ITNS FOR ALL ESP CHN, PREGNANT WOMEN• ADVOCATE FOR SCREENING OF DOORS, DINDOWS WITH

NETTING• PREGNANT WOMEN ON INTERMITTENT PREVENT

TREATMENT USING SULPHADOXINE-PYRIMETHAMINE (SP)• INDOOR RESIDUAL SPRAYING• TARGETED LARVICIDING• TARGETED SPACE SPRAYING• ADVOCATE FOR ENVIRONMENTAL MANAGEMENT

B. CURATIVE INTERVENTION• USE OF EFECTIVE, ANTIMALARIALS: ARTEMISING-BASED

COMBINATION FOR SIMPLE MALARIA; INJ ARTESUNATE; QUININE FOR SEVERE MALARIA

Indoor Residual Spraying

• IRS remains a powerful vector control tool for reducing and interrupting malaria transmission. In 2011, 80 countries, including 38 in the African Region, recommended IRS for malaria control.

• In 2011, 153 million people were protected by IRS worldwide, or 5% of the global population at risk.

• In the African Region, the proportion of the at-risk population that was protected rose from less than 5% in 2005 to 11% in 2010 and remained at that level in 2011, with 77 million people benefiting from the intervention.

WHY LARVICIDING??• Larviciding of temporary and permanent water bodies is an

integral component of malaria interventions

o Adult mosquitoes are highly mobile; & detect and avoid many interventions

o Mosquito eggs, larvae and pupae are however confined within relatively small aquatic habitats so cannot readily escape control measures

• This makes larval control a reliable and effective measure for reducing mosquito population.

• Larvicides affect all types of mosquito larvae: culex, aedes, anopheles,

Different Mosquito Species• Females of the genus Anopheles, unlike all other genera of

mosquitoes, have palpi as long as the proboscis

Anopheles

Progress Made in Ghana in Malaria

Control-1Indicators/years 2003

GDHS2008 GDHS

2011 MICS

2012 KAP BY SPH

TARGET 2015

Remarks

% Households with at least one insecticide treated net

3.2% 32.6% 48.9% 96.7% 100% 2012 TARGET ALMOST CLOSE TO 2015 SET TARGET

% children under 5 sleeping under insecticide treated net

4%53.9% 39% 77.6% 85% 2012 FIGURE

ALREADY CLOSE TO MDGs 2015

% Pregnant women sleeping under ITN

2.7% 50.4% 32.6% 59.7% 85% More than half of Pregnant Women Sleep under LLINs

25

PROGRESS MADE IN MALARIA CONTROL-2

26

Indicators/years 2003 DHS

2008 GDHS

2011 MICS

2015 TARGET

Remarks

% Pregnant women receiving at least2 doses of SP (IpTp)

1.3% 43,7% 64.4% 100% Two third of all Pregnant women protected

Proportion of children under 5 with fever who are treated with appropriate anti malaria drugs (ACTs)

0% 23.7% 42% 90%) 2012 figure shows we have attained less than half of 2015 set target.

Parasite Prevalence (among 6 to 59months)

75.0% 27.5% 18.7% Parasite prevalence has dropped more than 50%.

ON COURSE TO ATTAIN MDGs

National Urban Rural Male Female0.0

5.0

10.0

15.0

20.0

25.0

30.0

Percentage of Children Under 5 Years who received ACTs within 2 weeks in Ghana MICS

2006 and MICS 2011 Compared

perc

enta

ge

Trend: Health Insured Patients and non-Insured Malaria Cases Admitted: 2008-2012

Progress Made in Ghana in Malaria

Control-3

Indicators/years 2000 2011

2012TARGET

FOR 201575%

REDUCED OF 2000

LEVELS

Remarks

Death associated with malaria

6108 3256 2815 1527 Reduced by 53.9%

Under 5 years Malaria Cases Fatality Rate (CFR)(Severe Malaria admission)

14.4%

1.2% 0.8% 1.0%Reduced by 95.8%

More admitted malaria cases survive now than in the past.

29

Trends in Malaria DEATHS versus NON-malaria

deaths in Ghana, 2005-2012; UNDER-FIVE YEARS

2005 2006 2007 2008 2009 2010 2011 2012 -

500

1,000

1,500

2,000

2,500

3,000

3,500

4,000

-

500

1,000

1,500

2,000

2,500

3,000

3,500

4,000 Mal_DeathsNon mal death

Mal

aria

dea

ths

Non

-mal

aria

dea

ths

AMFm ACTs

Trends in Malaria DEATHS versus NON-malaria

deaths in Ghana, 2005-2012; ABOVE-FIVE YEARS

2005 2006 2007 2008 2009 2010 2011 2012 -

500

1,000

1,500

2,000

2,500

3,000

-

2,000

4,000

6,000

8,000

10,000

12,000

14,000

Mal_Deaths Non mal death

Mal

aria

dea

ths

Non

-mal

aria

dea

ths

AMFm ACTs

Challenges• Parasite resistance to Artemisinins

• Mosquito resistance to insecticides

• Poor Environmental management

• Threat of Galamsey/surface illegal mining to malaria vector control intervention

• Existence of sub-standard/counterfeit anti-malaria on the market

• Over-dependence on external funding esp. Global Fund/Sustainability of funding

DOMESTIC: INCL GOV-ERNMENT

66%GLOBAL

FUND8%

EXTERNAL26%

Total Budget by Broad sources

Illegal Mining Activities

Progress Made, Ghana Should Move from Control Phase to Elimination

WHAT WILL IT TAKE TO MOVE FROM

CONTROL TO ELIMINATION?ENSURING SUSTAINABLE RESOURCES

• TO SUSTAIN/ACCELERATE PROVEN INTERVENTIONS

MALARIA VACCINE• An effective vaccine against malaria has long been

envisaged as a potentially valuable addition to the available tools for malaria control. Ghana has 2 sites piloting vaccine….. Ready 2015??

BIOLARVICIDE: ..TO KILL THE LARVAE. KILL THEM YOUNG

CONCLUSION• We are at a critical tipping point in the

fight against malaria. • Defeating malaria requires the

engagement of a number of sectors outside of health, including finance, education, defence, environment, mining, industry and tourism.

• IT IS POSSIBLE..OTHERS HAVE DONE IT, WEST AFRICA CAN DO IT TOO.